Page 64 - International guidelines for groin hernia management

Hernia

Evidence in literature and discussion normal appearance. 57 In a meta-analysis of randomized
There is no generally accepted definition of sexual dys- studies of lightweight mesh vs heavyweight mesh, the
function after hernia operations. Publications can roughly incidence of testicular atrophy was reported as 0.8% irre-
be divided into those reporting on pain having a negative spective of repair method. 60
59
effect on sexual function such as neuropathic pain in the Testicular function is related to testicular perfusion.
groin, pubalgia, and orchialgia (discussed in Chapter 19 on Animal studies have shown considerable structural changes
pain, briefly mentioned in this text), those focusing on in the cord and testicle after hernia repair, more pro-
negative effects of hernia operations on fertility and tes- nounced after the use of mesh. 59, 61, 62 In clinical studies,
ticular gonadal function and those evaluating complica- mesh repairs have negative effects on testicular perfusion
tions having an influence on both symptoms and function, and testicular volume, and reduce testosterone levels and
i.e., dysejaculation and ischemic orchitis. sperm motility during the early postoperative period. 59, 63
Groin or genital pain interfering with sexual activity was However, long-term follow-up has not shown statistically
assessed in two follow-up questionnaire studies from the significant differences in testicular perfusion or spermato-
Danish Hernia Database. In the first, consisting mainly of genesis compared to preoperative values. 64, 65 Further
open repairs, 28% admitted to some pain, while the second studies are in progress. 66
study of exclusively laparoscopic repairs reported 11% Apart from above-mentioned complications, infertility
some pain 53, 54 with 2.8% of the mainly open and 2.4% of may be caused by operative injury to the vas deferens by
the laparoscopic group reporting that pain moderately to division, ligation, clipping, stapling, electrocauterization,
severely impaired their sexual activity. The incidence of and scarification. Damage to the vas is estimated to occur
55 67
dysejaculation felt to be caused by spermatic duct trauma in 0.3% of adults and 0.8–2.0% of children. The
and/or a mesh-related inflammatory reaction along the duct inflammatory response to mesh can be so severe that vas
typically causing pain at the superficial inguinal ring) was obstruction results. 68 One of the major arguments for the
7.6 and 3.1%, respectively. 56 routine use of mesh in IH surgery, however, is to preserve
Ischemic orchitis is caused by damage to the arterial fertility. The theory is that by decreasing the generally
and/or venous structures in the spermatic cord. An early accepted recurrence rate in the general population from 10
clinical review suggested that the condition was related to to 15% seen with Bassini and its variants to less than 5%
venous thrombosis caused by the operative trauma. 57 In a with the mesh tension-free approach, reoperative surgery,
subsequent study, when distal indirect sacs were left in situ with its heavy toll of testicular loss, is avoided. 69 The
and recurrent hernias were operated upon with preperi- development of sperm antibodies as a result of extravasa-
toneal technique, the risk of ischemic orchitis was reduced tion of sperm from an injured duct is of particular concern,
58
from 0.65 to 0.03% and from 2.25 to 0.97%, respectively. because the argument is challenged that the patient is
In most cases, the acute condition subsides postoperatively, protected by the opposite testicle when a unilateral inguinal
59 70, 71
but may result in testicular atrophy. In atrophic testicles herniorrhaphy is done.
after ischemic orchitis, seminiferous tubes are usually There was no increased risk of male infertility after
absent. Leydig cells producing testosterone and supporting bilateral hernia surgery with or without mesh when com-
Sertoli cells are, however, usually still present and have a pared to the general population in a prospective

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