Short-term outcome after mesh or Shouldice
herniorrhaphy: A randomised, prospective study. Barth R J, Burchard K W,
Tosteson A et al. Surgery 1998; 123: 121-126.
The long-term recurrence rates after both Lichtenstein mesh and
Shouldice hernia repairs are both low. Rate of less than 1% have often
been reported using either technique. Differences in short-term outcome
may therefore be more important determinants in the selection of hernia
repair techniques. No prospective comparative studies of the short-term
morbidity after these two techniques have previously been reported. In
this study 105 patients were randomised to receive either a Lichtenstein
mesh or Shouldice hernia repair. Most were performed as day cases under
local anaesthetic. Patients were unaware of the technique used until all
data had been collected at four weeks. Post-operative pain, analgesic use
and resumption of activity were used as outcome measures. There was no
difference in any of these factors between the two groups. Recovery was
rapid and complications were minimal in most patients irrespective of the
technique used. The median time to resumption of normal activity was nine
days in both groups. It was concluded that the short-term outcome was
similar in both groups.
Laparoscopic versus open repair of groin hernia: a
randomised comparison. The MRC Laparoscopic Groin Hernia Trial Group.
Lancet 1999; 354: 185-190.
Groin hernia repair is one of the commonest operations performed in the
United Kingdom. It has been estimated that between 10 and 25 per 1000
population hernia repairs are performed annually in the UK and USA.
Long-tern follow-up of traditional sutured hernia repairs has shown an
unacceptably high recurrence rate of between 15 and 30%. However, with the
introduction of tension-free mesh repairs, the recurrence rate has fallen
to less than 1%. Using open techniques the mesh can be place in either an
anterior or pre-peritoneal position. With recently introduced laparoscopic
techniques the mesh is also placed in a pre-peritoneal position via either
a transabdominal or extraperitoneal approach. Laparoscopic hernia repair
is not without complication and visceral, vascular and neurological
injuries are well recognised. Recurrences after laparoscopic repair are
often attributed to the long learning curve. The aim of this study was to
directly compare laparoscopic and open hernia repairs. 928 patients with
groin hernias from 26 hospitals in UK and Ireland were randomly allocated
to laparoscopic (n=468) or open (n=460) hernia repair. Patients were
clinically assessed at one week and one year and were sent questionnaires
at three months and one year. The primary end-points were complications,
return to usual activity, hernia recurrence and groin pain persisting at
one year. At one week, at least one complication was found in 108 (30%) of
laparoscopic and 155 (44%) of open repairs (P<0.001). There were three
serious complications (bladder, vascular and neurological) all of which
occurred in the laparoscopic group. Patients in the laparoscopic group
returned to normal activity sooner and at one year had a lower incidence
of groin pain. All seven recurrences occurred in the laparoscopic group
(p=0.017). It was concluded that laparoscopic hernia repair has advantages
for patients. However, concerns over the safety and recurrence rates
suggests that laparoscopic hernia surgery should be performed by
A comparison of suture repair with mesh repair for
incisional hernia. Luijendijk R W, Hop W C J, Van den Tol P
et al. N Eng J Med 2000; 343: 392-398.
Incisional hernias are a frequent complication of abdominal surgery
occurring in between 10% and 20% of those who undergo a laparotomy.
They are associated with significant morbidity including incarceration and
strangulation. Many techniques for repairing incisional hernias have
been described but the results are often disappointing with recurrence
rates ranging from 25 to 50%. The use of a prosthetic mesh to close
the defect may give better results but high recurrence rates
continue to be reported. Most previous studies of mesh repair for
incisional hernias have been uncontrolled and non-randomised. As a
result it remains uncertain as to whether the use of a mesh repair is
superior to a suture repair. By performing a randomised,
multi-centre trial, the aim of this study was to define the indications
for the use of a mesh repair in patients with a midline abdominal
incisional hernia. Between 1992 and 1998, 200 patients scheduled to
undergo repair of a primary or first recurrence of an incisional hernia of
a ventral midline wound, less than 6 cm in length, were randomised to
either a suture or mesh repair. Patients were followed up for 3 years.
Recurrence rates and potential risk factors for recurrence were analysed
with the use of life tables. Amongst the 154 patients with primary
hernias and 27 patients with first-time recurrent hernia, 56 (28%)
developed recurrence during the follow up period. The cumulative
recurrence rates amongst those undergoing suture and mesh repair of
primary hernias were 43% and 24% respectively (p=0.02). The
cumulative recurrence rates amongst those undergoing suture and mesh
repair for first-time recurrence were 58% and 20% respectively (p=0.10).
The risk factor for recurrence were suture repair, infection, symptoms of
bladder outflow obstruction and previous surgery for abdominal aortic
aneurysm. The size of the hernia did not affect the recurrence rate.
It was concluded that amongst patients with midline abdominal incisional
hernias, mesh repair is superior to suture repair with regard to the
recurrence rates. This effect was independent of the size of the
Pilot randomised controlled study of preservation or
division of the ilioinguinal nerve in open mesh repair of inguinal hernia.
Ravichandran D, Kalambe B G, Pain J A. Br J Surg
2000; 87: 1166-1167.
