Planned ilioinguinal nerve excision for prevention of chronic pain after inguinal hernia repair: a meta-analysis

Perioperative Risk Factors for Persistent Postsurgical Pain After Inguinal Hernia Repair: Systematic Review and Meta-Analysis

Persistent postsurgical pain (PPSP) is one of the most bothersome and disabling long-term complications after inguinal hernia repair surgery. Understanding perioperative risk factors that contribute to PPSP can help identify high-risk patients and develop risk-mitigation approaches. The objective of this study was to systematically review and meta-analyze risk factors that contribute to PPSP after inguinal hernia repair. The literature search resulted in 303 papers included in this review, 140 of which were used for meta-analyses. Our results suggest that younger age, female sex, preoperative pain, recurrent hernia, postoperative complications, and postoperative pain are associated with a higher risk of PPSP. Laparoscopic techniques reduce the PPSP occurrence compared to anterior techniques such as Lichtenstein repair, and tissue-suture techniques such as Shouldice repair. The use of fibrin glue for mesh fixation was consistently associated with lower PPSP rates compared to tacks, staples, and sutures. Considerable variability was observed with PPSP assessment and reporting methodology in terms of study design, follow-up timing, clarity of pain definition, as well as pain intensity or interference threshold. High or moderate risk of bias in at least one domain was noted in >75% of studies. These may limit the generalizability of our results. Future studies should assess and report comprehensive preoperative and perioperative risk factors for PPSP adjusted for confounding factors, and develop risk-prediction models to drive stratified PPSP-mitigation trials and personalized clinical decision-making. PERSPECTIVE: This systematic review and meta-analysis summarizes the current evidence on risk factors for persistent pain after inguinal hernia repair. The findings can help identify patients at risk and test personalized risk-mitigation approaches to prevent pain. PROSPERO REGISTRATION: htttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=154663.

Chronic postoperative inguinal pain: A narrative review

Inguinodynia or chronic postoperative inguinal pain is a growing problem between patients who undergo surgical repair of an inguinal hernia. The change in results measurement proposed by many authors towards Patient Reported Outcome Measurement has underlined the importance of chronic postoperative inguinal pain, because of the great limitations in everyday life and the huge socioeconomic impact that it causes. In this article a narrative review of the available literature in PUBMED, EMBASE and Cochrane Library is performed and the most relevant aspects about epidemiology, etiology prevention, diagnosis and treatment of chronic postoperative inguinal pain are discussed. A new management algorithm is also proposed. The variability in its incidence and clinical presentation makes diagnosis of chronic postoperative inguinal pain a very challenging issue. There is no standardized therapy and an adequate etiological diagnosis is key point for a successful treatment. There are many treatment options that have to be sequentially used and adjusted to each patient and their clinical features.

[Inguinal and femoral hernia surgery : Open mesh procedure. Video article]

There are several techniques for repair of symptomatic inguinal and femoral hernias. There is an increased acceptance and tendency favoring minimally invasive procedures, such as plug or transinguinal preperitoneal mesh prosthesis (TIPP) and endoscopic procedures, such as totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) repair. In the present review the classical techniques of Irving L. Lichtenstein (1986) and Jean Rives (1965), two indispensable procedures, are presented and the results from the literature are discussed. The videos show the repair of three interesting and complex cases. The surgical techniques are demonstrated in detail with the help of a video of the operation and which is available online. It is essential that each hernia surgeon should have proficiency in performing both procedures in order to be able to counsel patients and tailor the procedure according to the clinical findings.

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.

Routine Neurectomy of Inguinal Nerves During Open Onlay Mesh Hernia Repair: A Meta-analysis of Randomized Trials

OBJECTIVE

The aim of the study was to establish whether an inguinal neurectomy at the time of hernia repair would reduce the risk of postoperative pain for open tension-free sutured mesh repair.

BACKGROUND

Inguinal hernia repair is a common operative procedure. The development of postoperative pain is uncommon, but at times debilitating. The role of inguinal neurectomy is currently unknown, with no single large study available, and previous reviews included only a few heterogeneous studies.

