Guideline on the treatment of inguinal hernia in adult patients according to European Hernia Society – EHS
M. P. Simons T. Aufenacker M. Bay-Nielsen J. L. Bouillot G. Campanelli J. Conze D. de Lange R. Fortelny T. Heikkinen A. Kingsnorth J. Kukleta S. Morales-Conde P. Nordin V. Schumpelick S. Smedberg M. Smietanski G. Weber M. Miserez
EHS gives a guideline on the treatment of inguinal hernia containing recommendations for treatment and postoperative care. The work group includes 14 countries with their specialists, members of the EHS. The purpose of this guideline is to provide answers to the many issues related to inguinal hernia:
1.What are the indications for surgery and is it necessary?
2.Which one is the best treatment technique?
3.Which mesh is the best?
4.What are the complications of the separate techniques and how are they treated?
5.What causes pain and how is it treated?
6.Which anesthesia is the best?
7.Can hernia be operated outpatient? Does this reduce the cost and does it increase the quality?
8.Does one need routine use of antibiotics?
Guideline on the treatment of inguinal hernia in adult patients > 18-years-old
It is recommended that asymptomatic (without pain or discomfort) or minimally symptomatic hernias in men are actively monitored by the surgeon. When trapped hernias need emergency surgery. Symptomatic hernias are operated.
Inguinal hernias are operated to reduce symptoms and to avoid potential complications.
What diagnostic methods are best suited to diagnose patients with "inguinal" complaints?
The diagnosis is made by physical examination with specificity near 93%. It is important to differentiate the femoral from inguinal hernia rather than direct from indirect inguinal hernia. Ultrasound, CT, MRI and other examinations can also be performed.
Differential diagnosis of inguinal hernia is done with relapsed hernia, femoral hernia, postoperative hernia, lymphadenopathy, aneurysm, varicose veins, skin tumors, endometriosis, genital tumors, adductor tendinitis, osteitis of the pubic bone, irradiated pain.
Classification of inguinal hernia: there are many classifications of hernias, but EHS recommends classifying lateral, medial and femoral as well as primary or relapse.
What is the best technique for the treatment of inguinal hernias according to the type of hernia and the patient?
All men over 30 years with complaints should be operated, it is recommended to use an equipment with mesh. If you choose a method without mesh, it is advisable to be the method of Schouldice. The method of Lichtenstein and endoscopic techniques are best for unilateral hernia, but depend on the experience of the surgeon. For relapse hernia after open method it is recommended endoscopic treatment. About one-act treatment of bilateral hernia the best method is endoscopic treatment. When a patient has chronic pain and discomfort in the inguinal area, it is recommended endoscopic treatment.
The use of light with large pores meshes over open technique reduces postoperative discomfort.
For large scrotal hernia when it is not possible to use general anesthesia, is recommended the method of Lichtenstein.
Open surgery in adults consists of three important elements:
1.Dissection of the hernia bag from the cordon.
2.Reduction of the hernia bag contents and reduction of the bag.
3.Recovery of the fascial defect on the back wall of the inguinal canal.
In open methods of surgical treatment of inguinal hernia in women there is a higher risk of relapse than those in men. In women femoral hernia should always be distinguished. Endoscopic treatment is recommended.
In inguinal hernia in young men (18-30 years) it is advisable to use methods with mesh. In methods without mesh around 5% of hernia recur.
What type of mesh is best suited for the recovery of inguinal hernia?
It is suitable to use a tension free technique, with the use of synthetic resorbable meshes. It is also possible to use combined mesh (with resorbable component).
There is no clarity according to EHS what are the parameters for the best mesh. Using mesh hides its risks, pain, infection, shrinkage, erosion, dislocation. Currently, there is no definite and sufficiently objective proof of sexual dysfunction caused by using different meshes and techniques.
Can a hernia operation be carried out as one-day surgery - is it safe and is it cheaper?
Surgical treatment is safer, effective and cheap in terms of one-day surgery, even in the elderly and patients with ASA III/IV. It is recommended treatment in these type of structures than patients to be hospitalized, which poses its own additional risks.
Is a routine antibiotic prophylaxis necessary?
In surgery without mesh the use of antibiotics does not reduce the risk of wound infection. The use of mesh in a group of low-risk patients the use of antibiotics does not reduce the risk of wound infection. By endoscopic treatments there are no indications for antibiotic prophylaxis. In patients with recurrent hernia, persistent surgery, the use of drainage and in immune compromised patients is good to obtain antibiotic prophylaxis.
