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378
ab
cd
S. Rocchetti et al.
Fig. 39.2 Laparoscopic repair of an incarcerated ingui-
nal hernia. (a) Ischemic incarcerated small bowel, (b) hernia sac after reduction of the incarcerated bowel, (c) mesh
positioning, (d) appearance of the incarcerated bowel
after the repair: the jejunal loop is vital and no resection is
needed
On the other hand, classical surgical teaching
contraindicates the use of prosthetic materials in
the setting of strangulation due to the fear of a
higher rate of mesh-related complications in
those settings. Furthermore, the consequences of
wound infection in the presence of grafts may be
more difcult to treat. If gross contamination
occurs or if a surgeon feels that the risk of mesh
infection is high, the only available options are
tissue repairs (commonly employed are the
Bassini, McVay, and Shouldice repairs),
Lichtenstein with biologic mesh, and absorbable
mesh plug such as polyglactin mesh.
In case of incarceration, prior to assessing the
actual contamination of the surgical eld due to
bowel necrosis, two approaches can be considered: open and laparoscopic. Laparoscopic hernia repair has merit in selected patients.
Diagnostic laparoscopy can be performed with
attempted manual extracorporeal reduction and/
or laparoscopic reduction. Aside from the minimally invasive approach for reduction, bowel
viability can be easily inspected, and laparoscopic hernia repair could be followed (Fig.39.2).
Open repair can proceed in one of two ways,
supra-inguinal or via laparotomy. If bowel is
unable to be reduced safely, or resection and
anastomosis will be technically challenging, then
laparotomy should be performed to facilitate
resection and anastomosis. The hernia is often
constricted by the internal inguinal ring; therefore, sharply incising the internal inguinal ring
can allow reduction and/or evaluation of the hernia contents. Once performed, it is key to prevent
the hernia from reducing into the abdominal cavity until the hernia sac has been opened and
39 Surgical Emergencies inInguinal Hernia
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379
contents identied. If the hernia content was
reduced, laparoscopy again is a useful adjunct to
evaluate for bowel viability.
Strangulated bowel can be addressed via the
groin incision, laparotomy, or laparoscopy. If the
bowel is not grossly ischemic or infarcted, then
reduction into the abdominal cavity is appropriate. It is prudent to ascertain return of blood supply prior to the denitive repair.
In case of incarceration with no sign of strangulation or contamination of surgical eld, a
Lichtenstein repair is appropriate and safe, with a
small risk of recurrence.
Bibliography
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strangulated inguinal hernia: a systematic review with
meta-analysys. World J Surg. 2014;38:2784–90.
2. Alvarez JA, etal. Incarcerated groin hernias in adults:
presentation and outcome. Hernia. 2004;8(2):121–6.
3. Derici H, Unalp HR, Bozdag AD, Nazli O, Tansug
T, Kamer E.Factors affecting morbidity and mortality in incarcerated abdominal wall hernias. Hernia.
2007;11(4):341–6.
4. Nilsson H, Nilsson E, Angeras U, Nordin P.Mortality
after groin hernia surgery: delay of treatment and
cause of death. Hernia. 2011;15(3):301–7.
5. Nilsson H, Stylianidis G, Haapamaki M, Nilsson E,
Nordin P. Mortality after groin hernia surgery. Ann
Surg. 2007;245(4):656–60.
6. Hernandez-Irizarry R, Zendejas B, Ramirez T, Moreno
M, Ali SM, Lohse CM, et al. Trends in emergent
inguinal hernia surgery in Olmsted County, MN: a
population-based study. Hernia. 2012;16(4):397–403.
7. Huerta S, Pham T, Foster S, Livingston EH, Dineen
S. Outcomes of emergent inguinal hernia repair in
veteran octogenarians. Am Surg. 2014;80(5):479–83.
8. Altom LK, Snyder CW, Gray SH, Graham LA, Vick
CC, Hawn MT.Outcomes of emergent incisional hernia repair. Am Surg. 2011;77(8):971–6.
9. Beadles CA, Meagher AD, Charles AG. Trends in
emergent hernia repair in the United States. JAMA
Surg. 2015;150(3):194–200.
10. Samuel JC, Tyson AF, Mabedi C, Mulima G, Cairns
BA, Varela C, et al. Development of a ratio of emergent to total hernia repairs as a surgical capacity metric. Int J Surg. 2014;12(9):906–11.
