Page 6 - International guidelines for groin hernia management

Hernia

Future directions Research and Evaluation). They are not a textbook, so
extensive background information is not included. How-
Standardizing groin hernia repairs and improving outcomes ever, they represent the results of an extensive literature
requires that many questions be answered. Best operative search spanning to 1 January 2015 for systematic reviews
techniques should have the following attributes: low inci- and to 1 July 2015 for randomized controlled trials and best
dence of complications (pain and recurrence), relatively evidence. During five 2-day meetings (Amsterdam April
easy to learn, fast recovery, reproducible results, and cost 2014, Edinburgh June 2014, Warsaw October 2014,
effectiveness. Treatment of groin hernia patients will Cologne February 2015 and Milano April/May 2015) and a
improve if we honor all stakeholders’ interests (patients, 4-day meeting in Amsterdam in September 2015, a stan-
hospitals, surgeons and society). dard evidence-based process was rigorously used. Teams
Worldwide, groin hernia surgery outcomes need of two or three HerniaSurge members performed standard
improvement. Recurrence rates—as measured by the proxy search strategies and scored greater than 3500 articles
of reoperations—still range from 10 to 15%; although the according to Oxford, SIGN and Grade methodology. 12, 13
increasing use of mesh has resulted in falling recurrence Level of evidence was first graded up or down by teams
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rates. There are great concerns about the complication of and later in all recommendations by the whole committee.
chronic pain which still occurs in 10–12% of patients. Then, the statements and recommendations were developed
and these were also graded during three consensus meet-
Our process ings. Statements are scored according to the levels very
low, low, moderate or high. The recommendations contain
The HerniaSurge guidelines that follow have been devel- the terms ‘‘recommend’’ when strong and ‘‘suggest’’ when
oped to address all questions concerning groin hernia repair weak. The grading consists of moving up or down in level
in adults, worldwide. They contain recommendations for after discussing the evidence in HerniaSurge meetings
all groin hernia types, in all kinds of patients and in all (Fig. 1). The first consensus was sought within the com-
parts of the world. It has been written by and endorsed by mittee of 50 surgeons. The second consensus was sought
experts from every continent and from all the major hernia via the internet and the final consensus during the EHS
societies—European, Americas, Asia-Pacific, Afro-Mid- Rotterdam meeting of June 2016. The results of the con-
dle-East and Australasian. Fifty expert surgeons from 19 sensus studies (including further consensus meetings dur-
countries crafted these state-of-the-art guidelines. We ing the APHS in October 2016 and AHS in March 2017
consider this work a ‘‘living document’’, open to interpre- meetings) will be published separately. This strategy of
tation, modification and improvement over time with combining evidence and expert opinion by consensus led to
increasing experience and knowledge. some very strong recommendations that not only reflect the
The involved experts have extensive clinical and sci- evidence in literature, but also truly reflect the opinions of
entific experience and a combined scholarly output of 50 international leaders in groin hernia surgery. Expert
hundreds of publications focused on various aspects of opinion in this case is the opinion of the entire committee.
groin hernia management. They are experienced in open For some important recommendations, long and passionate
non-mesh, open mesh and both TEP and TAPP techniques. discussions led to the consensus found in these guidelines.
The HerniaSurge steering committee has done its best to Our discussions transcended countries and cultures and
include and honor all treatment approaches, without prej- withstood pressures from finance and/or industry-moti-
udice and self-interest. Although evidence in the scientific vated opinions. Statements and recommendations some-
literature forms the foundation for the guidelines, we times strongly favor certain treatments but are not
searched to incorporate patients’ wishes and surgeon’s necessarily suited to use in all parts of the world depending
expectations. Factors like financial resources and logistics on local tradition, training capabilities and/or resources.
were taken into account as well. Our aim was to offer The adage applies that any technique, thoroughly taught
unbiased guidance to all surgeons and patients wherever and frequently performed with good results, is valid. Some
they reside. techniques are easily learned and offer good results whilst
others might be very difficult to master but offer great
Guideline formulation results. All these techniques are highly dependent on the
surgeon’s knowledge of anatomy, caseload and dedication
The HerniaSurge guidelines are developed according to the to groin hernia surgery.
AGREE instrument II (Appraisal of Guidelines for

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