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40
J.F. Kukleta et al.
operation due to a higher occurrence of femoral
hernias. (Level 2c). A preperitoneal (endoscopic)
approach should be considered in female hernia
repair (Grade D).
In Update of IEHS Guidelines [13], two large
prospective, nonrandomized trials [20, 21] of the
Danish and Swedish hernia database identied
female gender as a risk factor for chronic pain, but
only a small fraction of the patient population had
Scrotal hernias, incarcerated/strangulated hernias, recurrence aer open repair using plugs or
3D devices, recurrence aer TAPP or TEP, and
groin hernias aer radical prostatectomy are
not the recommended indications for LE repair.
Quite oen feasible in very experienced hands but
always a good reason to rethink one’s own abilities
and “in dubio pro reo” (open repair might not be
ideal but safer).
an endoscopic hernia repair.
5
Endoscopic repair is the preferred surgical
approach in case of a femoral hernia (LoE, 5 men/2c
References
women; LoC, consensus, 108 of 144=75%) [9].
Koch et al. [22] report in 2005 from the
Swedish hernia register that women have higher
risk for reoperation than men (RR 2.6in female,
1.9in men). Women have lowest risk for reoperation with TAPP (0.31) or TEP (0.41) when compared with Lichtenstein repair (1.0).
5.2.4 Unilateral Primary Groin
Hernia
Significant advantages for endoscopy over
Lichtenstein include lower incidence of wound
infection, hematoma, and chronic pain/numbness,
with earlier return to normal activities or work [24].
Systematic review by Kuhry in 2007 [25] comparing open mesh and suture repair versus endoscopic TEP also showed a shorter hospital stay in
6/11 trials.
Sevonius etal. [23] report in 2011 signicantly
lower risk of reoperation aer TAP/TEPP or open
preperitoneal repair in men P<0.001.
Aasvang etal. [26] presented in 2010 a study
of predictive risk factors for persistent postherniotomy pain. ere was about 50% less risk of persistent pain aer the laparoscopic repair and with
a lower intensity than aer Lichtenstein repair.
To appreciate all the possible advantages of LE
repair requires strict adherence to standardized
TAPP or TEP techniques, delicate tissue handling,
and sucient operative experience [12, 13].
5.2.5 Complicated (Complex?) Groin
Hernia
Unlike the LE repair in uncomplicated primary
hernia, there are several conditions which require
extensive expertise in corresponding technique.
1. van den Heuvel B, Dwars BJ, Klassen DR, Bonjer HJ.Is
surgical repair of an asymptomatic groin hernia appropriate? A review. Hernia. 2011;15(3):251–9.
2. Neutra R, Velez A, Ferrada R, Galan R.Risk of incarceration of inguinal hernia in Cali Colombia. J Chronic Dis.
1981;34(11):561–4.
3. Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO,
Dunlop DD, Reda DJ, McCarthy M Jr, et al. Watchful waiting vs repair of inguinal hernia in minimally
symptomatic men: a randomized clinical trial. JAMA.
2006;295(3):285–92.
4. O’Dwyer PJ, Norrie J, Alani A, Walker A, Duy F, Horgan P. Observation or operation for patients with an
asymptomatic inguinal hernia: a randomized clinical
trial. Ann Surg. 2006;244(2):167–73.
5. Chung L, Norrie J, O’Dwyer PJ.Long-term follow-up
of patients with a painless inguinal hernia from a randomized clinical trial. Br J Surg. 2011;98(4):596–9.
6. Fitzgibbons RJ Jr, Ramanan B, Arya S, Turner SA, Li
X, Gibbs JO, et al. Investigators of the original trial.
Long-term results of a randomized controlled trial of
a nonoperative strategy (watchful waiting) for men
with minimally symptomatic inguinal hernias. Ann
Surg. 2013;258(3):508–15. https://doi.org/10.1097/
SLA.0b013e3182a19725.
