Page 86 - International guidelines for groin hernia management

Hernia

Since recurrence rates are difficult to know, reoperation another. 288 These data suggest that virtually all IH
rates are used as a proxy, with the assumption that recur- patients—whether primary or recurrent—will require
rences are up to twice as common as reoperations. 11 In a repair, usually because of pain or discomfort.
2014 long-term Danish observational study, the reoperation A 2014 cohort study of 1032 patients undergoing IH
rate after primary Lichtenstein repair was 2.4 and 3.3% repair in the 16 months after the adoption of watchful
after laparoscopic repair. 281 A 2011 Swedish study found waiting for asymptomatic or minimally symptomatic her-
the cumulative 24-month reoperation rate to be 1.7% for nia compared with 978 in the 16 months before the adop-
11
primary repair and 4.6% for recurrent repair. In Australia, tion of watchful waiting showed a higher incidence of
the recurrence rate following IH repair is estimated at emergency repair (5.5 vs 3.6%, 95% confidence interval:
283
7.9%, and appears unchanged over 2 decades. This is, 1.03–2.47), a higher adverse events rate (18.5 vs 4.7%,
perhaps, disappointing, since, in Australia in 2014, 51% of adjusted OR: 3.68, 95% CI 2.04–6.63), and higher mor-
IH repairs were done laparoscopically, compared with 20% tality (5.4 vs 0.1%, p \ 0.001, Fisher’s exact test). 289
in 2000. 284 Currently, there is no evidence on either watchful
Promisingly though, in highly specialized centers, 1% waiting or elective repair for those with recurrent IHs.
long-term recurrence rates have been achieved. 285 These Discussions about, and plans for repair, should be shared
same investigators have found that the recurrence rate for apace with recurrent IH patients.
laparoscopic recurrent IH repair after failed anterior repair Open repair for recurrent inguinal hernia
approaches that of primary hernia repair. This strongly Details of prior hernia operations are important in planning
supports the notion that hernia surgery specialization may for a recurrent IH repair. Regardless of the procedure
have a positive impact on outcomes, particularly recur- chosen to repair a recurrent hernia, it is highly likely to be
286
rence rates. more difficult than a primary repair.
An anterior approach for recurrence after primary
Key question anterior repair means that scarred tissues with distorted
tissue planes must be entered. In our experience/judge-
KQ20.a Are recurrence rates still too high despite inno- ment, this increases the risk of testicular atrophy and nerve
vations like endoscopic repair, anterior preperitoneal entrapment with consequent postherniorrhaphy chronic
repair, and new mesh prosthetics? groin pain. If an endoscopic repair was previously per-

Key question formed, then an anterior repair where tissue planes are
290
undisturbed is recommended. At least one authority has
KQ20.b Is surgery necessary for all recurrence patients? stated, given that the extra-peritoneal space has already

Evidence in literature been dissected, an open preperitoneal approach including
291
The current guidelines on a watchful waiting approach to the PHS and Kugel should be avoided.
patients with primary IHs remain unchanged from the 2009
EHS guidelines. 12 However, our 2016 update states that Key question
while watchful waiting is relatively safe, there is a high
likelihood of crossover to surgery (23% at 2 years and 72% KQ20.c Which management strategy is the best for
at 7.5 years in one study 287 and 68% at 5 years in recurrence after anterior repair?

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