HerniaSurge: international guidelines for groin hernia management
Introduction
Evolution of groin hernia surgery
Future directions
Our process
Guideline formulation
Risk factors for the development of inguinal hernias in adults
Introduction
Key questions
Evidence in literature
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Gender (IH repair is approximately 8–10 times more common in males).
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Collagen metabolism (a diminished collagen type I/III ratio).
Diagnostic modalities
Introduction
Key questions
Evidence in literature
Groin hernia classification
Introduction
Key questions
Evidence in literature
Indications: treatment options for symptomatic and asymptomatic patients
Introduction
Key questions
Evidence in literature
Discussion, consensus and clarification of grading
Surgical treatment of inguinal hernias
General introduction
Key questions
Introduction
Evidence in literature
Discussion, consensus and clarification of grading
Introduction
Evidence in literature
Discussion, consensus and grading clarification
Introduction
Evidence in literature
Discussion, consensus and grading clarification
Introduction
Evidence in literature
Discussion, consensus and grading clarification
Introduction
Evidence in literature
Operation time, recurrence rate, pain, costs, access-related complications and conversion
Discussion, consensus and clarification of grading
Introduction
Evidence in literature
Discussion, consensus
Introduction
Evidence in literature
Evidence in literature
Individualization of treatment options
Introduction
Key question
Evidence in literature
Discussion, consensus and grading clarification
Additional recommendations for individualization
Occult hernias
Introduction
Key questions
Evidence in literature
Day surgery
Introduction
Key questions
Evidence in literature
Discussion
Meshes
General introduction
Key question
Evidence in literature
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Material reduction can decrease mesh-related complication risk; larger pore flat meshes have a lower risk of mesh-related complications than do small-pore flat meshes.
Conclusion
Key question
Evidence in literature
Discussion
Key question
Introduction
Evidence in literature
Systematic reviews and meta-analysis
Discussion
Introduction
Key question
Evidence in literature
Introduction
Key question
Evidence in literature
Introduction
Key question
Evidence in literature
Introduction
Key question
Evidence in literature
Introduction
Key question
Evidence in literature
Introduction
Key question
Evidence in literature
Introduction
Key question
Evidence in literature
Mesh fixation
Introduction
Key question
Evidence in literature
Systematic reviews on fixation methods
Key questions
Evidence in literature
Fixation versus non-fixation in TEP and TAPP
Permanent versus non-permanent fixation (staple/tack vs glue) in TEP repair
Permanent versus non-permanent fixation (staple/tack vs glue) in TAPP repair
Self-fixing mesh in TAPP
Discussion
Antibiotic prophylaxis
Introduction
Key questions
Evidence in literature
Anesthesia
Key question
Introduction
Evidence in literature
Discussion, consensus, clarification of grading
Key question
Introduction
Evidence in literature
Discussion, consensus, clarification of grading
Key question
Introduction
Evidence in literature
Early postoperative pain prevention and management
Introduction
Key questions
Evidence in literature
Discussion and grading clarification
Convalescence
Introduction
Key question
Evidence in literature
Discussion
Groin hernias in women
Introduction
Key Questions
Evidence in literature
Discussion
Key question
Evidence in literature
Discussion
Key question
Evidence in literature
Discussion
Femoral hernias
Introduction
Key questions
Complications: prevention and treatment
Introduction
Key questions
Evidence in literature
Key questions
Evidence in literature and discussion
Key questions
Evidence in literature
Discussion
Key question
Evidence in literature
Discussion
Key questions
Evidence in literature
Key questions
Evidence in literature
Discussion
Mortality
Key question
Evidence in literature
Discussion
Pain: prevention and treatment
Pain prevention
Key question
Key question
Evidence in literature
Definition of chronic pain
Prevalence of chronic pain
Discussion
Introduction
Key question
Evidence in literature
Key question
Evidence in literature
Introduction
Key question
Evidence in literature
Discussion
Introduction
Key questions
Evidence in literature
Discussion
Evidence in literature
Discussion
Evidence in literature
Introduction
Key question
Evidence in literature
Discussion
Introduction
Key question
Evidence in literature
Discussion
Introduction
Key question
Evidence in literature
Discussion
Introduction
Key question
Evidence in literature
Introduction
Key question
Evidence in literature
Evidence in literature
Discussion
Pain treatment
Introduction
Key question
Evidence in literature
Key question
Evidence in literature
Discussion
Key question
Evidence in literature
Discussion
Key question
Evidence in literature
Discussion
Key question
Evidence in literature
Discussion
Key question
Evidence in literature
Discussion
Recurrent inguinal hernias
Introduction
Key question
Key question
Evidence in literature
Key question
Key question
Key question
Key question
Conclusion
Emergency treatment of groin hernia
Introduction
Key question
Evidence in literature
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Hernia-related hospitalizations in the year preceding hernia repair
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Female gender
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Femoral hernias, particularly those on the right side
Discussion
Key question
Evidence in literature
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Prolonged symptom duration305