METHODS

Relevant randomized trials were identified from searches of MEDLINE, EMBASE, and EBM Review databases until October 2014. Meta-analysis was performed based on Cochrane Methods using RevMan v5.3 software. Pain, pain scores, sensory changes, and complications over short (half to <3 months), mid (3 to <12 mo), and long term (≥12 mo) were recorded.

RESULTS

All included studies performed Lichtenstein hernia repair. Eleven studies on 1031 patients showed significant reduction in pain with neurectomy for short (RR = 0.61, 0.40-0.93) and midterm (RR = 0.30, 0.20-0.46), but not for long term (RR = 0.50, 0.25-1.01). Three studies (270 patients) showed significantly reduced short-term pain (RR = 0.69, 0.52-0.90). No studies included genitofemoral neurectomy. Rates of hematoma, infection, urinary retention, and recurrence were not different between groups.

CONCLUSIONS

Routine ilioinguinal neurectomy during Lichtenstein-type herniorrhaphy seems to be a safe and effective method to reduce pain in the short and midterm, but may have little long-term impact. Iliohypogastric neurectomy seems to reduce pain in at least the short term.

Neurectomy for the Treatment of Chronic Postoperative Pain after Surgery of the Trunk

BACKGROUND

Incidence of chronic postoperative neurogenic pain after open and laparoscopic trunk operations is reported between 1 and 20 percent, rendering a large population in the United States and worldwide. One possible treatment is selective surgical neurectomy.

METHODS

All patients who underwent neurectomy for chronic trunk or groin postoperative neurogenic pain were identified. Based on individual history and examination, patients underwent neurectomies of the ilioinguinal, iliohypogastric, genitofemoral, lateral-femoral cutaneous, or intercostal nerves. Recorded preoperative pain levels (Likert score ranging from 0 to 10) were compared to postoperative pain levels and quality-of-life indices were assessed.

RESULTS

Fifty-six patients (32 men and 24 women) were included. Mean age was 49 years. All patients underwent preoperative nerve blocks by either surgeon, radiologist, or referring physician, and had either complete or significant response defined as over 50 percent relief. Forty-five patients completed the survey. Median follow-up was 2.8 years (range, 1.0 to 5.7 years). Average pain level was 9.0 preoperatively and 3.5 postoperatively. Quality-of-life impairment improved from 8.3 preoperatively to 3.5 postoperatively. A subset of patients (n = 12) had minimal improvement, reporting a decrease in pain from 8.5 to 7.2 and quality-of-life improvement from 8.5 to 7.1.

CONCLUSIONS

Complete avoidance of nerve injury during all trunk and groin operations is likely unattainable. When chronic postoperative neurogenic pain develops, neurectomy can be an effective means of treatment, significantly improving pain and quality of life in most patients. Better insight is necessary into a patient subset responding to nerve blocks yet experiencing minimal postoperative improvement.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Risk factors of chronic pain after inguinal hernia repair: a systematic review

Introduction

Chronic postoperative inguinal pain (CPIP) is the most common complication after inguinal hernia operation. Eighteen percent (range, 0.7%-75%) of patients suffered from CPIP after open inguinal hernia repair and 6% (range, 1%-16%) reported CPIP after laparoendoscopic groin hernia repair. The incidence of clinically significant CPIP with impact on daily activities ranged between 10% and 12%. Debilitating CPIP with severe impact on normal daily activities or work was reported in 0.5%-6% of the cases.

Materials and methods

PubMed, Medline, Embase, and the Cochrane Database were searched for studies on risk factors for chronic pain after open and endoscopic hernia repair. A systematic review of the literature was conducted using the grading of recommendations, assessment, development, and evaluations (GRADE) methodology.

