John Syng Dorsey once stated:
The large proportion of mankind who are afflicted with this complaint; -- the great variety of forms in which it appears; -- the fatality which results from its improper treatment, and the ample resources of surgery in preventing its evil consequences, are circumstances which combine to render the investigation of hernia peculiarly interesting.
These thoughts, written in the early 19th century by an American surgeon, are still an apt introduction to a symposium on hernia management that was presented at the American College of Surgeons 91st Annual Clinical Congress in San Francisco, California, on October 18, 2005.
About 700,000 inguinal hernia operations are performed each year in the United States, making this disease one of the most common conditions requiring surgical treatment. Although the disease is associated with considerable morbidity, mortality is rare, except in remote areas, where delay in treatment can lead to strangulation and death.
Several factors account for the frequency of this disease: our upright position, occupational hazards, and conditions, such as persistent cough or constipation, that increase intra-abdominal pressure. Inguinal hernias are more common in men than in women because of migration of the male reproductive gonads through the abdominal wall during embryologic development, which weakens the abdominal wall, increasing the likelihood of an inguinal hernia.
The objective of this symposium was to answer several questions, including the following:
What is the preferred approach for the repair of inguinal hernias: laparoscopic or open surgery?
Is "watchful waiting" ever justified and, if so, under what circumstances?
What is the role of implantable mesh?
Do surgeons accept "evidence-based" recommendations for hernia surgery, or do they select procedures based on their own training and experience?
The symposium's moderator, Dr. Leigh Neumayer of the Department of Surgery, The University of Utah, Salt Lake City, Utah, is also the first author of a definitive hernia outcome study that compared the results of open mesh (Lichtenstein technique) with laparoscopic mesh repair. This large randomized, controlled, Veterans Affairs (VA) study was based on inguinal hernia procedures on 1983 patients at 14 VA medical centers. Two-year follow-up assessment was available for 1696 patients. The study required a large number of patients because several of the end points, such as recurrence or serious complications, were low. For recurrent hernias, the recurrence rate was similar in both groups, but for primary inguinal hernias recurrence rates were higher after laparoscopic repair. Some of the main findings are presented in the Table.Table. Comparison of Open vs Laparoscopic Mesh Repair of Inguinal Hernia in the Veterans Affairs Randomized Controlled Study
|Open Repair||Laparoscopic Repair|
|Use of local anesthesia||11.5%||< 1%|
|Intraoperative complications||Less frequent (1.9%)||More frequent (4.8%)|
|Early postoperative complications||19%||24%|
|Serious complications||< 1%||1.1%|
|Recurrence rate at 2 years||4.9%||10.1%|
The conclusions of this large randomized controlled trial were that open mesh repair has a lower recurrence rate, is simpler to perform, and is the preferred method for herniorrhaphy. A European prospective study reported similar findings. There have been questions about the US VA study because the recurrence rates in both groups seem higher than in many other reports, and there were wide differences in recurrence rates at the individual participating centers. However, the variation in recurrence rates in the participating centers is more likely to reflect surgical experience obtained in various hospitals throughout the country than recurrence rates from controlled trials reported by hernia specialists.
Dr. Parviz K. Amid, Department of Surgery, Harbor-UCLA Medical Center, presented a strong case for open mesh repair. He reviewed several of the reported controlled trials, including the Neumayer trial, and concluded that level I evidence favors the open mesh Lichtenstein repair. The goal of any type of inguinal hernia surgery should be to perform the operation with an overall recurrence rate of less than 1% and with less than 1% of patients complaining of persistent postoperative groin pain. It is much easier to approach these goals with an open approach rather than a laparoscopic approach.
Dr. Amid pointed out another potential late problem after laparoscopic repair: Most hernia patients are men, and in later life some will require radical surgery for prostate cancer. Radical prostate surgery is much more complicated if a mesh has been previously placed in the prepubertal space during a laparoscopic repair.