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Delay to admission, diagnosis, and surgery22
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Prolonged time from admission to start of surgery308
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Incarceration for more than 24 h310
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Symptom duration of 3 or more days307
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Bowel obstruction308
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Lack of health insurance308
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Associated midline laparotomy for exploration after incarcerated/strangulated hernia reduction311
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ASA class III and IV, BMI > 30, and recurrent hernia30 and
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Anticoagulant use307
Discussion
Key question
Evidence in literature
Discussion
Key question
Evidence in literature
Discussion
Key questions
Evidence in literature
Discussion
Key questions
Evidence in literature
Discussion
Key question
Evidence in literature
Discussion
Key question
Evidence in literature
Key question
Evidence in literature
Key question
Evidence in literature
Training and the learning curve
General introduction
What are the learning curves of the different techniques?What are the best methods to teach groin hernia repair?
Evidence in literature
Discussion, consensus and grading clarification
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Reaching minimum safety standards
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Reaching physician-reported outcomes similar to traditionally available procedures
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Reaching an institutional performance level at which the above standards and outcomes are met and patient-reported outcomes exceed those of traditionally available procedures
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Given the overall small number of expected complications for hernia repair, large numbers of procedures are needed to identify a statistically significant change in an outcome (e.g., complication, recurrence rate). When a statistically significant increase in complication occurs in small patient cohorts (e.g., n = 20), that may signal a large effect size in complication rates.
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The development and learning of the techniques by early independent pioneers in the 1990s should be regarded separately from current structured surgical training programs.
Specialized centers and hernia specialists
Introduction
Level | Level 1 | Level 2 Competence center | Level 3 Reference center |
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No of hernia patients treated yearly | Min 30 | Min 200 (min 30 incisional hernia) | Min 250 (min 50 incisional hernia, 5 complex hernias, 5 hiatal hernias) |
Science | Membership German and European Hernia Society, subscription Herniaa | Yearly attendance at atleast one hernia meeting | At least two presentations at a hernia congress or one publication |
Education | – | – | Education seminars, guest visits |
Costs
Introduction
Evidence in literature
Groin Hernia Registries
Introduction
Evidence in literature
Pros
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Cons
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Registry-based studies
| High external validity Includes all patients at aligned units Involves many surgeons with varying level of skill and experience Reflects routine clinical practice Provides separate data from participating hospitals and aggregated data for all participating units Requires a limited contribution from all surgeons Excellent tools for observing changes over time Includes documentation and adjustment of several confounders Permits post hoc subgrouping of patients at high risk May investigate even rare events Power increases over time | Requires a limited contribution of a large number of surgeons Recurrence rate are replaced by re-operation for recurrence Generally lower rate of follow-up than in RCT Low internal validity if not data are monitored |
RCT
| High internal validity Allows for comparison of methods of repair under standardized study conditions Simple statistical analyses with comparative methods Can prove the impact of a specific change in treatment on a specific outcome in a specific setting Short-term rates of recurrence and chronic pain can be determined | Specified inclusion and exclusion criteria limit the external validity Inclusion of all consecutive patients is difficult Results are mostly obtained by a limited number of experts under optimal conditions Extensive contribution from participating study investigators is required Follow-up for more than a few years is rarely possible Focus on a single primary endpoint All confounders are usual not considered Post hoc subgrouping usually is not possible or justified Usually insufficient power to detect rare events |
Discussion
Outcomes and Quality Assessment
Introduction
Evidence and discussion
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Which outcomes?
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Should risk adjustment be performed?
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How should risk adjustment be done (if it is done)?
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Are data collected accurately and reliably?
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When does a valid outcome manifest after an operation?
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What follow-up time is required?
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How is outcome information collected when routine follow-up is not done?
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Will outcome data collection significantly add to surgeons’ workloads?