The ilioinguinal nerve is a sensory nerve that supplies the skin over
the medial aspect of the thigh, upper part of the scrotum and penile root.
It is often encountered during open hernia repair and may interfere with
placement of the mesh. It may be inadvertently damaged during
surgery. Nerve entrapment is believed to be a cause of chronic pain
following hernia repair and division of the nerve may be required for
relief of symptoms. The purpose of this study was to investigate
whether preservation or elective division of the nerve during open hernia
repair influenced post-operative pain and sensory loss. Twenty men
with primary bilateral inguinal hernias undergoing open tension-free mesh
hernia repair were randomised to either division or preservation of the
ilioinguinal nerve on each side. Patients were reviewed at 1 day, 4
weeks and 6 months postoperatively. Any pain, numbness or loss of
sensation in the distribution of the nerve was recorded. There was
no significant difference in pain or numbness between the divided and
preserved sides. Sensory loss detected by clinical examination was
more common following division of the nerve compared with preservation.
It was concluded that within the limitations of a small sample size,
elective division of the ilioinguinal nerve during inguinal hernia repair
does not appear to be associated with a significant increase in
Effect of single-does prophylactic ampicillin and
sulbactam on wound infection after tension-free inguinal hernia repair
with a polypropylene mesh. Yerdel M A, Akin E B, Dolalan
S et al. Ann Surg 2001; 233: 26-33.
Wound infections have been reported to occur in up to 15% of patient
undergoing inguinal hernia repair. The role of antibiotic
prophylaxis in such 'clean' surgery is unclear and few studies have
established a benefit for prophylaxis in elective hernia surgery.
With the introduction of tension-free hernia surgery with the implantation
of a prosthetic mesh, the consequences of wound infection could now be
regarded as more significant and antibiotic prophylaxis may be useful.
In an effort to clarify the role of antibiotic prophylaxis during hernia
surgery a prospective, double-blind, randomised trial was conducted to
assess the value of a single dose of preoperative antibiotic.
Patients undergoing unilateral primary inguinal hernia repair using a
Lichtenstein technique were randomised to receive either 1.5 grams of
ampicillin plus sulbactam or an equal volume of placebo. Patients
with recurrent, bilateral, femoral or incarcerated hernias were excluded.
Age, sex, body mass index, ASA score, type of hernia, type of anaesthesia,
duration of surgery and use of a drain were recorded. Wound
infection was the primary outcome measure and was defined according to the
criteria of Centres for Disease Control. All complications were
recorded. Over a two year period, 280 patients were entered into the
study. Overall, 11 patients were excluded from the analysis due to
protocol violations. The groups were well matched for all variables
studied. Wound infection occurred in 9% of the control group but
only 0.7% of the treatment group (p=0.001). Removal of the mesh was
required in one and two patients in the treatment and control groups
respectively. It was concluded that the rate of wound infection was
reduced ten-fold by antibiotic prophylaxis. The need for readmission
and mesh removal was also lessened. Proponents of tension-free mesh
hernia repair should consider using antibiotic prophylaxis.
Pain and functional impairment one year after inguinal
herniorrhaphy: a nationwide questionnaire study. Bay-Nielsen M,
Perkins F M, Kehlet H for the Danish Hernia Database. Ann
Surg 2001; 233: 1-7.
Chronic pain following inguinal hernia surgery is well recognised but
its exact incidence is unclear. Furthermore, the extent to which
chronic pain interferes with function has not been well described.
No previous cross-sectional cohort study has addressed this problem.
Several factors have been proposed to predict for chronic pain including
surgery for a recurrent hernia, intensity of postoperative pain,
experience of the surgeon and the type of repair utilised. The aim of this
study was determine the incidence of groin pain one year after inguinal
herniorrhaphy and to assess the influence of chronic groin pain on
function. The study population consisted of all patients over the
age of 18 years, registered in the Danish Hernia Database, who underwent
surgery between 1st February 1998 and 31 March 1998. Two sets of
self-administered questionnaires were mailed one year after surgery.
The first questionnaire established the incidence of chronic groin pain.
The second characterised the pain and the effect of pain on the function
of those reporting pain. The response rate to the first
questionnaire was 81%. Groin pain was reported by 29% and in 11%
this interfered with their work or leisure activity. Pain was more
prevalent in younger patients. No difference in the reporting of
pain was observed for different types of hernia, operative or
anaesthesia technique. The response rate to the second questionnaire
was 83%. Of those reporting pain it was moderate or severe at rest
in 3% and moderate or severe on exercise in 8%. Impairment of daily
activities was reported by 16%. It was concluded that one year after
inguinal hernia repair pain is common and is associated with functional
impairment in more than half of those with pain. The question of
postoperative pain needs to be discussed with patients when considering
surgical intervention for an inguinal hernia.
Unexplained groin pain: safety and reliability
of herniography for the diagnosis of occult hernias. Gwanmesia I I,
Walsh S, Bury R, Bowyer K, Walker S. Postgrad
Med J 2001; 77: 250-251.
Patients with groin pain but no obvious hernia present both a
diagnostic and therapeutic challenge. Investigation often fails to
identify significant pathology and groin exploration in the absence of a
confirmed hernia often does not lead to lasting symptomatic relief.