11. Arabamson, etal. Abdominal operations. Englewood
Cliffs: Prentice-Hall; 1997. p.479–80.
12. Yerdel MA, etal. Effects of single dose prophylactic
ampicillin and sulbactam on wound infection after
tension free inguinal hernia repair with polypropylene mesh. The randomized, double-blind, prospective
trial. Ann Surg. 2001;233:26–33.
13. Yuri W.Nowitsky, Hernia Surgery, current principles.
Basel: Springer International; 2016.
14. Muhammad S, etal. Diagnostic laparoscopy through
deep inguinal ring: a literature-based review on
the forgotten approach to visualize the abdominal
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9788821429736.
Results andComplications
ofInguinal Hernia Repair
DavidK.Nguyen andDavidC.Chen
40
Inguinal hernia repair is performed annually on
approximately 20 million individuals worldwide,
making it one of the most common operations
performed [1]. Inguinal hernia operations have
evolved a great deal since the rst descriptions
involved ligation of the hernial sac and reapproximation of muscular and fascial tissues to reinforce the posterior inguinal canal. In the late
1880s, Bassini dened the inguinal anatomy and
developed a viable tissue-based repair fostering
the modern era of successful hernia repair techniques with minimal morbidity. Introduction of
mesh prosthetics in the 1960s resulted in the
widespread adoption of tension-free mesh-based
repairs as a way to further reduce recurrence. In
the 1990s, laparoscopic posterior approaches
allowed greater exposure and understanding of
the myopectineal orice and preperitoneal placement of mesh. The evolution of technology with
regard to materials, prosthetics, devices, optics,
and robotics has contributed additional tools and
techniques to the treatment of inguinal hernias.
A general surgeon should have familiarity and
competency with the available tissue- and meshbased and endoscopic techniques for repair.
Detailed knowledge of current outcomes and
complications of inguinal hernia repair is crucial
to improve personal outcomes and operative
D. K. Nguyen · D. C. Chen (*)
Lichtenstein Amid Hernia Clinic, University of
California at Los Angeles, Los Angeles, CA, USA
e-mail: dcchen@mednet.ucla.edu
technique and to appropriately manage patients
affected by potential complications. Patients,
especially in developed countries, are well
informed and expect a surgeon who can engage
them in thoughtful, shared decision-making. In
resource-limited settings, it is important to know
which techniques are most effective and durable,
as a successful repair can mean the difference
between a person remaining a functional, contributing member of society and one who is
unable to work and care for themselves or their
loved ones.
40.1 Watchful Waiting
There is a growing body of literature suggesting
that surgeons may be overtreating inguinal hernias, especially those that are asymptomatic or
minimally symptomatic [2–9].
40.2 Results andComplications
In 2006, Fitzgibbons et al. conducted an RCT
with 720 men, looking at superiority of elective
inguinal hernia repair over watchful waiting in
asymptomatic or minimally symptomatic men
[2]. Primary outcomes were pain interfering with
normal activities and change in physical function
as measured by the physical component score of
the SF-36 at 2 years. Secondary outcomes
included complications, and patient reported
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_40
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D. K. Nguyen and D. C. Chen
pain, functional status, activity levels, and satisfaction. At 2years, pain interfering with normal
activities occurred in 5.1% of the watchful waiting group and 2.1% in the operative group
(p= 0.52) [2]. However, long-term follow-up of
this study and similar RCTs all demonstrate
crossover rates of greater than 60% primarily due
to pain 2–4years out from study inclusion [2–6].
A more recent trial published in 2017 examined
the non-inferiority of watchful waiting versus
inguinal hernia repair in asymptomatic to minimally symptomatic men over the age of 50 [5].
This study involved 496 men with a primary endpoint of 0.20-point difference in pain scores as
evidence of non-inferiority with 24 months of
follow-up. Their results did not demonstrate noninferiority. Only 40% of watchful waiting patients
crossed over at 2 years, with no differences in
postoperative complications or recurrences compared to the initial surgery group [5].
Long-term data regarding watchful waiting
was published by Fitzgibbons in 2013 as a follow-up to their original randomized clinical trial
[5]. Two hundred fty-four patients in the original watchful waiting cohort were followed for at
least 10years. Eighty-one (31.9%) crossed over
to surgical repair before the end of the original
3-year study. The cumulative crossover rate at
10years was 68% with men over 65years crossing over at a considerably higher rate than
younger men (79% vs. 62%) [9]. At 10years, the
incidence of morbidity remained low with no
mortality. The authors concluded that watchful
waiting is reasonable and safe, but symptoms,
especially pain, are likely to progress with eventual need for surgery [9].
