Langenbecks Arch Surg (2014) 399:553–558 DOI 10.1007/s00423-014-1212-8

REVIEW ARTICLE

Current treatment concepts for groin hernia Stavros A. Antoniou & Rudolph Pointner & Frank A. Granderath

Received: 2 May 2014 / Accepted: 5 May 2014 / Published online: 14 May 2014 # Springer-Verlag Berlin Heidelberg 2014

Abstract Purpose The purpose of this study is to review the latest evidence on operative and perioperative management of patients with groin hernia. Methods A literature review of medical databases was undertaken. Recent scientific evidence provided by quality reports was selected and discussed critically. Results The Shouldice repair results in low recurrence rates compared to other tissue reconstructions. However, mesh repairs are superior to tissue reconstruction in terms of recurrence. Lichtenstein’s technique remains the gold standard, with low incidence of hernia recurrence and minimal morbidity. Endoscopic techniques have been popularized during the past decades, as alternative approaches to open surgery. Both transabdominal preperitoneal repair (TAPP) and the totally extraperitoneal repair (TEP) are effective in the treatment of groin hernia, although the steep learning curve precludes popularization and may account for increased perioperative morbidity. Conclusions Groin hernia surgery remains an evolving field of investigation. Mesh application remains the mainstay of durable results. Individual patient factors and hernia S. A. Antoniou : F. A. Granderath Center for Minimally Invasive Surgery, Neuwerk Hospital, Mönchengladbach, Germany S. A. Antoniou Department of General Surgery, University Hospital of Heraklion, University of Crete, Heraklion, Greece R. Pointner Department of General and Visceral Surgery, Hospital Zell am See, Zell am See, Austria S. A. Antoniou (*) Athinon-Souniou 11, 19001 Keratea, Athens, Greece e-mail: [email protected]

characteristics need to be taken into account when considering the most appropriate surgical practice. Keywords Groin hernia . Inguinal hernia . Hernia repair . Hernioplasty

Introduction Groin hernia represents one of the most common surgical pathologies. Approximately 0.8 % of the general Western population is subjected to surgical repair in a 5-year period [1]. Furthermore, an average of over 500 records on groin hernia has been added annually in the Medline database during the past decade. As the body of clinical evidence is expanding, it is becoming evident that the need for informed clinical decisions requires update scientific information. Considering the high prevalence of groin hernia, the dissemination of a variety of surgical techniques, the potential implications of surgery on quality of life, and the economic burden of therapeutic options on health-care delivery systems, an evidence-based approach on treatment concepts is essential. The present article provides a comprehensive overview of established clinical practice and an update of evidence on treatment options for groin hernia.

Historical background The era of modern surgical repair of groin hernia (late nineteenth to twenty-first century) may be divided into two sections, according to the anatomical approach of the repair [2]. Reconstruction of the anterior wall of the inguinal canal characterizes the first short period of the modern era of groin hernia repair. The principle of the anterior repair consisted

