Contralateral metachronous inguinal hernias in adults: role for prophylaxis during the TEP repair

Laparoscopic iliopubic tract repair for asymptomatic contralateral occult inguinal hernia

PURPOSE

Metachronous contralateral inguinal hernia (MCIH) may occur after unilateral inguinal hernia (IH) repair, potentially as a result of occult IH (OIH). Contralateral OIH can be checked for during laparoscopic transabdominal hernioplasty for the treatment of unilateral IH. This study aims to assess the efficacy of laparoscopic iliopubic tract repair (IPTR) in treating contralateral OIH to reduce MCIH.

METHODS

The medical charts of 3165 patients aged > 18 years who underwent laparoscopic transabdominal hernioplasty for unilateral IH from January 2013 to December 2021 were retrospectively reviewed. The patients were categorized into two groups based on contralateral OIH presence: negative OIH (nOIH, 2657 patients) and OIH (508 patients). In cases of OIH, IPTR was performed, involving suturing of the iliopubic tract and transversalis fascia arch.

RESULTS

MCIH was indirect in 26 and direct in 4 patients in the nOIH group, and was direct in 3 patients in the OIH group. The incidence of indirect MCIH was higher in the nOIH group than in the OIH (1.0% [n = 26/2657] vs. 0.0% [n = 0/508], p = 0.048). There was no difference in postoperative complication rates, pain scores, return to daily life, or duration of hospitalization between the nOIH and OIH groups.

CONCLUSION

Laparoscopic IPTR for OIH treatment is an effective method for reducing the risk of indirect MCIH.

Incidence and risk factors of metachronous contralateral inguinal hernia development up to 25 years after unilateral inguinal hernia repair: a single-centre retrospective cohort study

BACKGROUND

Patients undergoing unilateral inguinal hernia repair (IHR) are at risk of metachronous contralateral inguinal hernia (MCIH) development. We evaluated incidence and risk factors of MCIH development up to 25 years after unilateral IHR to determine possible indications for concomitant prophylactic surgery of the contralateral groin at the time of primary surgery.

METHODS

Patients between 18 and 70 years of age undergoing elective unilateral IHR in the University Hospital of Leuven from 1995 to 1999 were studied retrospectively using the electronic health records and prospectively via phone calls. Study aims were MCIH incidence and risk factor determination. Kaplan-Meier curves were constructed and univariable and multivariable Cox regressions were performed.

RESULTS

758 patients were included (91% male, median age 53 years). Median follow-up time was 21.75 years. The incidence of operated MCIH after 5 years was 5.6%, after 15 years 16.1%, and after 25 years 24.7%. The incidence of both operated and non-operated MCIH after 5 years was 5.9%, after 15 years 16.7%, and after 25 years 29.0%. MCIH risk increased with older age and decreased in primary right-sided IHR and higher BMI at primary surgery.

CONCLUSION

The overall incidence of MCIH after 25-year follow-up is 29.0%. Potential risk factors for the development of a MCIH are primary left-sided inguinal hernia repair, lower BMI, and older age. When considering prophylactic repair, we suggest a patient-specific approach taking into account these risk factors, the surgical approach and the risk factors for chronic postoperative inguinal pain.

Comparison of bilateral to unilateral total extra-peritoneal (TEP) inguinal hernia repair: a systematic review and meta-analysis

PURPOSE

Laparoscopic herniorrhaphy (LH) has become the treatment of choice in many centers for patients with inguinal hernia (IH). Our aim was to compare the morbidity outcomes of bilateral vs unilateral IH repair using the laparoscopic total extra-peritoneal (TEP) technique, to determine whether undertaking bilateral IH repair places patients at additional risk.

METHODS

Manuscripts published up to the end of 2021 on PubMed/MEDLINE, EMBASE, Cochrane Library, Scopus, and Web of Science were searched. Patients (> 16 years) undergoing a primary elective unilateral or bilateral TEP operation, using the standard 3-port laparoscopic technique, were identified. Quality of evidence was assessed using the GRADE criteria. Meta-analysis was conducted where possible. Where this was not possible, vote counting was conducted using effect direction plots.