Herniography has been advocated as a simple method for the detection of
occult groin hernias but has not been widely adopted in the United
Kingdom. The aim of this study was to review the initial experience
with this radiological investigation in a district general hospital.
Over a three year period 43 herniograms were performed in 41 patients (27
males, 14 female; median (range) age = 57 (16-77) years). Four
herniograms were unsuccessful due to failed intraperitoneal contrast
injection of which 2 were repeated (success rate = 91%). A total of
25 groin hernias were identified radiologically with 2 being on the
asymptomatic side. Overall, 21 patients underwent surgery with a
hernia confirmed in 19 subjects (true positive rate = 91%). The
other 16 herniograms were considered negative and after a median follow up
of 24(16-42) months none of these patients had presented with a hernia.
Nine of the 16 (60%) patients noted spontaneous improvement in their
symptoms. There were no major complications related to the
investigation. It was concluded that herniography is a safe and
reliable method of confirming or excluding the presence of an occult groin
Totally extraperitoneal endoscopic repair of recurrent
inguinal hernia. van der Hem J A, Hamming J F, Meeuwis J D,
Oostvogel H J M. Br J Surg 2001; 88: 884-886.
Recurrence rates following primary groin hernia repair using an
anterior approach, without a mesh, have been reported of between 0.2 and
20%. Rates as high 36% have been reported following recurrent hernia
surgery. Because of the earlier operation, the anatomy of the groin
may be changed and scarring may hinder dissection. To avoid the two
aetiological factors in recurrence, namely collagen deficiency and tissue
tension, the use of synthetic mesh has been extensively reported for
anterior hernia repairs. These techniques has been adapted for
endoscopic surgery with the mesh applied using either a transperitoneal or
extraperitoneal approach. The aim of this study was to investigate
the feasibility and short-term results of the endoscopic totally
extraperitoneal (TEP) technique in recurrent inguinal hernia. A
retrospective review was performed of 108 recurrent inguinal hernia
repairs in 104 patients. Follow-up was for at least one year.
Types of recurrence, time of recurrence after previous surgery, duration
of operation, complications, duration of hospital stay and number of
re-recurrences were evaluated. Follow-up ranged from 12-29 months.
Overall 43 recurrences were direct , 41 indirect and 15 combined.
Median time from previous operation was 36 (range 8 days to 42 years)
months. Median duration of surgery was 63 (range 25-100) min.
Twelve (12%) patients had postoperative complications. Two direct
re-recurrences occurred as a result of inadequate positioning of the
prosthetic mesh. It was concluded that the endoscopic totally
extraperitoneal techniques is safe and effective for the repair of
recurrent inguinal hernia.
Prospective randomised trial of polypropylene mesh
compared with nylon darn in inguinal hernia repair. Koukourou A,
Lyon W, Rice J, Wattchow D A. Br J Surg 2001; 88:
Since 1887, when Bassini reported his method, many techniques of
inguinal hernia repair have been described. Extensive clinical trials have
been undertaken to assess the outcome using more than 80 different methods
of hernia repair. High recurrence rates using fascia for the hernia repair
or the use of sutures under tension prompted the development of minimal
tension nylon darns or the use of polypropylene mesh to reinforce the
posterior wall of the inguinal canal. The aim of this study was to
directly compare the nylon darn and mesh technique commonly employed in
the treatment of primary inguinal hernias in men, assessing complications,
pain, return to normal activity and early recurrence. A prospective
randomised controlled trial was undertaken with patients followed up at
one week, 6 weeks and one year. Overall, 100 men underwent 105 primary
hernia repairs performed by either a consultant surgeon or registrar.
There were 54 mesh and 51 nylon darn repairs. Demographics in both groups
were similar at the start of the trial, as were the types of hernia. The
pain scores at 24, 48 and 72 hours were similar as were the duration of
analgesic requirements. There was no difference in either early or late
complications. Return to normal activity in each group was similar with a
mean time of 5 weeks. The recurrence rate in both groups was comparable;
4% after mesh repair and 4% after darn repair at the 1-year review. It was
concluded that open inguinal hernia repair with a nylon darn technique was
equivalent to polypropylene mesh with respect to early measures of
postoperative outcome and recurrence at one year.
Randomised trial of Lichtenstein versus Shouldice
hernia repair in general surgical practice. Nordin P,
Bartelmess P, Jansson C, Svensson C, Edlund G.
Br J Surg 2002; 89: 45-49.
Reports on the outcome of inguinal hernia surgery show that the
recurrence rates five years after operation can vary from 0.1 to over 20%.
One way to reduce this variation is to avoid the influence of experience
on outcome by employing a standard technique. This study was
performed a randomised trial to compare the outcome after either a
Shouldice or Lichtenstein hernia repair with respect to recurrence rate,
technical difficulty, convalescence and chronic pain. A further aim was to
determine to what extent general surgeons in routine surgical practice
were able to reproduce the excellent results reported from specialist
hernia centres. Overall, 350 patients with primary inguinal hernias
were randomized to either a Shouldice or tension-free Lichtenstein repair.
