Chronic groin pain, discomfort and physical disability after recurrent groin hernia repair: impact of anterior and posterior mesh repair

Transinguinal preperitoneal (TIPP) versus minimally invasive inguinal hernia repair: a systematic review and meta-analysis

PURPOSE

The transinguinal preperitoneal (TIPP) technique is an open approach to groin hernia repair with posteriorly positioned mesh supposed to reduce recurrence rates. However, transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) techniques have similar mesh positioning with the advantages of minimally invasive surgery (MIS). Hence, we performed a systematic review and meta-analysis comparing TIPP and MIS for groin hernia repair.

SOURCE

Cochrane, Embase, Scopus, Scielo, and PubMed were systematically searched for studies comparing TIPP and MIS techniques for groin hernia repair. Outcomes assessed were recurrence, chronic pain, surgical site infection (SSI), seroma, and hematoma. We performed a subgroup analysis of TAPP and TEP techniques separately. Statistical analysis was performed with R Studio.

PRINCIPAL FINDINGS

81 studies were screened and 19 were thoroughly reviewed. Six studies were included, of which two compared TIPP with TEP technique, two compared TIPP with TAPP, and two compared TIPP with both TEP and TAPP techniques. We found lower recurrence rates for the TEP technique compared to TIPP (0.38% versus 1.19%; RR 2.68; 95% CI 1.01 to 7.11; P = 0.04). Also, we found lower seroma rates for TIPP group on the overall analysis (RR 0.21; P = 0.002). We did not find statistically significant differences regarding overall recurrence (RR 1.6; P = 0.19), chronic pain (RR 1.53; P = 0.2), SSI (RR 2.51; P = 0.47), and hematoma (RR 1.29; P = 0.76) between MIS and TIPP. No statistically significant differences were found in the subgroup analysis of TAPP technique for all the outcomes.

CONCLUSION

Our systematic review and meta-analysis found no differences between TIPP and MIS approaches in the overall analysis of recurrence, SSI, and chronic pain rates. Further research is needed to analyze individual techniques and draw a more precise conclusion on this subject.

PROSPERO REGISTRATION

ID CRD42024530107, April 8, 2024.

Non-mesh inguinal hernia repair: Review

Hernioplasty stands as one of the most common abdominal surgical interventions. The "gold standard" treatment for inguinal hernias remains Lichtenstein mesh hernioplasty. Nonetheless, clinical practice continues to grapple with issues concerning complications such as recurrence, chronic postoperative pain, and infection. The myriad types of surgery lead to conflicting opinions regarding the superiority and drawbacks of inguinal canal plastic surgery methods. This article presents current data on the surgical treatment of non-mesh inguinal hernias, delineating the most prevalent techniques while exploring their respective advantages and disadvantages. Additionally, the researchers' experiences are analyzed in detail.

Laparoscopic totally extraperitoneal repair for recurrent inguinal bladder hernia: A case report

We present a case of a recurrent inguinal bladder hernia that was previously unsuccessfully operated on three times and was repaired using totally extraperitoneal repair (TEP). A 79-year-old man presented with a right inguinal swelling that had been treated three times on the same side with anterior approaches. Computed tomography confirmed a recurrent inguinal bladder hernia. TEP was performed after identifying the bladder hernia preoperatively, with previous surgeries that used a plug-and-patch technique through an anterior approach. The extraperitoneal approach allowed the bladder to be reduced without injury and the hernia to be safely repaired using a 3D Max® Light Mesh. The postoperative recovery was uneventful, with no recurrence after 1 year. TEP facilitates the diagnosis and repair of bladder hernias, emphasizing the importance of preoperative diagnosis and the efficacy of endoscopic procedures in bladder hernia repair, even in recurrent cases.

Elective Recurrent Inguinal Hernia Repair: Value of an Abdominal Wall Surgery Unit

BACKGROUND

The aim of this study was to analyze the impact of an abdominal wall surgery unit on postoperative complications (within 90 days postoperatively), hernia recurrence and chronic postoperative inguinal pain after elective recurrent inguinal hernia repair.

