Table of contents
Introduction
1A. Systematic review of RCTs (with consistent results from individual studies). |
1B. RCTs (of good quality). |
2A. Systematic review of 2B studies (with consistent results from individual studies). |
2B. Prospective comparative studies (or RCT of poorer quality). |
2C. Outcome studies (analyses of large registries, population-based data, etc.). |
3. Retrospective, comparative studies, case–control studies. |
4. Case series (i.e., studies without control group). |
5. Expert opinion, animal or lab experiments. |
Chapter 1: Perioperative management: what is the evidence for antibiotic and thromboembolic prophylaxis in laparoscopic inguinal hernia surgery?
Agneta Montgomery
Department of Surgery, University Hospital Skåne, Malmö, Sweden
Level 5 | There is insufficient evidence for routine antibiotic prophylaxis in laparoscopic hernia surgery. |
Level 5 | There is insufficient evidence for routine thromboembolic prophylaxis in laparoscopic hernia surgery. |
Grade D | Antibiotic prophylaxis for elective laparoscopic inguinal hernia repair cannot be universally recommended. |
Grade D | It is recommended that antibiotic prophylaxis should be considered in the presence of risk factors for wound and mesh infection based on patient (advanced age, corticosteroid usage, immunosuppressive conditions and therapy, obesity, diabetes, and malignancy) or surgical complications (contamination, long operation time, drainage, urinary catheter). |
Grade D | It is recommended that thromboembolic prophylaxis is given according to usual routines in patients with risk factors. |
Author | Prophylaxis Total n
| Infection prophy laxis (%) | Nonprophylaxis Total n
| Infected nonprophylaxis (%) | RRA CI 95% | NNT | Level of evidence |
---|---|---|---|---|---|---|---|
Open hernia surgery included in Cochrane | |||||||
Evans et al. (1973) [16] | 48 | 2.1 | 49 | 4.1 | 2 (−4.9, 8.9) | 50 | 3b |
Anderson et al. (1980) [17] | 137 | 3.6 | 150 | 4 | 0.4 (−4.1, 4.7) | 285 | 2b |
Platt et al. (1990) [18] | 301 | 1.3 | 311 | 1.9 | 0.6 (−1.4, 2.6) | 167 | 1b |
Lazhortes et al. (1992) [19] | 155 | 0 | 153 | 4.6 | 4.6 (1.2, 7.9) | 22 | 2b |
Taylor et al. (1997) [20] | 283 | 8.8 | 280 | 8.9 | 0.1 (−4.6, 4.7) | 1057 | 1b |
Morales et al. (2000) [21] | 237 | 1.7 | 287 | 2.1 | 0.4 (−1.9, 2.7) | 248 | 1b |
Yerdel et al. (2001) [22] | 136 | 0.7 | 133 | 9 | 8.3 (3.2, 13.4) | 12 | 2b |
Oteiza et al. (2004) [23] | 124 | 0.8 | 123 | 0 | −0.8 (−2.4, 0.7) | 124 | 2b |
Aufenacker et al. (2004) [24] | 475 | 1.7 | 472 | 1.9 | 0.2 (−1.5, 1.9) | 449 | 1b |
Celdan et al. (2004) [25] | 50 | 0 | 49 | 8.1 | 8.2 (0.5, 15.8) | 12 | 2b |
Pessaux et al. (2005) [5] | 2008 | 3.4 | 394 | 5.1 | 1.7 (−0.6, 4) | 59 | 2b |
Perez et al. (2005) [26] | 174 | 1.7 | 176 | 3.4 | 1.7 (−1.6, 5) | 59 | 2b |
Total | 4,128 | 2.9 | 2577 | 3.9 | 1.1 (0.2, 2) | 92 | |
Laparoscopic hernia surgery not included in Cochrane | |||||||
Schwetling and Bärlehner (1998) [14] | 40 | 0 | 40 | 0 |
ns
| 2b | |
Open hernia surgery not included in Cochrane | |||||||
Tzovaras et al. (2007) [15] | 193 | 2.6 | 193 | 4.4 |
p = 0.4 | 2b |
Study | Name, country | Antibiotic prophylaxis | Total | Lap group | Lap infect. (%) | Open group | Open infect. (%) |
n
|
---|---|---|---|---|---|---|---|---|
Liem et al. (1997) [6] | Coala, Netherlands | ? | 994 | 487 TEP | 0 | 507 Optional | 1.2 | 0.03 |
MRC 1999 [7] | MRC, UK | ? | 928 | 468 TEP, TAPP | 2.8 | 460 Optional | 3.1 | NS |
Berndsen et al. (2002) [8] | SMIL I, Sweden | No | 1,042 | 518 TAPP | 0.8 | 524 Shouldice | 0.8 | NS |
Neumayer et al. (2004) [9] | AV, USA | ? | 1,983 | 989 TEP, TAPP | 1 | 994 Lichtenstein | 1.4 | NS |
Eklund et al. (2006) [10] | SMIL II, Sweden | No lap yes open | 1,371 | 665 TEP | 1.4 | 706 Lichtenstein | 0.7 | 0.21 |
Total | 6,318 | 3,127 | 1.2 | 3,191 | 1.3 |
Chapter 2: Technical key points in transabdominal preperitoneal patch plasty (TAPP)
Jan F. Kukleta, Reinhard Bittner
Klinik Im Park Zurich, CH/Stuttgart, D
Level 5 | The level of evidence for the different technical key points is very heterogeneous. |
Level 5 | The supposed consensus on the technical requirements for TAPP is not well supported by the literature. |
Grade D | To standardize particular technical steps in TAPP is a complex task; thus, it is recommended to adhere strictly to the principles of minimally invasive techniques and to structure teaching and training. |
Grade D | Specialized centers or high-volume teaching institutions are recommended. |
Level 4 | If the patient does not empty his/her urinary bladder, the operation may be more difficult with a higher risk of bladder injury. |
Level 4 | Perioperative catheterisation of urinary bladder is very rarely necessary. |
Grade D | It is recommended that the patient empty his/her bladder before the operation. |
Grade D | Restrictive per- and postoperative intravenous fluid administration reduces the risk of postoperative urinary retention. |
Grade D | If you expect technical difficulties (e.g., after prostatic surgery, scrotal hernia) or an extended operating time, consider using a urinary catheter during the intervention. |
Grade 1A | There is no evidence for a difference in surgical site infections SSI between hair removal or no removal before surgery. |
Grade 1A | Shaving causes significantly more SSIs than hair clipping. |
Grade 1A | There is no difference in SSIs when hair is shaved or clipped 1 day before surgery or on the day of surgery. |
Level A | Clipping results in fewer SSIs than razor shaving. |
Level A | Hair can be removed even the day before surgery. |
Level 2B | Chronic pain may develop after inguinal hernia repair. |
Level 5 | In a significant number of cases, unsuspected hernias are found on the contralateral side at surgery. |
Grade B | The patient should be informed about the possibility of a negative outcome (chronic pain). |
Grade D | The patient with unilateral groin hernia should be asked to give his/her consent to allow simultaneous repair if a contralateral occult hernia is found and he/she wishes it. |
Level 1A | There is no definitive evidence that the open entry technique for establishing pneumoperitoneum is superior or inferior to the other techniques currently available. |
Level 1B | In thin patients (BMI <27), the direct trocar insertion is a safe alternative to the Veress needle technique. |
Level 2C | Establishing pneumoperitoneum to gain access to the abdominal cavity represents a potential risk of parietal, intra-abdominal, and retroperitoneal injury. |
Patients after previous laparotomy, obese patients, and very thin patients are at a higher risk. | |
Level 3 | Waggling of the Veress needle from side to side must be avoided, because this can enlarge a 1.6-mm puncture injury to an injury of up to 1 cm in viscera or blood vessels. |
Level 4 | The various Veress needle safety tests or checks provide insufficient information on the placement of the Veress needle. |
The initial gas pressure when starting insufflation is a reliable indicator of correct intraperitoneal placement of the Veress needle. | |
Left upper quadrant (LUQ, Palmer’s) laparoscopic entry may be successful in patients with suspected or known periumbilical adhesions or history or presence of umbilical hernia, or after three failed insufflation attempts at the umbilicus. |
Grade A | When establishing pneumoperitoneum to gain access to the abdominal cavity, extreme caution is required. Be aware of the risk of injury. |
The open access should be utilized as an alternative to the Veress needle technique, especially in patients after previous open abdominal surgery. | |
Grade C | The technique of access should be adapted in case of obesity, previous intra-abdominal surgery, and abdominal wall hernias. |
Level 1B | The radially dilating trocars cause less acute injuries (bleeding at trocar site) and less chronic tissue damage (trocar hernias). |
Level 2B | Visual entry trocars are not superior to other trocars, because they do not avoid visceral and vascular injury. |
Level 2B | The visual entry cannula trocars have the advantage of minimizing the size of the entry wound and reducing the force necessary for insertion under visual control. |