7. Ramanan B, Maloley BJ, Fitzgibbons RJ Jr. Inguinal hernia: follow or repair? Adv Surg. 2014;48:1–11.
8. Kohler A, Beldi G.Asymptomatic inguinal hernia: is there
an indication for surgery. Ther Umsch. 2014;71(12):775–
80. https://doi.org/10.1024/0040-5930/a000625.
9. Poelman MM, van den Heuvel B, Deelder JD, Abis GSA,
Beudeker N, Bittner RR, et al. EAES consensus development conference on endoscopic repair of groin
hernias. Surg Endosc. 2013;27:3505–19. https://doi.
org/10.1007/s00464-013-3001-9.
10. Simons MP, Aufenacker T, Bay-Nielsen M, Bouillot JL,
Campanelli G, Conze J, etal. European Hernia Society
guidelines on the treatment of inguinal hernia in adult
patients. Hernia. 2009;13(4):343–403.
11. Miserez M, Peeters E, Aufenacker T, Bouillot JL, Campanelli G, Conze J, etal. Update with level 1 studies
of the European Hernia Society guidelines on the
treatment of inguinal hernia in adult patients. Hernia.
2014;18(2):151–63. https://doi.org/10.1007/s10029-
014-236-6. Epub 2014 Mar 20.
12. Bittner R, Arregui ME, Bisgaard T, Dudai M, Ferzli GS,
Fitzgibbons RJ, et al. Guidelines for laparoscopic
Indication forSurgery: Open or Laparoendoscopic Techniques inGroin Hernias
41
5
(TAPP) and endoscopic (TEP) treatment of inguinal
hernia [International Endohernia Society (IEHS)]. Surg
Endosc. 2011;25(9):2773–843.
13. Bittner R, Montgomery MA, Arregui E, Bansal V, Bingener J, Bisgaard T, et al. Update of guidelines on
laparoscopic (TAPP) and endoscopic (TEP) treatment
of inguinal hernia (International Endohernia Society).
Surg Endosc. 2015;29:289–321. [Epub ahead of print].
15. McCormack K, Scott NW, Go PM, Ross S, Grant AM,
EU Hernia Trialists Collaboration. Laparoscopic techniques versus open techniques for inguinal hernia
repair. Cochrane Database Syst Rev. 2003;1:CD001785.
16. Demetrashvili Z, Qerqadze V, Kamkamidze G, Topchishvili G, Lagvilava L, Chartholani T, etal. Comparison
of Lichtenstein and laparoscopic transabdominal
preperitoneal repair of recurrent inguinal hernias. Int
Surg. 2011;96(3):233–8.
17. Karthikesalingam A, Markar SR, Holt PJ, Praseedom
RK. Meta-analysis of randomized controlled trials
comparing laparoscopic with open mesh repair of
recurrent inguinal hernia. Br J Surg. 2010;97(1):4–11.
https://doi.org/10.1002/bjs.6902.
18. Langeveld HR, van’t Riet M, Weidema WF, Stassen LP,
Steyerberg EW, Lange J, et al. Total extraperitoneal
inguinal hernia repair compared with Lichtenstein
(the LEVEL-trial): a randomized controlled trial. Ann
Surg. 2010;251(5):819–24.
19. Deysine M.Hernia clinic in a teaching institution: creation and development. Hernia. 2001;5(2):65–9.
20. Bay-Nielsen M, Perkins FM, Kehlet H.Pain and functional
impairment 1 year after inguinal herniorrhaphy: a nationwide questionnaire study. Ann Surg. 2001;233:1–7 (1B).
21. Kalliomäki ML, Meyerson J, Gunnarsson U, etal. Longterm pain after inguinal hernia repair in a populationbased cohort, risk factors and interference with daily
activities. Eur J Pain. 2008;12:214–225 (2B).
22. Koch A, Edwards A, Haapaniemi S, Nordin P, Kald
A.Prospective evaluation of 6895 groin hernia repairs
in women. Br J Surg. 2005;92(12):1553–8.