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largely on reduction of the hernia sac and narrowing of the external ring [3]. Recurrence rates as high as 30 % suggested that the anterior approach cannot effectively prevent hernia recurrence. The landmark for the posterior repair of the inguinal canal was the introduction of the transection of the external oblique aponeurosis by Just LucasChampionniére in 1892 [4]. This revolutionary approach of the anatomy of the hernia defect was the first step to the basic principles of groin hernia surgery. Bassini described reinforcement of the posterior inguinal wall using the internal oblique muscle, the transverse abdominal muscle, and the transversalis fascia, with application of multiple interrupted sutures [5]. Furthermore, he suggested entering the preperitoneal space after division of the transversalis fascia and high ligation of the hernia sac. Whereas several modifications of the Bassini procedure were reported, Edward Earle Shouldice (1890– 1965) was the first to highlight the importance of the transversalis fascia in the pathogenesis and the surgical treatment of groin hernia [6]. The evolution of alloplastic materials has radically changed the approach to the posterior repair, facilitating reinforcement of the inguinal floor with a durable material, without the need to reconstruct the transversalis fascia. Polypropylene, polyester, polytetrafluoroethylene (PTFE), and expanded PTFE (ePTFE) were available from the 1940s. Lichtenstein introduced the tensionfree repair with an oval-shaped polypropylene mesh, which was placed on the floor of the inguinal canal and was sutured to the pubic tubercle, the inguinal ligament, and the conjoint tendon, with a slit at the lateral end to encircle the emerging spermatic cord [7]. The excellent results of Lichtenstein’s technique soon led to the wide popularization of tensionless hernia repair. In the same period, Stoppa proposed complete dissection of the preperitoneal spaces of Retzius and Bogros, and placement of a large mesh to cover the myopectinal orifices [8]. The latest advantage of open groin hernia repair was introduced by Arthur Gilbert and later by Rutkow and Robbins, with the use of an umbrella-shaped polypropylene plug into the deep inguinal ring, in order to prevent recurrence of indirect hernia [9, 10]. The first laparoscopic approach to groin hernia diverged from the classic surgical principles of open surgery. Ralph Ger examined the effectiveness of closure of the neck of the hernia with metal clips during laparotomy for other pathologies, and after a laparoscopic clipping device had been developed, he performed an experimental study on 15 canine models [11, 12]. Upon completion of his study, he initiated a clinical trial [13]. Several years later, the transabdominal preperitoneal repair (TAPP) and the totally extraperitoneal repair (TEP) of

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groin hernia using a synthetic mesh were introduced by Arregui and Dulucq [14, 15].

Open repair Tissue repair As the Bassini repair has been largely abandoned, the Shouldice technique is being considered the principal representative of sutured groin hernia repair. A systematic review reports on a cumulative recurrence rate of 2 % after Shouldice repair, whereas a Cochrane review of randomized and quasirandomized studies in 2009 found a significantly lower pooled recurrence rate for the Shouldice repair compared to other tissue repairs (odds ratio 0.62, 95 % confidence interval 0.45–0.85), although this research group underscored the lack of long-term comparative results and quality randomized trials [16, 17]. Nevertheless, there seems to be sufficient evidence to support the use of the Shouldice over other non-mesh repairs. It must be however highlighted that several published and anecdotal modifications of this technique exist, which may account for heterogeneity of results. Internal audit of operative outcomes may be considered necessary to provide internal evidence in individual institutions regarding the relative effectiveness of either approach. Tissue repairs, although implicated for higher recurrence rates, are still considered treatment options by several surgeons especially for younger patients, due to a presumed inflammatory reaction and fibrosis of the spermatic cord, which is supposed to result in higher infertility rates. Such an association has however not been proven to date. Mesh repair Mesh repair has been popularized in the surgical community as an effective treatment of groin hernia, obviating the need for extensive dissection and tissue reconstruction. Inguinal wall reconstruction with the use of alloplastic material may regard the anterior wall of the inguinal canal (anterior approach), the preperitoneal space (posterior approach), or both (combined approach). The most popular representative of the anterior wall reinforcement is the Lichtenstein repair. This includes placement of a flat, oval-shaped mesh against the inguinal floor and suturing of its circumference to the pubic tubercle, the conjoint tendon, and the inguinal ligament. Rutkow and Robbins proposed placement of an umbrella-shaped mesh into the internal ring, additionally to the flat mesh of Lichtenstein, to reduce the risk of recurrence of an indirect hernia. The Kugel patch repair regards the preperitoneal placement of a polypropylene mesh with a memory recoil ring. Extensive preperitoneal dissection and placement of a large polypropylene mesh through a midline approach and the rectus