METHODS

We conducted a retrospective cohort study of all adult patients who underwent elective recurrent inguinal hernia repair between January 2010 and October 2021. Short- and long-term outcomes were compared between the group of patients operated on in the abdominal wall surgery unit and the group of patients operated on by other units not specialized in abdominal wall surgery. A logistic regression model was performed for hernia recurrence.

RESULTS

A total of 250 patients underwent elective surgery for recurrent inguinal hernia during the study period. The patients in the abdominal wall surgery group were younger (P ≤ 0.001) and had fewer comorbidities (P ≤ 0.001). There were no differences between the groups in terms of complications. The patients in the abdominal wall surgery group presented fewer recurrences (15% vs. 3%; P = 0.001). Surgery performed by the abdominal wall surgery unit was related to fewer recurrences in the multivariate analysis (HR = 0.123; 95% CI = 0.21-0.725; P = 0.021).

CONCLUSIONS

Specialization in abdominal wall surgery seems to have a positive impact in terms of recurrence in recurrent inguinal hernia repair. The influence of comorbidities or type of surgery (i.e., outpatient surgery) require further study.

Improved patient-reported outcomes after open preperitoneal inguinal hernia repair compared to anterior Lichtenstein repair: 10-year ACHQC analysis

INTRODUCTION

The Lichtenstein repair has been synonymous with "open" inguinal hernia repair (IHR) for 40 years. However, international guidelines have suggested that posterior mesh placement results in advantageous biomechanics and reduced risk of nerve-related chronic pain. Additionally, the use of local anesthetics has been shown to reduce postoperative pain and complication risks. An open transrectus preperitoneal/open preperitoneal (TREPP/OPP) repair combines posterior mesh placement with the use of local anesthetic and as such could be the ideal repair for primary inguinal hernia. Using the Abdominal Core Health Quality Collaborative (ACHQC) registry, we compared open anterior mesh with open posterior mesh repairs.

METHODS

We performed a propensity score matched analysis of patients undergoing open IHR between 2012 and 2022 in the ACHQC. After 1:1 optimal matching, both the TREPP/OPP and Lichtenstein cohorts were balanced with 451 participants in each group. Outcomes included patient-reported quality of life (QoL), hernia recurrence, and postoperative opioid use.

RESULTS

Improvement was seen after TREPP/OPP in EuraHS QoL score at 30 days (OR 0.558 [0.408, 0.761]; p = 0.001), and the difference persisted at 1 year (OR 0.588 [0.346, 0.994]; p = 0.047). Patient-reported opioid use at 30-day follow-up was significantly lower in the TREPP/OPP cohort (OR 0.31 [0.20, 0.48]; p < 0.001). 30-day frequency of surgical-site occurrences was significantly higher in the Lichtenstein repair cohort (OR 0.22 [0.06-0.61]; p = 0.007). There were no statistically significant differences in hernia recurrence risk at 1 year, or rates of postoperative bleeding, peripheral nerve injury, DVTs, or UTIs.

CONCLUSION

Our analysis demonstrates a benefit of posterior mesh placement (TREPP/OPP) over anterior mesh placement (Lichtenstein) in open inguinal hernia repair in patient-reported QoL and reduced opioid use.

Treatment of recurrent inguinal hernia after TransInguinal PrePeritoneal (TIPP) surgery: feasibility and outcomes in a case series

BACKGROUND

TransInguinal PrePeritoneal (TIPP) inguinal hernia repair (IHR) combines an open anterior approach with a preperitoneal position of the mesh. Advantages include reduced chronic postoperative inguinal pain, low recurrence rates and quick recovery. Critics have expressed concerns that recurrent IHR after TIPP could be difficult and with an increased risk of complications due to the formation of scar tissue in both the anterior and posterior anatomical inguinal planes. This study reports feasibility and outcomes of recurrent IHR after TIPP repair.

