Chronic groin pain, discomfort and physical disability after recurrent groin hernia repair: impact of anterior and posterior mesh repair.

UNLABELLED: Chronic pain and physical disability are well-known problems after primary groin hernia surgery, but the outcome after recurrent hernia surgery is much less known. PURPOSE: To study the impact of anterior mesh repair (AMR) and posterior mesh repair (PMR) on chronic pain and disability after first recurrent groin hernia surgery in a population-based cohort derived from the Swedish Hernia Register. METHODS: Consecutive unilateral, first and second recurrent hernia repairs, registered between 1998 and 2007, were included. Follow-up was performed in 2009 based on the Inguinal Pain Questionnaire (IPQ) and selective clinical examination, comparing prevalence of pain between AMR, endoscopic (E-PMR) and open posterior mesh repairs (O-PMR) after first recurrent repair. Chronic pain after a second recurrent repair was analysed. RESULTS: Altogether 671 first recurrent repairs were analysed: 329 AMRs, 161 E-PMRs and 181 O-PMRs. IPQ response rate was 70.6%. If the index repair was anterior, the E-PMR was associated with a lower risk of chronic pain and disability compared to AMR [OR 0.54 (CI 0.30-0.97), p = 0.039]. The risk of chronic pain increased after a second recurrent repair. A surgeon's annual volume >5 O-PMRs was related to a lower risk compared to ≤5 [OR 0.42 (CI 0.19-0.94), p = 0.034]. CONCLUSION: Endoscopic repair for first recurrent groin hernia surgery, after an index anterior repair, was associated with less chronic pain, discomfort and disability compared to anterior approach. Chronic pain increased after a second recurrent repair. A high surgeon's volume reduced the risk of chronic pain after open posterior mesh repair.

The impact of type of mesh repair on 2nd recurrence after recurrent groin hernia surgery.

BACKGROUND: According to the Swedish Hernia Register (SHR), the reoperation rate is more than doubled after recurrent groin hernia repair compared with primary repair. The aim was to study the impact of type of mesh repair used in recurrent groin hernia surgery on a 2nd recurrence in a population-based cohort derived from the SHR. MATERIAL AND METHOD: All 1st recurrent hernia repairs in the south-west region of Sweden, registered in SHR between 1998 up to 2007 were included. A questionnaire was sent in 2009. Patients stating a new lump or persisting problems were examined. A 2nd recurrence was identified as a 2nd reoperation or at physical examination. The incidence was analysed comparing anterior mesh repair (AMR) and posterior mesh repairs (PMR) (endoscopic and open). RESULTS: Eight hundred and fifteen recurrent operations in 767 patents were analysed, 401 AMRs and 414 PMRs. PMR had a lower 2nd recurrence rate compared with AMR (5.6 vs. 11.0 %) (p = 0.025). An increased risk [3.21 (CI 1.33-7.44) (p = 0.009)] of a subsequent 2nd recurrence was seen after anterior index repair followed by AMR and a decreased risk [0.08 (CI 0.01-0.94) (p = 0.045)] after posterior index repair followed by AMR. CONCLUSION: PMR in recurrent groin hernia surgery was associated with a lower 2nd recurrence rate compared to anterior. A posterior approach for 1st recurrent operation is recommended after an anterior index repair and an anterior approach after a posterior index operation.

Reoperation for persistent pain after groin hernia surgery: a population-based study.