Results

Risk factors for CPIP with strong evidence include female gender, young age, high intensity of preoperative pain, high early postoperative pain intensity, history of chronic pain other than CPIP, operation for a recurrent hernia, and open repair technique. Risk factors for CPIP with moderate evidence include postoperative complications, neurolysis, and preservation of the ilioinguinal nerve in Lichtenstein repair. Risk factors for CPIP with low evidence include genetic predisposition (DQB1*03:02 HLA haplotype), lower preoperative optimism, high pain intensity to tonic heat stimulation, inadequate suture/staple/clip mesh fixation, ignorance of the inguinal nerves, less experienced surgeon, sensory dysfunction in the groin, and worker's compensation.

Conclusion

Detailed knowledge of the risk factors, meticulous operative technique with profound knowledge of the anatomy, proper nerve identification and handling, optimization of prosthetic materials, and careful fixation are of utmost importance for the prevention of CPIP.

Clinical, histological, and biochemical predictors of postsurgical neuropathic pain

Surgical nerve injury sometimes leads to chronic postsurgical neuropathic pain (CPSNP). The risk factors for this condition are not well understood. We prospectively assessed 46 patients scheduled for iliac crest bone harvest, 2 days (D2) and 3 months (M3) after surgery, to determine the time course of nerve fiber degeneration and expression of the TNF-α and NGF genes in skin punch biopsies. Mechanical and thermal detection and pain thresholds were evaluated at D2 and M3, by quantitative sensory testing. Skin punch biopsies were also obtained from the thighs ipsilateral and contralateral to iliac crest bone harvest. Intraepidermal nerve fiber density (IENFD) and cutaneous TNF-α and NGF gene expression were analyzed. Forty-five volunteers matched for age, sex, skin color were examined as controls. Chronic postsurgical neuropathic pain was defined as pain in an area of hypesthesia with a positive Douleur Neuropathique 4 questionnaire score. Overall, 73% (N = 32) of patients developed hypesthesia and 40% (N = 13) of these patients had developed CPSNP at M3. Quantitative sensory testing results, IENFD, and skin TNF-α and NGF gene expression at D2 and M3 did not differ between patients with and without CPSNP. However, in patients with CPSNP, burning, compression, and pain provoked by brushing were correlated with IENFD at M3, suggesting a possible association between partial nerve lesions and more intense CPSNP, than with total nerve lesion. Furthermore, preoperative pain and opioid use were higher in patients who developed CPSNP than in those without CPSNP. These findings suggest that the predictors of CPSNP development are clinical rather than histological or biochemical.

Current concepts of inguinal-related and adductor-related groin pain

Groin pain encompasses a number of conditions from the lower abdomen, inguinal region, proximal adductors, hip joint, upper anterior thigh and perineum. The complexity of the anatomy, the heterogeneous terminology and the overlapping symptoms of different conditions that may co-exist epitomise the challenges in diagnosis and treatment. Inguinal-related and adductor-related pain is the most common cause of groin pain and will be discussed in this article.

Sportsman's hernia? An ambiguous term

Groin pain is common in athletes. Yet, there is disagreement on aetiology, pathomechanics and terminology. A plethora of terms have been employed to explain inguinal-related groin pain in athletes. Recently, at the British Hernia Society in Manchester 2012, a consensus was reached to use the term inguinal disruption based on the pathophysiology while lately the Doha agreement in 2014 defined it as inguinal-related groin pain, a clinically based taxonomy.

This review article emphasizes the anatomy, pathogenesis, standard clinical assessment and imaging, and highlights the treatment options for inguinal disruption.

Management of Postherniorrhaphy Chronic Neuropathic Groin Pain: A Role for Dorsal Root Ganglion Stimulation

Chronic neuropathic groin pain is a sequela of hernia surgery that occurs at unacceptably high rates, causing widespread impacts on quality of life. Although the medical community is beginning to recognize the role of surgical technique in the initiation and maintenance of postherniorrhaphy neuropathic pain, little information exists regarding pain management strategies for this condition. This review presents a summary of the pain condition state, its treatment options, and treatment recommendations. Both literature review and clinical experience were used to develop a proposed a treatment algorithm for the treatment of postherniorrhaphy pain. The development of chronic pain may be prevented via a number of perioperative measures. For pain that is already established, some surgical approaches including inguinal neurectomy can be effective, in addition to standard pharmacological treatments and local infiltrations. An unmet need may still exist with these options, however, leaving a role for neuromodulation for the treatment of intractable cases. A pain management algorithm for iterative interventions including stimulation of the dorsal root ganglion (DRG) is described. It is expected that cross-disciplinary awareness of surgeons for nonsurgical pain management options in the treatment of chronic neuropathic postherniorrhaphy pain will contribute to better clinical outcomes.

