Page 5 - International guidelines for groin hernia management

Hernia

2014, concluding it was both necessary and logical to from cultural differences amongst surgeons, different
develop a universal set of guidelines for groin hernia reimbursement systems and differences in resources and
treatment. ‘‘Groin Hernia Guidelines’’ was selected as the logistical capabilities.
name for the collaborative effort since information on Surgeons searching for ‘‘best’’ treatment strategies are
femoral hernias was included for the first time. A move- challenged by a vast diverse scientific literature, much of
ment was launched to develop a state-of-the-art series of which is difficult to interpret and apply to one’s local
guidelines spearheaded by passionate hernia experts for all practice environment. As noted, hernia repair techniques
aspects of abdominal wall hernia treatment. The European vary broadly, dependent upon setting. Mesh use probably
societies—EHS, IEHS and EAES—invited scientific soci- varies from 0 to 5% in low-resource settings to 95% in
eties worldwide with a focus on groin hernias to partici- settings with the highest resources. Currently, open mesh
pate. The project was named ‘‘HerniaSurge’’ (http://www. repair (mainly Lichtenstein repair) is still most frequently
herniasurge.com), forged from the combination of ‘‘her- used. There are specialist hernia surgeons and specialized
nia’’ and ‘‘surge’’ as a metaphor for waves crossing all hospitals that promote non-mesh repair especially in
continents. patients with a low-risk profile for recurrence. Meshes
used in gynecological operations have caused many
Evolution of groin hernia surgery lawsuits and the spin-off is a justified alertness by media
and the public questioning its safety in inguinal hernia
The first groin hernia surgeries were done during the end of repair. There are concerns about influence of insurance
the sixteenth century. They involved hernia sac reduction companies and industry. There are patients that refuse the
and resection and posterior wall reinforcement of the use of mesh.
inguinal canal by approximating its muscular and fascial Laparo-endoscopic surgery use varies from zero to a
components. Subsequently, many hernia repair variants maximum of approximately 55% in some high-resource
were introduced. Prosthetic material utilization com- countries. The average use in high-resource countries is
menced in the 1960s, initially only in elderly patients with largely unknown except for some examples like Australia
9
recurrent inguinal hernias. Favorable long-term results of (55%), Switzerland (40%), 10 the Netherlands (45%) and
these mesh repairs encouraged adoption of mesh repair in Sweden (28%). 8 Sweden has a national registry with
younger patients. Presently, the majority of surgeons in the complete coverage. Interesting are the following percent-
world favor mesh repair of inguinal hernias. In Denmark, ages for the year 2015: Lichtenstein 64%, TEP 25%, TAPP
with its complete IH repair statistics in a national database, 3%, open pre-peritoneal mesh 3.3%, combined open and
7
mesh use is currently close to 100%. In Sweden, mesh use pre-peritoneal 2.7% and tissue repair in 0.8%. The German
8
is above 99%. In the early 1980s, minimally invasive Herniamed registry which contains data on about 200,000
techniques for groin hernia repair were first performed and patients (not complete national coverage, so possibly
reported on in the scientific literature, adding another biased) contains interesting information confirming that a
management modality. Laparoscopic Trans Abdominal wide variety of techniques are in use. The percentages over
Pre-Peritoneal (TAPP) and Totally Extra Peritoneal (TEP) the period 2009–2016 were: TAPP 39%, TEP 25%,
endoscopic techniques, collectively, ‘‘laparo-endoscopic Lichtenstein 24%, Plug 3%, Shouldice 2.6%, Gilbert PHS
surgery’’, have been developed as well. 2.5% and Bassini 0.2%. Other reliable data from Asia and
The fact that so many different repairs are now done America are lacking and often outdated once published.
strongly suggests that a ‘‘best repair method’’ does not Table 1 indicates current hernia repair techniques.
exist. Additionally, large variations in treatments result

Table 1. Current inguinal hernia repair techniques
Non-mesh techniques Shouldice
Bassini (and many variations)
Desarda
Open mesh techniques* Lichtenstein
Trans inguinal pre-peritoneal (TIPP)
Trans rectal pre-peritoneal (TREPP)
Plug and patch
PHS (bilayer)
Variations
Endoscopic techniques Totally extra-peritoneal (TEP)
Trans abdominal pre-peritoneal repair (TAPP)
Single incision laparoscopic repair (SILS)
Robotic repair
*These can be modified; and different types of mesh are in use.

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