In 2014, a group out of England reported on
the clinical implications of a watchful waiting
strategy [10]. Their retrospective comparison of
1000 patients pre- and post-implementation of
watchful waiting was performed with a 59% rise
in emergent hernia repairs. These emergent hernia repairs were also associated with signicantly
more adverse events (18.5% vs. 4.7%). However,
the study inadequately controlled for the prior
medical histories of the patients [10].
Inguinal hernia repair is effective, but there
will always be patients hesitant to undergo sur-
gery or with signicant medical comorbidities.
For this subgroup of patients who are asymptomatic or minimally symptomatic, it is appropriate
to continue watchful waiting after a discussion
regarding complications of emergent surgery, the
likelihood of potential complications while waiting, and the high likelihood of requiring surgery
later in life.
40.2.1 Open Inguinal Hernia Repair
40.2.1.1 Mesh-Based Repair
The use of mesh in inguinal hernia repairs was
rst proposed in the 1960s primarily in elderly
patients with recurrent inguinal hernias.
Favorable long-term results from these early
operations emboldened surgeons to use mesh in
younger patients with primary inguinal hernias.
Lichtenstein and Amid subsequently popularized
the concept of a mesh-based, tension-free technique for routine inguinal hernia repair, and since
then several variations of mesh repair including
plug and patch, bilayer mesh, and preperitoneal
mesh have been developed.
In 2009, the European Hernia Society (EHS)
published guidelines on the basis of grade A evidence stating that all male adults over age 30 with
a symptomatic inguinal hernia should be treated
with a mesh-based repair [11]. In the 2015 EHS
updated guidelines, mesh-based repairs were
again given a strong recommendation [12].
40.2.1.2 Mesh Types
It is difcult to study and identify an ideal mesh
for inguinal hernia repairs. Mesh comes in many
different materials, shapes, sizes, weights, and
porosity. Each variation is touted for its benets
and has its fair share of limitations. The ability to
withstand stress, repetitive loading, and good
biocompatibility all contribute to outcomes
including repair durability, return to activity, and
incidence of chronic postoperative inguinal pain.
Studying each characteristic and each potential
effect while risk-stratifying for potential confounders makes comparisons of mesh types and
translating those ndings to clinical practice difcult. Three-dimensional meshes and plugs
40 Results andComplications ofInguinal Hernia Repair
383
incite different foreign body reactions as compared to the aforementioned at, large-pore
meshes and are difcult to directly compare.
There are few studies looking specically at at
or large-pore meshes. With regard to weight,
lightweight meshes are compared to midweight
or heavyweight meshes with regard to the outcomes of recurrence and chronic pain.
In open repairs, studies demonstrated a shortterm lower incidence of pain with lightweight
mesh, with no difference between lightweight
and heavyweight with long-term follow-up [13–
21]. Notably, foreign body sensation was also
less frequent with lightweight mesh [16–21]. For
laparoscopic TEP and TAPP repairs, there were
also higher rates of chronic pain with heavier
mesh with the same recurrence rates [22–24].
The variations in porosity, however, limit the
implications of these studies as porosity greatly
affects ingrowth and inammation. More recent
meta-analyses attempting to address the question
of mesh weight and outcomes also reported conicting results [22–24]. Most of these studies
found that lightweight mesh was associated with
less foreign body sensation and chronic pain [22–
24]. However, they did not agree upon whether
recurrence was increased with lightweight mesh
compared to heavyweight mesh. These studies
were also heterogeneous in nature, with variations in study inclusion, xation technique, and
lack of comparison between xation and mesh
characteristics in contributing to chronic pain and
recurrence [13–24].
40.2.1.3 Lichtenstein Repair
In 2012, a systematic review and meta-analysis
covering all prior randomized controlled trials
(RCT) up until September of 2011 examined
Shouldice repair versus other open techniques
[25]. This review looked at 6 RCTs with 1565
patients comparing the Shouldice technique versus open mesh repairs (one study with plug and
patch, the rest with Lichtenstein). Overall, RCT
quality was rated as low and all studies examined
recurrence as the primary outcome. There was no
standardization of acute and chronic pain denitions and measurements. The studies were quite
heterogeneous, and the authors had concern
regarding standardization of techniques and hernia classications.