Wide resection of inguinal nerves versus simple section to prevent postoperative pain after prosthetic inguinal hernioplasty: our experience

BACKGROUND

In the literature, chronic groin pain (i.e. lasting >3 months) occurs in about 10 % of patients who undergo inguinal hernioplasty with prosthesis; it is characterized by a broad range of symptoms, and is relative to individual perceptions of pain. In 2-5 % of cases, the painful symptomatology is so intense that it interferes with daily activities, and can be debilitating in 0.5-6 % of cases. The best known cause of inguinodynia is neuropathy, due to implication of one or more inguinal nerves (iliohypogastric, ilioinguinal, and genitofemoral nerves) into fibroblastic processes; or from nervous stimulation caused by prosthetic material on adjacent nervous trunks. Many therapeutic strategies have been proposed to treat chronic groin pain, including intra-operative prophylactic neurectomy.

OBJECTIVE

The purpose of our study was to perform a comparative analysis between outcomes from wide resections of inguinal nerves versus those from simple nervous section (or minimal resection).

PATIENTS AND METHODS

We considered 350 patients who had undergone inguinal prosthetic hernioplasty with Trabucco's technique between 2004 and 2010. Wide nervous resection (removal of nerve segments 3-8 cm in length) was performed in 180. The other 170 patients underwent simple section or minimal resection. All patients were checked 1 week, 1 month, and 1 year after surgery.

RESULTS

Group 1: At 1-week follow-up, 63 patients (35 %) reported no pain, 113 (63 %) reported moderate pain, and 4 (2 %) intense pain; 1 month after the procedure, 152 patients (84.4 %) reported no pain, 25 (14 %) complained of moderate pain, and 3 (1.6 %) of severe pain; 1 year after surgery, only 1 patient (0.5 %) complained of constant pain. Group 2: At 1 week follow-up, 48 patients (28 %) reported no pain, 101 (59 %) reported moderate pain, and 21 (13 %) intense pain; 1 month after the procedure, 81 patients (47.6 %) had no pain, 72 (42.4 %) complained of moderate pain, and 17 (10 %) of severe pain; 1 year after surgery, 11 patients (6.5 %) had constant pain, and two of them were re-admitted for surgery. The lower incidence of chronic pain after long nervous resection is statistically significant (0.5 vs. 6.5 %; p = 0.006); the incidence of moderate pain 1 month after operation is also lower (14 vs. 42.4 %; p < 0.0001); patients who underwent a long resection experienced faster resolution of pain symptomatology, during a month. Also noteworthy is the lower incidence of intense pain in the short and medium term (after 1 week, 13 vs. 2 %, p = 0.0005; after 1 month, 10 vs. 1.6 %, p = 0.0018).

CONCLUSIONS

The prophylactic wide resection of selected segments of inguinal nerves, despite the apparent paradox of greater tissue damage, appears more effective than simple section at preventing postoperative inguinodynia, given both the lower incidence and the faster resolution of painful symptomatology.

[Diagnostics and therapy of chronic pain following hernia operation]

The frequency of chronic pain after hernia repair is currently much higher than the recurrence rate. For inguinal hernias it has been shown that mesh-based techniques are comparable to mesh-free techniques concerning chronic pain. Risk factors could be clearly identified for inguinal hernia repair and include open repair, meshes with small pores, mesh fixation with sutures or tacks, pre-existing pain and severe pain during the early postoperative period. The last two risk factors are also important for incisional hernias. For laparoscopic incisional hernia repair, the width (> 10 cm) of the gap seems to correlate with chronic pain. The diagnostic measures are restricted to the identification of a segmental problem in terms of nerve entrapment which can be blocked by local anesthesia or definite neurectomy. In some cases of chronic pain after inguinal hernia repair removal of the mesh will be advisable. After incisional hernia repair a segmental involvement is rarely seen. Localized pain may be induced by stay sutures which can be removed. Mesh removal is, however, a complex procedure especially after open repair resulting in hernia recurrence and therefore represents a salvage technique. The prophylaxis of chronic pain is therefore of utmost importance as is the identification of patients at risk which is now possible. These patients for example with inguinal hernias should be treated laparoscopically with an adequate technique including meshes with big pores and without fixation or fixation with glue only.