RESULTS

Eight observational studies, with a total of 18,153 patients were included. Operative time was significantly longer for bilateral operations. There was no significant difference in conversion to open, post-operative seroma, urinary retention, haematoma, and length of hospital stay. There was an increased rate of hernia recurrence in patients undergoing bilateral IH repair.

CONCLUSION

Although limited by the observational nature of the included studies, there is no conclusive evidence to suggest a differential burden of morbidity between unilateral and bilateral TEP IH repair. As all included papers are from observational studies only, evidence from all outcomes is at best very low quality. This manuscript thereby highlights a need for randomized controlled trials to be conducted in this area.

Should asymptomatic contralateral inguinal hernia be laparoscopically repaired in the adult population as benefits greatly outweigh risks? A systematic review and meta-analysis

PURPOSE

When laparoscopically repairing a symptomatic inguinal hernia, surgeons will discover a contralateral asymptomatic hernia in 22% of patients. It is estimated 30% of asymptomatic hernias become symptomatic and require repair. Thus, should they be repaired in a 2-for-1 operation? The main purpose is to examine the evidence and make a recommendation for the need to repair the contralateral asymptomatic inguinal hernia prophylactically in the adult population during unilateral inguinal hernia presentation.

METHOD

A systematic literature search was conducted up to 15 February 2021 using PubMed and the Cochrane Library. Management pathway taken, mean operating time, duration of follow-up, pain, duration of hospital stay and perioperative complications were extracted. Risk of bias was assessed using the ROBINS-I tool.

RESULTS

Six non-randomised studies (1774 patients) were included; 978 patients had both hernias repaired, 796 patients had only the symptomatic hernia repaired. There was no significant difference in length of hospital stay, return to activities of daily living nor complications. Mean operating time was slightly lower for patients who had unilateral hernia repair (mean difference = - 14.57 min, 95%CI - 25.59, - 3.45). Reported pain scores were lower for patients who only had one hernia repaired (- 0.33 units, 95%CI - 0.48, - 0.18). The overall risk of bias for the six studies were low-to-moderate risk.

CONCLUSION

Asymptomatic inguinal hernias can be repaired when found. While there is minimal increase in operation time and pain, no significant difference to total hospital stay. Importantly, this is likely to prevent the need for another operation in almost a third of patients.

Laparoscopic Totally Extraperitoneal (TEP) Groin Hernia Repair in Patients After Contralateral TEP Groin Hernia Repair

BACKGROUND

The totally extraperitoneal (TEP) repair for groin hernia is considered difficult in patients with a healed surgical scar in the lower abdomen. We reported the feasibility of repair in those patients and found that the most frequent previous procedure in patients for whom the procedure was changed intraoperatively was a contralateral TEP after TEP repair. We now report an expanded patient cohort with a suggested unified treatment strategy.

MATERIALS AND METHODS

From 2006 to 2020, 443 patients underwent laparoscopic TEP groin hernia repair. A contralateral TEP after TEP repair was performed in 35 patients. The conversion rate after TEP was compared with that after other operations. Patients were divided into completed contralateral TEP after TEP repair (N=28) and changed procedure groups (N=7). Clinical characteristics were compared including age, body mass index, location and type of hernia, and interval after previous surgery. Multivariate analysis was performed to evaluate risk factors for conversion of the TEP procedure.

RESULTS

Patients undergoing contralateral TEP after TEP repair were significantly overrepresented among patients for whom the procedure was changed compared with other previous operations (P<0.01), with an odds ratio of 19.91. Comparing completed TEP after TEP repair and changed procedure groups, there were no significant differences regarding age (mean: 67 vs. 69 y old), body mass index (22.4 vs. 22.5 kg/m2), type of hernia (indirect or direct), or duration after previous TEP repair (median: 642 vs. 470 d) and identified no significant risk factors.

CONCLUSIONS

The contralateral TEP after TEP repair for groin hernia is feasible. However, dense adhesions may be present if balloon dissection was performed at the previous TEP repair, and it is necessary to carefully dissect being ready to convert to other procedures such as TAPP repair or an anterior approach.