23. Sevonius D, etal. Recurrent groin hernia surgery. Br J
Surg. 2011;98(10):1489–94.
24. Schmedt CG, Sauerland S, Bittner R. Comparison of
endoscopic procedures vs Lichtenstein and other
open mesh techniques for inguinal hernia repair: a
meta-analysis of randomized controlled trials. Surg
Endosc. 2005;19:188–99.
25. Kuhry E, van Veen RN, Langeveld HR, Steyerberg EW,
Jeekel J, Bonjer HJ. Open or endoscopic total extraperitoneal inguinal hernia repair? A systematic review.
Surg Endosc. 2007;21:161–6.
26. Aasvang EK, Gmähle E, Hansen JB, Gmähle B, Forman
JL, Schwarz J, et al. Predictive risk factors for persistent postherniotomy pain. Anesthesiology. 2010;112:
957–69.
27. Dedemadi G, Sgourakis G, Karaliotas C, Christodes T,
Kouraklis G, Karaliotas C.Comparison of laparoscopic
and open tension-free repair of recurrent inguinal hernias: a prospective randomized study. Surg Endosc.
2006;20:1099–104.
28. Eklund A, Rudberg C, Leijonmarck CE, Rasmussen
I, Spangen L, Wickbom G, et al. Recurrent inguinal
hernia: randomized multicenter trial comparing
laparoscopic and Lichtenstein repair. Surg Endosc.
2007;21:634–40.
Patient Selection
forLaparoendoscopic
Inguinal Hernia Repair
MazenIskandar andGeorgeFerzli
6.1 Introduction – 44
6.2 Patient-Related Factors – 44
6.3 Hernia-Related Factors – 46
6.4 Surgeon-Related Factors – 47
6.5 Anesthesia-Related Factors – 47
43
6
6.6 Conclusion – 47
6.7 Indications forTreatment – 47
6.8 Risk Factors andPrevention – 48
6.9 Anesthesia-Related Factors – 48
6.10 Inguinal Hernia inWomen – 49
References – 49
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_6
44
M. Iskandar and G. Ferzli
6.1 Introduction
cept of watchful waiting in asymptomatic men
with long- term follow-up (up to 11.5years) was
When evaluating a patient with an inguinal hernia and considering a laparoscopic or endoscopic
approach, several factors need to be accounted
for. A tailored approach that takes into consideration patient-related, anesthesia-related, and
surgeon- related factors oers the best outcome
and reduces complications and recurrences.
Experience not only helps in the operating room
studied by Fitzgibbons in a large randomized trial
that reported initially a low incidence of herniarelated complications but with the majority of
patients (60–70%) crossing over to the surgical
arm mostly due to pain [1, 2]. erefore, watchful waiting is reasonable in asymptomatic patients
that are aware to seek help when their hernias
become symptomatic.
but is as important in patient selection and choice
of operation. Proper patient selection would
6
require a panoramic view of the patient as a
whole and not just focusing on the hernia type or
whether it’s primary or recurrent.
e discussion on indications for laparoscopic inguinal hernia repair should commence
by answering the question whether inguinal hernias need to be xed in the rst place. ere is
no controversy over the fact that all symptomatic
hernias and hernias in women must be xed to
prevent hernia-related complications. e con-
6.2 Patient-Related Factors
1. Risk stratication
According to the AHA/ACC guidelines, peri-
operative risk for major adverse cardiac event
(MACE) can be best predicted by using the
NSQIP online risk calculator or the Revised
Cardiac Risk Index incorporating the surgical risk (. Fig. 6.1 and . Table 6.1) [3]. e
NSQIP calculator may be a better tool because
. Fig. 6.1 ACS NSQIP risk calculator
Patient Selection forLaparoendoscopic Inguinal Hernia Repair
45
6
. Table6.1 Revised cardiac risk index
SIX independent predictors, 1999
Clinical variable Points
High-risk surgery 1
H/o Ischemic heart disease 1
H/o Congestive heart failure 1
H/o cerebrovascular disease 1
Insulin treatment for
diabetes mellitus
Pre-operative serum
creatinine levels >2.0mg/dl
(180mcgmol/L)
Interpretation of risk score
Risk class Points Risks of
I.Very low 0 0.4 %
II.Low 1 0.9 %
III.Moderate 2 7.0 %
IV.High 3+ 11.0 %
1
1
complications (%)
it also estimated noncardiac complications
that need to be discussed with patients preoperatively. TEP, for example, would fall under
the low-risk group because it is extraperitoneal and involves low-pressure insuation
and subsequently less hemodynamic changes
attributed to pneumoperitoneum.