[Intervention-specific complications of hernia surgery]

Hernia surgery is generally a rewarding task, patient satisfaction is high and the long-term results are generally good. Incisional hernias are more heterogeneous and there is a higher variability of morphologies to be matched with the available therapeutic approaches but the majority of patients are also satisfied with the results. This positive scenario for hernia surgery can be largely attributable to careful preoperative planning, effective surgical techniques and a high degree of standardization. The picture is somewhat clouded by the complications associated with hernia surgery. If complications do arise, the outcome largely depends on how well the surgeon responds. For inguinal and femoral hernias, the risk profile of the patient is crucial to the surgical planning and the wrong operation on the wrong patient can be disastrous. Open procedures have complication risks in common but the question of how best to deal with the nerves has yet to be answered. Endoscopic procedures are an indispensable part of the hernia surgery repertoire and the hernia specialist should be proficient in TEP and TAPP techniques. Ventral and incisional hernias have higher complication rates and the treatment is similar despite differences in etiology and pathophysiology. Although open procedures are better for morphological reconstruction they are accompanied by a higher complication rate. Laparoscopic procedures had a severe complication profile early on but the situation has greatly improved today due to continued refinement of the learning curve. A critical approach to the application of methods and meshes, a deep knowledge of anatomical peculiarities and the careful planning of tactics for dealing with intraoperative problems are the hallmarks of today's good hernia surgeon.

Current treatment concepts for groin hernia

PURPOSE

The purpose of this study is to review the latest evidence on operative and perioperative management of patients with groin hernia.

METHODS

A literature review of medical databases was undertaken. Recent scientific evidence provided by quality reports was selected and discussed critically.

RESULTS

The Shouldice repair results in low recurrence rates compared to other tissue reconstructions. However, mesh repairs are superior to tissue reconstruction in terms of recurrence. Lichtenstein's technique remains the gold standard, with low incidence of hernia recurrence and minimal morbidity. Endoscopic techniques have been popularized during the past decades, as alternative approaches to open surgery. Both transabdominal preperitoneal repair (TAPP) and the totally extraperitoneal repair (TEP) are effective in the treatment of groin hernia, although the steep learning curve precludes popularization and may account for increased perioperative morbidity.

CONCLUSIONS

Groin hernia surgery remains an evolving field of investigation. Mesh application remains the mainstay of durable results. Individual patient factors and hernia characteristics need to be taken into account when considering the most appropriate surgical practice.

Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients

PURPOSE

In 2009, the European Hernia Society published the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. The guidelines expired January 1, 2012. To keep them updated, a revision of the guidelines was planned including new level 1 evidence.

METHODS

The original Oxford Centre for Evidence-Based Medicine ranking was used. All relevant level 1A and level 1B literature from May 2008 to June 2010 was searched (Medline and Cochrane) by the Working Group members. All chapters were attributed to the two responsible authors in the initial guidelines document. One new chapter on fixation techniques was added. The quality was assessed by the Working Group members during a 2-day meeting and the data were analysed, especially with respect to any change in the level and/or text of any of the conclusions or recommendations of the initial guidelines. In the end, all relevant references published until January 1, 2013 were included. The final text was approved by all Working Group members.

RESULTS

For the following topics, the conclusions and/or recommendations have been changed: indications for treatment, treatment of inguinal hernia, day surgery, antibiotic prophylaxis, training, postoperative pain control and chronic pain. The addendum contains all current level 1 conclusions, Grade A recommendations and new Grade B recommendations based on new level 1 evidence (with the changes in bold).