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Will outcome data collection significantly add to other healthcare workers’ workloads?
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Will costs be increased?
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Who will pay for these cost increases (if they occur)?
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Data available to the lay public must be both understandable and detailed enough to provide valid decision making tools.
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Will there be legal implications of outcome data collection and dissemination?
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Will there be regulatory or governmental implications?
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The EQ-5D Index, a general measure of patients’ quality of life
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The EQ-VAS, which provides a simple snapshot of patients’ self-reported health.
Dissemination and Implementation
Introduction
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What are the target groups for the guidelines?
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What are the most important messages of the guidelines, both general and specific, for the targeted groups?
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Which channels can be used for guidelines distribution?
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How can the guidelines be supported by Internet tools, platforms, Apps and social media?
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What is the evaluation strategy for the implementation process?
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Surgeons and physicians treating groin hernia patients
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Healthcare providers performing services for the treatment of hernias
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Groin hernia patients and their family members
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Branding—HerniaSurge. The aim is for the guidelines to be well-recognized, effective and disseminated worldwide.
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Translation of the key statements and recommendations of the guidelines into languages that are most spoken: Mandarin, Spanish, French, Portuguese, Arabic, Russian, Japanese and German.
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Website: http://www.HerniaSurge.com—a platform that consolidates the main aspects of the guidelines, gives insight into their development methodology, provides a database of the multimedia supplements and also includes resources for patients and medical professionals.1841.Patient Resources
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Short videos explaining the pathology of IH and the most common surgical procedures.
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A brief explanation of the purpose for which the guidelines were created.
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Highlights of the most important issues that are of particular interest to IH patients (e.g., the prevention and treatment of chronic pain).
2.Resources for medical professionals-
Full guidelines.
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Short explanations of main objectives, methods and key recommendations in several languages.
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Database with literature.
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Social media: Facebook and LinkedIn pages including several selected topics (much more concise than the HerniaSurge website)1.Resources for patients: three to four videos as mentioned above with simple explanations on the aim of the guidelines and the key recommendations that are of particular interest to patients, translated into different languages.2.Resources for medical professionals: short explanations on main objectives, methods and key recommendations in several languages.
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Publication of the key recommendations with reference to the full guidelines (on the HerniaSurge website) through every Hernia or National General Surgery Society after an inventory of these societies worldwide.
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Presentation of the key recommendations worldwide at hernia congresses (EHS/AHS/EAES/Annual congresses of Hernia Societies).
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Mass media: several mass channels (for example, Euronews, BBC, CNBC) should be approached through media and communication departments to communicate the existence of the first worldwide surgical guidelines. Spokesmen will be chosen for this task.
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Video—tutorial videos for procedures. Videos of the most common hernia operations for the instruction of new learners (Lichtenstein, TEP, TAPP).
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Podcasts—recorded discussions on the guidelines conducted by recognized hernia experts and authorities. There will be a few selected essential topics like algorithms for groin hernia treatment pointing out the advantages and disadvantages of proposed procedures as well as defining the indications. Most importantly, this information will be submitted in an understandable and accessible fashion so that they are clear even for novice surgeons. The information should focus on the complexity of the treatment selection accordingly to defined factors such as gender, age, etc. These factors will be determined by the HerniaSurge Group and presented in the Podcast.
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Teaching—PowerPoint presentations will be developed and available on the website. Surgeons worldwide will be able to use these for teaching/learning in their own institutions.
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App—HerniaSurge will create an application for PC, smartphones and other devices which will help to analyze and select the best treatment option for individual patients according to the guidelines. Further it will contain critical information on the topic, an anatomical atlas of the groin region, answers on all frequently asked questions and a knowledge quiz to entertain and stimulate the curiosity of residents and experts.
Inguinal Hernia Surgery in Low Resource Settings
Introduction
Evidence in literature
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Antibiotics are recommended, particularly when mesh is implanted.
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For incarcerated hernias without bowel necrosis, a mesh repair with antibiotic coverage might be recommended.
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Antibiotics are recommended in all strangulated hernia repairs with or without bowel necrosis.
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Antibiotic administration was not standardized across the studies.
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No recommendations about nutritional supplementation were made.
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Surgeons needing focused training and skill development
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Hernia societies can create a hernia surgery certificate program whereby LRS surgeons receive a certificate of completion/competence after finishing a supervised course of study and demonstrate competent performance of a series of IH repair skills.