Grade A | Cutting trocars should be avoided. |
Level 1B | A significant proportion of incidental defects will progress to a symptomatic hernia if left untreated. |
Level 2B | Clinical examination is accurate only in 75–89% of patients. The sensitivity of ultrasound is clearly higher than a mere physical examination. |
Level 2B | TAPP enables rapid evaluation of the “contralateral groin” (clinically unsuspected) hernia. |
Level 2C | TAPP is beneficial in avoiding unnecessary explorations and repairs of the contralateral side. |
Grade A | The patient with unilateral hernia should be informed about the possibility of having undiagnosed contralateral hernia. |
The patient should be informed about advantages and disadvantages of simultaneous repair. | |
Grade B | In case of clinical uncertainty diagnosing the hernia, an ultrasound examination should be done. |
If the patient agrees, the incidental contralateral defect should be repaired simultaneously. | |
Grade D | In case of diagnostic uncertainty (inguinal pain, inconclusive clinical evaluation, recurrence, occult hernia) despite extensive use of the diagnostic tools—ultrasound, CT scan, MRT—TAPP may be the approach of choice. |
Grade D | When at laparoscopy no hernia opening is visible in patients with strong clinical suspicion of hernia, a preperitoneal exploration is indicated. |
Level 5 | There is not enough data available on the influence of the particular steps of the surgical technique and the individual performance on the outcome. |
Level 5 | Taking down adhesion between omentum or bowel to the peritoneum of groin or to the hernia sac is mostly not necessary. It carries additional risk of intestinal injury. |
Grade D | A meticulous operative technique and the adequate extent of preperitoneal anatomical dissection (whole pelvic floor) belong to the most important key points of TAPP repair. |
Grade D | Reduction of the hernia sac inclusive adherent content if excising should be done en bloc. |
Level 2C | Cord lipomas or lipomas in the femoral canal may imitate primary hernia, hernia recurrence, or become symptomatic in later course. |
Level 4 | Complete reduction of the hernia sac does not increase the incidence of sero-hematomas if careful dissection and control of hemostasis are done. |
Level 5 | Complete reduction of the hernia sac may eliminate the occurrence of chronic seroma/“pseudo-hydrocele.” |
Grade B | Lipomas of spermatic cord/round ligament and the preperitoneal lipomas of direct and femoral sacs should be removed. |
Grade D | In case of unclear anatomy, first identify spermatic vessels. |
Grade D | If dense adhesions to the cord structures are present in a long hernia sac, the sac may be exceptionally transected at the level of inner inguinal ring to prevent injury. |
Level 2B | The incidence of seromas in direct hernias can be significantly reduced when the lax transversalis fascia is inverted. |
Level 2C | Seroma is a common early postoperative minor complication in endoscopic preperitoneal hernia repair. |
Grade B | In voluminous direct hernias, the extended transversalis fascia should be inverted. |
Level 3 | Incomplete peritoneal closure or its breakdown in endoscopic preperitoneal hernia repair increases the risk of bowel obstruction. |
Level 3 | TAPP procedure presents a higher statistical risk of small-bowel obstruction than TEP. |
Level 5 | The most appropriate peritoneal closure is achieved by running absorbable suture. |
Level 5 | Running suture seems to cause less pain compared with clip/tack closure. |
Level 5 | The closure of entrance of indirect sacs may reduce the risk of internal hernia with consecutive incarceration, strangulation, or small-bowel obstruction. |
Grade C | A thorough closure of peritoneal incision or peritoneal tears should be done. |
Grade D | The peritoneal closure can be accomplished by running suture. |
Level 3 | Use of 10-mm trocars or larger may predispose to hernias, especially in the umbilical region or in the oblique abdominal wall. |
Grade C | Trocar sites with fascial defects of 10 mm or larger can be closed. |
Level 5 | Additional use of local anaesthetic positively influences postoperative pain in TEP and TAPP. Infiltration of trocar wounds with long-acting local anaesthetic in TAPP improves patient’s well-being and accelerates return to ambulation. |
Grade D | To improve postoperative pain control, trocar wounds can be infiltrated by local anesthetics. |
Chapter 3: Technical key points: total extraperitoneal patch plasty (TEP) repair
P. Chowbey, F. Köckerling, D. Lomanto
Level 5 | The patient is kept in the supine position. |
Level 5 | The operating surgeon and the camera assistant stay on opposite sides of the hernias. |
Level 4 | Direct open access is a simple and reproducible technique for accessing the preperitoneal space. |
Access by transperitoneal visualization is an alternative but is associated with the risks of entering the peritoneal cavity. | |
Suprapubic Veress needle technique also is used by few surgeons. |
Grade D | Direct access with the Hasson trocar via a 1–2-cm subumbilical incision on the side of hernia and opening of the rectus sheath, enlargement of the space between the rectus muscle and the posterior sheath. |
Level 1B | Balloon dissection is associated with significantly reduced postoperative pain at 6 h, scrotal edema, and seroma formation compared with telescopic dissection. |
At 3 months follow-up, balloon dissection did not offer significant advantage over direct telescopic dissection. | |
The use of a dissection balloon in TEP reduces the conversion rate and may be especially beneficial early in the learning curve. | |
The technique of balloon dissection provides adequate extraperitoneal space creation and is evolving as a method of choice; indigenous balloons contribute to cost-effectiveness. | |
Dissection with the telescope is another frequently used method. | |
Anatomical delineation of inguinal area and dissection in the extraperitoneal space in TEP repair was equally satisfactory in both the balloon dissection and the telescope dissection group. |
Grade A | Balloon dissection should be considered for extraperitoneal space creation, especially during the learning period, when it is difficult to find the correct plane in the preperitoneal space. |
Level 2 B | Needlescopic TEP is a safe technique for the repair of inguinal hernia. |
Postoperative recovery after needlescopic and conventional TEP was similar. | |
Needlescopic TEP conferred a significantly lower pain score upon coughing on the first day after operation. |
Grade C | In patients with a low pain threshold, a needlescopic TEP can be performed. |
Level 5 | The midline ports have the advantage of accessing both sides with equal ease and minimal risk of injuries to the inferior epigastric vessels. |
All three ports made in the midline at the commencement of the procedure enable bimanual dissection right from the start. | |
Another technique of a 10-mm port at the umbilicus, a 5-mm port a few centimeters lower, and another 5-mm trocar laterally near the anterior–superior iliac spine is the next alternative. Overlapping mesh in the midline is thought to be easier with this technique. | |
Lateral ports, two in number, just lateral to the rectus muscle, used along with a midline camera port are an option. |
Grade D | Two alternatives for the trocar placement: two 5-mm working ports in the midline, and in the midway between the camera port and the pubic symphysis. |
Alternatively, the second working trocar (5 or 10 mm) can be placed after lateral dissection approximately 3–4 cm superior and 1–2 cm anterior to the anterosuperior iliac spine. | |
Lateral working trocars are favored when mesh overlap over the midline is perceived to be difficult. |
Level 3 | The dissection should extend superiorly up to the subumbilical area, inferiorly to the space of Retzius, inferolaterally to the psoas muscle and Bogros space until spina iliaca anterior superior is reached, and medially beyond the midline. |