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musculature is the concept of the Stoppa procedure. The Prolene Hernia System is a combined posterior and anterior approach to abdominal wall reconstruction, using a bipolar polypropylene mesh device with a connecting funnel, which passes through the deep inguinal ring or the transversalis fascia [18]. Mesh reinforcement has been showed to result in reduced incidence of recurrence with durable results. Selected recent evidence on open groin hernia repair is outlined in Table 1. The Cochrane meta-analysis, which compared mesh repairs to the Shouldice technique, has found a nearly fourfold decreased risk for recurrence following mesh repair (odds ratio 3.80, 95 % confidence interval 1.99–7.26) [18]. Three metaanalyses investigating the outcome of mesh repairs have been published recently. Li et al. tested the hypothesis of different outcomes for the Lichtenstein repair and various posterior repairs (Kugel, Prolene Hernia System, Nyhus), which were pooled in a well-designed meta-analysis of randomized trials [19]. Long-term follow-up outcomes were provided by the majority of studies; methodological quality was however low. The authors have found a similar incidence of complications, but a lower incidence of recurrence for the posterior approaches (odds ratio 0.51, 95 % confidence interval 0.28– 0.92). Sanjay et al. focused on the comparative outcome of the Prolene Hernia System and the Lichtenstein repair [20]. Interestingly, a higher incidence of intraoperative complications was documented for the Prolene Hernia System, although recurrence rates were similar. The strengths of this meta-analysis were the excellent methodology and the moderate or high quality of the majority of the included reports. In a further moderate quality meta-analysis of randomized studies which compared the Lichtenstein with the mesh-plug repair, no difference was found with regard to recurrence, pain, or sensory defects [21].

Laparoscopic repair The transabdominal approach (TAPP) to groin hernia repair has been popularized as an alternative mesh repair. It requires establishment of pneumoperitoneum and placement of a trocar at the umbilical region for the laparoscope and two further working ports symmetrically in the lower abdomen. The peritoneum is incised from the anterior superior iliac spine toward the medial umbilical ligament, some centimeters above the hernia defect. An extensive dissection of the pelvic floor is recommended, which facilitates visualization of the myopectineal orifice and allows identification of direct inguinal, indirect inguinal, femoral, or obturator hernias. The hernia sac is dissected free from surrounding structures. Data from a prospective case-control series support fixation of the lax transversalis fascia onto the inguinal ligament in the presence of large direct hernias, in order to reduce the incidence of seroma formation [22]. A polypropylene mesh is placed in a fashion to adequately cover the hernia defects and is fixated with clips, tacks, or fibrin glue. The latter alternative seems to become increasingly popular in view of recent evidence suggesting reduced postoperative pain compared to other invasive methods [23–25]. The peritoneal incision is sutured, in order to prevent mesh-associated abdominal complications. For the totally extraperitoneal repair (TEP), the rectus sheath is incised in the subumbilical region. The preperitoneal and the extraperitoneal spaces are dissected to provide adequate working area, using either a balloon or the laparoscope. Balloon dissection may be advantageous in terms of operative time and the need for conversion, as advocated by a randomized study [26]. The working trocars may be placed either on the midline, between the optical trocar and the pubic symphysis, or in a triangular fashion, in approximation to the anterior superior iliac spine, unilateral to the hernia site. An extensive

Table 1 Summary of recent quality evidence on outcomes of open groin hernia repair Author (year)

Study type

Comparison

Main outcomes

Notes

Amato et al. (2012) [17]

Meta-analysis of RCTs and quasirandomized trials Meta-analysis of RCTs and quasirandomized trials Meta-analysis of RCTs

Shouldice versus other tissue repairs

Lower incidence of recurrence for Shouldice

Short-term follow-up, low quality of included studies

Shouldice versus mesh repairs

Mesh repairs associated with lower incidence of recurrence

Short-term follow-up, low quality of included studies

Lichtenstein versus posterior repairs

Lower incidence of recurrence for posterior repairs, similar morbidity Similar incidence of recurrence, higher incidence of intraoperative complications for PHS Similar incidence of recurrence, pain, sensory deficits

Well-designed meta-analysis, low methodological quality of trials, long-term follow-up High-quality meta-analysis, moderate-/high-quality RCTs

Amato et al. (2012) [17] Li et al. (2012) [19] Sanjay et al. (2012) [20]

Meta-analysis of RCTs

Lichtenstein versus PHS

Li et al. (2012) [21]