Recurrence rates were higher in the Shouldice
group compared to the mesh group (ve studies)
(OR 3.65, 95% 1.79–7.47, NNH 36). No signicant differences were identied between mesh
and Shouldice groups in terms of postoperative
stay, chronic pain, seroma/hematoma, or wound
infection. Operative time was shorter for mesh
repairs compared to the Shouldice repair (WMD
9.64min; 95% CI 6.96–12.32).
Since the Cochrane review, several additional
RCTs have been published but with small sample
size or not directly comparing Shouldice to
Lichtenstein [26–29]. One RCT did compare the
Desarda technique, which is a new tissue-based
repair to the Lichtenstein repair [30]. In 208
patients with short-term follow-up, there was a
comparable 1.9% recurrence rate with no signicant differences in postoperative pain.
Two large population-based studies from
Denmark involving more than 24,000 patients
evaluated outcomes between tissue-based repairs
and the Lichtenstein repair [31–33]. These studies were limited by the fact that not all tissue
repairs were Shouldice operations (13%
Shouldice). In addition, reoperation was used as a
proxy for recurrence, so true recurrence rates are
not known. The reported recurrence rates for tissue repairs in this large population study were
8% for tissue repairs and 3% for the Lichtenstein
repair [31–33]. This study does provide valuable
insight into real-life practice patterns and outcomes and is thus useful for surgeons in their discussions with patients.
In summary, the Lichtenstein repair has recurrence rates in the largest population studies of
about 3%. In RCTs involving a Lichtenstein
repair, recurrence rates range between 1 and 7%.
Chronic pain for the Lichtenstein repair, while
dened heterogeneously in various studies,
ranges between 6 and 12%.
40.2.1.4 Non-Lichtenstein Mesh
Repairs
Several mesh-based alternatives for open anterior
inguinal hernia repairs exist in addition to the
classically described Lichtenstein operation [34].
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D. K. Nguyen and D. C. Chen
These include the use of a mesh plug and onlay
patch, bilayer hernia systems, self-gripping
mesh, and open mesh xation with glue [35–38].
For preperitoneal approaches, these include the
Kugel technique, the transinguinal preperitoneal
(TIPP) approach, the transrectus sheath preperitoneal (TREPP) approach, the Wantz technique,
the Onstep technique, and the Rives technique
[39–44]. Generally speaking, TIPP, Onstep, and
Rives access the preperitoneal space through the
inguinal canal, whereas TREPP, Kugel, and
Wantz approach the preperitoneal space without
entering through the inguinal canal.
40.2.1.5 Plug andPatch
Two meta-analyses of seven RCTs have accrued
and analyzed the best data on plug and patch
repairs compared to Lichtenstein repairs [45,
46]. In these studies, there were signicantly
shorter operative times (5–10min) with plug and
patch repairs compared to the Lichtenstein. In
addition, two RCTs performed long-term follow-up of their patient cohort [47, 48]. The rst
study, with a median follow-up of 7.6 years,
found that recurrence rates were 9.9% and 5.6%
for plug and patch and Lichtenstein repairs,
respectively (p= 0.77) [47]. Chronic pain rates
were similar at 5.6% and 5.5% [46]. In the second study, with median follow-up of 6.5 years,
recurrence rates were 7.8% and 8.1% for plug
and patch versus Lichtenstein repairs, respectively (p=0.92) [48]. Chronic pain, rated as a
visual analog score (VAS) greater than 3, was
not signicantly different between the two
groups [48].
40.2.1.6 Bilayered Mesh System
Bilayered mesh repairs (Prolene Hernia System
(PHS)/Ultrapro Hernia System (UHS)) utilize an
anterior at-based mesh connected to a posterior
at mesh to cover both the inguinal canal and
myopectineal orice. The highest-quality study
comparing outcomes of bilayer repair had a mean
follow-up of 7.6years [47]. This study had a PHS
arm, Lichtenstein arm, and plug and patch arm
with 270 patients completing long-term followup. Comparison of PHS to Lichtenstein demonstrated a recurrence of 3.3% and 5.6%,
respectively (p= 0.77). Chronic pain was 6.7%
and 5.6%, respectively (p=0.785).