The landmarks to be visualized are the pubic bone, Cooper’s ligament, inferior epigastric vessels, cord structures, the myopectineal orifice boundaries, and the fascia over psoas muscle. | |
Posteriorly, the peritoneum is reflected to the point of which the vas turns medially. | |
Level 4 | Extensive preperitoneal dissection with complete exposure of the myopectineal orifice of Fruchaud is critical to the success of the laparoscopic inguinal hernia repair. |
Grade B | Complete parietalization of the vas deferens and the testicular vessels needs to be performed. |
Complete dissection of the whole pelvic floor (anatomical) should be done for flat placement of the mesh to cover the entire myopectineal orifice and prevent its folding. |
Level 3 | The incidence of peritoneal tear is 47%. |
Techniques for the closure of a peritoneal opening include pretied suture, loop ligation, endoscopic stapling, and endoscopic suturing. | |
To decrease the potential for peritoneal tear, the balloon dissection is modified. Less volume of saline is used for inflation; the balloon is sited away from the scar. | |
Careful dissection in close proximity to the vas deferens and adhesions, in addition to cautious use of traction and counter traction, associated with prudent application of sharp dissection with endo-scissors to divide adhesions can help to prevent peritoneal laceration. |
Grade D | It is recommended that peritoneal tears be closed whenever feasible to prevent adhesions. |
Level 3 | In patients who have previously undergone lower abdominal surgery or suprapubic catheterization, injury to the bladder is the most common major complication of TEP (0.06–0.3%). |
Recognized intraoperatively bladder injuries may be managed endoscopically. |
Grade C | Utmost caution to prevent a bladder injury is necessary in a patient with previous lower abdominal surgery and a high index of suspicion to recognize one intraoperatively and manage if it were to occur. |
Level 3 | Plane should be developed with inferior epigastric vessels anteriorly and the cord structures posteriorly. |
In 2.75%, bleeding from epigastric branches, vessels on the pubic bone or testicular vessels can occur. | |
Level 4 | Inferior epigastric vessels were ligated in 3%, because they blocked the view of the surgeon. |
Inferior epigastric vessel injury occurred in 0.4% of patients during trocar insertion. |
Grade C | Dissection should be performed in the plane posterior to the inferior epigastric vessels, because they are prone to injury when they drop down and also obstruct the view of the surgeon. |
Level 2B | In large direct hernias, inversion and fixation of the extended fascia transversalis to Cooper’s ligament may reduce the frequency of occurrence of serohematoma. |
Level 3 | Direct Hernias are already largely reduced by inflation of the balloon, through the wall of which the whitish enlarged fascia transversalis can be seen overlapping the Cooper’s ligament. |
Seroma formation seems to be more common after repair of direct hernia with significantly enlarged transversalis fascia. | |
In an incarcerated hernia, the opening of the defect may be enlarged to allow safe dissection of its contents. A releasing incision is made of the anteromedial aspect of the defect to avoid injury to epigastric or iliac vessels. |
Grade B | The direct sac should be inverted and anchored to Cooper’s ligament to decrease the risk of seroma and external hematoma formation. |
Grade D | In incarcerated direct hernias, the opening of the defect may be enlarged or an anteromedial releasing incision may be used. |
Level 4 | Dissection of the indirect hernial sac, for the most part blunt, is performed under exposure of the spermatic cord/round ligament and all inguino-femoral hernial orifices. |
Complete dissection of large indirect sacs may carry the risk of an injury of the cord structures or may disturb blood circulation to the testis. |
Grade C | A large indirect sac may be ligated proximally and divided distally. |
Level 2C | Women have a higher risk of recurrence after an open inguinal hernia repair operation due to a higher occurrence of overlooked femoral hernia at primary operation. |
Grade D | A preperitoneal endoscopic approach should be considered in female hernia repair. |
Level 3 | The incidence of incipient unsuspected contralateral hernia is 11.2–20%. |
Laparoscopic hernia repair (TAPP) has a major advantage of allowing the surgeon to explore the site contralateral to the clinically diagnosed hernia without any additional dissection steps. | |
In TEP, the contralateral medial space can be explored easily, but the exploration of the deep inguinal ring may be difficult. |
Grade D | The systematic exploration of the contralateral side using the TEP technique is controversial. |
Further studies are needed. |
Level 1A | Patients who receive anticoagulant are prone to afterbleed. |
The most frequent early complications are hematomas and seromas (8–22%). | |
The incidence of hematomas is lower for endoscopic (4.2–13.1%) techniques than for open repair (5.6–16%). | |
The risk of seroma formation is higher for endoscopic techniques than for open repairs. | |
Level 1B | The use of Fibrin sealant for mesh fixation during bilateral TEP leads to a significant reduction of analgesic consumption but is associated with an increased incidence of postoperative seroma. |
Level 3 | Most seromas disappear spontaneously within 6–8 weeks. |
Infection after aspiration of seromas is described. | |
Level 5 | Perioperative drainage to prevent seromas is contradictory. |
Grade B | It is recommended that wound drains be used only when specifically indicated (large blood loss, coagulopathies). |
Anticoagulants should be stopped before surgery. | |
Seromas are best not aspirated. | |
Grade D | If indicated, a closed suction drain is kept as per the assessed requirements. |
Grade C | The mesh should be taken out of its packaging just before introduction under absolutely sterile conditions. |
Level 1B | To treat bilateral hernias, implantation of two meshes overlapping by 1–2 cm in the midline above the pubic symphysis or one large mesh are options. |
Level 2B | The issue stills remain unresolved as to whether two different meshes of adequate size with overlap in the midline or a single large mesh be used to treat bilateral inguinal hernias. |
After implantation of two meshes, the recurrences detected (direct and bilateral) suggest the presence of a weak zone in the midline despite the two meshes overlapping in the midline. | |
Level 3 | Implantation of one large mesh seems to be technically more difficult than that of two meshes. |
Grade C | In bilateral hernias, a sufficiently large mesh should be used or two different meshes (e.g., 15 × 13 cm on both sides). |
Level 4/5 | Mesh overlapping of less than 2–3 cm may lead to a protrusion of the mesh into the hernia opening. |
The larger the hernia opening the more overlapping there should be. | |
In large direct defect, danger for protrusion of mesh into the opening is increased. |
Grade C | The minimum distance between the margin of the prosthesis and that of the hernial opening should be equal to the diameter of the opening in hernias of size 2 cm or larger. |
For smaller lesions (<1–2 cm), a minimum mesh overlap of 2 cm is required. For hernias ≥4 cm, the prosthesis should be fixed to prevent recurrence. | |
In direct hernia, medial overlapping should be >4 cm. | |
Grade D | The mesh should cover without wrinkles all the facial defects in the groin, including Hesselbach’s triangle, the indirect ring, the femoral ring, and the obturator ring. |
Level 3 | Uprolling of mesh is one main cause for recurrence. |
Insufficient preperitoneal dissection (parietalization) is the main cause for uprolling of mesh. |
Grade B | Extensive preperitoneal dissection is critical to prevent uprolling of mesh. |
Desufflation of retropneumoperitoneum should be done under vision. | |
Grade D | When fibrin sealant is used, it is applied to the Cooper’s ligament, the inferior edge, and medial corner of the mesh, which is steadied in position in graspers for a few minutes to ensure firm adhesion before desufflation. |
Chapter 4: TEP versus TAPP: which is better for the patient?