PURPOSE: The aim of the present study was to assess the outcome results after reoperation for persistent pain after hernia surgery in a population-based setting. METHODS: All patients who had undergone surgery for persistent pain after previous groin hernia surgery 1999-2006 were identified in the Swedish Hernia Register (n = 237). Data on the surgical technique used were abstracted from the medical records. The patients were asked to answer a set of questions including SF-36 to evaluate the prevalence of pain after reoperation. RESULTS: The study group consisted of 95 males and 16 females, mean age 53 years. In 27 % of cases an intervention aimed at suspected ilioinguinal neuralgia was performed. The mesh was removed completely in 28% and partially in 13%. A suture at the pubic tubercle was removed in 13% of cases. Decrease in pain after the most recent reoperation was reported by 69 patients (62%), no change in pain by 21 patients (19%) and increase in pain in 21 patients (19%). There was no significant difference in outcome between mesh removal, removal of sutures at the tubercle or interventions aimed at the ilioinguinal nerve. All subscales of SF-36 were significantly reduced when compared to the age- and gender-matched general population (p < 0.05). CONCLUSIONS: Patients reoperated for persistent pain after hernia surgery often report a reduction in pain, but the natural course of persistent pain, the relatively low response rate and selection of patients make it difficult to draw definite conclusions.

Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients.

PURPOSE: In 2009, the European Hernia Society published the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. The guidelines expired January 1, 2012. To keep them updated, a revision of the guidelines was planned including new level 1 evidence. METHODS: The original Oxford Centre for Evidence-Based Medicine ranking was used. All relevant level 1A and level 1B literature from May 2008 to June 2010 was searched (Medline and Cochrane) by the Working Group members. All chapters were attributed to the two responsible authors in the initial guidelines document. One new chapter on fixation techniques was added. The quality was assessed by the Working Group members during a 2-day meeting and the data were analysed, especially with respect to any change in the level and/or text of any of the conclusions or recommendations of the initial guidelines. In the end, all relevant references published until January 1, 2013 were included. The final text was approved by all Working Group members. RESULTS: For the following topics, the conclusions and/or recommendations have been changed: indications for treatment, treatment of inguinal hernia, day surgery, antibiotic prophylaxis, training, postoperative pain control and chronic pain. The addendum contains all current level 1 conclusions, Grade A recommendations and new Grade B recommendations based on new level 1 evidence (with the changes in bold). CONCLUSIONS: Despite the fact that the Working Group responsible for it tried to represent most kinds of surgeons treating inguinal hernias, such general guidelines inevitably must be fitted to the daily practice of every individual surgeon treating his/her patients. There is no doubt that the future of guideline implementation will strongly depend on the development of easy to use decision support algorithms tailored to the individual patient and on evaluating the effect of guideline implementation on surgical outcome. At the 35th International Congress of the EHS in Gdansk, Poland (May 12-15, 2013), it was decided that the EHS, IEHS and EAES will collaborate from now on with the final goal to publish new joint guidelines, most likely in 2015.

European Hernia Society guidelines on the treatment of inguinal hernia in adult patients.

The European Hernia Society (EHS) is proud to present the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. They have been developed by a Working Group consisting of expert surgeons with representatives of 14 country members of the EHS. They are evidence-based and, when necessary, a consensus was reached among all members. The Guidelines have been reviewed by a Steering Committee. Before finalisation, feedback from different national hernia societies was obtained. The Appraisal of Guidelines for REsearch and Evaluation (AGREE) instrument was used by the Cochrane Association to validate the Guidelines. The Guidelines can be used to adjust local protocols, for training purposes and quality control. They will be revised in 2012 in order to keep them updated. In between revisions, it is the intention of the Working Group to provide every year, during the EHS annual congress, a short update of new high-level evidence (randomised controlled trials [RCTs] and meta-analyses). Developing guidelines leads to questions that remain to be answered by specific research. Therefore, we provide recommendations for further research that can be performed to raise the level of evidence concerning certain aspects of inguinal hernia treatment. In addition, a short summary, specifically for the general practitioner, is given. In order to increase the practical use of the Guidelines by consultants and residents, more details on the most important surgical techniques, local infiltration anaesthesia and a patient information sheet is provided. The most important challenge now will be the implementation of the Guidelines in daily surgical practice. This remains an important task for the EHS. The establishment of an EHS school for teaching inguinal hernia repair surgical techniques, including tips and tricks from experts to overcome the learning curve (especially in endoscopic repair), will be the next step. Working together on this project was a great learning experience, and it was worthwhile and fun. Cultural differences between members were easily overcome by educating each other, respecting different views and always coming back to the principles of evidence-based medicine. The members of the Working Group would like to thank the EHS board for their support and especially Ethicon for sponsoring the many meetings that were needed to finalise such an ambitious project.

