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Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 9341]

INGUINAL
INGUINAL HERNIA
HERNIA REPAIR
REPAIR -- ACTUAL
ACTUAL STATUS
STATUS (Abstract):
(Abstract): Even
Even in
in 2006,
2006, there
there are
are aa
lot
lot of
of controversy
controversy about
about the
the best
best technique
technique for
for inguinal
inguinal hernia
hernia repair.
repair. The
The factors
factors that
that influence
influence
the
the choice
choice of
of the
the technique
technique are:
are: uniuni- or
or bilateral
bilateral hernia,
hernia, Nyhus
Nyhus type
type of
of hernia,
hernia, complicated
complicated
hernia,
hernia, large
large inguino-scrotal
inguino-scrotal hernia,
hernia, recurrent
recurrent hernia
hernia or
or previous
previous surgery,
surgery, preferred
preferred type
type of
of
anaesthesia.
anaesthesia. Surgeon
Surgeon has
has to
to answer
answer to
to three
three question
question when
when he
he choices
choices aa type
type of
of hernia
hernia repair:
repair:
What
What are
are there
there specific
specific indications
indications for
for this
this repair?
repair? What
What are
are the
the specific
specific complications
complications of
of the
the
repair
repair technique?
technique? What
What are
are the
the results
results with
with the
the repair
repair technique?
technique? In
In the
the literature
literature there
there are
are aa lot
lot
of
of studies
studies which
which give
give comparisons
comparisons about
about the
the techniques
techniques of
of hernia
hernia repair:
repair: type
type and
and rate
rate of
of
complications,
complications, recurrence
recurrence rate,
rate, costs
costs and
and economic
economic impact.
impact. There
There are
are various
various types
types of
of
evidence:
evidence: retrospective
retrospective studies,
studies, prospective
prospective randomized
randomized trials,
trials, meta-analyses.
meta-analyses. This
This paper
paper
reviews
reviews some
some of
of the
the literature
literature studies
studies about:
about: techniques
techniques of
of open
open non-mesh
non-mesh hernia
hernia repair,
repair, types
types
of
of open
open mesh
mesh repair,
repair, mesh
mesh vs
vs non-mesh
non-mesh open
open techniques,
techniques, open
open vs
vs laparoscopique
laparoscopique techniques
techniques
and
and types
types of
of laparoscopic
laparoscopic hernia
hernia repair
repair techniques.
techniques. Conclusion:
Conclusion: Open
Open non-mesh
non-mesh repairs
repairs should
should
be
be avoided.
avoided. Lichtenstein
Lichtenstein mesh
mesh repair
repair isis the
the best
best open
open technique.
technique. Laparoscopic
Laparoscopic techniques
techniques
(TAPP
(TAPP &TEP)
&TEP) induce:
induce: less
less pain,
pain, shorter
shorter hospital
hospital stay,
stay, earlier
earlier return
return to
to work,
work, more
more rapid
rapid
resumption
resumption of
of activities
activities and
and lower
lower recurrence
recurrence rates
rates but
but at
at aa higher
higher cost,
cost, especially
especially in
in nonnonworking
working population.
population.

INGUINAL HERNIA REPAIR

Actual Status
--------------------------------------Prof. Dr. R.Van Hee
University of Antwerp
Belgium
European Academy of Surgical Sciences

KEY
KEY WORDS:
WORDS: GROIN
GROIN HERNIA,
HERNIA, MESH
MESH REPAIR,
REPAIR, TAPP,
TAPP, TEP
TEP

Hernia Repair: Historical Overview

-------------------------------------------

Inguinal Hernia Repair

-----------------------------

In 2006 :
Still much controversy
Still many techniques

Eduardo Bassini (1844-1924): own technique 1877

Bassini modifications (Halsted,Kirschner,Houdard..)
Chester McVay (1911-1987): own technique 1948
Edward Shouldice (1890-1965): technique 1945-51
Lloyd Nyhus (1923): type-related techniques 1955
Irving Lichtenstein (1920): tension-free techn.1986

Hernia Repair: actual situation

-------------------------------------- Open techniques
Shouldice repair
Lichtenstein repair
Plug-mesh repair
Other variants

Factors influencing type of repair

----------------------------------------

Laparoscopic techniques
TAPP repair
TEP repair
Plug repair
Other variants

180

Uni- or Bilateral hernia

Nyhus type of hernia
Incarceration of hernia
Large inguinoscrotal hernia
Recurrent hernia or Previous surgery
Preferred type of anaesthesia (patient/surgeon)

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Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 9341]

Evidence concerning Hernia Repair

----------------------------------------------

Choice of type of hernia repair

--------------------------------------

1. Prolific number of clinical trials!!!

2. Various types of evidence
-retrospective studies
-prospective randomized trials
-meta-analyses
3. Different end-points
-type and rate of complications
-recurrence rate
-costs and economic impact

Which type does one use?

Are there specific indications for this repair?
Are there specific complications with this repair?
What are the results with this repair?