Misra Mahesh Chandra, Kumar Subodh, Bansal Virinder Kumar, Krishna Asuri
Department of Surgical Disciplines, All India institute of Medical Sciences, New Delhi-29, India
Level 2 A | Potentially serious adverse events are rare after both TAPP and TEP. |
Level 3 | Regarding overall complication rate, there is no obvious difference between TAPP and TEP. |
TAPP and TEP show a noticeable “learning curve.” | |
TAPP has a shorter operation time in inexperienced and experienced surgeons. | |
Level 4 | TEP is more suitable for regional anesthesia. |
Level 5 | Unsuspected hernias on the contralateral side are easier to detect with TAPP. |
Grade B | Both techniques are acceptable treatment options for inguinal hernia repair, but there is insufficient data to allow conclusions to be mde about relative effectiveness of TAPP compared with TEP. |
Grade D | In selected patients having a contraindication for general anesthesia, TEP in regional anesthesia can be done. |
Study ID | Vascular injury | Visceral injury | Deep/mesh infection | Port site hernia | Conversion | |||||
---|---|---|---|---|---|---|---|---|---|---|
Comparative studies | TAPP % (n/N) | TEP % (n/N) | TAPP % (n/N) | TEP % (n/N) | TAPP % (n/N) | TEP % (n/N) | TAPP % (n/N) | TEP % (n/N) | TAPP % (n/N) | TEP % (n/N) |
Felix et al. (1995) [15] | 0 (0/733) | 0 (0/382) | 0.4 (3/733) | 0 (0/382) | 0 (0/733) | 0 (0/382) | 0.8 (6/733) | 0 (0/382) | 0 (0/733) | 1.8 (7/382) |
Khoury (1995) [16] | 0 (0/60) | 3 (2/60) | 0 (0/60) | 0 (0/60) | 0 (0/60) | 0 (0/60) | 1.7 (1/60) | 0 (0/60) | 0 (0/60) | 0 (0/60) |
Cohen et al. (1998) [17] | NR | NR | 0.9 (1/108) | 0 (0/100) | NR | NR | 3.7 (4/108) | 0 (0/100) | 0 (0/108) | 4 (4/100) |
Van Hee et al. (1998) [18] | 0 (0/33) | 0 (0/58) | 0 (0/33) | 0 (0/58) | 0 (0/33) | 0 (0/58) | 0 (0/33) | 0 (0/58) | 5 (2/33) | 7 (4/58) |
Bobrzynski et al. (2001) [19] | 0.52% (3/809) | 0.32% (1/368) | NR | NR | NR | NR | NR | NR | NR | NR |
Lepere et al. (2000) [20] | 0 (0/1290) | 0 (0/682) | 0 | NR | NR | NR | NR | NR | ||
Weiser and Klinge (2000) [21] | NR | NR | 0 (0/1216) | 0.06 (1/1547) | 0.2 (2/1216) | 0 (0/1547) | 0.3 (4/1216) | 0.1 (2/1547) | NR | NR |
Ramshaw et al.a (2001) [22] | NR | NR | 1 (3/300) | 1 (3/300) | NR | NR | NR | NR | NR | NR |
Case series | ||||||||||
Schultz et al. (2001) [23] | 0.28 (7/2500) | NA | 0.16 (4/2500) | NA | 0 (0/2500) | NA | 0.24 (6/2500) | NA | 0.24 (6/2500) | NA |
Kapiris et al. (2001) [24] | NR | NA | 0.19 (7/3530) | NA | 0.11 (4/3530) | NA | NR | NA | 0.19 (7/3530) | NA |
Bittner et al. (2002) [25] | 0.3 (25/8050) | NA | 0.2 (17/8050) | NA | 0.1 (8/8050) | NA | 0.7 (57/8050) | NA | 0.12 (10/8050) | NA |
Chiofalo et al. (2001) [26] | NA | NA | NA | NR | NA | NR | NA | NR | NA | 0.5 (2/431) |
Vanclooster et al. (2001) [27] | NA | 0.3% (4/1259) | NA | 0.08 (1/1259) | NA | NR | NA | NR | NA | 0.4 (5/1259) |
Tammeet al. (2003) [28] | NA | 0.56 (29/5203) | NA | 0.15 (8/5203) | NA | 0.02 (1/5203) | NA | 0 (0/5203) | NA | 0.23 (12/5203) |
Dulucq et al. (2008) [29] | NA | 0.47 (11/3100) | NA | 0.04 (1/3100) | NA | 0.04 (1/3100) | NA | 0.1 (3/3100) | NA | 1.2 (36/3100) |
Total | 0.25 (35/13475) | 0.42 (47/11160) | 0.21 (35/16604) | 0.11 (14/12009) | 0.08 (14/16122) | 0.02 (2/10350) | 0.6 (78/12700) | 0.05 (5/10450) | 0.16 (25/15014) | 0.66 (70/10593) |
Study ID | TAPP repair | TEP repair | ||||||
---|---|---|---|---|---|---|---|---|
Visceral injury (n) | Vascular Injury (n) | Visceral injury (n) | Vascular Injury (n) | |||||
Bowel injury | Bladder injury | Inferior epigastric vessels | Iliac vessels | Bowel injury | Bladder injury | Inferior epigastric vessels (IEV) | Iliac vessels | |
Felix et al. [15] | 3/733 | – | – | – | – | – | – | – |
Cohen et al. [17] | – | 1/108 | – | – | – | – | – | – |
Bobrzynski et al. [19] | – | – | 3/809 | – | – | – | – | 1 |
Bittner et al. [25] | 9/8050 | 8/8050 | 14 (trocar site) | – | – | – | – | – |
5 (inguinal) | ||||||||
6 (others) | ||||||||
Schultz et al. [23] | 1/2500 | 3/2500 | 5/2500 | – | – | – | – | – |
1 (mesenteric) | ||||||||
1 (corona mort.) | ||||||||
Kapiris et al. [24] | – | 7/3530 | – | – | – | – | – | – |
Ramshaw et al. [22] | 2/300 | 1/300 | – | – | 2/300 | 1/300 | – | – |
Khourey [16] | – | – | – | – | – | – | 2/60 | – |
Vanclooster et al. [27] | – | – | – | – | 1/1259 (large bowel) | – | 4/1259 | – |
Tamme et al. [28] | – | – | – | – | 8/5203 | 29/5203 (11 IEV) | – | |
Dulucq et al. [29] | – | – | – | – | 1/3100 | – | 11/3100 | – |
No. of patients | Complications rate N (%) | Recurrence rate N (%) | |
---|---|---|---|
Bittner et al. [30] | 3400 | 241 (7.1) | 31 (0.9) |
Phillips et al. [31] | 1944 | 120 (6.2) | 19 (1) |
Tetik et al. [32] | 553 | NR | 4 (0.7) |
Fitzgibbon et al. [33] | 562 | NR | 28 (5) |
Felix et al. [15] | 733 | 9 (1.2) | 2 (0.2) |
Ramshaw et al. [34] | 300 | 13 (4.3) | 6 (2) |
Fielding [35] | 386 | 4 (1) | 2 (0.5) |
Kald et al. [36] | 339 | 42 (11) | 7 (2) |
Stoker et al. [37] | 75 | 6 (8) | 0 |
Payne et al. [38] | 48 | 6 (12) | 0 |
Maddern et al. [39] | 42 | 7 (17) | 0 |
Lawrence et al. [40] | 58 | 7 (12) | 1 (1.7) |
Wright et al. [41] | 67 | 15 (22) | NR |
Total | 8507 | 470 (6.36) | 100 (1.33) |
Study | No. of patients | Complications rate N (%) | Recurrent rate N (%) |
---|---|---|---|
Smith et al. [42] | 100 | 14 (14) | 2 (2) |
Vanclooster et al. [27] | 158 | 23 (6.3) | 0 |
Phillips et al. [31] | 253 | 36 (14.2) | 2 (0.3) |
Felix et al. [15] | 382 | 40 (10.5) | 1 (0.2) |
Heithold et al. [43] | 346 | 7 (2) | 1 (0.4) |
McKernan and Laws [44] | 633 | 73 (11.5) | 4 (0.6) |
Phillips et al. [45] | 578 | 55 (9.5) | 0 |
Tetik et al. [32] | 457 | – | 2 (0.4) |
Fitzgibbon et al. [33] | 87 | – | 0 |
Ramshaw et al. [34] | 600 | 5 (0.8) | 2 (0.3) |
Fielding [35] | 218 | 0 | 2 (0.9) |
Kald et al. [36] | 87 | 7 (8) | 0 |
Liem et al. [46] | 487 | 15 (3) | 16 (3.4) |
Total | 4386 | 275 (7.6) | 32 (0.60) |
Study | No. of patients | Complications rate N (%) | Recurrence rate N (%) |
---|---|---|---|
Lepere et al. [20] | 1290 | 129 (10) | 13 (<1) |
Weiser and Klinge [21] | 1216 | 83 (6.8) | 15 (1.2) |
Ramshaw et al. [22] | 300 | 9 (3) | 6 (2) |
Bobrzynski et al. [19] | 809 | 95 (11.7) | 23 (2.84) |
Schultz et al. [23] | 2500 | 89 (3.56) | 26 (1.04) |
Kapiris et al. [24] | 3530 | 300 (8.5) | 22 (0.62) |
Bittner et al. [25] | 8050 | 209 (2.6) | 32 (0.4) |
Total | 17695 | 914 (5.2) | 137 (0.77) |
Study |
N
| Complications rate N (%) | Recurrence rate N (%) |
---|---|---|---|
Lepere et al. [20] | 682 | 68 (10) | 7 (<1) |
Weiser and Klinge [21] | 1547 | 135 (8.7) | 8 (0.5) |
Ramshaw et al. [22] | 924 | 6 (0.64) | 2 (0.21) |
Bobrzynski et al. [19] | 416 | 69 (16.6) | 8 (1.92) |
Tamme et al. [28] | 5203 | 164 (3.15) | 31 (0.6) |
Chiofalo et al. [26] | 431 | 25 (5.7) | 2 (0.5) |
Vanclooster et al. [27] | 1259 | 106 (8.4) | 1 (0.1) |
Dulucq et al. [29] | 3100 | 167 (5.4) | 14 (0.46) |
Total | 13562 | 740 (5.4) | 73 (0.54) |
Chapter 5: Laparoscopic surgery in complicated hernia: feasibility, risks, and benefits