METHODS

Patients who underwent recurrent IHR after TIPP between January 2013 and January 2015 in a single hernia-dedicated teaching hospital were included. Exclusion criteria were femoral hernia, incarcerated hernia and reasons for unreliable follow-up. Electronic medical records were assessed retrospectively to register surgical outcomes and complications.

RESULTS

Thirty-three patients underwent surgical repair of recurrent inguinal hernia after TIPP. Twenty patients were treated with a "re-TIPP when possible" strategy; resulting in 13 successful re-TIPPs and 7 conversions to Lichtenstein repair. Eleven patients underwent a primary Lichtenstein's repair, the remaining two patients underwent recurrent IHR using other techniques (TransREctus sheath PrePeritoneal and TransAbdominal PrePeritoneal repair). Mean time of surgery was 44.7 min (standard deviation 16.7). There was one patient (3.0%) with a re-recurrent inguinal hernia during follow-up. Other minor complications included urinary tract infection.

CONCLUSION

These results indicate that after TIPP it is feasible and safe to perform re-surgery for recurrent inguinal hernia with an anterior approach again. For these recurrences, a Lichtenstein repair can be performed, or a "re-TIPP if possible" strategy can be applied by experienced TIPP surgeons, tailored to the intraoperative findings. Whether a re-TIPP has advantages over Lichtenstein should be evaluated in a prospective manner.

Outcomes of primary and recurrent inguinal hernia repair with prosthetic mesh in a single region over 15 years

BACKGROUND

Sutured inguinal hernia repairs are now uncommon, with evidence suggesting that those augmented with mesh are associated with a lower recurrence rate. We aimed to explore the suggestion that the established use of mesh does indeed lower the rate of operation for recurrence in a single National Health Service region.

METHOD

We collected retrospective Office of Population Censuses and Surveys coded data across one region of all primary and recurrent inguinal hernia repairs over 15 years (2004-2019). Electronic records of recurrent repairs were scrutinised to identify year and type of previous primary repair.

RESULTS

In total, 7,234 repairs were performed during this time, of which 289 (4%) were for symptomatic recurrence. Operations for primary repair increased year on year (111 in 2004 to 402 in 2019). Frequency of operation for recurrent herniation declined with increasing use of mesh (8.8% in 2004 to 3.5% in 2019). The majority of repairs (73%) for recurrence were by an open approach. As opposed to an open mesh repair, a primary laparoscopic repair was associated with an earlier recurrence.

CONCLUSIONS

Inguinal hernia repairs are increasing in frequency but operations for later symptomatic recurrence following an open primary prosthetic mesh repair are not.

Laparoscopic transabdominal preperitoneal repair for recurrent groin hernia after failed anterior-posterior repair

INTRODUCTION

The International Guidelines for Groin Hernia Management recommends an anterior repair after a failed posterior repair, and laparoscopic repair after a failed anterior tissue repair or Lichtenstein repair. However, there are not enough studies to guide decision-making for patients with recurrent hernia patients after combined anterior-posterior repair. We investigate the safety and usefulness of transabdominal preperitoneal repair (TAPP) for recurrent hernia patients after failed anterior-posterior repair.

METHODS

We conducted a retrospective analysis of 13 consecutive patients with recurrent groin hernia who underwent TAPP after prior anterior preperitoneal mesh repair (that created anterior and posterior scarring) between September 2013 and October 2018. The control group comprised 45 patients who underwent TAPP for recurrent hernia after anterior repair (43 nonmesh repairs and two Lichtenstein repairs).

RESULTS

There were no intraoperative complications, and chronic pain was not reported by the patients with prior anterior preperitoneal mesh repair. The mean operative time was 113 ± 31.3 minutes, and the mean postoperative stay was 1.62 ± 0.87 days. The Wong-Baker FACES rating scale score for pain on postoperative day 1 was 1.91 ± 1.5; on postoperative day 7, the score was 1.0 ± 0.89. None of these findings was significantly different from the findings in patients who had a prior anterior repair. A single patient experienced a further recurrence and underwent repeat TAPP.

