Page 35 - International guidelines for groin hernia management

Hernia

over 90 has a tenfold higher mortality rate compared with determine acceptable safety and outcome parameters. For
younger patients. 296 now, the available evidence supports the idea that many
A recent publication based on data from 82,911 patients patients are well served by day surgery repair of IHs.
with IH operations documented in the German hernia
registry ‘‘Herniamed’’ revealed that patients with prophy-
lactic or therapeutic use of platelet aggregation inhibitors
and oral anticoagulants had a significant higher risk of Chapter 10
bleeding complications (3.9 vs 1.1%; p \ 0.001) compared
to those patients without such a medication. 363 These data
suggest that IH day surgery of patients on anticoagulants Meshes
cannot generally be recommended.
A number of additional factors will either encourage or D. Weyhe and U. Klinge
discourage day surgery. The anesthesiologist’s preopera-
tive assessment is extremely important, because he/she has General introduction
primary responsibility for the perioperative- and immedi-
ately postoperative phase. 357 Other hospital-, physician- Because of human anatomy and physiology, mesh must
and patient-related factors must be considered also. 345 In a conform to a certain structure and stability profile.
facility with considerable day surgery experience and a Requirements for mesh construction include: sufficient
good infrastructure (i.e. easy availability of pre-assessment strength to reinforce the repair, the ability to stretch,
consultation and a smoothly functioning day surgery cen- elasticity, the ability to integrate into tissues without
ter), a large percentage of IH repairs may occur in day forming blocking scars, a low risk of precipitating chronic
surgery. Surgical factors (quick operations and few com- inflammation, and a low risk of bacterial adherence.
plications) and anesthetic factors (effective pain and nausea Although postoperative complications may occur due to
control making rapid patient discharge possible) may poor surgical technique or patient-specific risk factors, the
influence the decision to proceed with day surgery. risk of complications may be increased by the use of a
Day surgery for IH repair is becoming increasingly more poorly designed mesh. Mesh selection is therefore an
popular. 354, 356 In Spain in 2005, day surgery inguinal important factor to consider if one wishes to optimize
herniorrhaphies constituted 34% of the total. 364 From 2000 surgical outcomes.
to 2010 the rate of IH day surgeries in the Netherlands The porosity, elasticity, strength and the polymer itself
265, 296
increased from 36 to 54%. Data from the Swedish are mechanical properties, which all influence tissue reac-
National Registry indicate that 75% of IH repairs are per- tion. A general classification, which is based on a specific
formed in day surgery. From 2000 to 2009 the incidence of property of the mesh and which is able to reflect all risks,
day surgery for IHs increased from 62 to 87% in the currently is not available, and even hardly conceivable.
Northern Italian Veneto region. 358 However, this consid- Unfortunately, most of studies have only used the term
erable regional variation is not explained solely by the lightweight (LWM) and heavyweight (HWM) as classifi-
scientific evidence supporting the acceptability of day cation criteria; and no further details of the meshes were
surgery IH repair. Healthcare financing and reimbursement given in the published data. This must be considered in
almost certainly play a role. 365 evaluation of results, statements and recommendations
outlined below.
Discussion
Key question
Our present and future challenge is to provide ever more
effective, less invasive, and safe ambulatory hernia surgery KQ10.a Is there a ‘‘best mesh’’? What characteristics are
to a broadening array of complex, aged and sicker patients. important and can be used for classifying the mesh-related
More studies are needed on these high-risk groups to risks?

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