The inguinal hernia management in Costa Rica according to a survey between surgeons: result comparison with 2018 International Groin Hernia Guidelines.

BACKGROUND: Inguinal hernia surgery is a frequent procedure among general surgeons in Costa Rica, but the management and technique are not uniform. The International Guideline for Groin Hernia management was published in 2018 to standardize the inguinal hernia surgery, but the diffusion of the guidelines and its adherence have been extremely varied. PURPOSE: Collect and analyze the current reality regarding groin hernia management in Costa Rica. Secondly evaluate the diffusion and development comparing it to the guideline's recommendations. METHOD: Questionnaire of 42 single and multiple answer questions according to the topics of the International Guideline directed to general surgeons. Diffusion of the inquiry through surgical and hernia association chats and email. Timeframe June-December 2019. RESULTS: 64 surveys were collected, which is a representative number of the general surgeons national college. The most frequent procedure between these was the abdominal wall surgery. Every surgeon did more than 52 groin hernia surgeries in one year, most of them outpatients. The epidural anesthesia was used the most and Lichtenstein's technique was the most frequently used (64%). 68% of the surgeons know how to perform a minimally invasive inguinal hernia surgery but with variable volumes. 38% of participants considered themselves experts in groin hernia management and 52% did not know the 2018 International Guideline. The recommendations of such guideline are followed only partially. CONCLUSIONS: The 2018 Hernia Surge International Guidelines have low diffusion among Costa Rican surgeons. The laparoscopic approach is widely accepted but there are no studies to assess the results and the quality. There should be protocols and studies adapted to Costa Rica's national situation.

Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)): Part B.

In 2014 the International Endohernia Society (IEHS) published the first international "Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias". Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature. METHODS: For the development of the original guidelines all relevant literature published up to year 2012 was analyzed using the ranking of the Oxford Centre for Evidence-Based-Medicine. For the present update all of the previous authors were asked to evaluate the literature published during the recent years from 2012 to 2017 and revise their statements and recommendations given in the initial guidelines accordingly. In two Consensus Conferences (October 2017 Beijing, March 2018 Cologne) the updates were presented, discussed, and confirmed. To avoid redundancy, only new statements or recommendations are included in this paper. Therefore, for full understanding both of the guidelines, the original and the current, must be read. In addition, the new developments in repair of abdominal wall hernias like surgical techniques within the abdominal wall, release operations (transversus muscle release, component separation), Botox application, and robot-assisted repair methods were included. RESULTS: Due to an increase of the number of patients and further development of surgical techniques, repair of primary and secondary abdominal wall hernias attracts increasing interests of many surgeons. Whereas up to three decades ago hernia-related publications did not exceed 20 per year, currently this number is about 10-fold higher. Recent years are characterized by the advent of new techniques-minimal invasive techniques using robotics and laparoscopy, totally extraperitoneal repairs, novel myofascial release techniques for optimal closure of large defects, and Botox for relaxing the abdominal wall. Furthermore, a concomitant rectus diastasis was recognized as a significant risk factor for recurrence. Despite still insufficient evidence with respect to these new techniques it seemed to us necessary to include them in the update to stimulate surgeons to do research in these fields. CONCLUSION: Guidelines are recommendations based on best available evidence intended to help the surgeon to improve the quality of his daily work. However, science is a continuously evolving process, and as such guidelines should be updated about every 3 years. For a comprehensive reference, however, it is suggested to read both the initially guidelines published in 2014 together with the update. Moreover, the presented update includes also techniques which were not known 3 years before.

Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS))-Part A.

In 2014, the International Endohernia Society (IEHS) published the first international "Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias." Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature. METHODS: For the development of the original guidelines, all relevant literature published up to year 2012 was analyzed using the ranking of the Oxford Centre for Evidence-Based Medicine. For the present update, all of the previous authors were asked to evaluate the literature published during the recent years from 2012 to 2017 and revise their statements and recommendations given in the initial guidelines accordingly. In two Consensus Conferences (October 2017 Beijing, March 2018 Cologne), the updates were presented, discussed, and confirmed. To avoid redundancy, only new statements or recommendations are included in this paper. Therefore, for full understanding both of the guidelines, the original and the current, must be read. In addition, the new developments in repair of abdominal wall hernias like surgical techniques within the abdominal wall, release operations (transversus muscle release, component separation), Botox application, and robot-assisted repair methods were included. RESULTS: Due to an increase of the number of patients and further development of surgical techniques, repair of primary and secondary abdominal wall hernias attracts increasing interests of many surgeons. Whereas up to three decades ago hernia-related publications did not exceed 20 per year, currently this number is about 10-fold higher. Recent years are characterized by the advent of new techniques-minimal invasive techniques using robotics and laparoscopy, totally extraperitoneal repairs, novel myofascial release techniques for optimal closure of large defects, and Botox for relaxing the abdominal wall. Furthermore, a concomitant rectus diastasis was recognized as a significant risk factor for recurrence. Despite insufficient evidence with respect to these new techniques, it seemed to us necessary to include them in the update to stimulate surgeons to do research in these fields. CONCLUSION: Guidelines are recommendations based on best available evidence intended to help the surgeon to improve the quality of his daily work. However, science is a continuously evolving process, and as such guidelines should be updated about every 3 years. For a comprehensive reference, however, it is suggested to read both the initial guidelines published in 2014 together with the update. Moreover, the presented update includes also techniques which were not known 3 years before.

Locoregional versus general anesthesia for open inguinal herniorrhaphy: a National Surgical Quality Improvement Program analysis.

Our objective was to study outcomes associated with open inguinal herniorrhaphy performed under locoregional (LR) versus general anesthesia (GA). National Surgical Quality Improvement Program (NSQIP) data from 2005 to 2009 was queried to capture patients undergoing initial unilateral inguinal herniorrhaphy. We excluded patients with incarcerated/strangulated hernia or those undergoing a concomitant procedure. Outcomes were anesthesia and operative times, postoperative admission, and 30-day morbidity. Using the entire NSQIP sample, forward stepwise multivariate regression analysis was used to compare outcomes between patients receiving LR versus GA after adjustment for patient demographics and comorbid diagnoses. Outcomes were also compared for a smaller subgroup of patients propensity-matched for receiving LR anesthesia. A total of 25,213 patients were analyzed (16,282 GA and 8,931 LR). Patients in the LR group had a higher incidence of comorbid illnesses and were more likely to have an American Society of Anesthesiologists classification ≥ 3. Multivariate analyses demonstrated that LR anesthetic is associated with shorter anesthetic and operative times and a lower hospital admission rate. Comparison using a propensity-matched cohort for undergoing LR anesthesia confirms that these patients had significantly shorter anesthesia (32 vs 38 min, P < 0.0001) and operative times (53.3 vs 57.2 min, P < 0.0001), as well as a significantly reduced rate of postoperative admission (5.9% vs 10.9%, P < 0.0001) and 30-day morbidity (0.9% vs 1.3%, P < 0.05). Our analysis of NSQIP suggests that, compared with general anesthesia, the locoregional technique is associated with shorter anesthesia and operative times, reduced need for postoperative hospital admission, and a small but significant reduction in postoperative morbidity.