In a pretrial training programme the 5 participating surgeons were taught
to perform both techniques in a standard manner. Follow up was
performed at 8 weeks, 1 year and 3 years. The final examination was
performed by an independent blinded assessor. There was a
significant difference in operating time in favour of the Lichtenstein
technique. After a follow up of 36-77 months there were 7
recurrences in Shouldice group and one in the mesh group. Chronic
pain was reported by 4% and 6% in the Shouldice and Lichtenstein groups
respectively. It was concluded that the Lichtenstein repair was
easier to learn, tool less time to perform and resulted in fewer
recurrences. It was possible to achieve good results with this
technique in a general surgical unit.
Randomised clinical trial of non-mesh versus mesh
repair of primary inguinal hernia. Vrijland W W, van den Tol M
P, Luijendijk R W et al. Br J Surg 2002; 89:
No consensus has yet been reached about the best and most
cost-effective surgical approach to inguinal hernia repair.
Recurrence rates after non-mesh repair of inguinal hernia vary from 0.2%
to 33%, depending on the surgical method used, experience and length of
follow up. Tension-free repair, as popularised by Lichtenstein, has
been associated with a lower recurrence rate than suture repair. The
aim of this study was to establish the value of open mesh repair for
primary inguinal hernia in the general hospital setting, not only with
respect to clinical outcome but also quality of life and cost.
Between September 1993 and January 1996, all patients in six hospitals
scheduled for repair of a unilateral primary inguinal hernia were
randomised to to either non-mesh or mesh repair. The patients were
followed up at 1 week and 1,6,12,18, 24 and 36 months. Clinical
outcome, quality of life and costs were registered. Overall, 300
patients were randomised of of whom 11 were excluded. Three-year
recurrence rates differed significantly (7% for non-mesh repairs (n=143)
vs. 1% for mesh repairs (n=146). p=0.009). There was no
difference in in clinical variable, quality of life or costs. It was
concluded that mesh repair of primary inguinal hernias is superior to
non-mesh repair with regard to hernia recurrence and is cost effective.
Postoperative complications, pain and quality of life did not differ
between the two groups.
Pain from primary inguinal hernia and the effect of
repair on pain. Page B, Paterson C, Young D,
O'Dwyer P J. Br J Surg 2002; 89: 1315-1318.
Inguinal hernia repair is one of the most common general surgical
operations with a rate of 10 per 10,000 in the United Kingdom each year.
Recent evdience indicates that up to one-third of all patients undergoing
hernia repair have a painless hernia that has little or no effect on work
or leisure activities. In contrast, 3 to 6% of patients will have
severe pain and more than 30% will have mild pain, one year after a hernia
repair. This pain persists for many years and has a significant
effect on daily activity. The aim of this study was was to quantify
patients' pain from an inguinal hernia at rest and on moving and to assess
the effect of a hernia repair on the pain experienced. Linear
analogue pain scores at rest and on movement were recorded before
operation and at one year after surgery in a consecutive series of
patients undergoing elective repair of a primary inguinal hernia.
During the study period, 323 patients underwent inguinal hernia repair.
Overall, 86 (27%) recorded no pain at rest from the hernia and 174 (54%)
had mild pain only on movement. Only 1.5% experienced severe at rest
and 10% severe pain on movement. There was no association between pain and
hernia type. One year after operation only 25% had no pain from the
hernia site at rest and 22% had no pain form the hernia site on movement.
Overall, there was a significant reduction in mean pain score at rest
compared with preoperative values and this was mainly due to a large
effect seen in those with high preoperative pain scores. Patients
who had no pain at rest before the operation had significant pain scores
at rest at one year (p=0.001). It was concluded that clinical
trials are required to evaluate hernia repair in patients with
asymptomatic hernias. Results from such trials should help to
determine whether repair is the treatment of choice for these patients.
The groin hernia - an ultrasound diagnosis?
Bradley M, Morgan D, Pentlow B, Roe A. Ann R
Coll Surg Engl 2003; 85: 178-180.
Pain in the groin is a relatively common condition that may prove
difficult to diagnose as the clinical signs are frequently incomplete.
As a result, imaging may have a role in helping to reach a diagnosis.
Herniography has been described as a useful tool in the investigation of
the occult hernia with a sensitivity up to 97% and specificity of 98%.
Ultrasound has excellent inherent soft tissue contrast and increasing
resolution lends itself as a possible contender for groin evaluation.
The aim of this study was to assess the accuracy of ultrasound in the
diagnosis of groin hernias. A total of 118 patients with a clinical
diagnosis of a groin hernia prospectively underwent a blinded, ultrasound
examination of the groin. All patients underwent surgery and the
findings at operation were compared with the ultrasound result.
Overall, 120 symptomatic groins in the 118 patients were operated on.
Ultrasound diagnosed 118 hernias and there were two normal ultrasound
examinations. Surgery confirmed the same two patients to be normal.
Two femoral hernias were seen in the study, both correctly identified at
ultrasound. Of the inguinal hernias, ultrasound identified 36 of 42
direct hernias (sensitivity 86%, specificity 97%) and 72 of 74 indirect
hernias (sensitivity 97%, specificity 87%). It was concluded that
ultrasound can accurately diagnose groin hernias and this may justify its
use in the assessment of the occult hernia.