2. Comorbidities and modiable risk factors
e patient’s medical history is one of the basic
factors in hernia management. Conditions
such as chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), and
prostatism not only increase the risk of primary hernia formation but also of recurrences
[4, 5]. Every eort to control or correct these
conditions must be attempted prior to surgery.
One cannot overemphasize the importance
of weight loss in the morbidly obese patient
and smoking cessation in the smoking patient
[6]. Such modiable risk factors and lifestyle
changes also lead to improved short- and
long-term outcomes. Care must also be taken
to oer screening colonoscopy as indicated
especially in patients with large inguinoscrotal hernias. Other rare conditions such as
connective tissue and collagen disorders must
be taken into consideration.
3. Patients on anticoagulation/antiplatelet
therapy
Each patient should be evaluated on an indi-
vidual basis, taking into account their form
of anticoagulation, duration of therapy, risk
factors, and other comorbidities (
. Table6.2).
For example, a patient on antiplatelet therapy
for a recently deployed drug-eluting stent is
dierent from the patient on the same therapy
for a bare metal stent. e patient on warfarin therapy for chronic atrial brillation is
approached dierently than the patient that
needs anticoagulation for a metallic mitral
valve. Involving the patient and their treating
physicians in the decision-making process
would help mitigate risk and stress associated
with such cases.
4. Patients with previous lower abdominal
surgery
Lower abdominal incisions present a chal-
lenge for TEP or TAPP but are not a contraindication. e challenge arises from the
presence of scarring and adhesions leading to
distorted anatomy and potentially inadequate
dissection, mesh placement, and increased
risk of recurrence. Special attention is given
to the patient with history of radical prostactomy and radiation therapy as these patients
are notorious for developing intense preperitoneal brosis [7]. An anterior, conventional
approach may be the safer approach in these
patients avoiding dissection of the preperitoneal space. (For more details, please refer to
7 Sect. 14.12.)
5. Patients with peritoneal dialysis catheters
Patients undergoing peritoneal dialysis are
prone to hernia formation and hernia recurrence aer repair due to several factors such as
increased intra-abdominal pressure, uremia,
and anemia [8]. Moreover, the dialysate can
extravasate along Scarpa’s fascia into the scrotum mimicking a hernia. It is important to
dierentiate between a true hernia or dialysate
extravasation with imaging as physical exam
can be misleading.