CONCLUSIONS

The use of TAPP after failed combined anterior-posterior mesh repair may be feasible and safe for recurrent groin hernia. Further study is needed to determine long-term outcomes.

Longitudinal cohort study on preoperative pain as a risk factor for chronic postoperative inguinal pain after groin hernia repair at 2-year follow-up

PURPOSE

To assess the rate of late chronic postoperative inguinal pain (CPIP) after groin hernia repair in patients with different categories of preoperative VRS (Verbal Rating Scale) pain and to make a pragmatic evaluation of the rates of potentially surgery-related CPIP vs. postoperative continuation of preexisting preoperative pain.

METHODS

Groin pain of patients operated from 01/11/2011 to 01/04/2014 was assessed preoperatively, postoperatively and at 2-year follow-up using a VRS-4 in 5670 consecutive groin hernia repairs. A PROM (Patient Related Outcomes Measurement) questionnaire studied the impact of CPIP on the patients' daily life.

RESULTS

Relevant (moderate or severe VRS) pain was registered preoperatively in 1639 of 5670 (29%) cases vs. 197 of 4704 (4.2%) cases at the 2-year follow-up. Among the latter, 125 (3.7%) cases were found in 3353 cases with no-relevant preoperative pain and 72 (5.3%) in 1351 cases with relevant preoperative pain. Relevant CPIP consisted of 179 (3.8%) cases of moderate pain and 18 (0.4%) cases of severe pain. The rate of severe CPIP was independent of the preoperative VRS-pain category while the rate of moderate CPIP (3.1%, 3.4%, 4.1%, 6.8%) increased in line with the preoperative (none, mild, moderate, and severe) VRS-pain categories. The VRS probably overestimated pain since 71.6% of the relevant CPIP patients assessed their pain as less bothersome than the hernia.

CONCLUSION

At the 2-year follow-up, relevant CPIP was registered in 4.2% cases, of which 63.5% were potentially surgery-related (no-relevant preoperative pain) and 36.5% possibly due to the postoperative persistence of preoperative pain. The rate of severe CPIP was constant around 0.4%.

Completely laparoscopic repair for recurrent inguinal hernia that developed after open posterior mesh repair

Surgeons tend to avoid performing completely laparoscopic repair (CLR) for recurrent inguinal hernia (RIH) that developed after the open posterior mesh repair (OPMR). For many, totally extraperitoneal repair or transabdominal preperitoneal repair after OPMR seems difficult because the previously placed mesh may pose an obstacle during the exfoliation of the parietal peritoneum. Moreover, these procedures could cause chronic pain if the "trapezoid of disaster" is injured. In this small case series, we describe our operative technique for CLR for RIH after OPMR, including modified transabdominal preperitoneal repair and modified intraperitoneal onlay mesh repair. The short-term and midterm outcomes of this procedure are also reported. Although we recognize the need for further analysis involving many more cases and a longer follow-up period, we will continue to perform CLR for RIH after OPMR because the results of this small case series were favorable.

Technical details and findings during a second Lichtenstein repair or a second laparoscopic repair in the same groin: a study based on medical records

PURPOSE

There are cases where surgeons repair a recurrent inguinal hernia using a second Lichtenstein repair (Lichtenstein-Lichtenstein) or a second laparoscopic repair (Laparoscopy-Laparoscopy) in the same groin even though this contradicts current guideline recommendations. The aim of this study was to provide an overview of surgical modifications and findings during these reoperations.

METHODS

Patients in this observational study were identified in the nationwide Danish Hernia Database during a 6-year period. Outcomes were identified in medical records. The primary outcome was the prevalence of tailored reoperations and standard reoperations for Lichtenstein-Lichtenstein and Laparoscopy-Laparoscopy, respectively. The secondary outcomes were findings during the reoperation such as inguinal hernia type and size, fibrosis, and difficulty to identify anatomical landmarks.