Bilayered mesh repair and plug and patch both
involve the anterior and posterior compartments
in addition to being three dimensional with more
risk of foreign body sensation. While acceptable
as standard repairs for inguinal hernias with
favorable outcomes, they do not provide any
added statistical benet over the Lichtenstein
repair. Furthermore, violation of both anterior
and posterior compartments at one operation
makes it more difcult to address pain and to utilize an alternative compartment to address a
potential recurrence. Recommendations from
HerniaSurge and the EHS also suggest that there
can be issues with meshoma formation and mesh
erosion and migration, and meticulous operative
technique is essential to replicate best practice
outcomes [
12]. These issues will be addressed
further in the Sect. 40.2.3 of this chapter.
40.2.1.7 Self-Gripping Mesh
There have been seven RCTs and ve meta-analyses examining ve of the RCTs published comparing self-gripping mesh to the Lichtenstein
repair [47, 49–60]. An RCT in 2014 with 557
male patients demonstrated recurrence rates of
1.5% vs. 2.8% in self-gripping and Lichtenstein
repairs (p=0.289) [61]. Immediate postoperative
pain scores were signicantly lower with selfgripping mesh compared to Lichtenstein, as well
as an average reduction of 7.6min of operating
time. However, follow-up at 1 year showed no
signicant difference in long-term pain scores.
Among the rest of available RCTs and meta-analyses, there were comparable recurrence and
chronic pain rates between the two groups, with a
shorter operative time of 1–12min in the selfgripping group [49–60].
40.2.1.8 Glue Fixation
Campanelli et al. performed an RCT of brin
sealant mesh xation versus standard Lichtenstein
repair in 319 patients with a primary endpoint
hypothesis of 50% reduction in postoperative
pain/numbness/groin discomfort and 1year follow-up [38]. Pain, numbness, and groin discomfort were rated by category on a VAS of 0–100.
40 Results andComplications ofInguinal Hernia Repair
385
The scores were then combined as a composite,
and values greater than 30 reected chronic disabling symptoms. At 12months, the prevalence
of one or more disabling complications was signicantly lower with glue xation versus suture
xation (8.1% vs. 14.1%, p=0.0344), with the
most signicant benet seen in active patients
versus retired patients. Recurrence rates were
less than 1% in both groups at 12months. At 1
and 6 months, there was also signicantly less
pain experienced by the glue xation group compared to suture xation as evidenced by less use
of analgesics (65.2% vs. 79.7%, p = 0.0009).
There is no long-term follow-up data available
for brin sealant mesh xation. In addition, there
may be issues related to cost and availability of
brin sealant depending on where a surgeon’s
practice is located.
40.2.1.9 Preperitoneal Approaches
Only TIPP and Kugel preperitoneal approaches
have been adequately studied and compared
against the Lichtenstein repair to formulate conclusions regarding their efcacy. The other
approaches mentioned above do not have sufcient available comparative data to generate an
informed opinion. In the most recent HerniaSurge
guidelines, three RCTs, one systematic review,
and two meta-analyses were identied and used
to generate recommendations [62–67]. The best
available data come from a meta-analysis in 2013
of 12 RCTs comparing TIPP repairs to
Lichtenstein repairs for both primary and recurrent inguinal hernias [63]. In this meta-analysis,
“TIPP” referred to the actual TIPP repair, Kugel
repair, and Rives repair. There was a reduced risk
of chronic groin pain with TIPP repairs (RR,
0.48; 95% CI, 0.26, 0.89; z = 2.33; p < 0.02)
without any change in the incidence of recurrence (RR, 0.18; 95% CI, 0.36, 1.83; z = 0.51;
p = 0.61). Other secondary outcomes such as
perioperative complications, duration of operation, and postoperative pain intensity were similar. Despite heterogeneity between the studies,
the author of the 2013 meta-analysis concluded
that TIPP repair was comparable to Lichtenstein
repair. An additional RCT published in 2012 randomized 301 patients to TIPP versus Lichtenstein
repair [63]. Primary outcome was presence of
chronic pain at 1year, with assessors and patients
blinded to the intervention. The TIPP patients
had a chronic pain incidence of 3.1% compared
to 12.9% for patients with Lichtenstein repairs
(p=0.004). Recurrence rates were similar in the
two groups.