The Value of Preoperative Ultrasound in the Detection of Contralateral Occult Inguinal Hernia in the Treatment of Symptomatic Inguinal Hernia

BACKGROUND

The true incidence of contralateral occult inguinal hernia (OIH) is a debate. The repair of contralateral OIH in the treatment context of clinical symptomatic unilateral inguinal hernia (IH) is controversial. This study aimed to assess the effect and clinical benefit of preoperative ultrasound (US) in the diagnosis of contralateral OIH performed before surgery.

METHODS

The retrospective data of 155 consecutive male patients who underwent IH repair between January 2014 and January 2020 were analyzed. The surgical procedures for IH and the clinical outcomes of the US were evaluated.

RESULTS

Of 155 patients, 29 (18.7%) presented with bilateral IH. Preoperative US was performed in 73 cases of clinical unilateral IH (n=126), and 30 (23.8%) patients were found to have a contralateral OIH. The totally extrapreperitoneal (TEP) or Lichtenstein repair was conducted. Bilateral IH repair was proposed for all, but only 28 agreed and underwent bilateral repair. Patients with clinically bilateral hernia had more complications compared with patients diagnosed to have occult contralateral IH after the US (n=3 vs. n=0). In the overall group, the TEP procedure resulted in shorter hospital stay (P=0.001) and less pain (P=0.021).

CONCLUSIONS

The preoperative US may be recommended to assess the presence of a contralateral OIH as it is a noninvasive, radiation-free, widely available, relatively cheap diagnostic method. The preoperative US may change the surgical approach in up to 1/4 patients with a clinical unilateral IH. Either Lichtenstein repair or TEP repair can be performed with an acceptable complication rate in the case of OIH.

The incidence and analysis of ipsilateral occult hernia in patients undergoing hernia repair: a single institution retrospective study of 1066 patients

BACKGROUND

Misdiagnosis or failure to intraoperatively detect occult hernia in the inguinal region can lead to the recurrence of postoperative hernia and the appearance of local pain symptoms, which affect the patient's quality of life and make it difficult to reperform hernia repair.

METHODS

This study included 1066 inguinal hernia patients who underwent surgical treatment at Shanghai Tongren Hospital between January 2016 and October 2018 to investigate ipsilateral occult hernia epidemiology, to analyze the characteristics of ipsilateral occult hernias with regards to patient age, gender, classification and anatomical site, and to explore the superiority and inferiority of the expert hernia surgeons/ non-expert hernia surgeons group and of operation methods in finding occult inguinal hernias.

RESULTS

The incidence of ipsilateral occult hernia in the surgical population was 8.26%. Ipsilateral occult hernia included indirect inguinal hernia, direct inguinal hernia, femoral hernia, obturator hernia, and spigelian hernia, among which the highest incidence was direct inguinal hernia (4.11%), followed by indirect inguinal hernia (2.45%). There was no difference in the incidence of ipsilateral occult hernia between males and females, but there were significant differences in the incidence of ipsilateral occult hernia, which decreased gradually with increasing age in patients younger than 70 years-old; there was no difference in incidence in patients over 70 years-old. There were significant differences in the incidence of ipsilateral occult hernia in the bilateral inguinal region between direct and femoral hernia, with the higher incidence found on the right side; in contrast, there was no difference in the incidence of indirect inguinal hernia in the bilateral inguinal region. There was no difference in the ability of experienced physicians to detect ipsilateral occult inguinal hernias, either professionally or by surgery.

CONCLUSIONS

Ipsilateral occult inguinal hernia has a higher incidence in patients with inguinal hernia, especially older patients; therefore, it is necessary for experienced surgeons to carefully detect for possible occult hernia during the operation and in elderly patients.

Comparison of Single-Port Laparoscopic Totally Extraperitoneal Hernioplasty Versus Conventional Laparoscopic Totally Extraperitoneal Hernioplasty : A Single-Center Study

BACKGROUND

To evaluate the safety and outcomes of single-port laparoscopic totally extraperitoneal (SPLTEP) and conventional laparoscopic totally extraperitoneal (CLTEP) hernioplasty.