G. Ferzli, M. Timoney.
Level 3 | TAPP and TEP are possible therapeutic options in scrotal hernia. |
Operation time, complication rate, and frequency of recurrences are higher than in normal hernia repair. | |
Sero-hematoma formation is the most frequent complication. | |
Results will improve with gaining experience. | |
Complete reduction of hernia sack is possible. | |
Level 5 | The higher recurrence rate may result in some of these cases (large hernia openings), because the standard mesh size (10 × 15 cm) was too small. |
In large hernia openings a mesh with less flexural stiffness (lightweight) or insufficient overlapping may be pushed into the defect. |
Grade C | TAPP and TEP may be safely used when performed by surgeons with a higher level of experience in either technique. |
Grade D | In large hernia openings (>3–4 cm), a larger mesh may be used (12 × 17 cm). |
In large direct defects (>3–4 cm), a stapled fixation of the mesh to the symphysis, Cooper’s ligament and rectus muscle may be done. | |
In large indirect defects (>4–5 cm), the overlapping of the mesh has to reach approximately 1–3 cm lateral to the spina iliaca anterior superior. In addition, fibrin fixation to the psoas muscle can be performed. | |
In large hernia defects, a mesh with greater flexural stiffness (heavyweight) or a well-fixed lightweight mesh with adequate overlapping may be used. | |
To reduce frequency of sero-hematomas, careful bleeding control by electrocoagulation should be done. |
Level 3 | Operation time is longer than in uncomplicated hernia. |
Complication rate and recurrences are similar to uncomplicated cases. | |
Advantage of laparoscopy is that bowel viability can be observed during the whole time of procedure. | |
Frequency of bowel resection is less compared with open hernia surgery. | |
Level 5 | Reduction of hernia content or cutting the hernia ring if necessary for reduction may be safer when overlooking both peritoneal and preperitoneal space. |
Grade C | TAPP may be used for the repair of incarcerated or strangulated inguinal hernias, but the technique should be reserved for surgeons with extensive experience in the TAPP technique. |
Grade D | Compromised bowel that is encountered during TAPP repair of strangulated hernia may be resected after the completion of the TAPP repair (after allowing time for the bowel to declare its viability). The resection should be performed extracorporeally for intestine or may be performed intracorporeally for omentum or appendix. |
Level 3 | The conversion rate in the acute setting is high. Recurrence and complication rates are higher than in the nonincarcerated hernia. |
Level 5 | A drawback to the TEP vs. TAPP approach for the strangulated inguinal hernia is that TEP does not allow inspection of the bowel without laparoscopy. |
Grade C | TEP may be used for repair of both incarcerated and strangulated inguinal hernias; however, the data on the subject are scant. |
Grade D | The umbilical port can be converted from a preperitoneal port to an intraperitoneal port to assess bowel viability when it is in question. |
Level 5 | There are only few reports of successful treatment of incarcerated femoral hernia. |
Reduction of hernia contents requires incision of the lacunar ligament. |
Grade D | Incarcerated femoral hernia may be safely repaired via the TAPP or TEP; however, in TEP additional laparoscopy for inspection of the incarcerated hernia content is necessary. |
Although in some cases a plug repair was done, the general opinion is that a flat mesh having usual size should be inserted. |
Level 5 | A high risk for mesh infection is feared. |
Grade D | Laparoscopic repair of incarcerated inguinal hernia should be avoided in the setting of peritonitis and if an infected abdominal wall or intra-abdominal cavity is found on laparoscopic exploration. |
Level IB | TAPP is advantageous in terms of defining anatomy and providing improved mechanical strength. |
Re-recurrence rate is equal or improved when compared with open techniques. | |
Complication rate at 1 week after surgery is less and sick leave is shorter compared with the Lichtenstein repair. | |
Acute and chronic pain are less compared with open mesh repair. | |
Level III | Effectiveness of TAPP-repair in recurrent hernia is equal compared with TAPP repair in primary hernia. |
Grade A | TAPP for repair of recurrent inguinal hernia is the preferred alternative to tissue repair and to the Lichtenstein repair for recurrence after prior anterior repair. |
Grade B | TAPP for recurrent hernia should only be performed by surgeons with extensive experience in the TAPP technique. |
Level I B | TEP is advantageous in terms of defining anatomy and providing improved mechanical strength. |
Re-recurrence rate is equal or improved compared with open techniques. | |
Level II C | Re-operation rate is less compared with open techniques. |
Grade A | TEP for repair of recurrent inguinal hernia is the preferred alternative to tissue repair and to the Lichtenstein repair for recurrence after prior anterior repair. |
Level IB | Compared with open repair, TAPP and TEP have a better profile in terms of level of pain and return to regular activity. |
Incidence of wound and mesh infection is lower compared with open hernia surgery. | |
Level IV | Effectiveness of TAPP versus TEP is similar. |
Grade A | Both techniques TAPP and TEP are recommended after an anterior approach, providing the surgeon is sufficiently experienced in the specific procedure. |
Level III | Re-TAPP is possible. |
Operation time is longer and morbidity higher compared with repair of primary hernia, but time of sick leave and re-recurrence rate are similar. | |
There is a steep learning curve. | |
Level IV/V | TAPP is superior to TEP. |
Grade C | TAPP repair of recurrent inguinal hernia after prior TAPP or TEP may be performed; however, it should only be attempted by experts in TAPP inguinal hernia repair. |
Level 3 | TAPP and TEP are possible treatment options. |
Operation time is longer and morbidity higher compared with repair of primary hernia, but time of sick leave and re-recurrence rate are similar. | |
There is a steep learning curve. | |
In TEP, there is a significant conversion rate to TAPP. | |
Level 5 | TAPP seems to be easier to perform. |
Grade D | TAPP or TEP repair may be performed, but it should only be attempted by experts in TAPP or TEP inguinal hernia repair. |
Level 4 | The presence of two or more meshes in the inguinal region does not seem to enhance the frequency of chronic pain. |
Removal of a previously implanted preperitoneal mesh may increase the risk for lesion of urinary bladder, bleeding complications, and substantial defects of the peritoneum. |
Grade D | Old mesh from prior preperitoneal hernia repair should be left in place. |
The re-repair should be defect-adapted. | |
When an old plug is encountered that does not allow placement of a flat mesh, the protruding part of the plug may be best cut away with the use of electrocautery. |
Level 4 | TAPP and TEP repair of inguinal hernia allow easy identification of the occult ipsilateral femoral or obturator hernia. |
TEP allows easy identification of concomitant contralateral direct hernias. | |
TAPP allows easy identification of concomitant contralateral direct and indirect hernias. | |
The laparoscopic approach obliterates these associated occult synchronous or potential hernias utilizing a single repair without any particular modification to the technique. |
Grade B | In inguinal hernia repair for diagnosis of occult ipsilateral hernia defects, a careful dissection of the whole pelvic floor should be done. |
Chapter 6: Mesh size and recurrence: what is the optimal size?
