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Surgical Management of Inguinal Hernia

Clinician Summary – Jul. 24, 2013

Surgical Management of Inguinal Hernia

Formats

Table of Contents

Research Focus for Clinicians

A systematic review of 151 clinical studies published between January 1990 and November 2011 sought to determine the comparative effectiveness and adverse effects of different surgical options for inguinal hernia in adults and children. There were 123 randomized controlled trials (RCTs), 2 registries, and 26 studies with other designs. This summary, based on the full report of research evidence, is provided to inform discussions of options with patients and to assist in decisionmaking along with consideration of a patient’s values and preferences. However, reviews of evidence should not be construed to represent clinical recommendations or guidelines.

Background

Surgical repair of inguinal hernias is the most commonly performed general surgical procedure in the United States. Such a large volume of procedures suggests that even modest improvements in patient outcomes would substantially improve population health. The primary goals of surgery include preventing strangulation, repairing the hernia, minimizing the chance of recurrence, returning the patient to normal activities quickly, improving quality of life, and minimizing postsurgical discomfort and the adverse effects of surgery. Recurrence occurs in approximately 1 to 5 percent of cases of inguinal hernia.

Surgical procedures for inguinal hernia repair generally fall into three categories: open repair without a mesh implant (i.e., sutured), open repair with a mesh, and laparoscopic repair with a mesh. The near-universal adoption of mesh means that the most relevant questions about hernia repair involve various mesh procedures. However, mesh is not recommended for repair of pediatric inguinal hernia for several reasons including concerns about inflammatory reactions, damage to the vas deferens and/or testes, infertility, and growth-related complications. The findings from the research review presented here may inform clinical decisions by patients and surgeons, treatment recommendations by professional societies, purchasing decisions by hospitals, and coverage decisions by third-party payers.

Conclusions

The typical adult in the studies included in this review was a man in his mid 50s, who is of average weight (median body mass index 25.3 kg/m2; interquartile range 25.0–26.7), and who had an elective repair of a primary unilateral inguinal hernia. About a quarter of the men worked in physically strenuous jobs; for these men, a durable repair is important to prevent a recurrence. The results of the review may inform decisions these men face. It is unclear how these results apply to women. However, it is also unclear how these results apply to men of other age groups.

Results indicate that laparoscopic repair of an inguinal hernia is associated with faster recovery times and less risk of long-term (≥6 months) pain; for recurrent hernia, such repair may also lower the risk of another hernia recurrence. Open hernia repair, however, is familiar to more surgeons. Such repair may be associated with fewer internal injuries and may have lower recurrence rates in the context of a primary inguinal hernia. Limited evidence suggests that choosing to repair a pain-free or minimally symptomatic inguinal hernia with a Lichtenstein or tension-free mesh repair over watchful waiting may improve quality of life; however, this may not be applicable to other types of repair procedures, and the evidence on adverse effects is inconclusive.

Research found most of the meshes or fixation methods to be equivalent in their effectiveness and risk of adverse effects with only a few exceptions. There are numerous reports that the risk of recurrence decreases when a more experienced surgeon performs a repair, but there are not enough congruent studies to perform a meta-analysis.

Clinical Bottom Line

Comparative Effectiveness of Interventions for Primary, Bilateral, or Recurrent Hernias

Pain-Free Primary Hernia
Painful Primary Hernia
Bilateral Hernia
Recurrent Hernia
Pediatric Hernia (Ages 3 Months to 15 Years)

95% CI = 95-percent confidence interval; SF-36 = 36-Item Short Form Health Survey; TAPP = transabdominal preperitoneal;
TEP = totally extraperitoneal

Surgical Bottom Line

Comparative Effectiveness of Open Mesh-Based Repair Procedures
Comparative Effectiveness of Laparoscopic Mesh-Based Repair Procedures

Comparative Effectiveness of Surgical Materials and Fixation Methods

Mesh Material
Fixation Methods

* Descriptions of the combination material mesh analyzed for this outcome can be found in the full report.

Strength of Evidence Scale

High: evidence high High confidence that the evidence reflects the true effect. Further research is very unlikely to change our confidence in the estimate of effect.
Moderate: evidence medium Moderate confidence that the evidence reflects the true effect. Further research may change our confidence in the estimate of effect and may change the estimate.
Low: evidence low Low confidence that the evidence reflects the true effect. Further research is likely to change our confidence in the estimate of effect and is likely to change the estimate.
Insufficient: evidence insufficient Evidence is either unavailable or does not permit a conclusion.