6. Patients with liver cirrhosis and ascites
Inguinal hernia repair can be safely performed
in patients with Child-Turcotte-Pugh classes
A and B even in the presence of ascites. For
class C, there may be an increased risk of com-
46
M. Iskandar and G. Ferzli
. Table6.2 Overview of the indications, properties, and reversal of common anticoagulant and antiplatelet
agents
Drug Mechanism of action Indications Reversal t
Heparin (UPH) Activates antithrombin III which
inactivates thrombin (IIa) and
factors IXa and Xa
Monitor aPTT
LMWH–
enoxaparin
(Lovenox)
Warfarin
6
(Coumadin)
Dabigatran
(Pradaxa)
Rivaroxaban
(Xarelto)
Clopidogrel
(Plavix)
Aspirin Irreversible inhibition by
Inactivates factor Xa DVT prophylaxis, PE,
Vitamin K antagonist
Prevents activation of prothrombin and factors VII, IX, and X and
proteins C and S by blocking the
γ carboxylation of their glutamate residues
Monitor INR
Direct thrombin inhibitor
Liver metabolism to active
metabolite
Renal excretion
Reduced risk of stroke
Direct factor Xa inhibitor
Liver metabolism no active
metabolite
2/3 renal and 1/3 fecal excretion
Reduced risk of stroke
Irreversible blockade of platelet
P2Y
receptors, which prevents
12
ADP- stimulated activation of the
GP
receptor preventing
IIb/IIIa
platelet aggregation
acetylation of cyclooxygenase,
which is required by platelets to
synthesize TX
aggregation and vasoconstriction
Inhibits synthesis of prostacyclin
which promotes
A2
DVT prophylaxis, PE,
VTE, ACS, DIC,
angioplasty, CABG,
dialysis
VTE, ACS, orthopedic
procedures
Prevent VTE progression and recurrence
Mechanical prosthetic
heart valves, atrial
brillation
2° prevention TIA
and MI
Atrial brillation of
non-valvular origin
VTE prophylaxis
Orthopedic procedures
Atrial brillation of
non-valvular origin
ACS
2° prevention stroke
and MI
Post angioplasty with
stenting
Primary and secondary
prophylaxis of MI and
stroke
Protamine
sulfate
Partial with
protamine
Vitamin K
(PO or IV)
FFP
rFVIIa
2/3 dialysis 12–17h
None 7–11h
Platelets Eect
None Eect
1
1/2
Dose
dependent
1.5h
4–6h
Duration
of action:
2–5days
7–10days
7–10days
Recommendations: Each patient should be evaluated on an individual basis, taking into account their form of
anticoagulation, duration of therapy, risk factors, and other comorbidities
plications, and that should be outweighed by
6.3 Hernia-Related Factors
the presence of symptoms for hernia repair
[9, 10]. Surgical repair in the elective setting
avoids the high morbidity and mortality associated with repair in the case of bowel strangulation in this delicate and fragile population.
An open anterior or endoscopic preperitoneal
repair in experienced hands avoids entry into
the abdominal cavity and wound complications associated with ascites.
Classic indications for laparoscopic inguinal hernia
repair focus more on the type of the inguinal hernia.
Laparoscopic hernia repair has been reported in
almost every possible scenario and is mainly dependent on the surgeon’s comfort level and mastery of
the technique. However, in certain scenarios, either
the laparoscopic or the open approach is clearly
favored. Namely, the laparoscopic approach has
Patient Selection forLaparoendoscopic Inguinal Hernia Repair
47
6
been advocated for recurrent inguinal hernias aer
an anterior approach, bilateral inguinal hernias,
femoral hernias, hernias in women, and hernias in
young men wanting a rapid return to their physical
activities with high level evidence (see 7 Chap. 11 for
more details). e open approach has been favored
for primary inguinal hernias in elderly patients,
large inguino- scrotal hernias, prior pelvic surgery,
and incarcerated and strangulated inguinal hernias.
Other relative contraindications for an endoscopic
or laparoscopic repair include previous laparoscopic
repair and prior groin irradiation [11, 12].
6.4 Surgeon-Related Factors
A recurring theme in most laparoscopic hernia
repairs is that of the learning curve associated with
this technique. It is understood that prociency
of a surgeon and his/her ability to deal with complex hernias are proportional to the number of
cases performed. e number of cases needed to
achieve technical prociency varies among dierent studies and can be as low as 30 or as high as
250 cases [13]. It is dicult to establish a golden
number where prociency is reached as dierent
surgeons possess dierent abilities. However, not
only the number of repairs performed is important
for gaining prociency but also at what place and
in what quality was the training process. A wellstandardized technique and a strict supervision
are indispensable preconditions for proper learning best taking place in a recognized hernia center.
