Up ] Breast papers ] Cardiothoracic papers ] Colorectal papers ] Critical care papers ] Endocrine papers ] General papers ] Hepatobilary paper ] [ Hernia papers ] Laparoscopy papers ] Orthopaedic papers ] Neurosurgery papers ] Paediatric papers ] Trauma papers ] Upper GI papers ] Urology papers ] Vascular papers ] Historical papers ] Critical appraisal ] Intercollegiate exam ]

Hernia papers


Levels of Evidence

  • Level 1
  • Level 2
  • Level 3
  • Level 4
  • Level 5

Printer friendly version

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 specialists surgeons.

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 hernia.    

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 postoperative symptoms.

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 hernia.

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: 931-934.

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:  293-297.

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 routine use.

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 supervision.

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 alArch 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;  240:  578-585.  

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 repair. 

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:  1372-1376.

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.


Last modified:



Copyright 1997- 2012 Surgical-tutor.org.uk