Surgical site infection after groin hernia repair.
Taylor E W, Duffy K, Lee K et al. Br J Surg
2004; 91: 105-111
Postoperative infection remains a common complication after most types
of surgery. In 'clean' operations no bacterially colonised tract of
the body is opened and the incidence of postoperative wound infection may
be seen a reflection of environmental conditions or surgical expertise.
The incidence of surgical site infection (SSI) depends on the definition
of wound infection used and on the intensity of surveillance for its
occurrence. Post-discharge surveillance for 30-days is needed to
determine the true incidence of SSI. The aim of this study was to
determine the incidence of, and risk factors for SSI after groin hernia
repair. A total of 3150 patients who had undergone groin hernia
repair in 32 Scottish hospitals were telephoned 10, 20 and 30 days after
operation to screen for SSI. Patients who believed the wound to be
infected were seen by a healthcare worker to confirm the diagnosis.
Details of operations and risk factors were obtained by case-note review.
Overall, 104 patients (3.3%) declined to give a contact telephone number.
Some 108 patients (3.4%) could not be contacted at any point giving a
response rate of 93.3%. Complete data was available for 2665
patients. Overall, 140 patients (5.3%) developed SSI and 57 patients
(2.1%) thought the wound to be infected but this was not confirmed by a
healthcare worker. Patients given prophylactic antibiotics as lower
incidence of SSI (p=0.002) but neither an increase in ASA grade nor
prolonged duration of operation was a significant risk factor for
infection. It was concluded that SSI after groin hernia repair is
common and large clinical trials are required to determine whether the use
of prophylactic antibiotics reduces the incidence of infection.
Randomised clinical trial of lightweight composite
mesh for Lichtenstein inguinal hernia repair. Post S, Weiss B,
Willer M et al . Br J Surg 2004; 91: 44-48.
The use of prosthetic mesh for open surgical repair of inguinal hernias
has become increasingly popular. The Lichtenstein repair is the most
commonly used technique mainly owing to the ease of operation and because
it provides a tension free repair. In addition, several randomised
clinical trials have reported fewer recurrences with this technique than
with conventional suture repairs. Several studies have focused on
aspects of chronic pain and quality of life after hernia repair.
Many patients report a feeling of stiffness after implantation of a
polypropylene mesh. Recently, a new type of lightweight mesh,
composed of polypropylene fibres mixed with absorbable polyglactin threads
have been introduced. The aim of this study was to evaluate whether
patients noticed any difference between lightweight and standard
polypropylene mesh when used for the repair of an inguinal hernia.
Patients scheduled for elective repair of unilateral or bilateral, primary
or recurrent inguinal hernia by the Lichtenstein technique were randomised
to receive either conventional or a lightweight mesh. Quality of
life was assessed using the Short Form 36 before operation and 6 months
after surgery. Pain was assessed by means of a visual analogue scale
2 days and 6 months after surgery. The primary outcome measure was
the feeling of foreign body in the groin at 6 months. Some 122
patients were randomised and 117 were included in the preoperative data
analysis. Overall 106 patients were re-examined at 6 months.
There was no difference between the treatment groups with respect to early
and late complications. Use of lightweight mesh was associated with
significantly less pain on exercise after 6 months (p = 0.042).
In addition, fewer patients reported the feeling of a foreign body after
repair with lightweight mesh (17% vs. 43%, p = 0.003).
Quality of life was improved significantly at 6 months compared with
preoperative assessment and there was no differences between the treatment
groups. It was concluded that lightweight polypropylene mesh may be
preferable for Lichtenstein hernia repairs and that a larger cohort of
patients with longer follow-up is needed before it can be recommended for
Effects of training and supervision on recurrence
rates after inguinal hernia repair. Robson A J, Wallace C G,
Sharma A K et al. Br J Surg 2004; 91: 774-777.
Inguinal hernia repair is one of the commonest surgical procedure and
is an important training operation for young surgeons. It combines
low mortality risk with an appropriate technical challenge. There are
conflicting reports on the results of hernia repair by trainee surgeons
compared with experienced surgeons. Furthermore, there is little
information about the effect of supervision on outcome in inguinal hernia
surgery. The aim of this study was to examine the effect of trainee
surgeons and their supervision on hernia recurrence. All primary
inguinal hernia repairs carried out between 1994 and 2001 were registered
prospectively in the Lothian Surgical Audit database. Subsequent
problems that required re-referral were identified from the database.
Patients who required reoperation for recurrence a median of 3 (range 1-7)
years after surgery were identified. Overall. some 4406 repairs,
including 90 recurrences (2%) were identified. Open mesh, open
sutured and laparoscopic techniques were employed. Senior trainees
(registrars and senior registrars) has similar recurrence rates to
consultants. Junior trainees (senior house officers) had similar
recurrence rates to consultants provided they were supervised by either a
senior trainee or a consultant. Unsupervised junior trainees had
unacceptably high recurrence rates (Open mesh RR 21. 95% CI = 7.3 -
59. p<0.001; Open sutured RR 16.5. 95% CI 7.2 - 37.8.
p<0.001). It was concluded that senior trainees may operate
independently and supervise junior trainees with recurrence rates equal to
those of consultant surgeons. Junior trainees should be encouraged
and given more practice inguinal hernia repair with appropriate
Randomised clinical trial of the use of a prosthetic
mesh to prevent parastomal hernia. Janes A, Cengiz Y,
Israelsson L A. Br J Surg 2004; 91: 280-282.
