Introduction
References (in parentheses graduation of evidence)
Chapter 1: Perioperative management: evidence for antibiotic and thromboembolic prophylaxis in endoscopic/laparoscopic inguinal hernia surgery?
Agneta montgomery
References (in parentheses graduation of evidence)
Chapter 2: Technical key points in TAPP repair
Jan F. Kukleta, Reinhard Bittner
Level 1B | In thin patients (BMI < 27), the direct trocar insertion is a safe alternative to the Veress needle technique (stronger evidence). |
Grade C | The direct trocar insertion (DTI) can be used in order to establish pneumoperitoneum as a safe alternative to Veress needle, Hasson approach or optical trocar, if patient’s risk factors are considered and the surgeon is appropriately trained (new recommendation). |
Level 2B | Use of 10-mm trocars or larger may predispose to hernias, especially in the umbilical region or in the oblique abdominal wall (Stronger evidence). |
Grade B | Fascial defects of 10 mm or bigger should be closed (Stronger evidence). |
Grade B | A thorough closure of peritoneal incision or bigger peritoneal tears should be achieved (Stronger evidence). |
References (in parentheses graduation of evidence)
Chapter 3: Technical key points in TEP
Ferdinand Köckerling, Pradeep Chowbey, David Lomanto
Level 4 | Alternatively to fixation of the extended fascia transversalis to Copper’s ligament the direct inguinal hernia defect can be closed by a pre-tied suture loop (new statement). |
Grade D | As alternative the primary closure of direct inguinal hernia defects with a pre-tied suture loop can be used (new recommendation). |
Level 3 | Transection of a large indirect sac does not lead to significant differences in postoperative pain, length of hospital stay and recurrence, but to a significant higher seroma rate (new statement). |
Grade C | A large indirect sac may be ligated proximally and divided distally without the risk of a higher postoperative pain and recurrence rate, but with an increased postoperative seroma rate (new recommendation). |
Level 3 | Drain after TEP significantly reduces the incidence of seroma formation with increasing the risk of infection or recurrence (new statement). |
Grade C | A closed-suction drain can be used to reduce the risk of seroma formation without increased risk of infection (new recommendation). |
Level 1 A | Extraperitoneal bupivancaine treatment during endoscopic TEP inguinal hernioplasty is not more efficacious for the reduction of pain than placebo. |
Grade A | Extraperitoneal bupivacaine treatment during endoscopic TEP inguinal hernia repair for the reduction of postoperative pain should not be performed. |
Chapter 3
Chapter 4: TEP versus TAPP: which is better?
Subodh Kumar, Mahesh C. Misra, Virinder K. Bansal, Devanshu Bansal
Level 1A | TAPP has a longer hospital stay compared to TEP (new). |
Level 1B | Potentially serious adverse events are rare after both TAPP and TEP (stronger evidence). |
TAPP has a longer operation time compared to TEP (new). | |
Level 2C | TEP has more intra-operative and postoperative surgical complication rate compared to TAPP (new). |
Grade A | Both techniques are acceptable treatment options for inguinal hernia repair and there is sufficient data to conclude that both TAPP and TEP are effective methods of laparoscopic inguinal hernia repair (stronger evidence). |
References (in parentheses graduation of evidence)
Chapter 5: Endoscopic/laparoscopic surgery in complicated hernias: feasibility, risks, and benefit
George Ferzli, Michel Timoney
Level 3 | TEP inguinal-scrotal hernia repair remains an advantageous approach during the difficult scrotal hernia that requires “conversion” to an open repair, because the pre-peritoneal dissection performed laparoscopically allows for reduction of the hernia and optimal mesh placement once the hernia repair has been converted and is performed from the anterior approach (new). |
Grade C | TEP approach for the large, difficult scrotal hernia may serve as an adjunct to dissection and definition of the pre-peritoneal space allowing for easier hernia and mesh placement once the case is “converted” to open repair (new). |
Level 3 | Laparoscopic hernia repair for incarcerated inguinal hernia has been successfully and safely performed in the pediatric population (new). |
Grade C | Laparoscopic hernia repair for incarcerated inguinal hernia may be successfully and safely performed in the pediatric population by surgeons with laparoscopic expertise (new). |
Level 4 | Women are at increased risk of having an occult synchronous femoral hernia (New). |