METHODS

Retrospectively, we collected patients who underwent a laparoscopic totally extraperitoneal approach. The inclusion criteria were as follows: (1) male patients aged >20 years, (2) untreated hernia, and (3) American Society of Anesthesiologists (ASA) score ≤3. The exclusion criteria included: (1) additional procedures received during surgery, (2) inguinoscrotal hernia, (3) ASA score >3, (4) previous lower abdominal surgery, (5) bleeding disorders, and (6) incarcerated, obstructed, strangulated, or recurrent inguinal hernias. Patients were classified into SPLTEP and CLTEP groups. The demographics, body mass index (BMI), ASA score, comorbidities, blood loss, operation time, postoperative length of stay (LOS)/complications, hernia recurrence, visual analog scale (VAS), and postoperative analgesic requirements were collected for analysis.

RESULTS

A total of 246 patients were enrolled. There were 103 patients in the SPLTEP group and 143 patients in the CLTEP group. The mean age was 56.1 ± 16.2 years versus 57.9 ± 15.1 years. There were no significances in demographics, BMI, ASA score, comorbidities, blood loss, operation time, postoperative LOS/complications, and hernia recurrence. The SPLTEP group had a shorter postoperative LOS, lower VAS at 18 hours postoperation, and a reduced amount of 24-hour postoperative analgesics.

CONCLUSION

SPLTEP hernioplasty is as safe as the CLTEP procedure. In addition, the SPLTEP group had a shorter LOS and a lower VAS score and required less postoperative analgesics. Further studies may focus on long-term complications, hernia recurrence, and chronic pain in these 2 groups.

Modified port positions for totally extraperitoneal (TEP) repair for groin hernias: our experience

BACKGROUND

Totally extraperitoneal repair (TEP) is the preferred method of inguinal hernia repair for many surgeons worldwide. However, because of limited working space, there may be difficulties when operating on large and irreducible groin hernias and short stature patients. There are many ways in which the port positions can be modified during TEP for different kinds of hernias and according to the comfort of the surgeons.

METHODS

This is a retrospective analysis of prospectively collected data. We describe two different variations in port placement for TEP in patients with large irreducible hernias and short stature patients.

RESULTS

A total of 19 procedures were performed with these port positions. Most of these were large irreducible hernias or patients with short stature. With these modified port positions, difficult hernias could be completed with extraperitoneal approach. We had no recurrence and 5 seromas that eventually settled in 1-3 months.

CONCLUSION

Modified port positions in TEP by shifting the ports farther away can be useful for hernias where the surgery is difficult due to limited working space and is a good alternative to TAPP.

Management of Occult Contralateral Inguinal Hernia: Diagnosis and Treatment With Laparoscopic Totally Extra Peritoneal Repair

BACKGROUND

Up to 33% risk of occult contralateral inguinal hernia has been reported. This study aims to evaluate diagnostic and treatment modalities in the case of occult contralateral hernia and the role of ultrasonography (USG).

MATERIALS AND METHODS

Patients who had undergone inguinal hernia repair between 2009 and 2018 were studied retrospectively. The detection rate of occult inguinal hernia by USG and results of laparoscopic totally extra peritoneal repair (TEP) were evaluated.

RESULTS

Of 295 patients, USG was performed to the contralateral site in 80 with clinically unilateral hernia and occult hernia was detected in 44 (55%). Bilateral TEP was performed for these patients. There was no recurrence and no significant complication.

CONCLUSIONS

As it is noninvasive, easily accessible and has high sensitivity, USG is recommended in diagnosis. In the case of occult contralateral inguinal hernia, bilateral TEP is considered as a safe procedure. Thus, the need for a second operation and related complications can be prevented. We recommend routine USG to detect whether contralateral occult inguinal hernia is present.

Comparing the Incidences of Occult Contralateral Hernia under Laparo-Endoscopic Techniques and of Contralateral Metachronous Hernia after a Unilateral Groin Hernia Repair in Open Technique

The aim of this study was to evaluate the utility of immediate repair of a contralateral occult hernia at the same time as incipient hernia repair. A total of 693 patients were diagnosed preoperatively with a unilateral groin hernia from January 2006 to December 2017. The open technique was used for 541 patients, and the laparo-endoscopic technique was used for 152 patients. The incidences of occult contralateral hernia confirmed during surgery under laparo-endoscopic techniques and those of contralateral metachronous hernia after a unilateral groin hernia repair with open technique were compared. Fifty-one (9.4%) of 541 patients underwent a contralateral metachronous hernia repair after unilateral groin hernia repair. Twenty-three (15.1%) of 152 patients had occult contralateral hernias using laparo-endoscopic techniques. There was a significant difference in the incidence of contralateral metachronous hernia and that of occult contralateral hernia (P = 0.02). It is concluded that finding and repairing an occult contralateral hernia at the time of laparoendoscopic technique has the advantage of avoiding a second operation. However, it has been considered overtreatment to repair all patients with an occult contralateral hernia.