Parastomal hernia occurs in up to 50% of patients after the
construction of a stoma and several modifications of the surgical
technique have fruitlessly been tried to prevent its development. A
lower rate is however encountered when the stoma is brought out through
the rectus abdominis muscle. One in three parastomal hernias require
surgical intervention and following local aponeurotic repair or stoma
relocation recurrence rates of between 30 and 76% have been reported.
With prosthetic mesh repair the results have been better. The
addition of a mesh at the operation has also been assessed in
non-randomised trials. The aim of this study was to evaluate stoma
complications when patients were randomised to either a conventional stoma
or the same procedure with the addition of a lightweight mesh placed in a
sublay position. Patients undergoing permanent colostomy were
randomised to either a conventional stoma or the addition of a mesh placed
in the sublay position. A large-pore light weight mesh with a
reduced polypropylene content and a high proportion of absorbable material
was used. Overall, 27 patients were randomised to have a
conventional stoma and 27 to have a mesh. No infection, fistula
formation and pain occurred. At the 12-month follow-up, parastomal
hernia was present in 8 of the 18 patients without a mesh and 0 of 16
patients in whom a mesh was used. It was concluded that a
lightweight mesh in a sublay position at the stoma site was not associated
with infection or other early complications. Preliminary results
indicate that the mesh prevented the development of parastomal hernia.
Randomised controlled trial of preservation or
elective division of ileoinguinal nerve on open inguinal hernia repair
with polypropylene mesh. Picchio M, Palimento D, Attanasio U et al.
Arch Surg 2004; 139: 755-758.
Pain after inguinal hernia repair may be an incapacitating complication
that represents an important diagnostic and therapeutic challenge. Normal
postoperative pain affects patients immediately after surgery and
gradually subsides within a few days. Some patients experience chronic
debilitating pain that is unresponsive to medical treatment, including
non-steroidal anti-inflammatory drugs and opiates. Neuropathy is a widely
recognised cause post-herniorrhaphy pain and one possible cause may be
damage to the sensory nerves. The aim of this study was to evaluate the
effect of preservation or elective division of the ileoinguinal nerve on
pain and postoperative symptoms after open inguinal hernia repair using a
mesh. Between 1997 and 2002, 813 patients undergoing primary inguinal
hernia repair were randomly allocated to surgery with ileoinguinal nerve
preservation (Group A, n=408) or elective transaction (Group B, n=405).
The hernia repair was performed with sutureless apposition of a
polypropylene mesh. The primary outcome measure was the evaluation of
chronic pain one year after surgery. Secondary outcome measures were
postoperative symptoms assessed at one week, one, 6 and 12 months after
operation. Telephone interviews were performed 35 months (range 12-59
months) after operation to assess the presence of chronic pain. Of the 302
patients in Group and 291 patients in Group B who were assessed at one
year, pain was absent in 231 (77%) and 213 (73%) respectively. There was
no difference in mild, moderate or severe pain between the two groups. One
year after surgery, the two groups were comparable with respect to loss of
pain sensation, but touch sensation remained reduced in Group B. It was
concluded that pain after open hernia repair is not affected by elective
division of the ileoinguinal nerve. Sensory disturbances in the area of
distribution of the transacted nerve is significantly reduced.
Long-term follow-up of a randomized controlled trial
of suture versus mesh repair of incisional hernia. Burger J W A,
Luijendijk R W, Hop W C J et al. Ann Surg 2004;
Incisional hernia remains a frequent complication of abdominal surgery
with a reported incidence of between 2 and 20%. Long-term results of
incisional hernia repair are lacking. Retrospective studies and the
mid-term results of this study indicated that mesh repair is superior to
suture repair. The objective of this study was to determine
the best treatment of incisional hernia, taking into account recurrence,
complications, discomfort, cosmetic result and patient satisfaction.
Between 1992 and 1998, a multicentre trial was performed in which 181
eligible patients with a primary or first-time recurrent mid-line
incisional hernia were randomly assigned to a suture or mesh repair.
In 2003, follow-up was updated. Median follow-up was 75 months for
the suture repair group and 81 months for the mesh repair patients.
The 10-year cumulative rate of recurrence was 63% for the suture repair
and 32% for the mesh repair (p<0.001). Abdominal aneurysm (p=0.01)
and wound infection (p=0.02) were identified as independent risk
factors for recurrence. In patients with small incisional hernias,
the recurrence rates were 67% after suture repair and 17% after mesh
repair (p=0.003). In the mesh repair group, 17% suffered a
complication compared with 8% in the suture repair group (p=0.17).
Abdominal pain was more frequent in suture repair patients but there was
no difference in scar pain, cosmetic result and patient satisfaction. It
was concluded that mesh repair results in a lower recurrence rate and less
abdominal pain and does not result in more complications than suture
Open mesh versus laparoscopic mesh repair of inguinal
hernia. Neumayer L, Giobbie-Hurder A, Jonasson O et al.