Meta-analysis of RCTs

Lichtenstein versus mesh-plug repair

RCT randomized controlled trial, PHS Prolene Hernia System

Moderate-quality meta-analysis, moderate-quality RCTs, not reporting duration of surgery

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dissection is also recommended for TEP, which allows adequate visualization of the hernia defects and facilitates optimal placement of the mesh. It must be highlighted that peritoneal tears occur frequently [27] and may require suturing or clipping to maintain the working space and minimize loss of gas into the peritoneum. Conversion to TAPP or open surgery is rather rarely needed [28]. After adequate dissection, the mesh is placed against the myopectineal orifice. There is no consensus regarding the need to fixate the mesh, although the International Endohernia Society recommends fixation in the presence of hernia defects larger than 4 cm [29]. Both minimally invasive techniques are considered effective approaches to recurrent hernia following open repair; however, adequate experience is strongly recommended [29]. Complex cases of irreducible or strangulated hernias may be also approached by TAPP or TEP, although relevant evidence on the effectiveness and safety is rather scarce. Several factors are speculated to impose a risk for development of complications, such as previous prostatectomy and lower abdominal surgery [30, 31], whereas the International Endohernia Society recommends emptying the urinary bladder before surgery and restrictive fluid administration intraoperatively to reduce the risk of vesical injury, on the basis of anecdotal data [29]. The latest evidence provided by quality studies is summarized in Table 2. A meta-analytical comparison of endoscopic repair (TAPP/TEP) with the Shouldice technique was published in 2005 [16]. Although pooled analysis suggested similar recurrence rates for both techniques and reduced pain and incidence of sensory deficits for the endoscopic approaches, inherent limitations of the analysis and the poor-quality randomized studies preclude definitive conclusions regarding the

comparative outcomes of endoscopic techniques and tissue repair. Limited evidence on endoscopic and open mesh repairs exist. In a systematic review and meta-analysis, O’Reilly et al. investigated perioperative morbidity and hernia recurrence following endoscopic and open tissue or mesh repair [32]. Pooled analysis demonstrated increased recurrence rates for TEP compared to open repairs (odds ratio 3.72, 95 % confidence interval 1.66–8.35), with moderate heterogeneity among trials. Furthermore, a higher incidence of perioperative complications for TAPP was evident, when this technique was compared to open repairs (odds ratio 1.22, 95 % confidence interval 1.18–1.84). Although adequate duration of follow-up was reported by the majority of studies, the included trials were mostly unblinded and of moderate quality, which makes further comparative evaluation of recurrence following TEP and open repairs necessary. This hypothesis was recently tested by Koning et al. in a meta-analysis and sequential analyses of randomized trials, which compared TEP to Lichtenstein repair [33]. This model also found a trend toward an increased incidence of recurrence for TEP and a lower incidence of sensory deficits. Considering the low quality of available randomized trials, further comparative data or endoscopic and open mesh repairs are required. TEP seems nevertheless to be an effective approach to recurrent hernia. Recently, a meta-analysis of randomized trials and a decision analysis have suggested similar recurrence rates for TEP and Lichtenstein repair, with lower incidence of wound infection and less pain and cost benefit for the former [34, 35]. A steep learning curve for the endoscopic techniques must be however considered, whereas peritoneal tears occurring in almost half of the patients may render the

Table 2 Summary of recent quality evidence on outcomes of laparoscopic groin hernia repair Author (year)

Study type

Comparison

Main outcomes

Notes

O’Reilly et al. (2012) [32]

Meta-analysis of RCTs

TAPP/TEP versus tissue/mesh repair

Higher incidence of recurrence for TEP, higher morbidity for TAPP

Mostly unblinded studies, moderate quality RCTs, adequate follow-up

Koning et al. (2013) [33]

Meta-analysis and trial sequential analysis of RCTs Meta-analysis of RCTs

TEP versus Lichtenstein

Trend toward less pain, increased incidence of recurrence for TEPP; less sensory deficits for TEP Similar incidence of recurrence, lower incidence of wound infection and chronic pain for TEP Nyhus repair and TEP the most cost effective approaches Similar incidence of recurrence, pain, morbidity

