Page 92 - International guidelines for groin hernia management

Hernia

registries might further inform surgical decision-making on Key questions
this crucial issue.
KQ21.f In patients with intestinal incarceration without
Key questions signs of intestinal strangulation or concurrent bowel
resection (i.e., a clean surgical field) is mesh-based repair
KQ 21.e What is the optimal surgical approach for an recommended? Which mesh?
acutely incarcerated/strangulated groin hernia?

Evidence in literature Evidence in literature
No randomized studies, systematic reviews, or comparative One low-quality cohort study compared open anterior
cohort studies address the question which approach is best. polypropylene mesh repair with open anterior repair (ana-
Only one low-quality randomized trial compares a mesh- tomic repair, modified Bassini) without mesh. 319 The
based open posterior approach with a mesh-based open majority of patients had intestinal incarceration without
anterior approach and found no differences except for an intestinal strangulation or concurrent bowel resection (i.e.,
increased incidence of second incisions in the anterior a clean surgical field). No inter-group differences were
approach group. A preperitoneal approach was judged to be found in wound infection rates or postoperative compli-
as safe as an anterior Lichtenstein approach in incarcerated/ cations. No mesh-related problems were reported.
strangulated groin hernia repairs. 316 Another low-quality cohort study compared Lichten-
A very low-quality comparative cohort study recom- stein repairs in incarcerated versus elective IH patients and
mends a preperitoneal approach. 317 found no inter-group differences. Most patients had clean
No randomized studies or systematic reviews focus on surgical fields and were ASA class I and II. 320
TAPP or TEP repair techniques in patients with incarcer- One low-quality randomized trial compared Lichten-
ated/strangulated groin hernias. Only one low-quality stein with Bassini repairs in selected clean (no peritonitis,
comparative cohort study showed that TAPP repair is inflammatory hernias, or bowel resections) incarcerated
useful in elective and emergent cases such as those groin hernia patients. In this study, the Lichtenstein repair
involving strangulated hernias in selected patients (those was found to be safe and effective with an acceptable low
with scrotal hernias, previous pelvic or abdominal surgery, rate of postoperative complications and no recurrences. 321
and severe cardiac or pulmonary problems were All studies cited used polypropylene mesh. No data were
excluded). 318 found on absorbable mesh or biologic implants.

Discussion Discussion
The optimal technique for acutely incarcerated/strangu- In spite of low-quality medical evidence, the statement
lated IH repair remains an open issue, unknowable from the above received a strong grade, since benefits outweigh
present literature. Well-conducted RCTs and other studies risks when mesh is used in emergent clean hernia opera-
are needed to provide answers to the KQs posed above. tions. This is similar to the elective surgery experience.
Definitive research is needed on this subject.

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