..Why does one choose this type of repair?

Evidence concerning hernia repair

-------------------------------------------

Trials in Open non-mesh Repair

---------------------------------------

Often studies give comparisons between

incomparable hernia groups:
a. mixing of uni- and bilateral hernias
b. mixing of different Nyhus types
c. mixing of primary and recurrent hernias
d. multicenter studies can be accompanied
by slight but important differences in
technique (mesh size, type, fixation etc.)

Mostly before 1990

Comparing Bassini/Shouldice/McVay and other
techniques
Concluding evidence:
Shouldice technique is best repair,
with a recurrence rate of ~5% after 2 years,
but often raising to 10-15% after 10 years!

Results of Trials in
Open mesh Repair
----------------------------------

Trials comparing open

mesh and non-mesh repair
--------------------------------Meta-analysis performed by the

1. Lichtenstein repair (uni- or bilateral hernia)

-recurrence rate of <5%
- less tension and pain
2. Stoppa repair (bilateral hernia)
-recurrence rate ~ 1% after 6 years
-needs general anaesthesia!

EU Hernia Trialists Collaboration

(Brit.J.Surg. 2000, 87: 854-859)
Conclusion: in favour of mesh repair
1. Less pain
2. Earlier return to work
3. Recurrences 1.4%mesh) vs 4.4%(non-mesh)

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Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 9341]

Types of trials comparing

Open and Laparoscopic techniques
General trials: comparisons including multiple
types of both techniques
Specific trials: comparisons between single or
specific techniques
Meta-analyses: always including several types
of techniques

General Trials: open vs lap

-------------------------------All open procedures vs. all laparoscopic procedures
-on the short term lap techniques induce
1. earlier return to work
2. less chronic pain
3. variable rate of recurrences
P.J.ODwyer
Brit.J.Surg. 2004,70:105-118

General Trials: open vs lap technique

-------------------------------All open procedures vs. all laparoscopic procedures
-on the long term
1. recurrences identical
2. less chronic pain in lap techniques
P.J.ODwyer
Brit.J.Surg. 2004,70:105-118

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Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 9341]

Specific trials: Champault et al.[Fr]

(J.Chir.,1996)
--------------------

Specific trials: Fleming et al. Austr]

(BJS, 2001)
------------------------Shouldice (n=115) vs TEP (n=117)
------------------------------------------Endpoints were:
-operation time (56 vs 70 min)
-hospital stay (1-day:48 vs 68%)
-sick leave (30 vs 14 days)
- resumption of normal activities ( 35 vs 21 days)
-costs (40% cheaper vs TEP)
-complications at 1 year (9 vs 21%)

Stoppa (n= 49) vs TEP (n= 51)

-----------------------------------Endpoints were:
- operation time (identical for unilateral;
shorter for bilateral Stoppa)
- hospital stay ( 7.3 vs 3.2 days)
- sick leave (35 vs 17 days),
- postop. pain ( less in TEP)
- recurrence (6% vs 2%)

Specific trials: Wara et al.[De](BJS, 2005)

-------------------

Specific trials: Eklund et al.[S]( BJS, 2006)

------------------------

Lichtenstein (n=39537) vs. TAPP (n=3606)

----------------------------------------------------Endpoint: recurrence in various hernia categories
primary indirect:
1.0 % vs 0 %
primary direct:
3.1 % vs 1.1%
primary bilateral:
3.0 % vs 4.8 %
recurrent unilateral: 4.8 % vs 4.6 %
recurrent bilateral: 7.6 % vs 2.6 %

Lichtenstein (n=706) vs TEP (n= 665)

---------------------------------------------Endpoints were postop.pain, period of sick leave,
and resumption of normal activities:
ALL 3 were in favour of TEP (p<0.001)
-sick leave:
12 vs 7 days
-normal activities : 31 vs 20 days

Cost Aspect in Lap Surgery (TEP)

------------------------------------------(Champault et al., J.Chir., 1994)

Size of mesh in TEP or TAPP

-------------------------------------Investigation in 10 cadavers to assess the size of a
quadrangle, formed by the various hernia sites
(inguinal, femoral, obturator, supravesical):
mean surface of 71 cm.
Conclusion: mesh should at least measure
10 x 8 cm to close all sites adequately!

Hospitalisation costs higher (105 Euro), even in

case of reusable material
Gain in sick leave and return to work however
generates a benefit of 160 Euro.
Conclusion: TEP less costly only in case of
working class population

Tott et al. Eur.Surg.Res.,2005.

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Jurnalul de Chirurgie, Iasi, 2007, Vol. 3, Nr. 2 [ISSN 1584 9341]

Conclusions
--------------------- 1. Open non-mesh repairs should be avoided
2. Lichtenstein mesh repair : best open technique
3. Laparoscopic techniques (TAPP &TEP) induce
-less pain, shorter hospital stay, earlier return to
work, more rapid resumption of activities and
lower recurrence rates,
-but at a higher cost, specially in non-working
population

184