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Healthcare provider continuous education and skills training
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Open to surgeons and all others involved in IH patient care activities.
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May involve periodic visits from referral hospital personnel, telemedicine, review of educational materials.
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On-site support and training in hernia surgery by surgeon specialists from referral hospitals to outlying facilities.
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Operators/surgeons in outlying hospitals
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Can be visited on a rotating or as-needed basis by hernia specialists in a series of “surgical camps”.
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Questions for research
Incidence and epidemiology
Pathophysiology
Classification
Indications for surgery
Surgical treatment of inguinal hernia
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What is the true recurrence rate and risk for chronic pain after Shouldice repair?
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Is only SAC resection in young patients with an L1 inguinal hernia a safe procedure in terms of recurrence rate?
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Is there a significant difference in results of tissue (Shouldice) repair between an indirect and a direct hernia?
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Are the outcomes after repair with a self-adhesive mesh comparable with a repair with a flat mesh for Lichtenstein?
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Do TEP and TAPP truly have equal results to each other?
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What are the advantages of the use of Prolene Hernia System (PHS) or UltraPro Hernia System (UHS) compared to Lichtenstein and TEP, TAPP?
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What are the long-term recurrence rates after inguinal hernia repair with PHS or UHS? Are these results significantly better to justify the use and subsequent scarring of both the anterior and posterior compartment?
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There is a need to design a large RCT comparing laparo-endoscopic and Lichtenstein repair in primary unilateral inguinal hernia repair in male patients by surgeons who are experts in both these respective techniques.
Individualization in treatment options
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Which surgical technique should be used in patients with an inguinal hernia with the following characteristics: high preoperative pain, smoking, collagen disease, obesity, ascites, physical active or elderly?
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Which surgical technique should be used in patients with an inguinal hernia with the following characteristics: small indirect, (large) medial or large lateral hernias, non-reducible hernias, incarcerated hernias or strangulated hernias?
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What is the best management strategy in elderly patients with a minimal or asymptomatic inguinal hernia, watchful waiting or surgery?
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Is there an indication in certain cases (low risk for recurrence, high risk for pain) to perform non-mesh repair?
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Should open repair under local be promoted?
Occult hernia and bilateral repair
Day surgery
Meshes
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How are the physiological requirements of mesh with focus on strength and elasticity to meet its functional needs defined?
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Which mesh material or design avoids scar entrapment or erosion?
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What is the value of bioactive meshes with drug release to avoid chronic pain, adhesions, or infection?
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What are the characteristics of the mesh surfaces to minimize the risk for bacterial adherence and for infection in contaminated wounds or surroundings?
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What are the molecular details of the wound healing process around a foreign body?
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Mesh related complications manifest with a considerable delay, the incidence rises with time and is higher for younger patients. Should there be a limitation by the patients’ age to perform a mesh procedure? What is the impact of age on the risk–benefit ratio of meshes or mesh procedures?
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There is a need for a propensity score matching of large data from registries comparing the use of different kinds of meshes (e.g., large-pore versus small-pore) in primary unilateral inguinal hernia repair in male patients.
Clinical outcome
Mesh fixation
Antibiotic prophylaxis
Anesthesia
Postoperative pain, prevention and management
Convalescence
Groin hernia in women
Complications, prevention and treatment
Emergency groin hernia treatment
Training and learning curve
Specialized centers and hernia specialists
Costs
Registries
Outcomes and quality assessment
Implementation
Inguinal hernia surgery in low resource settings
Proposed trials
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A randomized controlled trial including young male adults (18–25-years-old) with an inguinal hernia comparing SAC resection only with a Shouldice repair and a Lichtenstein/TEP. Follow-up should entail 5 years with primary outcomes recurrence and pain.
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A randomized controlled trial in a specialized environment comparing Shouldice with Lichtenstein and TEP/TAPP.
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Propensity score matching analysis comparing Shouldice versus Lichtenstein versus TEP versus TAPP in large patient population from registries with an equal distribution of patient characteristics, risk factors and hernia findings.
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An RCT in which unilateral one sided symptomatic IH is compared to bilateral repair (laparo-endoscopically) stratified for medial and lateral hernias. Prospective analysis of the prognosis of an occult hernia should be performed.
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Large registry randomized controlled trials with long-term follow-up (> 5 years) comparing all surgical techniques (open non-mesh, open anterior mesh, open posterior mesh and laparo-endoscopic) in primary and recurrent hernia, unilateral and bilateral inguinal hernia repair in male and female patients. Patients should be operated by expert surgeons in the respective technique.