What happens after no contralateral exploration in total extraperitoneal (TEP) herniorrhaphy of clinical unilateral inguinal hernias?

BACKGROUND

While performing unilateral TEP herniorrhaphy, controversy still exists about whether to do contralateral exploration or not. Routine contralateral exploration has been proposed to prevent metachronous contralateral hernias by the repair of incidental contralateral occult hernias. Some surgeons have even proposed to do prophylactic bilateral TEP herniorrhaphy for unilateral hernia patients. To evaluate the appropriateness of not doing contralateral exploration in unilateral TEP herniorrhaphy, we reviewed our experiences under our practice of no contralateral exploration and we also reviewed other published literature.

METHODS

A total of 305 patients who underwent 313 TEP herniorrhaphies for inguinal hernias by a single surgeon during August 2012-July 2016 at Chia-Yi Christian Hospital were enrolled in this retrospective study. Demographic, perioperative and follow-up data were obtained for analysis and review.

RESULTS

Of the 305 patients, 261 patients had unilateral TEP herniorrhaphy and 44 patients had bilateral TEP herniorrhaphy. The mean operation time for the unilateral TEP herniorrhaphy group was 59.8 min, and for the bilateral TEP herniorrhaphy group it was 85.2 min (p < 0.001). Seven of 261 (2.7%) patients had metachronous contralateral hernia after unilateral TEP herniorrhaphy. There were no statistically significant differences in any of the outcome variables when comparing the sequential and simultaneous primary bilateral TEP herniorrhaphies.

CONCLUSIONS

Without routine contralateral exploration, the incidence of metachronous contralateral hernia was 2.7% (7/261) in unilateral hernia patients. This is acceptable as metachronous hernia also occurred in 3.2% of patients with negative contralateral exploration according to our literature review. Sequential and simultaneous bilateral primary TEP herniorrhaphy outcomes were similar. We conclude that no exploration for the other groin is a justified decision for unilateral inguinal hernia patients.

International guidelines for groin hernia management

INTRODUCTION

Worldwide, 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.

METHODS

An 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. The 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 should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Risk factors for contralateral inguinal hernia repair after unilateral inguinal hernia repair in male adult patients: analysis from a nationwide population based cohort study

Background

To identify the rate of and risk factors for contralateral inguinal hernia (CIH) after unilateral inguinal hernia repair in adult male patients.

Methods

This retrospective cohort study identified from the Taiwan National Health Insurance Research Database (NHIRD). Information on all adult patients who underwent primary unilateral inguinal hernia repair without any other operation was collected using ICD-9 diagnostic and procedure codes. The exclusion criteria were laparoscopic hernia repair, non-primary repair, complicated hernia, other combined procedures, female and undetermined gender.

Results

A total of 170,492 adult male patients were included, with a median follow-up of 87 months. The overall CIH rate was 10.5%, with a median time of 48 months to a subsequent hernia operation. The 1-year, 2-year, 3-year and 5-year-recurrent rate was 2.6, 3, 4.3, and 6.7% respectively. Further, 3.7% patients who underwent CIH repair had a complicated inguinal hernia. Multivariate analysis demonstrated that age > 45 y, direct hernia, cirrhosis (HR = 1.564), severe liver disease (HR = 1.663), prostate disease (HR = 1.178), congestive heart failure (HR = 1.138), and history of malignancy (HR = 1.116) had a significantly higher risk of CIH repair.

Conclusions

Among adult male patients undergoing long-term follow-up, we identified several significant risk factors for CIH repair. If these risk factors are presented, the surgeon should inform the following risk of CIH repair to patients so that it can be repaired as soon as possible.