RESULTS

Of the 102 Lichtenstein reoperations, 43 (42%) were tailored repairs and 59 (58%) were standard repairs. The most common modifications were posterior wall reinforcement with permanent sutures, dividing a structure to enable sufficient hernioplasty, and a modification of the new mesh size and/or shape. There were no differences in the findings during tailored- and standard Lichtenstein reoperations. Of the 58 laparoscopic reoperations, 35 (60%) were tailored repairs and 23 (40%) were standard repairs. The most common modifications were necessitation of a coated mesh due to insufficient peritoneal coverage and use of unusual mesh sizes and/or shapes. Fibrosis was more commonly described during the tailored laparoscopic reoperations.

CONCLUSIONS

A substantial part of the Lichtenstein- and the laparoscopic reoperations was tailored approaches, and various modifications were used. Fibrosis was more commonly described during tailored laparoscopic reoperations.

A Comparison of Outcomes between Lichtenstein and Laparoscopic Transabdominal Preperitoneal Hernioplasty for Recurrent Inguinal Hernia

There remain concerns about the optimal technique for repairing recurrent inguinal hernias because of the high risks of complications and recurrence. The aim of this study was to compare Lichtenstein hernioplasty with the transabdominal preperitoneal (TAPP) laparoscopic technique in the treatment of recurrent inguinal hernias. One hundred twenty-two patients who underwent surgery for recurrent inguinal hernia were prospectively randomized to receive either Lichtenstein (n = 63) or TAPP (n = 59) hernioplasty between January 2010 and December 2014. Baseline characteristics, intraoperative complications, and short- and long-term postoperative factors were evaluated. Preoperative factors were comparable between the two groups. The average follow-up period was 46.2 ± 8.5 months. The two groups had similar intraoperative and short-term postoperative complication rates, whereas the rate of long-term postoperative complications was lower for the TAPP group than the Lichtenstein group (6.8% vs 23.8%, respectively, P = 0.012). The TAPP group had significantly lower visual analogue scale scores, fewer analgesics consumption, and faster recovery than the Lichtenstein group ( P < 0.05). Chronic pain was more prevalent in the Lichtenstein group than the TAPP group (15.9% vs 3.4%, respectively, P = 0.031). The recurrence rate was 4.8 per cent for the Lichtenstein group and 1.7 per cent for the TAPP group, with no significant difference ( P = 0.62). Both the Lichtenstein and TAPP procedures are safe and effective methods for repairing recurrent inguinal hernia with low incidence rates of life-threatening complications and recurrence. The TAPP procedure is superior to the Lichtenstein repair in terms of reduced postoperative pain, shorter sick leave, faster recovery, and better cosmetic results. Careful selection of the surgical procedures and implementation of technical essentials are necessary.

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.

Chronic postoperative pain: recent findings in understanding and management

Chronic postoperative pain is a poorly recognized potential outcome from surgery. It affects millions of patients every year, with pain lasting for months to years, resulting in patient suffering and ensuing economic consequences. The operations with the highest incidence of chronic postoperative pain are amputations, thoracotomies, cardiac surgery, and breast surgery. Other risk factors include preoperative pain, psychological factors, demographics, and the intensity of acute postoperative pain. Attempts to prevent chronic postoperative pain have often led to debatable results. This article presents data from recently published studies examining the incidence, risk factors, mechanisms, treatment options, and preventive strategies for chronic postoperative pain in adults. In summary, many of the previously identified risk factors for chronic postoperative pain have been confirmed and some novel ones discovered, such as the importance of the trajectory of acute pain and the fact that catastrophizing may not always be predictive. The incidence of chronic postoperative pain hasn’t changed over time, and there is limited new information regarding an effective preventive therapy. For example, pregabalin may actually cause more harm in certain surgeries. Further research is needed to demonstrate whether multimodal analgesic techniques have the best chance of significantly reducing the incidence of chronic postoperative pain and to determine which combination of agents is best for given surgical types and different patient populations.