It has been suggested that the learning curve can
be overcome by mastery of the open preperitoneal
repair, by the use of simulators, or by mentorship
from an experienced surgeon [14, 15]. Once prociency is achieved using a certain approach, the
outcomes will be optimal independent of the technique selected. As an example, if a surgeon is procient in the open anterior technique for a recurrent
inguinal hernia and not as much in laparoscopic,
it is best to perform an open approach or refer the
patient to a high volume laparoscopic surgeon.
6.5 Anesthesia-Related Factors
e choice of anesthesia impacts short- and
long- term outcomes in inguinal hernia surgery.
Compared to local anesthesia, the use of general
anesthesia is associated with increased short-term
complications such as bleeding, pain, and urinary
retention, whereas the use of general anesthesia in
the long term is associated with a decreased rate
of recurrence [16, 17]. Regional anesthesia falls
in between in terms of incidence of short- and
long- term complications. erefore, when evaluating a patient and considering them for a certain
approach, the short-term and long-term risks
should be weighed against the patient’s operative
risk and life expectancy. It is important to note here
that TEP, like the open approach, can be performed
under a transverse abdominis plane (TAP) block
or under regional anesthesia such as epidural,
while TAPP requires muscle relaxation and general
anesthesia to establish pneumoperitoneum [18].
6.6 Conclusion
In summary, not every patient with the same
inguinal hernia needs to be treated the same way.
Every patient is best served with an operation
that his/her surgeon is comfortable with and that
accommodates all the other patient and anesthesia factors discussed in this chapter. Experience
will not only improve the surgeon’s technical prociency but also their ability to select the appropriate procedure for every individual.
Evidence [11, 12, 19, 20]
6.7 Indications forTreatment
Level 1B
Watchful waiting is an acceptable option for
men with minimally symptomatic or asymptomatic inguinal hernias.
Recommendations
5 Grade A: It is recommended in minimally
symptomatic or asymptomatic inguinal
hernia in men to consider a watchful
waiting strategy; however, the patient
should be informed that in the long run,
in 60–70% of the patients, an operation
becomes necessary.
5 Grade A (upgraded by the authors): It is
recommended that strangulated hernias
are operated on urgently. It is recommended that symptomatic inguinal
hernias are treated surgically.
48
M. Iskandar and G. Ferzli
6.8 Risk Factors andPrevention
It is recommended that an endo-
Level 3
Smokers, patients with positive family hernia
history, patent processus vaginalis, and collagen
disease; and patients with an abdominal aortic
aneurysm, aer an appendectomy and prostatectomy, with ascites, on peritoneal dialysis,
aer long-term heavy work or with COPD have
an increased risk of inguinal hernia. is is not
proven with respect to (occasional) liing, constipation, and prostatism.
6
Recommendations
5 Grade C: Smoking cessation is the only
sensible advice that can be given with
respect to preventing the development
of an inguinal hernia.
Statement (Surgeon-Related Factors)
5 Level 2C: For endoscopic techniques,
adequate patient selection and training
might minimize the risks for infrequent
but serious complications in the learning
curve. There does not seem to be a negative eect on outcome when operated by
a resident versus an attending surgeon.
Specialist centers seem to perform better
than general surgical units, especially for
endoscopic repairs.
scopic technique is considered if a quick
postoperative recovery is particularly
important. It is recommended that, from
a hospital perspective, an open mesh
procedure is used for the treatment of
inguinal hernia. From a socioeconomic
perspective, an endoscopic procedure is
proposed for the active working population, especially for bilateral hernias.
5 Grade D: For large scrotal (irreducible)
inguinal hernias, after major lower
abdominal surgery, and when no general
anesthesia is possible, the Lichtenstein
repair is the preferred surgical technique.
In endoscopic repair, a mesh of at least
10×15cm should be considered. It is
recommended that an anterior approach
is used in the case of a recurrent inguinal
hernia which was treated with a posterior
approach. In female patients, the existence
of a femoral hernia should be excluded in
all cases of a hernia in the groin
A preperitoneal (endoscopic)
approach should be considered in
female hernia repair. All surgeons graduating as general surgeons should have
a profound knowledge of the anterior
and posterior preperitoneal anatomy of
the inguinal region. Complex inguinal
hernia surgery (multiple recurrences,
chronic pain, mesh infection) should be
performed by a hernia specialist.