Bilateral totally extraperitoneal (TEP) repair of the ultrasound-diagnosed asymptomatic contralateral inguinal hernia

BACKGROUND

The aim of this series is to determine the clinical utility of routine ultrasound (US) of the contralateral, clinically normal groin when a unilateral inguinal hernia is referred for hernia repair-specifically assessing the morbidity and short-term change in quality-of-life (QoL) due to repair of this occult contralateral hernia when also repairing the symptomatic side. TEP inguinal hernia repair affords the opportunity to repair any groin hernia through the same small incisions. US detects 96.6% of groin hernias with 84.4% specificity.

METHODS

234 consecutive male patients with clinically unilateral and clinically bilateral hernia were enrolled; those with a clinically unilateral hernia were sent for groin US and if positive, a bilateral TEP groin hernia repair was performed (USBH). If negative, a unilateral TEP groin hernia repair was performed (UNIH). Carolina's comfort scales (CCS) and visual analogue scores (VAS) were recorded at 2 and 6 weeks postoperatively, while a modified CCS (MCCS) was recorded for all patients preoperatively.

RESULTS

Bilateral TEP repair resulted in higher VAS scores than unilateral repair at 2 weeks but not 6 weeks. CCS were worse in the USBH group than UNIH group at 2 weeks but were similar by 6 weeks. Complications' rates were similar amongst all 3 groups. Factors contributing to worse scores were: smaller hernia, complications, worse preoperative MCCS results, recurrent hernia and bilateral rather than unilateral repair.

CONCLUSION

Bilateral TEP for the clinically unilateral groin hernia with an occult contralateral groin hernia can be performed without increased morbidity, accepting a minor and very temporary impairment of QoL.

Is contralateral exploration justified in endoscopic total extraperitoneal repair of clinical unilateral groin hernias - A Prospective cohort study

BACKGROUND

Laparoscopic adult hernia repair has the clinical advantage of allowing the surgeon to explore asymptomatic contralateral inguinal hernia. We conduct a retrospective study to compare the occurrence of contralateral metachronous inguinal hernia (CMIH) after laparoscopic total extraperitoneal (TEP) repair with or without contralateral exploration.

METHODS

One hundred and fifty-one consecutive patients undergoing unilateral laparoscopic TEP repair during November 2007 to November 2012 were enrolled into groups with contralateral or no contralateral exploration. Preoperative, intraoperative, and postoperative factors were recorded then reviewed for analysis. The primary end-point was the occurrence of contralateral inguinal hernia. The patients were regularly interviewed postoperatively at outpatient clinics.

RESULTS

Finally, 68 patients in the exploration group and 46 in the non-exploration group were eligible for analysis. All demographic data, except age, was comparable between the two groups. Twenty-three of 68 (33.8%) in the exploration cohort had at least one occult contralateral inguinal hernia detected and repaired at the time of primary repair. In contrast to the high incidence (6/46, 13%) of CMIH in the non-exploration cohort, there was only one metachronous occurrence (1/68, 1.4%) after negative contralateral exploration at a median follow-up of longer than 3 yrs (p = 0.02). The peri-operative results were comparable between groups regarding operative time, analgesic requirements, complications, and chronic pain.

CONCLUSIONS

Simultaneous exploration and repair of the incidental defects on the contralateral inguinal region during laparoscopic TEP repair of unilateral inguinal hernia is recommended in selected patients based on its high safety and clinical effectiveness in preventing later CMIH.

Long-term incidence of contralateral primary hernia repair following unilateral inguinal hernia repair in a cohort of 32,834 patients

BACKGROUND

Asymptomatic contralateral inguinal hernias are often present during initial inguinal hernia repair. Data on long-term results and progression to symptomaticity are sparse. The purpose of this study was to assess long-term rates and risk factors for contralateral inguinal hernia repair following unilateral inguinal hernia repair.

METHODS

Using New York Statewide Planning and Research Collaborative administrative data, 32,384 adults who underwent initial inguinal hernia repair during 2002-2003 in New York State and achieved 10-year follow-up were identified. ICD-9 and CPT codes were used to identify patients. Patients were followed for 10 years subsequent to their operation to assess for contralateral repair. Those who did not achieve 10-year follow-up were excluded. Risk factors were compared using descriptive univariate statistics. Significant variables were then analyzed via multivariate regression models.