The TREPP as alternative technique for recurrent inguinal hernia after Lichtenstein's repair: A consecutive case series

BACKGROUND

Recurrent inguinal hernias after initial repair with mesh are preferably treated via an alternative route (e.g. posterior after anterior). For recurrent inguinal hernias after an anterior repair such as Lichtenstein's, an endoscopic approach such as the total extraperitoneal or transabdominal preperitoneal technique (TEP or TAPP) is recommended if expertise is present. The TransREctus sheath PrePeritoneal (TREPP) technique is a promising open posterior technique and could be an alternative to endoscopic methods. This study aims to evaluate the results of the TREPP technique for recurrent inguinal hernia.

MATERIALS AND METHODS

Consecutive patients who underwent a TREPP repair for recurrent hernia after initial operation according to Lichtenstein were included in a retrospective manner. A minimum of one year follow-up after the TREPP repair was maintained. Data retrieved from the patient files were combined with the findings at an outpatient department visit.

RESULTS

Between January 2006 and December 2013 fifty-two patients were eligible for inclusion of which 38 patients were clinically evaluated. The mean follow-up of these thirty-eight patients was 65 months (range 17-108 months) in which 2 patients had developed a re-recurrence. One patient reported chronic postoperative inguinal pain (CPIP) since the TREPP and four patients experienced CPIP since the primary inguinal hernia repair. Peri-operative and <30 day complications were rare and no severe adverse events occurred.

CONCLUSION

TREPP seems to be a feasible alternative for recurrent inguinal hernia repair after an initial operation according to Lichtenstein. It may yield extra advantages compared to endoscopic repairs, such as a short learning curve, spinal anesthesia and lower costs.

Data and outcome of inguinal hernia repair in hernia registers - a review of the literature

Register-based observational studies in inguinal hernia repair deliver real-world data from very large patient populations and give answers to important clinical questions never evaluated in randomized controlled trials. Data from hernia registers can provide evidence of effectiveness of therapies in the general population. Hernia registers with high case load have existed in Sweden since 1992, in Denmark since 1998, and in Germany/Austria/Switzerland since 2009. In this review, the most important findings of register-based observational studies in inguinal hernia repair are presented. After an intensive literature search, 85 articles are relevant for this review. Numerous findings from these register-based studies have been incorporated into the various guidelines on inguinal hernia repair. These highlight the particular importance of hernia registers in answering key scientific and clinical questions in hernia surgery. The myriad of surgical techniques described – spanning more than 100 and with ongoing new additions – as well as the large number of associated medical devices call for, more than in other surgical disciplines, meticulous documentation of the methods used for the treatment of inguinal hernias.

Laparo-endoscopic versus open recurrent inguinal hernia repair: should we follow the guidelines?

INTRODUCTION

On the basis of six meta-analyses, the guidelines of the European Hernia Society (EHS) recommend laparo-endoscopic recurrent repair following previous open inguinal hernia operation and, likewise, open repair following previous laparo-endoscopic operation. So far no data are available on implementation of the guidelines or for comparison of outcomes. Besides, there are no studies for comparison of outcomes for compliance versus non-compliance with the guidelines.

PATIENTS AND METHODS

In total, 4812 patients with elective unilateral recurrent inguinal hernia repair in men were enrolled between September 1, 2009, and September 17, 2014, in the Herniamed Registry. Only patients with 1-year follow-up were included.

RESULTS

Out of the 2482 laparo-endoscopic recurrent repair operations 90.5% of patients, and out of the 2330 open recurrent repair procedures only 38.5% of patients, were operated on in accordance with the guidelines of the EHS. Besides, on compliance with the guidelines multivariable analysis demonstrated for laparo-endoscopic recurrent repair a significantly lower risk of pain at rest (OR 0.643 [0.476; 0.868]; p = 0.004) and pain on exertion (OR 0.679 [0.537; 0.857]; p = 0.001). Comparison of laparo-endoscopic and open recurrent repair in settings of compliance versus non-compliance with the guidelines showed a higher incidence of perioperative complications and re-recurrences for recurrent repairs that did not comply with the guidelines.

