Page 66 - International guidelines for groin hernia management

Hernia

between those operated upon by young trainees under Evidence in literature
supervision and those operated upon by experienced sur- Eight studies have examined anticoagulated hernia repair
geons. 92 However, it is possible that some hematomas were patients, five RCTs and three retrospective cohort stud-
missed owing to the study’s retrospective design. ies. 93–100 Two of the RCTs were excluded from our anal-
A prospective cohort study also investigated the impact ysis, because their results did not directly answer the KQs
of surgeons’ experience in TEP endoscopic hernia repair posed above. 95, 96 One retrospective cohort study has
patients. Significantly more complications were noted in investigated the influence of platelet aggregation inhibitors
surgeons’ first 100 cases compared with those of more on the incidence of hematoma formation. 101
experienced surgeons. 91 A 1981 study randomized otherwise healthy male adults
This finding is mirrored by another prospective cohort undergoing open hernia repair to either prophylactic hep-
study that reported a significant decrease in postoperative arin (5000 U 1 h before surgery and every 12 h thereafter
complication rates with enhanced learning curve experi- for 4 days) or placebo. 94 One hematoma occurred in the 30
ence with the TEP procedure 20 (see also chapter 22). study patients. There were no thromboembolic complica-
However, a direct comparison of hematoma formation tions. The study authors concluded that there were no
incidence was not made. significant inter-group differences.
A 1986 study randomized unilateral hernia patients to
Discussion either prophylactic heparin (5000 U heparin 1 h before
surgery and every 12 h for 4 days) or placebo. 93 All
The clinical relevance of hematoma formation following patients were discharged on postoperative day 5 and a
IH repair is unclear, since there is no hematoma severity variety of hernia repair techniques were employed. Sig-
classification and hematoma-related interventions are usu- nificantly more hematomas were seen in the heparin group.
ally not reported. Two cohort studies do report significant Another study involving the Bassini–Lotheisen repair
decreases in overall complications associated with progress randomized to heparin at 5000 U 2 h preoperatively and
along the TEP repair learning curve. However, this infor- every 8 h for 5 days and placebo. 96 Significantly more
mation is too indirect to allow conclusions about hematoma hematomas occurred in the heparin group. No throm-
formation and surgeons’ level of experience. In addition, boembolic complications occurred. The study authors
other outcome measures must be weighed when consider- concluded that heparin should be administered only to
ing which repair type to undertake. those with an increased thromboembolic risk. Notably, the
Anticoagulants heparin dose used was higher than that used in other
Anticoagulants and platelet aggregation inhibitors lower comparable studies.
the incidence of thromboembolic events perioperatively A 2000 retrospective study reviewed 465 patients
and postoperatively, and may also affect the incidence of undergoing Shouldice repair. Healthy patients did not
hematoma formation after open or endoscopic IH repair. receive anticoagulation. Prophylactic heparin was given to
those with risk factors for thromboembolism or for a longer
Key question operation. A higher incidence of hematoma formation and
100
surgical reintervention was seen in the heparin group.
KQ18.o Which patients undergoing anticoagulant or anti- A case-matched retrospective cohort study from 2008
platelet therapy are at risk of significant hematoma for- examined patients who developed hematomas after open
mation following hernia repair? IH repair and reported warfarin use as the only significant
predictor of postoperative bleeding. 98

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