RESULTS

For adult patients having primary unilateral hernia repair, 3364 patients (6.73 %) had contralateral repair during the follow-up period. After excluding "loss of follow-up" patients, the contralateral repair rate was 10.8 %. Contralateral hernia repairs first occurred at a mean of 3.9 ± 3.5 years and a median of 2.5 years after the initial surgery. Risk factors included age >45 years (OR 1.7 [1.4-2.0], p < 0.001), male gender (OR 2.2 [1.9-2.6], p < 0.0001), and white race (OR 1.6 [1.1-2.4], p < 0.001). Factors associated with decreased likelihood for repair included: congestive heart failure (OR 0.6 [0.4-0.9], p = 0.01), diabetes (OR 0.7 [0.5-0.8], p = 0.02), neurological disorders (OR 0.6 [0.4-0.9], p = 0.02), obesity (OR 0.3 [0.1-0.8], p = 0.01), and alcohol abuse (OR 0.2 [0.03-0.8], p = 0.03).

CONCLUSION

The 10-year probability of necessitating a contralateral inguinal hernia repair is significant. Elderly white males were more likely to undergo repair. Those less likely to undergo repair had significant comorbid conditions, possibly due to their poor suitability for intervention. These data highlight a key benefit of the laparoscopic approach over open repairs. Based on these data, an argument for laparoscopy with routine contralateral inspection in higher-risk patients can be made.

Bilateral and Unilateral Total Extraperitoneal Inguinal Hernia Repair (TEP) have Equivalent Early Outcomes: Analysis of 9395 Cases

INTRODUCTION

To date, no randomized controlled trials have been carried out to compare the perioperative outcome of unilateral and bilateral inguinal hernia repair using an endoscopic technique. In a Swiss registry study comparing unilateral with bilateral inguinal hernias, no further details were given regarding the nature of the intra- and postoperative complications. In addition, some authors have raised the issue of prophylactic repair of a clinically healthy other groin side.

PATIENTS AND METHODS

In the Herniamed Registry, in total 9395 patients with a TEP were enrolled. These comprised 6700 patients with unilateral (71.31%) and 2695 patients (28.69%) with bilateral inguinal hernia repair. The outcome variables, analyzed in a multivariable model, were the intra- and postoperative as well as general complication rates, reoperation rate, duration of operation, and length of hospital stay.

RESULTS

While no significant difference was found in the overall number of intraoperative complications between the unilateral and bilateral group (p=0.310), a significantly higher number of urinary bladder injuries in the bilateral TEP operation of 0.28% compared with 0.04% for unilateral TEP (p=0,008) were noted. The greater probability of reoperation (0.82% for unilateral vs. 1.78% for bilateral TEP; p<0,001) in the unadjusted analysis was confirmed in the multivariable model [OR 2.35 (1.504; 3.322); p=0.001]. A significantly higher intraoperative urinary bladder injury rate and reoperation rate because of postoperative surgical complications constitute a difference in the perioperative outcome between unilateral and bilateral TEP which that warrants attention. Based on these results, prophylactic operation of the healthy other groin should not be recommended.

Perioperative outcome of unilateral versus bilateral inguinal hernia repairs in TAPP technique: analysis of 15,176 cases from the Herniamed Registry

Introduction

Following repair of a unilateral inguinal hernia, there is a risk of 1 % per year of onset of an inguinal hernia on the other side. Comparison of bilateral with unilateral TAPP operation in a high-volume center found that morbidity and reoperation rates were only marginally higher for bilateral TAPP operation. Some authors are calling for prophylactic operation of the contralateral side.

Methods

Between September 2009 and April 2013, data were entered into the Herniamed Registry on 15,176 patients who had undergone TAPP operation. Of these patients, 10,887 had been operated on because of a unilateral (71.7 %) and 4289 because of a bilateral (28.3 %) inguinal hernia.

Results

A significant difference was noted in the rate of postoperative complications occurring within 30 days, which was 4.9 % for bilateral compared with 3.9 % for unilateral inguinal hernia (p = 0.009). The postoperative complications necessitated reoperation in 0.9 % of patients after unilateral and in 1.9 % of patients after bilateral inguinal hernia repair, thus attesting to the significantly higher risk presented by bilateral inguinal hernia repair (p = <0.001).Multivariate analysis confirmed the highly significant influence of bilateral TAPP on increased reoperation rates due to complications (p > 0.0001). The odds ratio was 2.13 (95 % CI 1.58–2.86). Comparison of the results from a high-volume center with those from the Herniamed Registry showed that perioperative complication rates were markedly higher.