N Engl J Med 2004; 350: 1819-1827.
Surgical repair of inguinal hernias is a common procedure in adult men.
However, recurrence of hernias has been reported to occur in 15% or more
cases and postoperative pain and disability are frequent. When
traditional surgical methods are used, outcomes after repair of recurrent
hernias have been worse than after primary repair. After the
introduction of tension-free surgical repair with the use of prosthetic
mesh, recurrence rates were reported to be less than 5%. A
laparoscopic method of performing tension-free repair has subsequently
been reported to result in low recurrence rates. The aim of this
study was to perform a randomised trial to compare recurrence rates and
other outcomes after either of two standardised tension-free
herniorraphies: open repair and laparoscopic repair. The primary
outcome was recurrence of hernias at two years. secondary outcomes
included complications and patient-centred outcomes. Overall, 2164
patients were randomly assigned to one of the two procedures and 1983
underwent an operation. Two-year follow up was complete in 1696
(85%) of patients. Recurrence was more common in the laparoscopic
group (10.1% vs. 4.9%. Odds ratio = 2.2, 95% CI 1.5 - 3.2). The rate
of complications was higher in laparoscopic surgery group (39.0% vs.
33.4%. Odds ratio = 1.3, 95% CI 1.1 - 1.6). The laparoscopic group
had less pain initially then the open-surgery group on both the day of
surgery and at two weeks and returned to normal activity one day earlier.
In prespecified analyses, there was a significant interaction between the
surgical approach (open vs. laparoscopic) and the type of hernia (primary
or recurrent). It was concluded that the open technique is superior
to the laparoscopic technique for mesh repair of primary hernias.
Chronic pain after open mesh and sutured repair of
direct inguinal hernia in young males. Bay-Nielsen M, Nilsson
E, Nordin P et al. Br J Surg 2004; 91:
The primary outcome parameter after inguinal hernia repair has usually
been the risk of recurrence and reoperation. However, with modern
surgical techniques that utilize mesh repair, recurrence rates have
decreased considerably. Concomitant with these developments,
increased attention has been paid to the risk of chronic pain following
herniorrhaphy, which as been reported to occur in about 10-15% of
patients. The effect of surgical technique and the social
consequence of the pain have not been well studied. The aim of this
study was to analyse chronic postoperative pain and its social
consequences in young males operated on for an indirect inguinal hernia.
This was a postal questionnaire study carried out within the Danish and
Swedish Hernia Database Collaboration. Some 2612 patients responded
(response rate 81%) of whom 1250 had undergone a Lichtenstein, 630 a
Shouldice and 732 a Marcy repair. Chronic pain had been experienced
within the previous month by 22.9% of the patients who responded.
There was an overall decrease in pain with time, from 29.7% at 6-12 months
to 18.1% at 37-48 months after surgery, with no overall difference between
the three types of repair. Pain was more common in patients younger
than 40 years of age. Some 3.9% of patients described the pain as
moderate to severe and as frequent or constant. Of all the patients
with pain, 10.7% experienced it as worse after than before surgery and
56.6% stated that it interfered with social activities. It was
concluded that chronic pain is common after primary inguinal hernia repair
in young males and there is no difference in the pain associated with open
and non-mesh repair.
Randomised clinical trial comparing lightweight
composite mesh with polyester or polypropylene mesh for incisional hernia
repair. Conze J, Kingsnorth A N, Flament J B et al.
Br J Surg 2005; 92: 1488-1493.
Incisional hernia is a complication in 11-20% of patients after
laparotomy and can lead to bowel strangulation requiring emergency
surgery. In most cases elective repair is the preferred option.
The rate of recurrence remains high although it has been reduced to less
than 10% by the use of prosthetic mesh. Complications of mesh
include wound infection and seroma, patient discomfort and restriction of
abdominal wall mobility. Standard flat mesh made from polypropylene
or polyester has a tensile strength that is far greater than that is
required physiologically. Reducing the amount of polypropylene by
increasing pore size produces a lightweight mesh that may improve the
functional properties and diminish local complications. Lightweight
composite mesh is the result of incorporating an absorbable component into
a reduced polypropylene mass. The aim of this study was to compare
standard mesh with new lightweight mesh in patients undergoing incisional
hernia repair. Patients were randomised to receive lightweight
composite mesh or standard polyester or polypropylene mesh. Outcomes
were evaluated at 21 days, 4, 12 and 24 months from patient responses to
the Short Form 36 (SF-36) and daily activity questionnaires.
Complications and recurrence rates were recorded. A total of 165
patients were included in an intention-to-treat analysis (83 lightweight
mesh and 82 standard mesh). Postoperative complication rates were
similar. The overall hernia recurrence rate was 17% with the
lightweight mesh vs. 7% with the standard mesh. p=0.052).
There was no difference in SF-36 physical function scores or daily
activities between 21 days and 24 months after the surgery. It was
concluded that the use of lightweight composite mesh for incisional hernia
repair and similar outcomes to polypropylene or polyester with exception
on a non-significant trend towards increased hernia recurrence. The
latter may be related to technical factors with regard to the specific
placement and fixation requirements of lightweight composite mesh.