Summary for general practitioners
Background
Management of groin hernia
Groin hernias: a patient’s perspective
Groin hernia: definition and some general comments
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Male gender
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Those with family members who have groin hernias
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So-called “impaired collagen metabolism” (collagen is a protein in many body tissues like muscle)
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Those with a previous hernia
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The elderly
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Those who’ve undergone removal of the prostate gland
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The obese
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Those who are extremely thin (so-called “low body mass index”).
Groin hernia diagnosis
Groin hernia treatment
Groin hernia operations: types and details
Complications
Groin hernia operation: recovery
Further reading
Acknowledgements
M. P. Simons | (MSI) | The Netherlands (coordinator SC) |
M. Smietanski | (MSM) | Poland (European Hernia Society, Treasurer, SC) |
H. J. Bonjer | (HJB) | The Netherlands (European Association for Endoscopic Surgery SC) |
R. Bittner | (RB) | Germany (International Endo Hernia Society, SC) |
M. Miserez | (MMI) | Belgium (Editor Hernia, SC) |
Th. J. Aufenacker | (TA) | The Netherlands (Statistical expert, SC) |
R. J. Fitzgibbons | (RJF) | USA (Americas Hernia Society, Editor Hernia, SC) |
P. K. Chowbey | (PC) | India (Asia Pacific Hernia Society, SC) |
H. M. Tran | (HT) | Australia (Australasian Hernia Society, SC) |
R. Sani | (RSA) | Niger (Afro Middle East Hernia Society, SC) |
F. Berrevoet | (FB) | Ghent | Belgium |
J. Bingener | (JBC) | Rochester | USA |
T. Bisgaard | (TB) | Copenhagen | Denmark |
K. Bury | (KB) | Gdansk | Poland |
G. Campanelli | (GC) | Milan | Italy |
D. C. Chen | (DCH) | Los Angeles | USA |
J. Conze | (JC) | München | Germany |
D. Cuccurullo | (DCU) | Naples | Italy |
A. C. de Beaux | (ADB) | Edinburgh | UK |
H. H. Eker | (HE) | Amsterdam | The Netherlands |
R. H. Fortelny | (RFO) | Vienna | Austria |
J. F. Gillion | (JG) | Antony | France |
B. J. van den Heuvel | (BJH) | Amsterdam | The Netherlands |
W. W. Hope | (WWH) | Wilmington | USA |
L. N. Jorgensen | (LNJ) | Copenhagen | Denmark |
U. Klinge | (UK) | Aachen | Germany |
F. Köckerling | (FK) | Berlin | Germany |
J. F. Kukleta | (JK) | Zurich | Switzerland |
I. Konate | (IK) | Saint Louis | Senegal |
A. L. Liem | (LL) | Utrecht | The Netherlands |
D. Lomanto | (DL) | Singapore | Singapore |
M. J. A. Loos | (MLO) | Veldhoven | The Netherlands |
M. Lopez-Cano | (MLC) | Barcelona | Spain |
M. C. Misra | (MM) | New Delhi | India |
A. Montgomery | (AM) | Malmö | Sweden |
S. Morales-Conde | (SMC) | Sevilla | Spain |
F. E. Muysoms | (FM) | Ghent | Belgium |
H. Niebuhr | (HN) | Hamburg | Germany |
P. Nordin | (PN) | Östersund | Sweden |
M. Pawlak | (MP) | Gdansk | Poland |
G. H. van Ramshorst | (GVR) | Amsterdam | The Netherlands |
W. M. J. Reinpold | (WR) | Hamburg | Germany |
D. L. Sanders | (DS) | Barnstaple | UK |
N. Schouten | (NS) | Utrecht | The Netherlands |
S. Smedberg | (SS) | Helsingborg | Sweden |
R. K. J. Simmermacher | (RSI) | Utrecht | The Netherlands |
S. Tumtavitikul | (ST) | Bangkok | Thailand |
N. van Veenendaal | (NVV) | Amsterdam | The Netherlands |
D. Weyhe | (DW) | Oldenburg | Germany |
A. R. Wijsmuller | (AW) | Rotterdam | The Netherlands |
J. Jeekel | Rotterdam | Europe |
A. Sharma | New Delhi | Asia |
B. Ramshaw | Knoxville | Americas |