Conclusion

Perioperative outcome of bilateral TAPP operation demonstrates significantly worse postoperative complication and reoperation rates compared with unilateral TAPP. Likewise, the results were markedly unfavorable compared with those of a high-volume center. If a bilateral hernia repair should be attempted in those patients with only a unilateral hernia, these data give the surgeon more information on how to better prepare a patient and obtain consent preoperatively.

Predictors of chronic groin discomfort after laparoscopic totally extraperitoneal inguinal hernia repair

BACKGROUND

Chronic groin discomfort is an undesired complication of laparoscopic totally extraperitoneal (TEP) inguinal hernia repairs. We examined whether perioperative factors may be associated with an increased risk of developing this problem and if their recognition could lead to preventive strategies.

STUDY DESIGN

We performed a retrospective review of 1 surgeon's experience with 1,479 TEP repairs on 976 patients from 1995 to 2009. A mailed survey, which included a groin discomfort questionnaire (Carolinas Comfort Scale), was distributed to all patients. Symptom severity grading (range 0, none to 5, severe) was used to sort individual responses. Perioperative factors were compared between asymptomatic and symptomatic patients with varying levels of discomfort.

RESULTS

There were 691 patients (71%) who provided complete responses to the questionnaire. Median follow-up was 5.7 years (range 0 to 14.4 years). The majority (n = 543, 79%) denied any symptoms of mesh sensation, pain, or movement limitation. In the remaining 148 (21%) patients, symptoms were most often mild (n = 108), followed by mild but bothersome (n = 25), and 15 patients (2%) had moderate or severe symptoms. Symptomatic patients were younger (median age 52 vs 57 years, p = 0.002) and were more likely to have had the TEP repair for recurrent hernias (24% vs 17%, p = 0.035). Operative diagnosis, bilateral exploration, mesh fixation techniques, perioperative complications, American Society of Anesthesiologists grade, and length of hospital stay were not associated with chronic groin discomfort.

CONCLUSIONS

The majority of patients are asymptomatic after a laparoscopic TEP inguinal hernia repair. Most of the symptomatic patients do not have any bothersome symptoms. Given that younger age and a repair for recurrent hernia were predictors of chronic groin discomfort, we counsel these patients about their increased risks.

Incidence of inguinal hernia repairs in Olmsted County, MN: a population-based study

OBJECTIVE

To determine age- and sex-specific incidence rates of inguinal hernia repairs (IHR) in a well-defined US population and examine trends over time.

BACKGROUND DATA

IHR represent a substantial burden to the US healthcare system. An up-to-date appraisal will identify future healthcare needs.

METHODS

A retrospective review of all IHR performed on adult residents of Olmsted County, MN, from 1989 to 2008 was performed. Cases were ascertained through the Rochester Epidemiology Project, a record linkage system with more than 97% population coverage. Incidence rates were calculated by using incident cases as the numerator and population counts from the census as the denominator. Trends over time were evaluated using Poisson regression.

RESULTS

During the study period, a total of 4026 IHR were performed on 3599 unique adults. Incidence rates per 100,000 person-years were greater for men: 368 versus 44 for women, and increased with age: from 194 to 648 in men, and from 28 to 108 in women between 30 and 70 years of age. Initial, unilateral IHR comprised 74% of all IHR types. The lifelong cumulative incidence of an initial, unilateral or a bilateral IHR in adulthood was 42.5% in men and 5.8% in women. Over time (from 1989 to 2008), the incidence of initial, unilateral IHR in men decreased from 474 to 373 (relative reduction, RR = 21%). Bilateral IHR increased from 42 to 71 (relative increase = 70%), contralateral metachronous IHR decreased from 29 to 11 (RR = 62%), and recurrent IHR decreased from 66 to 26 (RR = 61%); for all changes P < 0.001.

CONCLUSIONS

IHR are common, their incidence varies greatly by age and sex and has decreased substantially over time in Olmsted County, MN.