CONCLUSIONS

Despite the fact that the Working Group responsible for it tried to represent most kinds of surgeons treating inguinal hernias, such general guidelines inevitably must be fitted to the daily practice of every individual surgeon treating his/her patients. There is no doubt that the future of guideline implementation will strongly depend on the development of easy to use decision support algorithms tailored to the individual patient and on evaluating the effect of guideline implementation on surgical outcome. At the 35th International Congress of the EHS in Gdansk, Poland (May 12-15, 2013), it was decided that the EHS, IEHS and EAES will collaborate from now on with the final goal to publish new joint guidelines, most likely in 2015.

Incidence of pain after inguinal hernia repair in the elderly. A retrospective historical cohort evaluation of 18-years' experience with a mesh & plug inguinal hernia repair method on about 3000 patients

Background

Chronic pain after prosthetic inguinal hernioplasty is one of the most important current issues in the current literature debate. Mechanisms related to pain development are only partially known. Influence of age as well as other factors is still unclear. The aim of this work was to evaluate whether development of chronic pain after open prosthetic plug and mesh inguinal hernioplasty is influenced by age.

Methods

Analysis was retrospectively conducted, dividing our cohort of patients (2,902) who had undergone prosthetic open plug&mesh inguinal hernioplasty from Jannuary 1994 to May 2012, following only the age criterion (cut-off 65 yrs.), into two groups (Gr.A<65 yrs, Gr.B>65 yrs.). All patients were routinely submitted to a postoperative questionnaire. Complications such as analgesic assumption were registered in both groups. Pain intensity was classified following the Visual Analogic Scale (VAS). Incidence of chronic pain, discomfort, and numbness, was assessed in both groups. Statistical significance was assessed by X₂-test.

Results

Only 0.2% of patients suffered from a recurrence in our cohort. Postoperative chronic pain was observed in Gr. A in 0.12% of patients vs Gr.B 0.09% (p>0.05). Incidence of other postoperative symptoms such as discomfort or numbness were slightly prevalent on young patients (respectively p = 0.0286 and p = 0.01), while for hyperesthesia and sensation of foreign body no statistically significant difference of incidence between groups was observed.

Conclusions

Real chronic pain after inguinal hernioplasty is a rare clinical entity. Other causes of chronic pain should be accurately researched and excluded. In young patients psychological factors seem to show a slight influence. There was no influence of age on chronic postoperative pain incidence after inguinal hernioplasty.

Lightweight versus heavyweight in inguinal hernia repair: a meta-analysis

PURPOSE

The aim of this article is to compare the outcomes of lightweight mesh and heavyweight mesh in inguinal hernia repair.

METHOD

A comprehensive literature search was undertaken to identify studies comparing the influence of lightweight and heavyweight meshes on inguinal hernia.

RESULTS

The present meta-analysis pooled the effects of outcomes of a total 5,389 patients enrolled into 16 randomized controlled trials and 5 comparative studies. Lightweight mesh repair was associated with a significant less incidence of chronic postoperative pain [OR = 0.72, 95 % CI (0.57, 0.91)] and less feeling of foreign body than heavyweight mesh repair [OR = 0.50, 95 % CI (0.37, 0.67)]. Recurrence at 12 months was marginally increased in lightweight group (p = 0.05) [RD = 0.01, 95 % CI (0.00, 0.02)]. However, statistically there was no difference in the incidence of seroma [OR = 0.80, 95 % CI (0.52, 1.23)], infection [RD = -0.00, 95 % CI (-0.01, 0.00)], and testicular atrophy [RD = 0.01, 95 % CI (-0.01, 0.02)].

CONCLUSION

There was no difference regarding the incidence of seroma, infection, and testicular atrophy between lightweight mesh versus heavyweight mesh for inguinal hernia. There is a concern on the recurrence when lightweight mesh is used in large inguinal hernias. However, lightweight mesh repair do have advantages in terms of chronic postoperative pain and feeling of foreign body, and further well-structured trials with improved standardization of hernia types, operative techniques are necessary.