In his discussion, Dr. Robert J. Fitzgibbons, from the Department of Surgery, Creighton University, Omaha, Nebraska, favored an open mesh repair for several reasons: shorter operating time, lower complication rates, and lower costs. In addition, the Lichtenstein open mesh repair avoids the prolonged learning curve that is required to become a proficient laparoscopic hernia surgeon. Furthermore, life-threatening complications, such as serious hemorrhage, and even death, following the Lichtenstein repair, are much less likely to occur than with a laparoscopic repair. He pointed out that in the United States, less than 20% of all hernias are initially treated via the laparoscopic approach. However, laparoscopic surgery may be the preferred method when dealing with recurrent or bilateral hernias.
It should be noted that patients prefer laparoscopic repair because of reduced postoperative pain. In fact, one surgeon who had an open procedure on one side, followed a few years later by a contralateral laparoscopic herniorrhaphy, remarked, "Day 1 after laparoscopic surgery is like day 3 after open surgery."When Is Watchful Waiting Justified for Inguinal Hernias?
Dr. Fitzgibbons is currently conducting a multicenter, randomized, controlled hernia trial in which watchful waiting is being compared with tension-free open surgical repair for patients with inguinal hernia. The results of Dr. Fitzgibbons' study will be important because, in addition to the estimated 700,000 patients operated on yearly for an inguinal hernia, there are at least an equal number of patients with a hernia who choose not to have immediate surgery. We need to know what risks these patients face. Surgeons recognize that patients who postpone surgery for an inguinal hernia only occasionally develop serious complications, such as strangulation (Figure 1).
Figure 1. This patient waited for nearly 20 years before seeking repair of a large inguinal hernia. Note urinary catheter to reduce the likelihood of bladder injury during herniorrhaphy.
In addition, Medicare data suggest that the risk for mortality from watchful waiting may be no greater than after inguinal hernia repair. In fact, one source for the frequency of strangulation in patients with an untreated hernia goes back to a follow-up study of several thousand patients conducted in the 19th century, when the hernia was initially treated with a truss rather than with surgery (Figure 2).
Figure 2. Even in the early part of the 20th century, trusses were often used for treating hernias. Permission from Furneaux Historical Research Association Inc.
Dr. Fitzgibbons' study has recruited several hundred patients and should provide reliable data to determine the frequency of long-term complications after repair of a groin hernia and the outcomes of untreated inguinal hernias. The study also will look at other outcome variables, such as satisfaction, limitation of daily activities, and cost. The results will be adjusted for age and various comorbidities. A manuscript from this collaborative study has been submitted for publication, but the results are not yet available.
Are there ever circumstances when it would be better not to operate on a patient with an inguinal hernia? Ben Eiseman, a highly respected senior American surgeon, gave his own personal perspective on when not to operate on an inguinal hernia. His "don't operate" criteria include:
When the surgeon is 88 years old and hasn't performed a hernia operation for 20 years. (The enthusiastic audience response after this statement indicated complete agreement.)
When no hernia can be detected. His advice -- operate only when the hernia is easily detected. (This suggestion seems obvious, but Dr. Eiseman recalled patients who had been referred to him because of persistent groin pain and the questionable presence of a small hernia. Troublesome groin pain in these patients is likely to persist after surgery.)
When there is a severe existing medical problem, or there are several comorbidities.
When the patient's life expectancy is short and the hernia is asymptomatic.
Dr. Eiseman cited the case of Douglas MacArthur, the famous World War II general who developed bilateral hernias early in his military career but refused surgery until shortly before he died in his 80s. ("Old soldiers never die, they just fade away.")
Watchful waiting may be an acceptable approach for patients with small, asymptomatic hernias, but they should be given careful instructions and remain under surgical supervision. When the results from Dr. Fitzgibbons' controlled trial are available, we should have a better answer to this important question.Should the Decision to Operate on an Inguinal Hernia Be Evidence-Based?
