Page 65 - International guidelines for groin hernia management

Hernia

questionnaire study within the Swedish Hernia Register. 72 Evidence in literature
In a retrospective register study of bilateral hernia opera- Nine reviews and meta-analyses have compared open with
tions, a significantly higher incidence of infertility was endoscopic IH procedures, however, not all report on
found in a subgroup receiving mesh on both sides com- hematoma formation. 76–84
pared to sutured repairs. 73 However, the risk was very low, Several of the studies that did investigate the incidence
and both studies concluded that there is no increased of hematoma formation report it to be lower in hematoma
infertility risk after hernia repairs using mesh. 73 incidence after endoscopic versus open hernia repair but do
A recent publication on surgical treatment of chronic not cite exact differences. 76, 77
inguinodynia with tailored neurectomy, funicular release, A 2003 meta-analysis, which included the mean inci-
and/or mesh removal confirmed beneficial effects on dence of hematoma formation from 33 trials, reported a
dysejaculation with a significant reduction of VAS scores significantly lower incidence after endoscopic versus open
in 20 patients from 55 to 21 (p \ 0.001). Sexual life nor- techniques. 82 This difference was attributed mainly to the
malized in two-thirds of the patients. 74 Vasovagal anasto- TEP procedure which is associated with significantly less
mosis to correct infertility after hernia surgery is most often hematoma formation than are open repairs. No significant
reported after hernia operations performed when the patient difference in hematoma formation incidence was found
was a child. 75 In adult patients with previous polypropy- when TAPP and open repairs were compared. When
lene, mesh repairs and infertility caused by vasal obstruc- Shouldice versus endoscopic and Lichtenstein versus
tion, reconstruction, and eventual fertility restoration are endoscopic repairs were compared, a significantly lower
68
possible in only a minority of patients. incidence of hematoma formation was seen after endo-
Hematoma and perioperative vascular incidents scopic repairs. 80–83
The EHS guidelines on IH treatment in adults report that a Another meta-analysis which included 3410 patients,
significantly lower incidence of hematoma formation compared Shouldice repair to open mesh repairs and to
occurs following endoscopic versus open repairs. 12 The other open non-mesh repairs and reported no significant
occurrence of a hematoma is more clinically obvious at difference in the incidence of hematoma formation
inspection when performing an open than a laparoen- between Shouldice repairs versus either open mesh repair
doscoic repair. The definition of a hematoma that would be or non-mesh repair. 85
clinically relevant in both open and laparoendoscopic sur- A different meta-analysis compared open preperitoneal
gery is lacking, which makes results difficult to compare. A mesh repair with Lichtenstein repair and found no differ-
‘‘moderate’’ preperitoneal bleeding in laparoendoscopic ence in hematoma incidence. 86
repairs might be of the same magnitude as a wound Three other meta-analyses reported no difference in
hematoma that would be easily diagnosed in open repair. hematoma incidence amongst different types of open mesh
No trials include hematoma as a primary outcome. If repairs. 87–89
studies are planned that include hematoma formation, it is One RCT and three cohort studies have examined the
HerniaSurge opinion that only symptomatic hematomas influence of the endoscopic IH repair learning curve on
should be considered a postoperative complication. postoperative complications including hematoma
20, 90–92
formation.
Key questions The RCT compared endoscopically operated patients
with open-repair patients and investigated the effect of
KQ18.m Is hematoma formation related to hernia repair surgical residents’ postgraduate level. Besides a difference
method or mesh use? in the incidence of hernia recurrence, no difference was
KQ18.n Are intraoperative bleeding and postoperative found in overall complication rate. 90
hematoma formation related to a surgeon’s level of A retrospective cohort study investigated the learning
experience? curve influence on morbidity in laparoscopic IH repair
92
(TAPP). No inter-group morbidity differences were noted

123