Randomized clinical trial comparing 5-year recurrence
rate after laparoscopic versus Shouldice repair of inguinal hernia.
Arvidsson D, Berndsen F H, Larsson L G et al. Br J
Surg 2005; 92: 1085-1091.
Inguinal hernia surgery has changed dramatically over the past 10
years. One of the principle aims for hernia surgery in the modern
era has been to lower the recurrence rate. The Shouldice technique
was considered to be the 'gold standard' at the start of the 1990's and
recurrence rates as low as1-4% after 4-12 years of follow-up have been
achieved. Laparoscopic inguinal hernia repairs have already proven
to have excellent short-term results, whoever there are few large
randomized studies comparing long-term outcome. The aim of this
study was to compare 5-year recurrence rates after Shouldice and
laparoscopic transabdominal pre-peritoneal patch (TAPP) repair for primary
inguinal hernia. Men with a primary unilateral inguinal hernia were
randomised to either a Shouldice or TAPP repair. An independent
observer scored the surgeons performance. Follow-up comprised
clinical examination after one year, a questionnaire after 2 and 3 years
and a clinical examination at 5 years. Between February 1993 and
March 1996, 1183 patients were included. Overall, 920 patients were
followed up for 5 years, 454 in the TAPP group and 466 in the Shouldice
group. Recurrence rates were evenly distributed between the two
groups throughout the follow-up period. The cumulative recurrence
rate after 5 years was 6.6% in the TAPP group and 6.7% in the Shouldice
group. Postoperative pain was a risk factor for recurrence after
Shouldice repair but not after TAPP repair. There was a correlation
between a low surgeon's performance score and recurrence. It was
concluded that 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 repair.
Three-year results of a randomised clinical trial of
lightweight or standard polypropylene mesh in Lichtenstein repair of
primary inguinal hernia. Bringman S, Wollert S,
Osterberg J et al. Br J Surg 2006; 93: 1056-1059.
Tension-free surgery with mesh has become the standard technique in
inguinal hernia surgery. Although the use of mesh has been shown to
decrease the incidence of hernia recurrence compared with sutured repair,
there remains concern about mesh-induced problems such as groin pain and
infertility. Polypropylene, the material most commonly used for
mesh, is associated with a strong foreign-body reaction and can cause
potentially harmful side-effects including chronic inflammation and
decreased abdominal wall compliance. Lightweight (LW) mesh with less
foreign material has been developed. It has larger pore size and is
partially absorbable. This current study was a randomised trial to
examine whether LW polypropylene mesh could have long-term benefits in
terms of reduced chronic pain and inflammation after inguinal hernia
repair. Overall, 600 men with a primary unilateral inguinal hernia
were randomised to a Lichtenstein repair using either standard
polypropylene mesh or a LW mesh. The patients were blinded at to
which mesh they received. Clinical examination was performed and a
pain questionnaire completed three years after surgery. Of the 590
men who had surgery, 243 (83%) of the 294 in the standard mesh group and
251 (85%) of the 296 in the LW group were examined in the clinic at a
median of 37 (range 30-48 months) after surgery. There were 9
recurrent hernias in each group (3.7% with standard mesh and 3.6% with LW
mesh). Patients who had LW mesh had less pain on examination, less
pain on rising from lying to sitting and felt the mesh less often than
those with the standard mesh. It was concluded that the 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.
Total extraperitoneal inguinal hernia repair compared
with Lichtenstein (the LEVEL-Trial): A randomized controlled trial.
Langeveld H, van't Reit M, Weidema W et al. Ann Surg
2010; 251: 819-824.
This randomised controlled trial was designed to compare the most
common technique for open mesh repair (Lichtenstein) with the currently
preferred minimally invasive technique (total extra peritoneal, TEP) for
the surgical correction of inguinal hernia. A total of 660 patients
were randomised to Lichtenstein or TEP procedure. Primary outcomes were
postoperative pain, length of hospital stay, period until complete
recovery, and quality of life (QoL). Recurrences, operating time,
complications, chronic pain, and costs were secondary endpoints. Overall,
336 patients were randomized to TEP, and 324 to Lichtenstein repair. TEP
was associated with less postoperative pain until 6 weeks postoperatively
(p = 0.01). Chronic pain was comparable (25% vs. 29%). Less impairment of
inguinal sensibility was seen after TEP (7% vs. 30%, p = 0.01). Mean
operating time for a unilateral hernia with TEP was longer (54 vs. 49
minutes, p = 0.03) but comparable for bilateral hernias. Incidence of
adverse events during surgery was higher with TEP (5.8% vs. 1.6%, p <
0.004), but postoperative complications (33% vs. 33%), hospital stay and
QoL were similar. After TEP, patients had a faster recovery of daily
activities (ADL) and less absence from work (p = 0.01). After a mean
follow-up of 49 months, recurrences (3.8% vs. 3.0%, P = 0.64) and total
costs were similar. It was concluded that TEP procedure was
associated with more adverse events during surgery but less postoperative
pain, faster recovery of daily activities, quicker return to work, and
less impairment of sensibility after one year. Recurrence rates and
chronic pain were comparable. TEP is recommended in experienced hands.