40.2.1.10 Suture-Based Open Repairs
Many suture-based open repairs exist, with
eponyms such as Bassini, Halstead, McVay,
Marcy, Shouldice, Desarda, etc. Of these, the
Shouldice has been most studied with recurrence
rates as low as 2% in high-volume centers such as
the Shouldice Clinic. Eight RCTs with 2865
combined patients have compared the Shouldice
technique versus other suture-based techniques,
and these were examined in a systematic review
published in 2012 [25]. These studies were quite
heterogeneous with inadequate randomization
methods and insufcient blinding. Recurrence
rate was the primary outcome and pain was evaluated in only three of the trials. In addition, there
was no rigorous standardization of technique.
Recurrence rates were found to be lower with the
Shouldice technique (OR 0.62, 95% 0.45–0.85
NNH 40). In addition, these studies found less
incidence of chronic pain, less hematoma formation, slightly higher infection rates, and increased
hospital stay with Shouldice repair. This review
was limited by low-quality RCTs, non-blinded
outcome assessments, patient selection bias, loss
to follow-up, and bias based on degree of surgeon
familiarity with the Shouldice technique.
However, it remains the best studied tissue-based
technique, and updated guidelines for the
European Hernia Society recommend that the
Shouldice technique be utilized as the best suturebased repair [12]. At the same time, they acknowledge that the learning curve is substantial for this
technique, with 300 cases needed to be considered qualied at expert centers.
The Desarda technique is a novel addition to
suture-based repairs with increased interest due
to a lower learning curve and applicability in the
developing world where mesh is not always readily available. The premise is similar to prior tissue repairs describe by Halstead in the late 1800s.
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D. K. Nguyen and D. C. Chen
Early short-term results are encouraging with a
reported 1.9% recurrence rate and no differences
in complication rates [30]. However, more highquality studies and longer follow-up are needed
before stronger recommendations can be given
regarding this type of repair.
40.2.2 Laparoscopic Inguinal Hernia
Repair
Transabdominal preperitoneal (TAPP) hernia
repairs and totally extraperitoneal (TEP) hernia
repairs are generally accepted as the best evidence-based options for minimally invasive
inguinal hernia repair [12]. There has been a
recent shift to performing TAPP repairs with
robotic assistance as opposed to traditional laparoscopy. Data on robotic-assisted TAPP procedures is sparse and will not be addressed in this
chapter but in general can be extrapolated to at
least reproduce standard laparoscopic TAPP
repair.
Systematic reviews and meta-analyses from
1999, 2000, 2003, and 2012 compared TAPP and
TEP repairs to all open repairs [68–71].
Comparison to only Lichtenstein repairs was
done as a subgroup analysis in a 2005 meta-analysis [72]. There were signicant advantages for
laparoscopic approaches, including lower incidence of wound infection, less hematomas, less
nerve injury, earlier return to normal activities,
and fewer incidences of chronic postoperative
inguinal pain. There were no differences in urinary retention, bladder injury, vascular injury,
visceral injury, and testicular problems.
Lichtenstein performed better in terms of operative time, seroma formation, and, most importantly, recurrence (OR 2.00; 95% CI: 1.46–2.74;
p= 0.00001). This was a signicant nding and
often used to highlight the weaknesses of laparoscopic repair. However, it was greatly inuenced
by the Veterans Affairs multicenter trial, which
used a 7.6 × 15 cm mesh size for laparoscopic
repairs. These are dimensions typically considered inadequate for covering the myopectineal
orice, and when this study is excluded from
analysis, there is no signicant difference in
recurrence rates. The HerniaSurge committee
additionally examined results of 1237 TEP and
TAPP repairs compared to 1281 Lichtenstein
repairs in male patients with unilateral primary
hernias [73–82]. They found no differences in
intraoperative and immediate postoperative complications. Additionally, there were clear advantages with early postoperative pain, analgesic
use, and return to daily activities and work. There
was no signicant difference in the recurrence
rate (TEP vs. Lichtenstein with median follow-up
of 5.1years 2.4% vs. 1.2%; p=0.109 and TAPP
vs. Lichtenstein with median follow-up of
52months 1.3% vs. 1.2%; ns) once surgeons had
achieved the necessary cases to complete the
learning curve [73–76]. In TEP versus
Lichtenstein patients, chronic postoperative
inguinal pain occurred in 9.4% and 18.8%,
respectively, at a median follow-up of 5years. In
a separate study, TAPP patients had no chronic
pain compared to 3.9% of Lichtenstein patients
[79–82].