Discomfort five years after laparoscopic and Shouldice inguinal hernia repair: a randomised trial with 867 patients. A report from the SMIL study group.

BACKGROUND: In recent years long-term discomfort after inguinal hernia surgery has become an issue of great concern to hernia surgeons. Long-term results on discomfort from large randomised studies are sparse. METHODS: One-thousand one-hundred and eighty-three patients were randomised in a multicentre trial with the primary aim of comparing recurrence rates after laparoscopic TAPP and Shouldice repair. Evaluating late discomfort and its possible risk factors were secondary objectives, and are reported here. The patients were clinically examined after 1 and 5 years, and answered questionnaires 2 and 3 years postoperation. RESULTS: Of 1,068 operated patients, 867 were eligible for analysis after 5 years (81.2%). The percentage of patients experiencing discomfort of any kind were 8.5% in the TAPP group and 11.4% (p = 0.156) in the Shouldice group. Although discomfort was usually mild it was severe for 0.2 and 0.7%, respectively. Severe pain the first postoperative week was a risk factor for late discomfort in the Shouldice group (OR 2.25, P = 0.022) but not in the TAPP group. No other risk factor for late discomfort was found. CONCLUSION: There was no difference between late discomfort at five-year follow-up after laparoscopic TAPP and Shouldice repair. Discomfort was mostly mild and pain during the first postoperative week was a prognostic variable for late discomfort in Shouldice patients.

Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair.

BACKGROUND: Laparoscopic herniorrhaphy has emerged as a recognized operative method for inguinal hernia repair. This study compared the short-term results of two tension-free methods of repair: totally extraperitoneal (TEP) laparoscopic patch repair and the open Lichtenstein mesh technique. METHODS: A total of 1513 men from 11 hospitals who presented with a primary unilateral inguinal hernia were randomized to one of the two methods. Operating time, short-term complications, reoperations, postoperative pain, consumption of analgesics, sick leave and time to resumption of normal physical activities were recorded. RESULTS: Some 1371 of the 1513 men underwent surgery, 665 in the TEP group and 706 in the Lichtenstein group. The median duration of operation was 55 min for both procedures and 91.0 percent of the patients in both groups were discharged on the day of operation. Patients in the TEP group experienced less postoperative pain (P<0.001), consumed fewer analgesics (P<0.001), had a shorter period of sick leave (7 versus 12 days; P<0.001) and a shorter time to resumption of normal physical activity (20 versus 31 days; P<0.001). CONCLUSION: The TEP technique took no longer to perform, and was associated with less postoperative pain, a shorter period of sick leave and a faster recovery, compared with open Lichtenstein hernia repair.

Three-year results of a randomized clinical trial of lightweight or standard polypropylene mesh in Lichtenstein repair of primary inguinal hernia.

BACKGROUND: This randomized trial examined whether lightweight (LW) polypropylene mesh (large pore size, partially absorbable) could have long-term benefits in reducing chronic pain and inflammation after inguinal hernia repair. METHODS: Six hundred men with a primary unilateral inguinal hernia were randomized to Lichtenstein repair using a standard polypropylene mesh or a LW mesh in one of six centres. The patients were blinded to which mesh they received. Clinical examination was performed and a pain questionnaire completed 3 years after surgery. RESULTS: Of the 590 men who had surgery, 243 (82.7 percent) of 294 in the standard mesh group and 251 (84.8 percent) of 296 in the LW mesh group were examined in the clinic, a median of 37 (range 30-48) months after hernia repair. There were nine recurrent hernias in each group (3.7 percent with standard mesh and 3.6 per cent with LW mesh). Patients who had LW mesh had less pain on examination, less pain on rising from lying to sitting, fewer miscellaneous groin problems and felt the mesh less often than patients with standard mesh. CONCLUSION: Use of LW mesh for Lichtenstein hernia repair did not affect recurrence rates, but improved some aspects of pain and discomfort 3 years after surgery.