What is the learning curve and is it necessary to be qualified to treat hernia?
The learning curve in endoscopic procedures, particularly TEP, is longer than that of Lichtenstein and varies between 50 and 100 operations, having in mind that the first 30 surgeries are critical. For endoscopic techniques, particularly important is the selection of patients and skills to reduce the risks and complications during the study. Specialized centers give better results than general surgical units, especially in endoscopic techniques. According to EHS endoscopic techniques may be performed by surgeons with less experience, but with adequate instruction. All general surgeons should be well aware of the anatomy of the inguinal region and be able to treat all complications that might follow the surgery.
Anesthesia - It is recommended to use local anesthesia for open techniques for all age groups for unilateral hernias. Intravenous anesthesia with the use of a local sedation is also a good choice. Avoiding spinal anesthesia is recommended. Local anesthesia has a low risk of mortality in acute and elective treatment.
Which technique allows faster recovery?
Endoscopic techniques are recommended due to the more rapid postoperative recovery. Patients return to normal activities and work faster. After a plastics with mesh patient’s recovery is 4 days less compared to the conventional surgery and 7 days less compared for endoscopic surgery unlike open methods. The recovery of the patient is measured by a questionnaire.
Postoperative (at home) care. It is advisable not to put a limit on patients so that they are free to "do what they feel they can." It is possible to limit the very heavy exercise for 2-3 weeks.
Postoperative pain control - Local infiltration of the wound after surgery is preferred, because it reduces the use of analgesics and provides better control of pain.
What are the specific complications and how to reduce the risk of their occurrence?
The overall risk of complications in hernia according to various studies ranges between 15 and 28%. One of the most common complications are:
1.Hematoma - a complication that occurs most often in open techniques (10.8%) compared to the endoscopic techniques (8.6%). Small hematomas are treated conservatively, while large, causing pain and discomfort, it is necessary to be evacuated under anesthesia.
2.Seroma - More frequently observed in endoscopic procedures (5.7%) in contrast to the open technique (3.7%). Most seromas heal spontaneously.
3.Wound infection - the risk by the techniques with or without mesh is the same and it is the lowest in endoscopic techniques.
4. Urinary retention and impairment of the bladder - The risk of retention is the lowest during surgery under local anesthesia. Bladder catheterisation is mandatory before endoscopic techniques. Damage to the bladder becomes most common in open hernia when you do not take into account the possibility that it could be part of hernia contents. In endoscopic procedures this is extremely rare complication (0.2%).
5.Ischemic orchitis, testicular atrophy and damage to d.deferens. This type of complications are observed in all kinds of techniques. In order to avoid these complications fine dissection should be performed, no rude interference in dissecting the hernia bag and closing the internal opening does not have to be too tight.
6.Damage to the intestine - It is rare impairment (0.2%), which occurs in all of the methods, particularly in trapped hernias. To prevent it is advisable to avoid endoscopic techniques after previous abdominal surgery and after radiotherapy. By endoscopic techniques are also possible adhesions between the mesh and intestines when the peritoneum is closed improperly. Hernias at the port are rarely encountered.
7.Dislocation of the mesh - it can migrate to the small intestine, bladder, scrotum, preperitoneal space, the femoral vein. To avoid this type of complication the surgeon should pay attention to the way he attaches the mesh.
8.Specific endoscopic disabilities - very rare in the different studies, but these are: pneumomediastinum, pneumothorax, hypercapnia.
9.Damage of blood vessels - It is met in the open technique, the highest percentage is in the method of McVay. Endoscopic techniques avoid this complication by the open method of placing the first trocar.
10.Chronic pain – the risk of chronic pain diminishes with age. The risk is very low also in endoscopic techniques. Finding all inguinal nerves and their preservation reduces the risk of chronic postoperative pain.
11.Mortality - the risk is much higher in adult patients undergoing urgent surgery. According to studies, there is about 7% mortality in these operations.
Which is the cheapest and most effective way to treat primary hernia?
From socioeconomic perspective endoscopic procedures are offered to patients of working age, especially in those with bilateral hernia.