Grade C | When performing inguinal hernia repair in women, extra effort should be undertaken to reveal and treat occult synchronous femoral hernia (New). |
References (in parentheses graduation of evidence)
Chapter 6: Mesh size and recurrence
Thue Bisgaard, Jacob Rosenberg
References (in parentheses graduation of evidence)
Chapter 7: Heavy or light weight mesh in TAPP and TEP—functional outcome and quality of life
Dirk Weyhe, F. Koeckerling, Uwe Klinge
Level 1 A | The statistical significance that lighter meshes with larger pores results in improvement of quality of life is not consistent in recently published meta-analyses. Subset analysis revealed no higher risk of recurrence after using lightweight meshes in laparoscopic inguinal hernia repair (New). |
Level 2B | The middle- and long-term results of prospective studies in men do not support the hypothesis that bilateral inguinal hernia repair with alloplastic mesh prosthesis causes male infertility or decreasing the sperm motility (New). |
Grade B | A monofilament implant with a pore size of at least 1.0–1.5 mm (usually meaning low-weight) consisting of a minimum tensile strength in all directions (including subsequent tearing force) of 16 N/cm appeared to be most advantageous; however, this assumption mainly summarizes personal and published clinical and experimental experiences (stronger evidence). |
The application of large pore polypropylene meshes in endoscopic hernia repair is harmless concerning azoospermia and should therefore further used (New). |
References (in parentheses graduation of evidence)
Chapter 8: Slitting or not slitting of mesh—does it influence outcome?
Thue Bisgaard, Jacob Rosenberg
Level 1 | Cutting a slit in the mesh to allow the structures of the funicel to pass does not compromise testicular perfusion and testicular volume (New). |
Grade B | Based on available evidence we recommend not to cut a slit in the mesh although cutting does not compromise testis perfusion (New). |
References (in parentheses graduation of evidence)
Chapter 9: Mesh fixation modalities: is there an association with acute or chronic pain?
René H. Fortelny, Wolfgang Reinpold, Agneta Montgomery
Level 1A | Fixation and non-fixation of the mesh in TEP are associated with equally risk of postoperative pain or recurrence (New). |
Level 1B | Fibrin glue fixation is associated with less chronic pain than stapling. |
Grade A | If TEP technique is used, non-fixation has to be considered in all types of inguinal hernias except large direct defects (MIII, EHS classification) (stronger recommendation). |
Grade B | In case of TAPP repair non-fixation should be considered in types LI, II, and MI, II hernias (EHS classification). |
For fixation, fibrin glue should be considered to minimize the risk of acute postoperative pain (modified recommendations). |
References (in parentheses graduation of evidence)
Chapter 10: Risk factors and prevention of acute and chronic pain in TAPP and TEP
Wolfgang Reinpold
Level 1A | There is no difference of chronic pain after TEP and TAPP (stronger evidence). |
Fixation and non fixation of the mesh in TEP are associated with equally risk of postoperative pain (see chapter “Fixation”) (new). | |
Level 1B | Fibrin glue fixation is associated with less chronic pain than stapling (see chapter “Fixation”) (new). |
Level 2A | Age below median (40–50 years) is a risk factor for acute pain (stronger evidence). |
Age below median (40–50 years) is a risk factor for chronic pain (stronger evidence). | |
Severe acute postoperative pain is a risk factor for chronic pain (stronger evidence). |
Grade A | If TEP technique is used non fixation has to be considered in all types of inguinal hernias except large defects (L III, MIII; EHS classification; see chapter “Fixation”) (new). |
Grade B | In case of TAPP repair non fixation should be considered in types LI, LII, MI, MII hernias (EHS classification, see Chapter “Fixation”) (new). |
References (in parentheses graduation of evidence)
Chapter 11: Urogenital complications associated with TAPP and TEP
Robert J. Fitzgibbons
Level 2B | Inguinal hernia repair with mesh is not associated with an increased risk of, or clinically important risk for, male infertility. (new). |
Grade B | Groin hernia repair using mesh techniques may continue to be performed without major concern about the risk for male infertility. (new). |
References (in parentheses graduation of evidence)
Chapter 12: Intraperitoneal onlay mesh (IPOM) for inguinal hernia repair—still a therapeutic option?