Recommendations (Hernia-Related
Factors)
5 Grade A: The open Lichtenstein and
endoscopic inguinal hernia techniques
are recommended as the best evidencebased options for the repair of a primary
unilateral hernia, providing the surgeon
is sufficiently experienced in the specific
procedure. For the repair of recurrent
hernias after conventional open repair,
endoscopic inguinal hernia techniques
are recommended. When only considering chronic pain, endoscopic surgery is
superior to open mesh.
6.9 Anesthesia-Related Factors
Statements
5 Level 4: TEP is more suitable for regional
anesthesia.
Recommendations
5 Grade D: In selected patients having a
contraindication for general anesthesia;
TEP under regional anesthesia can be
done.
Patient Selection forLaparoendoscopic Inguinal Hernia Repair
49
6
6.10 Inguinal Hernia inWomen
Statement
5 Level 2C: Women have a higher risk of
recurrence (inguinal or femoral) than
men following an open inguinal hernia
operation due to a higher occurrence of
femoral hernias.
Recommendations
5 Grade D: In female patients, the exis-
tence of a femoral hernia should be
excluded in all cases of a hernia in the
groin. A laparo-endoscopic approach
should be considered in female hernia
repair because a better evaluation of the
femoral canal is possible.
References
1. Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, etal.
Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial.
JAMA. 2006;295(3):285–92.
2. Fitzgibbons RJ Jr, Ramanan B, Arya S, etal. Long-term
results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg.
2013;258(3):508–15.
3. Fleisher LA, Fleischmann KE, Auerbach AD, etal. 2014
ACC/AHA guideline on perioperative cardiovascular
evaluation and management of patients undergoing
noncardiac surgery: executive summary: a report of
the American College of Cardiology/American Heart
Association Task Force on practice guidelines. Developed in collaboration with the American College of
Surgeons, American Society of Anesthesiologists,
American Society of Echocardiography, American
Society of Nuclear Cardiology, Heart Rhythm Society,
Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and
Society of Vascular Medicine Endorsed by the Society
of Hospital Medicine. J Nucl Cardiol O Publ Am Soc
Nucl Cardiol. 2015;22(1):162–215.
4. Burcharth J, Pommergaard HC, Bisgaard T, Rosenberg
J.Patient-related risk factors for recurrence after inguinal hernia repair: a systematic review and meta-analysis
of observational studies. Surg Innov. 2015;22(3):303–17.
5. Matthews RD, Anthony T, Kim LT, etal. Factors associated with postoperative complications and hernia
recurrence for patients undergoing inguinal hernia
repair: a report from the VA Cooperative Hernia Study
Group. Am J Surg. 2007;194(5):611–7.
6. Rosemar A, Angeras U, Rosengren A, Nordin P.Eect of
body mass index on groin hernia surgery. Ann Surg.
2010;252(2):397–401.
7. Stranne J, Johansson E, Nilsson A, etal. Inguinal hernia
after radical prostatectomy for prostate cancer: results
from a randomized setting and a nonrandomized setting. Eur Urol. 2010;58(5):719–26.
8. Wetherington GM, Leapman SB, Robison RJ, Filo
RS.Abdominal wall and inguinal hernias in continuous
ambulatory peritoneal dialysis patients. Am J Surg.
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51
Watchful Waiting asa
Treatment Strategy in
Patients with
Asymptomatic Inguinal
Hernia
BrianBiggersta, ShreyaShetty, andRobertJ.Fitzgibbons, Jr.
7.1 Introduction – 52
7.2 North American Trial – 52
7
7.3 UK Trial – 54
7.4 Long-Term Follow-Up – 54
7.5 Summary – 55
References – 57
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_7