International guidelines for groin hernia management

Abstract

IntroductionWorldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.MethodsAn expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group’s first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as “strong” (recommendations) or “weak” (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term “should” refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores.Results and summaryThe risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with “watchful waiting” since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment s...

Outcome of the “Manchester Groin Repair” (Laparoscopic Totally Extraperitoneal Approach With Fibrin Sealant Mesh Fixation) in 434 Consecutive Inguinal Hernia Repairs

“…What constitutes a good repair remains a contentious question and in consequence any particular repair can be recommended by a surgeon with a high volume practice depicting evidence of good outcomes (8, 20). Recently published groin hernia guidelines promote a safe and evidence guided practice for hernia surgery (8, 21). In these guidelines, recommendations are made based on mesh type, fixation technique and the method of repair (8, 21).…”

“…Recently published groin hernia guidelines promote a safe and evidence guided practice for hernia surgery (8, 21). In these guidelines, recommendations are made based on mesh type, fixation technique and the method of repair (8, 21). This includes a recommendation for the use of atraumatic fixation methods, such as the use of FS and other “glues”, in reducing the incidence of CPIP (level 1b) (8).…”

“…Avoidance of CPIP is a primary goal for all inguinal hernia repairs and recommendations for achieving this include; (1) all three nerves are preserved and protected (avoidance of inadvertent nerve injury), (2) a minimal access technique is employed where available, (3) use of atraumatic mesh-fixation methods, and (4) use of a “lightweight” and flat mesh prosthesis (6–8). The quoted incidences of clinically significant CPIP is 10–12% with debilitating chronic pain affecting normal daily or work related activities at a very low rate of 0.5–6% (8, 9). …”

“…Laparoscopic or minimal access repair, in addition to a reduction in CPIP, have been shown to have an earlier return to normal activity and less immediate postoperative pain (8) (10&12). These benefits are further facilitated by the ongoing advancements in mesh technology.…”

“…The totally extra-peritoneal (TEP) repair is one minimal access technique that has been shown to provide a reduction in pain (CPIP) when performed with no method of mesh fixation (13–15) and when mesh is fixated with Fibrin Sealant (FS) (8, 16, 17). The use of FS incurs further benefits over a reduction in CPIP and combining the TEP repair with FS fixation, specifically ensuring that fixation in certain anatomical areas and with an increase in mesh size, was tested over a sustained period to try to demonstrate a reduced incidence of CPIP coupled with a low rate for hernia recurrence.…”