Thue Bisgaard, Jacob Rosenberg
Copenhagen, Denmark
Level 2A | A small mesh may be a risk factor for recurrence after laparoscopic inguinal hernia repair. |
Level 5 | Insufficient dissection of the preperitoneal space makes it difficult to place a large mesh properly and avoid folds and wrinkles. |
Fixation does not compensate for inadequate mesh size. |
Grade A | A mesh size of at least 10 × 15 cm is recommended. | |
Grade D | Use a bigger mesh (i.e., 12 × 17 cm or greater) for large hernias (direct >3–4 cm, indirect >4–5 cm). |
Chapter 7: Selection of mesh material
D. Weyhe, C. Schug-Pass, U. Klinge
Level 1A | In the long-term comparison, lighter meshes with larger pores do not lead to improvements of the quality of life or a reduction of discomfort that are of statistical significance. They offer advantages in terms of convalescence during the first few postoperative weeks. |
Grade B | The hernia repair in the TAPP/TEP technique with a so-called material-reduced mesh (less amount of material, bigger pores, some elasticity) decreases the rate of mesh-related complaints, at least within the first 3 months. |
Grade D | 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. |
Randomized | d- blind | VAS | SF-36 | Multicenter | Level | |
---|---|---|---|---|---|---|
TAPP [1] | No | No | No | No | No | 2b |
TAPP [2] | Yes | Yes | Yes | Yes | No | 1b |
TAPP [3] | Yes | Yes | Yes | Yes | No | 1b |
TEP [4] | Yes | Single | Yes | Yes | Yes | 1b |
TEP [5] | Yes | Single | Yes | Yes | Yes | 1b |
TEP [6] | Yes | Yes | Yes | No | No | 1b |
Accordance | 5 | 3 | 5 | 4 | 2 | – |
No. patients | Follow-up (%) | <3-month Adv. LM | 12-month Adv. LM | 60-month Adv. LM | |
---|---|---|---|---|---|
TAPP [1] | 672 | 81 | – | Yesa
| – |
TAPP [2] | 90 | 100 | Yesb
| – | – |
TAPP [3] | 180 | 97 | – | – | No |
TEP [4] | 139 | 94 | Yesc
| – | – |
TEP [5] | 137 | 88 | Yesd
| – | – |
TEP [6] | 50 | 100 | Yese
| Noe
| – |
Average | 211 | 93 |
n = 4 | – |
n = 1 |
Min. standard keyword |
---|
1. Monofile structure–infection |
2. Pore size 1–1.5-mm collagen (large pores usually are related with low weight) |
3. Tensile strength >16 N/cm stability |
Chapter 8: Cutting or not cutting of mesh: does it influence the recurrence rate?
Thue Bisgaard, Jacob Rosenberg
Copenhagen, Denmark
Level 3 | Cutting a slit in the mesh to allow the structures of the funicle to pass through the mesh may be a risk factor for recurrence after laparoscopic inguinal hernia repair. |
Level 1B | An intact mesh does not produce more postoperative complications or higher risk of recurrences compared with a cut mesh. |
Grade B | We recommend not to cut a slit in the mesh. |
Chapter 9: Mesh fixation modalities: is there an association with acute or chronic pain?
Esther Kuhry, Agneta Montgomery, Wolfgang Reinpold, Rene Fortelny
Level 1B | Fixation and nonfixation of the mesh are associated with equally low recurrence rates in both TAPP and TEP; however, in most studies the hernia opening was small (<3 cm) or not measured. |
Staple fixation is associated with a higher risk of acute and chronic pain compared with nonfixation. | |
Fixation is more expensive than nonfixation. | |
Fibrin glue is associated with low recurrence rates. | |
Fibrin glue is associated with less acute and chronic pain than stapling. | |
Level 5 | Fibrin glue is less expensive than most stapling devices. |
Grade B | If TAPP or TEP techniques are used, nonfixation could be considered in types LI, II, and MI, II hernias (EHS classification). |
For fixation, fibrin glue should be considered to minimize the risk of postoperative acute and chronic pain. | |
Grade D | For TAPP and TEP repair of big direct defects (LIII, MIII), the mesh should be fixated; however, fixation does not compensate for inadequate mesh size or overlap. |
Study | Follow-up | Type of repair | Recurrence | Level of evidence | |
---|---|---|---|---|---|
Fixation | No fixation | ||||
Taylor et al. (2008) [11] | 8 (6–13) monthsa
| TEP | 1/247 | 0/253 | 1b |
Smith et al. (1999) [18] | 16 (1–32) monthsa
| TAPP | 3/273 | 0/263 | 1b |
Moreno-Egea et al. (2004) [17] | 36 ± 12 monthsb
| TEP | 0/118 | 3/111 | 1b |
Koch et al. (2006) [15] | 19 (6–30) mob
| TEP | 0/20 | 0/20 | 2b |
Ferzli et al. (1999) [19] | 8 monthsc
| TEP | 0/50 | 0/50 | 2b |
Garg et al. (2008) [21] | 17 (6–40) monthsd
| TEP | 1/61 | 2/1692 | 3b |
Lau et al. (2003) [26] | 1 yearc
| TEP | 0/100 | 0/100 | 3b |
Khajanchee et al. (2001) [27] | 15 (1–23) monthsd
| TEP | 2/67 | 4/105 | 3b |
Morrison et al. (2008) [30] | 89% 1 year | TEP | – | 1/157 | 4 |
Tamme et al. (2003) [40] | Not specified | TEP | – | 29/5203 | 4 |
Kapiris et al. (2001) [28] | Not specified | TAPP | 22/3868 | 4 | |
Beattie et al. (2000) [42] | Not specified | TEP | – | 0/89 | 4 |
Spitz et al. (2000) [43] | Not specified | TEP | – | 0/203 | 4 |
Summary | 7/936 0.7% | 61/12114 0.5% |
Study | Pain score | Repair | Pain |
P-value | Level of evidence | |
---|---|---|---|---|---|---|
Fixation | No fixation | |||||
Taylor et al. (2008) [11] | Cunningham | TEP | ↑ | ↓ | 0.0003 | 1b |
Smith et al. (1999) [18] | Not specified | TAPP | = | = | – | 1b |
Moreno-Egea et al. (2004) [17] | VAS (24 mo) | TEP | = | = | 0.75 | 1b |
Koch et al. (2006) [15] | Likert scale (9 mo) | TEP | = | = | 0.15 | 2b |
Study | Follow-up | Type of repair | Recurrence | Level of evidence | |
---|---|---|---|---|---|
Stapling device | Fibrin glue | ||||
Olmi et al. (2007) [13] | 26 monthsa
| TAPP | 0/581 | 0/222 | 1b |
Lau et al. (2005) [44] | 1.2 yearsa
| TEP | 0/94 | 0/92 | 1b |
Lovisetto et al. (2007) [14] | 11.7 months | TAPP | 0/98 | 1/99 | 1b |
Ceccarelli et al. (2008) [20] | 19 (4–40) monthsb
| TAPP | 0/87 | 0/83 | 3b |
Santoro et al. (2007) [22] | 13.2 (5–24) monthsb
| TAPP | 0/245 | 0/250 | 3b |
Schwab et al. (2006) [23] | 23.7 (11–47) monthsb
| TEP | 5/87 | 2/86 | 3b |
Novik al (2006) [24] | 1, 16, 40 mo | TEP | 0/96 | 0/9 | 3b |
Topart et al. (2005) [25] | 28.3 ± 10.9 monthsb
| TEP | 3/117 | 1/81 | 3b |
23.9 ± 11.3 monthsb
| |||||
Total | 8/1405 0.6% | 4/922 0.4% |
Study | Repair | Acute pain |
P-value | Level of evidence | |
---|---|---|---|---|---|
Staples | Fibrin glue | ||||
Lau et al. (2005) [44] | TEP | = | = | n.s. | 1b |
Olmi et al. (2007) [13] | TAPP | ↑ | ↓ | <0.05 | 1b |
Boldo et al. (2008) [12] | TAPP | ↑ | ↓ | <0.05 | 2b |
Study | Pain score | Repair | Chronic pain |
P-value | Level of evidence | |
---|---|---|---|---|---|---|
Stapling device | Fibrin glue | |||||
Lau et al. (2005) [44] | Linear scale | TEP | = | = | n.s. | 1b |
Lovisetto et al. (2007) [14] | VAS (6 mo) | TAPP | ↑ | ↓ | <0.001 | 1b |
Boldo et al. (2008) [12] | VAS (1 week) | TAPP | = | = | n.s. | 2b |
Topart et al. (2005) [25] | Chronic pain | TEP | ↑ | ↓ | 0.037 | 3b |
Schwab et al. (2006) [23] | Chronic pain | TEP | ↑ | ↓ | 0.002 | 3b |
Ceccarelli et al. (2008) [20] | Chronic pain | TAPP | = | = | n.s. | 3b |
Chapter 10: Risk factors and prevention of acute and chronic pain
W. Reinpold
Level 1A | The risk of acute and chronic pain is lower after endoscopic groin hernia repair compared with open surgery with or without mesh. |
The risk of sensory disturbances of the groin is lower after endoscopic groin hernia repair compared with open surgery with or without mesh. | |
Level 1B | There is no difference of acute and chronic pain after TEP and TAPP. |
Preoperative pain is a risk factor for chronic pain. | |
The risk of acute and chronic pain after staple mesh fixation is higher compared with fibrin fixation or nonfixation (see Chapter “fixation”). | |
Bilateral TAPP and TEP repairs are not associated with more acute and chronic pain compared with unilateral repair. | |
The risk of acute and chronic is lower after endoscopic recurrent groin hernia repair compared with open surgery with or without mesh (see Chapter “Complicated hernia”) | |
Level 2A | There is no difference in chronic pain after endoscopic hernia repair with heavy or lightweight meshes (see Chapter “Mesh”). |
The use of light-weight meshes seems to reduce acute postoperative pain and discomfort compared with the use of traditional heavy-weight meshes (see Chapter “mesh”). | |
Level 2B | History of other pain syndromes is a risk factor for chronic pain. |
Severe acute postoperative pain is a risk factor for chronic pain. | |
Endoscopic recurrent groin hernia surgery is a risk factor for chronic pain. | |
Age younger than 65 years is a risk factor for acute pain. | |
Age below median (40–50 years) is a risk factor for chronic pain. | |
Women suffer more often from acute and chronic pain. | |