Methodological shortcomings of the analysis, mostly low-quality RCTs Short follow-up, low-quality RCTs

Yang et al. (2013) [34]

Sgourakis et al. (2013) [35] Bracale et al. (2012) [37] Antoniou et al. (2013) [38]

Decision analysis Network meta-analysis of RCTs Meta-analysis of RCTs

TAPP/TEP versus Lichtenstein

TEP versus various open posterior repairs TAPP versus TEP TAPP versus TEP

Trend toward higher morbidity for TAPP, similar incidence of recurrence, pain, sensory deficits

RCT randomized controlled trial, TAPP transabdominal preperitoneal repair, TEP totally extraperitoneal repair

Results dependent on institutional morbidity No data on quality of RCTs, no data on duration of follow-up In general, low-/moderate-quality RCTs, mostly short follow-up

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TEP a difficult task, if adequate experience is not available [36]. Minimally invasive repairs of inguinal hernia have been recently comparatively evaluated by two studies. Bracale et al. performed a network meta-analysis of randomized trials and found similar outcomes with regard to postoperative complications, pain, and recurrence [37]. Our group embarked on a meta-analysis of randomized studies comparing TAPP and TEP and could confirm similar perioperative outcomes, including sensory deficits. A trend toward higher incidence of perioperative complications was however evident for the transabdominal repair in sensitivity analysis with low heterogeneity among reports (odds ratio 1.85, 95 % confidence interval 0.95–3.56) [38].

Perioperative care Limited evidence on anesthetic approaches in open hernia repair exists [39]. Although local infiltration seems to provide adequate perioperative pain control, lack of experience and established practices may account for the limited popularization of this anesthetic technique. General anesthesia provides the advantage of extensive manipulations in cases of large hernias, although urinary retention may occur more frequently [39]. Local infiltration may be suitable in the presence of small or occult hernias because the patient is mostly in a position to cooperate performing the Valsava maneuver. Spinal anesthesia is being utilized in 10–20 % of patients, although perioperative adverse events including urinary retention and hemodynamic effects may be more frequent [39]. Further studies are expected to identify patients who will benefit from each approach. The need for perioperative antibiotic prophylaxis is being a matter of debate. In a frequentist meta-analysis of high-quality randomized studies, it has been showed that antibiotic administration reduces the risk for superficial surgical site infection (odds ratio 0.40, 95 % confidence interval 0.12–0.98), but not the risk for deep surgical site infection (odds ratio 0.59, 95 % confidence interval 0.11–3.20) [40]. This lack of evident effectiveness of antibiotic prophylaxis in deep tissues may be either due to the rarity of such events or may be related to the foreign body effect on the host tissue, inflammatory, and microcirculatory conditions. Unfortunately, the lack of riskbenefit assessment does not allow for a clear recommendation regarding the routine perioperative use of antibiotics in hernia repair. Selective administration of antibiotics, for example, in cases of strangulation or in the presence of risk factors such as obesity or diabetes, may be a prudent practice. No consensus exists regarding the management of the nerves which commonly interfere with the hernia

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structures. Three meta-analyses of mostly high-quality randomized trials converge to the conclusion that nerve preservation increases the incidence of late postoperative pain, although sensory defects are more common in the long term following routine nerve division [41–43]. An individualized approach may be a decisive factor for optimal postoperative outcomes, whereas further research may shed light to patient groups who are most likely to benefit from each practice. Furthermore, the use of mesh, its size, and microstructure also influence perioperative outcomes, including testicular perfusion and postoperative pain [44, 45]. The use of mesh in groin hernia repair is discussed in another review in this issue.

Conclusion Although groin hernia repair techniques have become evolving centuries ago, operative and perioperative management of these patients remain an evolving field of investigation. Mesh application remains the mainstay of practice, for both open and endoscopic approaches. Individual patient factors, hernia characteristics, and surgeon experience need to be taken into account when selecting the best surgical practice.

Conflicts of interest None. Funding None.

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