Kevin L. Grimes, Kirpal Singh, Maurice E. Arregui
References (in parentheses graduation of evidence)
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No new references.
Chapter 13: Role for open preperitoneal mesh placement in the era of endo/laparoscopic inguinal hernia repair
Kevin L. Grimes, Kirpal Singh, Maurice E. Arregui
Level 1B | Minimally invasive open approaches (i.e., Kugel) may offer a cost advantage over laparoscopic approaches. (new). |
References (in parentheses graduation of evidence)
Chapter 14: Single port surgery or reduced ports in endoscopic/laparoscopic hernia repair (New chapter)
Davide Lomanto
Level 2B
| Single port laparoscopic hernia repair is a safe and feasible alternative to traditional multiport technique although has not been showed to be superior or more effective. |
Single port laparoscopic hernia repair may offer a better cosmetic outcome and patient’s satisfaction. | |
Single port laparoscopic hernia repair has no increased risk compared with standard multiport technique. | |
Homemade ports, as an alternative to commercially available ports, provides a feasible and safe alternatives |
Grade B | Single port laparoscopic inguinal hernia repair is safe and feasible alternative options to conventional laparoscopy in selected cases but further RCTs are needed. |
Both TAPP and TEP can be performed with equal results in selected cases. |
References (in parentheses graduation of evidence)
Chapter 15: Convalescence after hernia surgery (New chapter)
Hartmut Buhck
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immediate full activity without strain limits (n = 1,069).
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reduced activity for 3–4 weeks (n = 1,306) or
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no specific recommendations (8,297 reference patients from the Danish Hernia Database).
Level 1B | There is no evidence for an increase in recurrence risk due to physical strain (including heavy lifting) after groin hernia surgery irrespective of the method of surgery. |
Level 3 | Immediate return to work (within 1–3 days) is not associated with hernia recurrence. |
Immediate resumption of activity of daily living (ADL) (within 1–3 days) is not associated with hernia recurrence. | |
Short convalescence is not associated with a higher recurrence risk, and some studies even show an inverse relation |
Grade B | Patients should be actively assured that physical activity of any kind does not jeopardize the stability of groin hernia repair. |
Patients should be encouraged to resume work and ADL after 1 day. |
Level 2A | Pain is an important limiting factor for the resumption of work and physical activities after groin hernia repair. |
Level 3 | Patients’ attitude toward convalescence is heavily influenced by their surgeons’ recommendation. |
Return to work is heavily influenced by the type of sick-leave compensation. |
Grade C | Effective pain control is a prerequisite of early return to work and ADL. |
Grade B | Patients should be counseled with regard to availability and side effects of analgesics. |
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Within series of patients with identical recommendations by the surgeon, pain is the single most important reason stated for extended periods of inactivity [16, 18–20].
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Between series, there are two important factors
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recommendation given by the surgeon (and the resulting expectation of the patient) [19, 21–23].
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type and generosity of sick-leave compensation [10, 24, 25].