Table 1. Comparative Effectiveness of Open Versus Laparoscopic Mesh-Based Repair of Painful Primary Hernias in Adults (N = 179,338; 38 Studies)
Outcome Surgery Favored Calculated Differences (95% CI) Strength of Evidence
95% CI = 95 percent confidence interval; OR = odds ratio; RR = relative risk
Hernia recurrence Open surgery RR = 1.43 (1.15 to 1.79); a 2.49% recurrence rate after open repair versus a 4.46% recurrence rate after laparoscopy evidence low
Length of hospital stay Approximate equivalence Summary difference in means = 0.33 days (0.14 to 0.52) evidence low
Return to normal daily activities Laparoscopic Summary weighted mean difference in days = 3.9 (2.2 to 5.6) evidence high
Return to work Laparoscopic Summary weighted mean difference in days = 4.6 (3.1 to 6.1) evidence high
Long-term pain Laparoscopic OR = 0.61 (0.48 to 0.78) evidence medium
Hematoma Laparoscopic OR = 0.696 (0.553 to 0.875) evidence low
Wound infection Laparoscopic OR = 0.49 (0.33 to 0.71) evidence medium
Epigastric vessel injury Open OR = 2.1 (1.1 to 3.9) evidence low
Small-bowel injury Inconclusive OR = 0.715 (0.112 to 4.555) evidence insufficient
Small-bowel obstruction Inconclusive OR = 2.159 (0.583 to 8.001) evidence insufficient
Urinary retention Inconclusive OR = 1.247 (0.836 to 1.861) evidence insufficient
Spermatic cord injury Inconclusive
  • In one study, 0 in 67 open repairs and 0 in 122 laparoscopic repairs
  • In a second study, 1% after open repair (8/994) and 0.1% after laparoscopic repair (1/989)
evidence insufficient

Description of Common Interventions Used To Repair Inguinal Hernias*

Laparoscopic Repair Techniques With a Mesh
  • Intraperitoneal onlay mesh technique: A hernia repair procedure wherein a mesh is placed under the hernia defect intra-abdominally to circumvent a groin dissection
  • Totally extraperitoneal (TEP) repair: A laparoscopic repair procedure wherein surgeons do not enter the peritoneal cavity but use a mesh to cover the hernia from outside the peritoneal space
  • Transabdominal preperitoneal (TAPP) repair: A laparoscopic repair procedure wherein surgeons enter the peritoneal cavity, incise the peritoneum, enter the preperitoneal space, and place the mesh over the hernia; the peritoneum is then sutured and tacked closed
Open Repair With a Mesh
  • Kugel® Patch repair: A hernia repair procedure wherein an oval-shaped mesh that is held open by a memory recoil ring is inserted behind the hernia defect and held in place with a single absorbable suture
  • Lichtenstein: A tension-free open hernia repair wherein a surgeon sutures mesh in front of the hernia defect
  • Mesh plug: A procedure wherein a surgeon introduces a preshaped mesh plug into the abdominal weakness during open surgery and places a piece of flat mesh on top of the hernia defect
  • PROLENE™ Hernia System: A one-piece mesh device constructed of an onlay patch connected to a circular underlay patch by a mesh cylinder
  • Stoppa: A procedure wherein a large polyester mesh is interposed in the preperitoneal connective tissue between the peritoneum and the transversalis fascia to prevent visceral sac extension through the myopectineal orifice

* A complete list of included interventions can be found in the full report of the comparative effectiveness review.
The U.S. Food and Drug Administration has recalled the Bard Composix® Kugel® Mesh Patch manufactured before October 2005, 14 lot numbers of XenMatrix™ Surgical Graft, and 15 lot numbers of Bard™ Flat Mesh.

 

Gaps in Knowledge

  • How the surgeon’s experience influences surgical outcomes such as recurrence and pain
  • The comparative effectiveness and adverse effects of laparoscopic repair versus watchful waiting for minimally symptomatic hernias in adults
  • The comparative effectiveness and adverse effects of contralateral exploration/repair versus watchful waiting in the pediatric population
  • More evidence on several outcomes related to the comparisons of mesh products and fixation methods including recurrence rates, perception of a foreign body, long-term pain, and infection rates
  • Clarification in future studies of whether the population includes emergent as well as elective surgeries and whether or not the findings apply equally to both populations

What To Discuss With Your Patients

  • If repair or watchful waiting is the right decision for their pain-free or minimally symptomatic inguinal hernia
  • How to choose between open or laparoscopic surgery if the option is available
  • What to expect from open or laparoscopic repair as far as outcomes and adverse effects, including the risk of long-term chronic pain
  • What to do if the hernia recurs

Resource for Patients

Surgery for an Inguinal Hernia, A Review of the Research for Adults is a free companion to this clinician research summary. It can help patients talk with their health care professionals about the decisions involved with the care and maintenance of an inguinal hernia. It provides information about:

  • Types of operative treatments
  • Current evidence of effectiveness and harms
  • Questions for patients to ask their health care professionals

Source

The information in this summary is based on Surgical Options for Inguinal Hernia: Comparative Effectiveness Review, Comparative Effectiveness Review No. 70, prepared by the ECRI Institute Evidence-based Practice Center under Contract No. HHSA 290-2007-10063 for the Agency for Healthcare Research and Quality, August 2012. This summary was prepared by the John M. Eisenberg Center for Clinical Decisions and Communications Science at Baylor College of Medicine, Houston, TX. It was written by Andrea D. Humphries, Ph.D., Mike K. Liang, M.D., and Michael Fordis, M.D.

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