Level 3B | Surgical complications (seroma, hematoma, wound infection, bowel or bladder injury, and bowel obstruction) are a risk factor for chronic pain. |
Surgery-related sensory disturbance of the groin is a risk factor for chronic pain. | |
Day-case surgery may be a risk factor for acute pain. | |
Employment status may be a risk factor for chronic pain. |
Grade A | To reduce acute pain and the risk of chronic pain after inguinal hernia repair, the endoscopic techniques (TAPP and TEP) should be preferred to open mesh or nonmesh repair if expertise is present. |
To reduce the risk of sensory disturbances of the groin after inguinal hernia repair, the endoscopic techniques (TAPP and TEP) should be preferred to open mesh or nonmesh repair if expertise is present. | |
Grade B | To reduce acute pain, the use of weight reduced macroporous (pore size >1 mm) monofilament meshes should be considered (see Chapter “Mesh”). |
Regarding frequency of chronic pain, the use of light and heavyweight meshes can be considered (see Chapter “Mesh”). | |
To reduce the risk of acute and chronic pain and discomfort, nonfixation of the mesh or fibrin glue fixation should be preferred to staples fixation (see Chapter “Fixation”). | |
Endoscopic groin hernia repair should be considered in patients with risk factors for acute and chronic pain if expertise is present. | |
Bilateral TAPP and TEP repair can be recommended without a higher risk of acute and chronic pain. | |
Grade D | Every endoscopic groin hernia surgeon has to be familiar with the anatomy of the inguinal nerves. The use of penetrating fixation devices in the “trapezoid of pain” and “triangle of doom” is prohibited. |
The nerves should not be exposed, leaving the protecting nerve fascia intact. | |
Electrocautery has to be used with care. |
Chapter 11: Urogenital complications associated with laparoscopic/endoscopic hernia repair
Robert J. Fitzgibbons, Jr., MD, FACS
Level 4 | Bladder injury can be the result of careless use of a Veress needle or a trocar. |
The bladder is especially prone to injury during LIH if the preperitoneal space has previously been dissected. |
Grade D | The bladder should be decompressed either by having the patient void immediately preoperatively (preferred method) or by the use of an indwelling catheter |
Grade A | Consider referral of patients in need of a preperitoneal inguinal hernia repair who had a previous preperitoneal dissection, e.g., prostatectomy or failed previous hernia repair to a specialty center. |
Level 4 | Polypropylene and expanded polytetrafluoroethylene will erode into the bladder in a small number of patients in whom it is implanted. The reason is not known. |
Level 1a | Urinary retention is higher after LIH than a conventional inguinal hernia performed under local anesthesia because of the need for general anesthesia for LIH |
Grade C | Intra- and postoperative intraveneous fluid administration should be restricted to no more than 500 cc. |
Level 2B | Incidence is highest in patients older than aged 74 years or who have a urinary catheter placed. |
Grade B | Antibiotic prophylaxis should be considered in patients at risk for infection [20]. Urinary catheterization should be avoided if at all possible. |
Level 1a | Testicular complications occur after both open and endoscopic hernia surgery. |
No significant difference in incidence between open and laparoscopic techniques was found in a large comparative trial and a Cochrane analysis did not show any difference between TEP and TAPP [20–22]. |
Level IA | Unequivocal evidence that LIH will decrease the incidence of orchitis/testicular atrophy is not available. |
Level III | In most cases, complete dissection and reduction of the hernia sac is possible without serious risk of orchitis or testicular atrophy. |
Grade B | In herniorrhaphies where there is a question that damage to the cord structures could occur with complete excision (e.g., large inguinal-scrotal hernias, sacs extending all the way to the testicle, densely adherent sacs), the surgeon should consider dividing the sac at a convenient point distal to the internal inguinal ring, leaving the distal sac in situ. The proximal sac should then be ligated. |
Grade C | Caution when dissecting the cord structures must be exercised to avoid the possibility of injury to the vas deferens or blood supply of the testicle. |
Chapter 12: Intraperitoneal onlay mesh (IPOM) for inguinal hernia repair—still a therapeutic option?
Kirpal Singh, Maurice E. Arregui
Level 1B | Higher recurrence rate with IPOM with longer follow-up. |
Lower operative times with IPOM technique. | |
Level 4 | Fixation may play a significant role. |
Level 5 | Leaving the sac in situ may lead to higher recurrence. |
Grade B | IPOM can not be recommended for main stream inguinal hernia repair at this time. |
Further long-term studies are needed to evaluate true recurrences. |
Chapter 13: Role for open preperitoneal mesh placement in the era of laparoscopic inguinal hernia repair
Kirpal Singh, Maurice E. Arregui
Level 1A | Laparoscopic approaches have fewer local complications. |
Laparoscopic approaches have less pain. | |
Laparoscopic approaches have faster return to normal activities. | |
Laparoscopic approaches have lower morbidities. | |
Level 1B | Laparoscopic approaches have longer operative times. |
Laparoscopic approaches have less pain and faster return to normal activity and work. | |
Level 5 | Minimally invasive open approaches (i.e., Kugel) have limited visualization and higher likely hood of injury or incomplete dissection. |
Both anterior and posterior spaces are violated leading to difficult reoperative surgery. |
Grade B | Laparoscopic approach is recommended over open preperitoneal due to less morbidity, less pain, and faster recovery. |
Grade D | Open approach may be considered in patients with recurrent hernia and inability to undergo general anesthesia. |
Study | Date | Type of repair | No. of patients | F/U (months) | OR time | Pain | LOS | Return to nl/work | Recurrence | Morbidity | Notes |
---|---|---|---|---|---|---|---|---|---|---|---|
Champault et al. [3] | 1997 | TEP vs. Stoppa | 100 pts w primary andrecurrent hernias | 93% @ 36 months | Longer for b/l and Recurr in TEP | Less in TEP (p = 0.0001 VAS) | 3.2 days (TEP) vs. 7.3 days (p = 0.01) | 11 days (TEP) vs. 17 days (p = 0.01) | 6% (TEP) vs. 2% Stoppa | 4% (TEP) vs. 29.5% (p = 0.01) | Higher RR with smaller Mesh (11 × 6 cm2. No diff in RR with Mesh size of 15 × 12 cm2
|
Beets et al. [4] | 1999 | TAPP vs. GPRVS | 79 pts w 93 recurrent and 15 primary hernias | 34 months | 79 min (TAPP) vs. 56 min | Less in TAPP (p = 0.05) | 92.5% in TAPP vs. 77% in GPRVS–same day | 13 days (TAPP) vs. 23 days (p = 0.03) | 12.5% (TAPP) vs. 1.9% (p = 0.04) | 0 (TAPP) vs. 4 pts (p = 0.04) with infection despite abx in GPRVS pts | TAPP group had 52 recurrent hernias in 42 pts vs. 41 recurrent hernias in 37 pts |
Aitola et al. [5] | 1998 | TAPP vs. open preperitoneal | 49 pts w Uni, bilateral and recurrent | 18 months | 66 min (TAPP) vs. 55 min (p < 0.01) | Less in TAPP (p < 0.01 for movement and p < 0.05 for coughing) | N/A | 7 days (TAPP) vs. 5 days (open) | 13% (TAPP) vs. 8% (open) | 21% (TAPP) vs. 8% | Concluded open is better due to less cost, higher RR, and no benefit with return to nl activity, although twice as many pts with recurrence and b/l hernias in TAPP. |
Johansson et al. [6] | 1999 | TAPP vs. open preperitoneal vs. conventional | 613 pts | 12 months | 65 min (TAPP) vs. 38 min (open) vs. 37 min | Less with TAPP @ 8 weeks compared with open (p = 0.02) | N/A (“mainly out-patient”) | 14.7 days (TAPP) vs. 17.7 days (open) vs. 17.9 days (p = 0.05) | 4 pts (TAPP) vs. 11 pts (open) vs. 4 pts | N/A | Most of the TAPP recurrences were early, i.e., technical |
Simmermacher et al. [7] | 2000 | TEP vs. Grid-Iron | 162 pts w primary unilateral hernias | N/A | 39 min (TEP) vs. 27 min (p < 0.001) | Same | Same | Same | N/A | 13 pts w 6 conversion to open (TEP) vs. 8 pts | Concluded that open is better due to less OR time, higher OR complications, and able to handle bleeding/tear with the same incision in open approach. But No F/U and NO RR. |
Chapter 14: Sportsman hernia—diagnosis and treatment
Moshe Dudai/Salvador Morales-Conde, Reinhard Bittner
Tel Aviv, Israel/Salvador Morales-Conde, Sevilla (Spain), Stuttgart, Germany
Level 3A | Chronic pain (longstanding groin pain–LSGP) is a leading cause of athletes’ retirement from competitive sports. |
Chronic pain in athletes is an obscure condition of uncertain etiology commonly seen in soccer, football, rugby, and ice hockey players. | |