Olga Jonasson, MD, FACS (Chicago, Illinois), discussed the assimilation of new knowledge by surgeons and the methods for evaluation of new data. She believes that we should base our decisions on level I evidence derived from several strong, randomized clinical trials or from carefully conducted meta-analyses. However, because conducting a randomized trial is difficult, costly, and can take years, surgical progress can be slow. As an example, she cited the long time that it took to change from the initial standard approach to breast cancer -- radical mastectomy -- to the current approach of minimal surgery plus radiation therapy and chemotherapy. Fortunately, well-designed studies are available for determining the best operation for inguinal hernia repair.Discussion Questions and Other Key Points
During the discussion period, the audience asked several questions:
"What about hernia surgery in developing countries?" The panel believed that because of cost, laparoscopic hernia repair is not an option. Even mesh repair may be unavailable or too costly for widespread use. Older methods, such as the Bassini or McVay repair, can give acceptable results, at an acceptable cost.
What about a 25-year-old, pregnant woman with a visible external hernia but no pain? "Wait until after delivery, unless the hernia is a femoral rather than an inguinal hernia." The panel could not remember any patient with an incarcerated inguinal hernia occurring during pregnancy.
"What about the use of mesh in young patients?" The discussants believed that mesh should not be used in patients younger than 18 years.
"What about the use of absorbable mesh?" Dr. Amid thought that, in general, using absorbable mesh was a bad idea. Many patients develop a hernia because of weakness of abdominal wall supporting tissue, so when the mesh disappears, the replacement tissue will still be weak. However, absorbable mesh can be useful if there is abdominal wall infection.
Other points emphasized at this hernia symposium were:
Procedures employing mesh repair are now widely used because they provide an efficient method for a tension-free hernia repair. There is evidence that the use of mesh lowers the recurrence rate after hernia repair by 30% to 50%.
One recent report of a randomized controlled trial of patients with incisional hernias concluded that suture repair of incisional hernia should be abandoned. The same admonition probably holds true for nearly all inguinal hernias.
Hernia treatment has changed dramatically in the past 25 years: Older procedures, such as the Bassini or the McVay repair, are rarely performed. At the end of the 20th century, surgeons began to repair hernias with a laparoscopic approach, but at about the same time, open mesh repair became popular. Both approaches are superior to the older techniques, but the open mesh repair is easier to learn, simpler to perform, and in follow-up studies has about the same or lower recurrence rate. Furthermore, serious complications are less common with the open mesh technique. The goal for any surgical treatment of hernia should be a recurrence rate of less than 1%, with less than 1% persistent postoperative groin pain.
How will surgeons treat hernias in the mid-21st century? Based on the changes that have already taken place in the management of hernias, we can predict that surgeons will develop new operations or will be using entirely different techniques. Is there a role for tissue glues? Will we be able to inject inert foam via the internal ring that eventually hardens to strengthen the inguinal region? One thing is certain: The frequency of inguinal hernias is unlikely to diminish over time. Repairing groin hernias will always be an important part of the surgical workload.References
Dorsey JS. The Elements of Surgery. Vol II. Philadelphia, Pa: Edward Parker; 1818:26.
Neumayer L, Giobbie-Hurder A, Jonasson O, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med. 2004;350:1819-1927. Abstract
Wara P, Bay-Nielsen M, Juul P, et al. Prospective nationwide analysis of laparoscopic versus Lichtenstein repair of inguinal hernia. Br J Surg. 2005;92:1277-1281. Abstract
McCormack K, Wake B, Perez J, et al. Laparoscopic surgery for inguinal hernia repair: systematic review of effectiveness and economic evaluation. Health Technol Assess. 2005;14:1-203.
Fitzgibbons RJ, Jonasson O, Gibbs J, et al. The development of a clinical trial to determine if watchful waiting is an acceptable alternative to routine herniorrhapy for patients with minimal or no hernia symptoms. J Am Coll Surg. 2003;196:737-742. Abstract
Neuhauser D. Elective inguinal herniorrhaphy versus truss in the elderly. In: Bunker JP, Barnes BA, Mosteller F, eds. Costs, Risks, and Benefits of Surgery. New York: Oxford University Press; 1977:223-239.
McCormack K, Scott NW, Go PMNYH, et al. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev. 2005;4.
Burger JW, Luijendijk RW, Hop WC, et al. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg. 2004;240:578-583. Abstract
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Cite this: Albert B Lowenfels. Managing Inguinal Hernias - Medscape - Nov 17, 2005.