Incisional hernia repair in Sweden 2002.

Incisional hernia is a common problem after abdominal surgery. The complication and recurrence rates following the different repair techniques are a matter of great concern. Our aim was to study the results of incisional hernia repair in Sweden. A questionnaire was sent to all surgical departments in Sweden requesting data concerning incisional hernia repair performed during the year 2002. Eight hundred and sixty-nine incisional hernia repairs were reported from 40 hospitals. Specialist surgeons performed the repair in 782 (83.8%) patients. The incisional hernia was a recurrence in 148 (17.0%) patients. Thirty-three per cent of the hernias were subsequent to transverse, subcostal or muscle-splitting incisions or laparoscopic procedures. Suture repair was performed in 349 (40.2%) hernias. Onlay mesh repair was more common than a sublay technique. The rate of wound infection was 9.6% after suture repair and 8.1% after mesh repair. The recurrence rate was 29.1% with suture repair, 19.3% with onlay mesh repair, and 7.3% with sublay mesh repair. This survey revealed that there is room for improvement regarding the incisional hernia surgery in Sweden. Suture repair, with its unacceptable results, is common and mesh techniques employed may not be optimal. This study has led to the instigation of a national incisional hernia register.

Early results of a randomised trial comparing Prolene and VyproII-mesh in endoscopic extraperitoneal inguinal hernia repair (TEP) of recurrent unilateral hernias.

The purpose of this study was to compare a lightweight mesh to a standard polypropylene hernia mesh in endoscopic extraperitoneal hernioplasty in recurrent hernias. A total of 140 men with recurrent unilateral inguinal hernias were randomised to a totally extraperitoneal endoscopic hernioplasty (TEP) with Prolene or VyproII in a single-blinded multi-center trial. The randomisation and all data handling were performed through the Internet. 137 patients were operated as allocated. Follow-up was completed in 88% of the patients. The median operation times were 55 (24-125) min and 53.5 (21-123) min for the Prolene and VyproII groups, respectively. The meshes had comparable results in the surgeon's assessment of the handling of the mesh, return to work, return to daily activities, complications, postoperative pain and quality of life during the first 8 weeks of rehabilitation, except in General Health (GH) SF-36, where the VyproII-group had a significantly better score (P=0.045). The use of Prolene and VyproII-meshes in endoscopic repair of recurrent inguinal hernia seems to result in similar short-term outcomes and quality of life.

Randomized clinical trial comparing 5-year recurrence rate after laparoscopic versus Shouldice repair of primary inguinal hernia.

BACKGROUND: The Shouldice technique is the 'gold standard' of open non-mesh hernia repair. The aim of this study was to compare 5-year recurrence rates after Shouldice and laparoscopic transabdominal preperitoneal patch (TAPP) repair for primary inguinal hernia. METHOD: Men with a primary unilateral inguinal hernia were randomized to either Shouldice or TAPP operation. An independent observer scored the surgeons' performance. Follow-up comprised clinical examination after 1 year, a questionnaire after 2 and 3 years, and a clinical examination after 5 years. RESULTS: Between February 1993 and March 1996, 1183 patients were included. Nine hundred and twenty patients were followed for 5 years, 454 in the TAPP group and 466 in the Shouldice group. Recurrences were evenly distributed between groups throughout the follow-up period. The cumulative recurrence rate after 5 years was 6.6 per cent in the TAPP group and 6.7 per cent in the Shouldice group. Postoperative pain was a risk factor for recurrence after Shouldice operation but not after TAPP repair. There was a correlation between a low surgeon's performance score and recurrence. CONCLUSION: The 5-year recurrence rate is acceptable, with no difference between TAPP and Shouldice repair. Poor operative performance resulted in a higher recurrence rate. The TAPP operation represents an excellent alternative for primary inguinal hernia repair.