At a high level of play, teams have significantly higher risk of injury than teams at a lower level. | |
Physical examination reveals no detectable inguinal hernia. | |
The differential diagnosis is difficult to make from physical examination and is thus largely established only at the time of surgery. | |
Although there are several reports of chronic pain in women, it is almost exclusively found in men. | |
Level 4 | Chronic pain is a challenging problem among not only athletes but also the general population. |
In the majority of athletic maneuvers, a tremendous amount of torque or twisting occurs in the midportion of the body, and the front or anterior portion of the pelvis accounts for the majority of the force. | |
The main muscles inserting at or near the pubis are the rectus abdominis muscle, which combines with the transversus abdominis. Across from these muscles, and directly opposing their forces, is the abductor longus. | |
The opposing forces of the muscles at their insertion site on the pubis cause a disruption of the muscle/tendon, causing chronic pain related to the fact that forces are excessive and imbalanced, leading to an increase of the weakness of the posterior wall of the groin or to a pubic bone stress injury (PBSI), which may lead to degenerative arthropathy of the pubic symphysis in advanced stages. | |
Chronic groin pain in athletes is mainly caused by two different pathologic entities: the sportsman hernia (SH) or the athletes pubalgia due to a pubic bone stress injury (PBSI). | |
PBSI include entities, such us tendon enthesitis, pubic osteitis, or avulsion fractures. | |
In SH, the likely causative factor is a posterior wall deficiency (PWD). | |
Entrapment of inguinal nerves may create symptoms that resemble those of a sports hernia. |
Level 4 | Groin pain starts during extreme sport activity, usually with no proper buildup of durability, acceleration, deceleration, and rotation. |
Pain responds to conservative treatment, anti-inflammatory drugs, and rest. | |
Pain typically recurs at the resumption of sport activity. |
Level 2B | In patients with chronic groin pain and clinically uncertain herniations, magnetic resonance imaging (MRI) and ultrasound (US) are valid diagnostic tools. |
Level 3B | Ultrasound is a useful adjunct diagnostic tool, not only to evaluate the groin for hernias, with high overall accuracy, but also in SH to identify inguinal canal posterior wall deficiency in young men with no clinical signs of hernia with chronic groin pain. |
Level 4 | The management of groin injuries demands the recruitment of a team with experience with different aspects of groin pain. |
Both the history and quality of symptoms and the physical examination may help to differentiate between SH and TE. | |
History of chronic groin pain that is nonresponsive to conservative treatment should raise suspicion of SH. | |
MRI appears to have excellent diagnostic potential for assessing various causes of long-standing groin pain (LSGP) in athletes. | |
MRI may not be a useful tool for deciding between operative or conservative treatment. | |
MRI is a valuable tool to monitor the alterations with reference to their response to conservative treatment, which alos may help the athletes to return to their activities. | |
Dynamic ultrasound shows promising results in accurately diagnosing SH. | |
In selected cases, laparoscopic inguinal exploration may be helpful. | |
Essentially, it is a diagnosis that can only be confirmed at surgery. |
Grade 3A | Comprehensive physical examination that requires excluding numerous other musculoskeletal and nonmuscoloskeletal conditions is mandatory. |
Plain radiography, ultrasonography, and scintigraphy should be the first-line investigations to supplement clinical investigation. | |
The cost of computed tomography and magnetic resonance imaging are such that their routine use for assessment of patients with groin pain cannot be justified. They may, however, be employed in difficult cases to help define the anatomical extent of a groin injury. | |
Dynamic ultrasound may be able to replace historical inguinal herniography. | |
Grade 4 | In unclear cases with some suspicion of posterior wall deficiency, surgical exploration should be performed. |
Gradual physical therapy combined with pharmacotherapy should be effective in most cases and should be part of the diagnosis process. |
Level 1B | An active physical therapy program designed to strengthen the muscles to stabilize the hip and pelvis has positive effects and leads to earlier return to sports at the same level, and it is superior to a physiotherapy treatment without active training. |
Level 3A | Until now, there has been no evidence-based consensus available to guide decision-making. |
The methodological quality of the studies available for analysis is low. | |
A single entheseal pubic cleft injection can be expected to afford at least 1 year of relief from adductor-related groin pain in a competitive athlete with normal findings on a magnetic resonance imaging scan. | |
Surgery seems to be more effective than conservative treatment for SH. | |
Good results can be obtained with surgery when posterior inguinal wall deficiency is the sole diagnosis. | |
Information on specific conservative interventions is poorly presented, and well-designed studies are lacking. | |
Level 4 | In PBSI, conservative management results more likely in an excellent outcome. |
In SH, the results of surgical repair to the posterior inguinal wall are excellent. |
Grade B | A multidisciplinary approach to groin pain should be adopted. |
Generally, conservative measures should be tried first, consisting of an initial period of rest or restricted activities, followed by physical therapy designed to stabilize the pelvis and hip. | |
When conservative management has failed, surgical intervention should be done. | |
Grade D | Athletes with chronic groin pain and PWD who are unable to compete in active sports should be considered for routine inguinal hernia repair if no other pathology is evident after clinical examination and investigation. |
Level 3A | Both open and laparoscopic surgical approaches have been reported to eliminate symptoms effectively and enable patients to return to previous sporting activity levels. |
The success rates are very good and comparable between open (92.8%) and laparoscopic (96%) repairs based solely on the criterion of return to sports activity. | |
A wide variety of open repair techniques are described with or without mesh, including repair of a presumed “thin” or damaged insertion of the tendon of the rectus abdominis onto the pubic crest, but there are no data allowing a comparison between these techniques. | |
There is no scientific evidence that an adductor tenotomy is of any additional value. | |
In open repair, ilioinguinal nerve resection seems to be beneficial. | |
Laparoscopic approach may provide better posterior inguinal wall exposure, enabling easier bilateral reinforcement. | |
During surgery, the inguinal canal should be thoroughly explored to find different entities responsible for inguinal pain (preperitoneal lipoma, etc.). | |
Laparoscopic techniques generally enable a quicker recovery time than open techniques. | |
Level 4 | Two variations of laparoscopic surgery are applied: the transabdominal preperitoneal patch plasty (TAPP) and the total extraperitoneal patch plasty (TEP); however, no study shows the superiority of one compared with the other. |
Grade C | Regarding time of recovery and return to preinjury sports activity levels, laparoscopic surgery—either TAPP or TEP—should be the treatment of choice. |
Well-designed prospective, randomized, controlled studies are greatly needed to establish the true efficacy of these different surgical approaches. |
Level 3A | A detailed description of postsurgical rehabilitation programs is generally lacking. |
Level 4 | For patients who underwent open repair, overall postsurgical recovery time (based on return to sports activity) was found to be 17.7 weeks compared with 6.1 weeks for laparoscopic repairs. |
Grade 3A | Early, sharp, sudden movements after surgery should be avoided, and core and leg musculoskeletal inflexibility, weakness, poor endurance, or poor coordination should be identified and corrected. |
Grade 4 | A gradually progressive 6-week rehabilitation program should be undertaken after both open and laparoscopic repair. |
Grade 5 | Well-designed studies are greatly needed. |