1. Aasvang E, Kehlet H (1986) Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain Suppl 3:S1–S226
2. Aasvang E, Kehlet H (2005) Chronic postoperative pain: the case of inguinal herniorrhaphy. Br J Anaesth 95:69–76
3. Aasvang E, Kehlet H (2005) Surgical management of chronic pain after inguinal hernia repair. Br J Surg 92:795–801
4. Aasvang EK, Møhl B, Bay-Nielsen M, Kehlet H (2006) Pain related sexual dysfunction after inguinal herniorrhaphy. Pain 122:258–263
5. Aasvang EK, Møhl B, Kehlet H (2007) Ejaculatory pain: a specific postherniotomy pain syndrome? Anesthesiology 107:298–304
6. Abe T, Shinohara N, Harabayashi T, Sazawa A, Suzuki S, Ka- warada Y, Nonomura K (2007) Postoperative inguinal hernia after radical prostatectomy for prostate cancer. Urology 69:326–329
7. Adamonis W, Witkowski P, Smietan´ ski M, Bigda J, Sledzin´ ski Z (2006) Is there a need for a mesh plug in inguinal hernia repair? Randomized, prospective study of the use of Hertra 1 mesh compared to PerFix Plug. Hernia 10:223–228
8. Agrawal A, Avill R (2006) Mesh migration following repair of inguinal hernia: a case report and review of literature. Hernia 10:79–82
9. Akpinar E, Turkbey B, Ozcan O, Akdogan B, Karcaaltincaba M, Ozen H (2005) Bilateral scrotal extraperitoneal herniation of ureters: computed tomography urographic findings and review of the literature. J Comput Assist Tomogr 29:790–792
10. Alam A, Nice C, Uberoi R (2005) The accuracy of ultrasound in the diagnosis of clinically occult groin hernias in adults. Eur Radiol 15:2457–2461
11. Alsarrage SAM, Godbole CSM (1990) A randomised controlled trial to compare local with general anaesthesia for inguinal hernia repair. J Kuwait Med Assoc 24:31–34
12. Alvarez JA, Baldonedo RF, Bear IG, Sol´ıs JA, Alvarez P, Jorge JI (2004) Incarcerated groin hernias in adults: presentation and outcome. Hernia 8:121–126
13. Amid PK (2000) Driving after repair of groin hernia. BMJ 321:1033–1034
14. Amid PK (2004) Causes, prevention, and surgical treatment of postherniorrhaphy neuropathic inguinodynia: triple neurectomy with proximal end implantation. Hernia 8:343–349
15. Amid PK, Shulman AG, Lichtenstein IL (1994) Local anesthesia for inguinal hernia repair step-by-step procedure. Ann Surg 220:735–737
16. Amid PK, Shulman AG, Lichtenstein IL (1994) Local anesthesia for inguinal hernia repair step-by-step procedure. Ann Surg 220:735–737
17. Amid PK, Shulman AG, Lichtenstein IL (1996) Open ‘‘tension- free’’ repair of inguinal hernias: the Lichtenstein technique. Eur J Surg 162:447–453
18. Andac N, Baltaciog˘ lu F, Tu¨ ney D, Cims¸ it NC, Ekinci G, Biren T (2002) Inguinoscrotal bladder herniation: is CT a useful tool in diagnosis? Clin Imaging 26:347–348
19. Andersen JR, Burcharth F, Larsen HW, Røder O, Andersen B (1980) Polyglycolic acid, silk, and topical ampicillin. Their use in hernia repair and cholecystectomy. Arch Surg 115:293–295
20. Arvidsson D, Smedberg S (2000) Laparoscopic compared with open hernia surgery: complications, recurrences and current trends. Eur J Surg Suppl 585:40–47
21. Arvidsson D, Berndsen FH, Larsson LG, Leijonmarck CE, Rimba¨ck G, Rudberg C, Smedberg S, Spangen L, Montgomery A (2005) Randomized clinical trial comparing 5-year recurrence rate after laparoscopic versus Shouldice repair of primary inguinal hernia. Br J Surg 92:1085–1091
22. Aufenacker TJ, van Geldere D, van Mesdag T, Bossers AN, Dekker B, Scheijde E, van Nieuwenhuizen R, Hiemstra E, Maduro JH, Juttmann JW, Hofstede D, van Der Linden CT, Gouma DJ, Simons MP (2004) The role of antibiotic prophy- laxis in prevention of wound infection after Lichtenstein open mesh repair of primary inguinal hernia: a multicenter double- blind randomized controlled trial. Ann Surg 240:955–960
23. Aufenacker TJ, Koelemay MJ, Gouma DJ, Simons MP (2006) Systematic review and meta-analysis of the effectiveness of antibiotic prophylaxis in prevention of wound infection after mesh repair of abdominal wall hernia. Br J Surg 93:5–10
Guideline on the treatment of inguinal hernia in adult patients according to European Hernia Society – EHS