One year results of a randomised controlled multi-centre study comparing Prolene and Vypro II-mesh in Lichtenstein hernioplasty.

A standard polypropylene mesh used in Lichtenstein's operation induces a strong foreign tissue reaction with potential harmful effects. A mesh with less polypropylene could possibly be beneficial. Six hundred men with primary unilateral inguinal hernias were randomised to Lichtenstein's operation using a Prolene- or Vypro II-mesh in six centres. The patients were blinded to which mesh they received. A validated questionnaire assessing recurrence and pain along with SF-36 Health Survey was sent after 1 year to all patients and a selected group was clinically examined. Of the 591 operated patients, 526 (89.0%) returned the questionnaire. 188 patients had some complaints or sensations of which 111 patients were clinically examined. The mean follow-up time was 13.6 (SD. 4.0) months. The incidence of hernia recurrence (four vs. four patients) and neuralgia (three vs. four patients) did not differ between Prolene and Vypro II-groups, respectively. One Vypro II-patient was re-operated due to neuralgia. There was no difference in the SF-36 scores. The results of Lichtenstein's operation with either Prolene or Vypro II do not seem to differ significantly.

Postoperative convalescence after inguinal hernia surgery: prospective randomized multicenter study of laparoscopic versus shouldice inguinal hernia repair in 1042 patients.

Interest in inguinal hernia surgery has increased significantly with the introduction of new operating techniques during the past decade. This multicenter study compared short-term results in patients treated by the laparoscopic transabdominal preperitoneal patch technique (TAPP; n = 518) and the Shouldice technique (n = 524). We evaluated demographics, operative data, complications, hospital stay, postoperative pain, use of cs, functional status, sick leave, and complaints up to 3 months postoperatively. The median operating time was shorter in the Shouldice group (55 vs. 65 min), but there were no significant differences in complication rates, and major complications were rare. The hospital stay was 1 day or less in over 98% of cases in both groups, but more operations were performed on outpatient basis in the Shouldice group. In the TAPP group postoperative pain and analgesic consumption were less, postoperative functional status was better, and sick leave was shorter (10 vs. 14 days). These results show that the two methods are equally safe and have few major complications. The TAPP operation is associated with less postoperative pain, better postoperative functional status, and shorter sick leave, but at the price of a longer operating time.

[Laparoscopic surgery--evidence-based ?]. / Laparoskopisk kirurgi--hur evidensbaserad är den?

The literature has been searched for current results in laparoscopic cholecystectomy, hernia repair, appendectomy and fundoplication. This was performed as a systematic review. Laparoscopic cholecystectomy was judged to be safe and cost/effective, with good patient acceptability. However a need for further studies is indicated. Laparoscopic technique in hernia repair has a longer learning curve and is more expensive than open repair, with no major difference in recurrence rates. It is preferable in bilateral repairs. Laparoscopic appendectomy in the hands of experienced surgeons is cost/effective. Time to recovery is shorter and the rate of infectious complications is lower than in conventional procedures. There are still too few results reported from laparoscopic fundoplication to permit reliable conclusions.

Laparoscopic mesh versus open preperitoneal mesh versus conventional technique for inguinal hernia repair: a randomized multicenter trial (SCUR Hernia Repair Study).