Large population studies from the Herniamed
registry corroborate RCT data [82]. A 2015 analysis of 17,388 patients (10,555 with Lichtenstein
and 6833 TEP) revealed nonsignicant differences with regard to recurrence rates (estimated
OR 0.775 95% CI 0.549–1.093; p = 0.146),
chronic postoperative pain requiring treatment
(estimated OR 1.066 95% CI 0.860–1.321;
p=0.560), and complication-related reoperation
rates (estimated OR 1.356 95% CI 0.960–1.913;
p=0.084). TEP demonstrated better postoperative complication rates, less pain at rest, and less
pain with exertion compared to the Lichtenstein
repair. From a direct cost-effectiveness standpoint, TEP and TAPP repairs are inferior to the
Lichtenstein repair. However, if one factors into
account quality of life measures affected by
numbness and chronic pain, then TEP and TAPP
repairs may be of increased utility.
Studies examining outcomes between TEP
and TAPP do exist but are insufcient in determining if one is better than the other due to bias,
lack of statistical power, and signicant heterogeneity in study design [83–99]. In addition, many
of these studies did not control for the learning
curve period, though characterizing the trend in
40 Results andComplications ofInguinal Hernia Repair
387
outcomes as surgeons become more experienced
is helpful. Over a 20-year period, recurrence rates
for TAPP and TEP dropped from 1.33% and
0.6% to 0.77% and 0.54% [100]. This likely
reects improvement in technical performance as
more surgeons adopted laparoscopic techniques
and became more comfortable. Large population
studies also failed to demonstrate any signicant
difference between the two techniques.
40.2.3 Complications
Complications from open and laparoscopic
inguinal hernia repairs include recurrence,
chronic postoperative inguinal pain, infection,
urinary dysfunction, sexual dysfunction, hematoma, seroma, vascular and visceral injuries, late
postoperative complications, and mortality.
40.2.3.1 Recurrence
Recurrence rates after inguinal hernia repair have
been reported to be as low as less than 1% to as
high as 15% [101]. In most studies, reoperation is
used as a proxy for recurrence, with the assumption that recurrences are twice as common as
reoperations. A Swedish study from 2011 found
24-month reoperation rates for primary hernias to
be 1.7% for primary repairs and 4.6% for recurrent repairs [102]. A Danish study from 2014
found reoperation rates for Lichtenstein repair to
be 2.4% and 3.3% for laparoscopic repair, with
no signicant difference between the two types
of repairs [33].
40.2.3.2 Chronic Pain
In 2008, an international consensus conference
formally dened chronic postoperative inguinal
pain (CPIP) as new or different quality of pain (if
there was pain prior to hernia repair) arising as a
direct consequence of a nerve lesion or a disease
affecting the somatosensory system after inguinal hernia repair [103]. The incidence of CPIP
ranges from 0.7 to 75%, depending on the study
and the denition of chronic pain used [103]. The
various etiologies include neuropathic pain, nociceptive pain, meshoma pain, orchialgia, and other
types of non-neuropathic pain and are covered in
detail in other chapters. The denitions used in
these studies were very heterogeneous. For
example, one RCT comparing Kugel versus
Lichtenstein repair dened chronic pain as VAS >
0 at 3months, with incidence of 20.7% and 45%,
respectively [104]. Another study conducted in
1992 with tissue repairs found 62% of patients
with some inguinal pain at 1year and 53.6% at
2years [105]. When further categorized as pain
limiting return to preoperative activities (moderate) or incapacitating pain (severe), the incidence
dropped to 11.9% at 1year and 10.6% at 2years
[105].
Long-term follow-up by the Danish Hernia
Database found 28.7% of patients with some
inguinal pain 1 year after their operation, with
11% reporting work- or daily activity-related
impairment and 4.5% receiving medical treatment [106]. Those with pain were then followed
for 6years, with 16.7% having the same pain and
7.5% having increased pain [107].
Meta-analyses of Lichtenstein repairs compared to preperitoneal or TEP repairs demonstrated CPIP rates of 7.1% for preperitoneal
repairs, 12.5% for TEP repairs, and 12.3–16.8%
for Lichtenstein repairs [72, 108]. These metaanalyses dened chronic pain as pain at 3months
or 6 months, depending on the study. There is
some evidence that suggests CPIP occurs less
after endoscopic procedures by experienced surgeons compared to open procedures, along with
the use of mesh, ne-tuning of surgical technique
such as nerve identication, pragmatic neurectomies versus prophylactic neurectomies, and limited mesh xation [73]. Specic strategies for
mitigating and preventing CPIP will be discussed in separate chapters. HerniaSurge estimated that clinically signicant CPIP happens to
10–12% of patients undergoing inguinal hernia
repair with debilitating CPIP affecting 0.5–6% of
patients [103].