CONCLUSION

The EHS guidelines for recurrent inguinal hernia repair are not yet being observed to the extent required. Non-compliance with the guidelines is associated with higher perioperative complication rates and higher risk of re-recurrence. Even on compliance with the guidelines, the risk of pain at rest and pain on exertion is higher after open recurrent repair than after laparo-endoscopic repair.

Randomized trial comparing self gripping semi re-absorbable mesh (PROGRIP) with polypropylene mesh in open inguinal hernioplasty: the 6 years result

OBJECTIVES

The use of absorbable polylactic acid hook self-gripping polypropylene mesh in open inguinal hernia may potentially reduce operative time and enhance patient recovery. The objective of this randomized trial is to compare the outcomes following self-gripping mesh repair to polypropylene mesh secured with sutures in open inguinal hernioplasty.

METHOD

Eligible patients aged 18-80 years old, who had primary unilateral uncomplicated inguinal hernia, were randomized into either Polypropylene (PL) group or PROGRIP (PG) group just before the placement of mesh intra-operatively by computer generated code. The primary outcome was the time from mesh placement to end of operation, whereas secondary outcomes included the total operative time, amount of analgesic used, length of post-operative stay, seroma formation, chronic discomfort, chronic pain score and recurrence. The study has been registered in http://www.clinicaltrial.gov carrying an ID of NCT00960011. Patients were followed-up in outpatient clinic for up to 6 years after operation.

RESULTS

From March 2009 to April 2016, 45 patients were included. The mean age of PG group (n = 22) was 62.0 ± 15.7 years old while that of the PL group was 62.6 ± 4.9 years old (n = 23). There was no significant difference regarding the smoking habit, drinking habit, comorbidities, previous hernia operation and Nyhus type of hernia between the two groups. The size of defects, the time of groin dissection and the size of incision were similar. In the PG group, there was significant reduction in the time for mesh placement (11.8 ± 3.1 vs. 21.0 ± 6.2 min, p < 0.001) and total operative time (39.2 ± 9.8 vs. 47.7 ± 8.0 min, p = 0.003). There was one recurrence in PL group and nil in PG group. Although there was a significant difference in paresthesia between 2 groups after operation, the difference disappears with time and comparable from post-operative 1 year onwards. There was no difference in chronic pain, chronic discomfort, affect daily activities, palpable mesh demonstrated throughout the whole study period till 6 years after operation.

CONCLUSIONS

The use of polylactic acid self-gripping mesh in open inguinal hernia repair effectively reduces the operating time with comparable long-term surgical outcome with traditional polypropylene mesh.

Location of recurrent groin hernias at TEP after Lichtenstein repair: a study based on the Swedish Hernia Register

PURPOSE

To investigate which type of hernia that has the highest risk of a recurrence after a primary Lichtenstein repair.

METHODS

Male patients operated on with a Lichtenstein repair for a primary direct or indirect inguinal hernia and with a TEP for a later recurrence, with both operations recorded in the Swedish Hernia Register (SHR), were included in the study. The study period was 1994-2014.

RESULTS

Under the study period, 130,037 male patients with a primary indirect or direct inguinal hernia were operated on with a Lichtenstein repair. A second operation in the SHR was registered in 2236 of these patients (reoperation rate 1.7 %). TEP was the chosen operation in 737 in this latter cohort. The most likely location for a recurrence was the same as the primary location. If the recurrences change location from the primary place, we recognized that direct hernias had a RR of 1.51 to having a recurrent indirect hernia compared to having a direct recurrence after an indirect primary hernia repair.

CONCLUSIONS

Recurrent hernias after Lichtenstein are more common on the same location as the primary one, compared to changing the location.