OBJECTIVE: To evaluate the influence of the laparoscopic technique in hernia repair regarding time to full recovery and return to work, complications, recurrence rate, and economic aspects. SUMMARY BACKGROUND DATA: Several studies have shown advantages in terms of less pain and faster recovery after laparoscopic hernia repair, whereas others have not, and the cost-effectiveness has been questioned. The laparoscopic technique must be thoroughly compared with the open procedures before its true place in hernia surgery can be defined. METHODS: Six hundred thirteen male patients aged 40 to 75 years were randomized to the conventional procedure, preperitoneal mesh placed by the open technique, or laparoscopic preperitoneal mesh (TAPP). Follow-up was after 7 days, 8 weeks, and 1 year. RESULTS: Of 613 patients undergoing surgery, 604 (98.5%) were followed for 1 year. Patients who underwent TAPP gained full recovery after 18.4 days, compared with 24.2 days for open mesh (p < 0.001) and 26.4 days for the conventional procedure (p < 0.001). Patients who underwent TAPP returned to work after 14.7 days, compared with 17.7 days for open mesh (p = 0.05) and 17.9 days for the conventional procedure (p = 0.04). They also had significantly less restriction in physical activities after 7 days. The TAPP procedure was more expensive, mainly as a result of longer surgical time and equipment costs, even after compensation for earlier return to work. Complications were more common in the TAPP group, with a varying pattern between the groups. Four recurrences in the conventional, 11 in the open mesh, and 4 in the TAPP group were recorded after 1 year (p = n.s.). CONCLUSION: The laparoscopic technique results in both shorter time to full recovery and shorter time to return to work, at the price of substantially increased costs.

Herniography: a diagnostic tool in groin symptoms following hernial surgery.

The diagnostic value of herniography for groin symptoms after hernial surgery was evaluated in 106 patients. When clinical examination indicated recurrent hernia, herniography was positive in 32 of 40 cases (80%). When no hernia was palpable, herniography revealed recurrence in 28 of 66 cases (42%). A narrow hernial neck was found in 33% of recurrent direct inguinal hernias. Preoperative herniographic findings were confirmed at subsequent surgery in 51 of 53 cases (96%). Postoperative herniography in symptomatic patients without palpable hernial recurrence increased the number of diagnosed recurrences by 44%. Herniography significantly adds to the reliability of clinical diagnosis, with specific information concerning type of recurrent hernia and appearance of the hernial neck.

Herniography in athletes with groin pain.

In the years 1974 to 1981, herniography was performed in 78 athletes with groin pain. The investigation comprised 101 painful groin sides in 23 athletes with bilateral symptoms. Before herniography, a hernia was palpated in only eight (7.9 percent) groins with pain. Hernias were found at herniography in 84.2 percent of the symptomatic groin sides and in 49.1 percent of the asymptomatic groin sides. Sixty-three hernia operations were performed. The herniographic and operative diagnoses corresponded well. Direct hernias dominated among the operated athletes, and were found in 55.6 percent of those below 30 years of age. Altogether 69.8 percent of the operated patients were cured by hernia repair and another 20.6 percent were improved. Tenoperiostitis of the adductor muscles was the most frequent diagnosis in those not cured by operation and among the nonoperated patients. Herniography was of great value in selecting those patients who needed a repair. A broad differential diagnostic approach when examining these patients is of the utmost importance.

Herniography in the diagnosis of obscure groin pain.

Obscure groin pain was investigated in 250 consecutive patients (including 171 males) with no palpable hernia or previous hernia operation. Herniography revealed nonpalpable but symptomatic hernia in 51% of the male and 21% of the female patients. Among the hernia patients with bilateral pain, 40% had unilateral hernia. Direct-type hernia was most commonly found. Of the surgically treated patients, 87% were free from groin pain postoperatively. Further clinical investigations with a broad diagnostic approach gave a treatable diagnosis in 70% of the patients without hernia surgery. Spontaneous improvement occurred during the investigation in 25%, and the cause of groin pain remained unclear in 5% of the patients. Herniography is a valuable diagnostic tool in obscure groin pain and its use is justified at an early stage of investigation. "Blind" exploration can thus be avoided.