Pubic pain and orchialgia are often related to
inguinal hernia repair. Tenderness over the medial
insertion of the inguinal ligament was reported as
the most common exam nding in patients with
CPIP in one study [105, 109–112]. Another study
found that 12% of non-neuropathic CPIP patients
had pain at the insertion of the inguinal ligament
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D. K. Nguyen and D. C. Chen
onto the pubic tubercle. Based on these ndings,
medial xation of mesh in repairs is recommended to not involve deep sutures to the periosteum [105]. For patients with orchialgia, the
suspected culprit is often excess dissection of the
spermatic cord, mesh-related inammation, or
trauma to the vas deferens and its associated visceral innervation during hernia repair. Several
studies and meta-analyses have differentiated
chronic pain to subgroups, including orchialgia.
Consistently across these studies, the incidence
of orchialgia was around 0.5–1% [113]. These
studies did not nd any differences in incidence
of orchialgia between Lichtenstein and preperitoneal repairs or between heavy- and lightweight
mesh.
40.2.3.3 Meshoma andOther MeshRelated Complications
Implantation of a foreign body inevitably causes
foreseen and unforeseen complications. Mesh
implantation predictably causes a foreign body
reaction, which can scar it in place and help reinforce the repair or cause an exuberant reaction
leading to shrinkage, meshoma, or nociceptive
chronic pain. Studies of mesh explants have
revealed foreign body granuloma with macrophages and foreign body giant cells [114, 115].
This inammation may occur in varying degrees,
from appropriate to exuberant to inadequate
inammation.
Mesh migration is another known risk of
mesh-based repairs. The available literature has
demonstrated that this phenomenon may happen
up to 20 years after the operation [116–120].
Shrinkage and an increase in tensile forces, especially with plugs and small onlay patches, can
increase the risk of mesh migration to the skin,
into the peritoneal cavity, the bladder, or the adjacent visceral or vascular structures [116–120]. It
is uncommon to see at mesh migrate unless it
has shrunken substantially or folded up to become
a meshoma. Mesh contraction occurs as it interfaces with surrounding tissues and forms crosslinking bers as an expected part of the
inammatory process [114, 121]. Small-pore
mesh or meshes with three-dimensional proles
have been found to lose up to 90% of the original
volume and may contract to become a meshoma
[122–127]. Mesh shrinkage, studied by placing
metallic clips at the edges and tracking movement over time, have shown average mesh contraction of 20% from the time of implantation,
with up to 50% or more contraction with plugs
[122–127]. When meshomas occur, patients
sometimes feel deep persistent pressure or ache.
In addition, if the meshoma is adherent to the
cord or any of the nerves, neuropathic pain can
also occur.
40.2.3.4 Infections
Infection is always a concern in inguinal hernia
repairs especially with implantation of prosthetic
material into the body. Studies looking at infection tend to evaluate high-risk or low-risk
patients. A meta-analysis found wound infection
rates of 2.3% in the low-risk environment placebo group and 1.6% in the prophylaxis group,
with no signicant difference. Other studies cite
even lower rates. The Swedish Hernia Register
identied only 5.6% of 14,053 patients receiving
perioperative antibiotics with postoperative
infection rates in this group ranging from 1.2 to
1.4%. A German study looking at 85,000 patients
with 70% receiving antibiotic prophylaxis demonstrated an infection rate of 0.2% in the endoscopic group and 0.6% in the open group
[128–131]. Based on these data, HerniaSurge
recommended that no antibiotic prophylaxis is
needed for normal or low-risk patients before
open or laparoscopic repair. High-risk patients or
high-risk environments still merit antibiotic
prophylaxis.
40.2.3.5 Urinary Retention
The incidence of postoperative urinary retention
(POUR) for inguinal hernia repair varies between
1% and greater than 20% in currently published
studies [132]. Review of these series demonstrated that use of general or regional anesthesia
predisposed patients to POUR. A study that
pooled results from 70 nonrandomized studies
and two RCTs found the incidence of POUR to
be 0.37% with local anesthesia, 2.42% with
regional anesthesia, and 3% with general anesthesia. Some series report POUR after
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