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Level 1B | No specific period of physical inactivity is required after groin hernia repair. |
Grade B | The patient’s individual wish after counseling is to be respected and facilitated, e.g., by generous analgesics prescription; however, extended periods of sick-leave are usually not necessary and should not be supported |
Level 1A | Postoperative pain is less pronounced after endoscopic as compared to open hernia repair. |
Endoscopy hernia surgery is associated with shorter vocational downtime and earlier resumption of ADL as compared to open hernia repair. |
Grade B | With respect to convalescence, endoscopic hernia repair is preferable over open techniques. |
References (in parentheses graduation of evidence)
Chapter 16: Sportsman hernia—diagnosis and treatment
Salvador Morales-Conde/Moshe Dudai, Reinhard Bittner
Level 2B | CT scan has high accuracy in detecting posterior wall deficiency (PWD. (new) |
Level 1B | Surgery (endoscopic placement of retropubic mesh) is more efficient than conservative therapy for the treatment of sportsman’s hernia. (stronger evidence). |
In Sportsman’s hernia the results of surgical repair to the posterior inguinal wall are excellent. (stronger evidence). | |
For conservative treatment the use of radiofrequency denervation of both ilio-inguinal nerve and inguinal ligament in the treatment of refractory Sportsman’s Hernia is safe and efficacious at least in the short term, and is superior to anesthetic/steroid injection. (new). |
Grade A | Endoscopic placement of retropubic mesh must be considered a serious option for Sportsman hernia. (stronger evidence). |
For conservative treatment of refractory Sportsman’s hernia, radiofrequency denervation of both ilio-inguinal nerve and inguinal ligament must be considered, in the short term, an alternative to anesthetic/steroid injection. (new). |
References (in parentheses graduation of evidence)
Chapter 17: Evidence based training for endoscopic/laparoscopic hernia repair (New chapter)
Juliane Bingener
Level 1A | Simulation training improves trainee satisfaction, trainee knowledge, time and process measure of skills, behaviors, compared to no training and to non-simulation training. |
Level 1A | Computer simulation and box trainers improve operative performance. |
Box training is as effective as computer simulation and results in higher learner satisfaction | |
Level 1B | Cognitive training plus mastery learning on box trainers improves patient outcome |
Level 2B | GOALS-GH is an objective and valid measure of skills required to perform LIHR (TAPP and TEP). |
Training on fresh frozen cadaver has higher face validity than training on a VR trainer. |
Grade A | A simulation trainer should be available to all learners to improve operative performance. |
At the current time, box trainers are preferred over computer-assisted simulation for inguinal hernia repair. | |
Grade B | A proficiency-based curriculum for the available trainer tool should be established to improve patient outcomes. |
A validated assessment tool should be used to assess proficiency. |
References (in parentheses graduation of evidence)
Chapter 18: Costs in endoscopic/laparoscopic and open hernia surgery (New chapter)
Reinhard Bittner, Ferdinand Köckerling
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Does hernia surgery offer value for money, is there a difference between open and laparoscopic surgery?
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Which factors are influencing the costs in inguinal hernia surgery?
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Which of the cost factors the surgeon is able to influence?
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Are there possibilities to reduce the costs?
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Are there differences in direct costs (hospital) between open and laparoscopic repair?
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Are there differences in indirect costs (societal) between open and laparoscopic repair?
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Are there differences in the costs per QALY between open and laparoscopic surgery?
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Which measures can be recommended for cost reduction?
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Can additional measures be recommended for practitioners who work in countries with limited health care resources?
Level 1A | When using disposable trocars and instruments direct costs (hospital) are higher for laparoscopic inguinal hernia repair. |
Total costs (hospital and societal) are lower for laparoscopic inguinal hernia repair compared to open. | |
Operation time is a cost-relevant factor. | |
Time for anesthesia is a cost-relevant factor. | |
Experience and quality of performance are cost-relevant factors. | |
Simulator-training may improve quality of performance. | |
Level 2C | Hernia surgery is cost-effective. It may be superior to “watchful waiting” in the long run. |
Laparoscopic hernia surgery offers a higher cost-utility compared to open. | |
Hospitals costs for laparoscopic hernia repair may be similar or lower compared to open but there is a large variation in cost per QALY generated by individual providers. | |
In hospitals with a high case load costs are lower. |
Grade A | Non-disposable trocars and instruments must be considered. |
Non-fixation techniques should be considered. Use of no or indigenous balloon must be considered. | |
Operative performance and education of the surgeons must be improved. | |
To shorten the learning curve of traineesurgeons, simulator training should be introduced. | |
Grade B | In hernia disease surgery might be superior to “watchful waiting”. |
From the point of cost-utility laparoscopic inguinal hernia repair may be considered. | |
To enhance the case load centralization of hernia surgery should be considered. |