Surgical Management of Inguinal Hernia

1
Surgical Management of Inguinal Hernia

• Prepared for
• Agency for Healthcare Research and Quality (AHRQ)
• www.ahrq.gov

2
Outline of Material

• Agency for Healthcare Research and Quality
  Comparative Effectiveness Review (CER) Process
• Background
• Clinical Questions Addressed in the CER
• Clinical Bottom Line Summary of CER Results
• Conclusions
• Gaps in Knowledge
• Resources for Shared Decisionmaking

3
Agency for Healthcare Research and Quality (AHRQ)
Comparative Effectiveness Review (CER) Development

• Topics are nominated through a public process,
  which includes submissions from health care
  professionals, professional organizations, the
  private sector, policymakers, the public, and
  others.
• A systematic review of all relevant clinical
  studies is conducted by independent researchers,
  funded by AHRQ, to synthesize the evidence in a
  report summarizing what is known and not known
  about the select clinical issue. The research
  questions and the results of the report are
  subject to expert input, peer review, and public
  comment.
• The results of these reviews are summarized into
  a Clinician Research Summary and a Consumer
  Research Summary for use in decisionmaking and in
  discussions with patients. The Research Summaries
  and the full report are available at
  www.effectivehealthcare.ahrq.gov/inguinal-hernia.c
  fm.

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

4
Strength of Evidence Ratings

• The strength of evidence ratings are classified
  into four broad ratings

High High confidence that the evidence reflects the true effect. Further research is very unlikely to change our confidence in the estimate of effect.
Moderate Moderate confidence that the evidence reflects the true effect. Further research may change our confidence in the estimate of effect and may change the estimate.
Low Low confidence that the evidence reflects the true effect. Further research is likely to change the confidence in the estimate of effect and is likely to change the estimate.
Insufficient Evidence either is unavailable or does not permit a conclusion.

• AHRQ Methods Guide for Effectiveness and
  Comparative Effectiveness Reviews. Available at
  www.effectivehealthcare.ahrq.gov/methodsguide.cfm.
  Owens DK, Lohr KN, Atkins D, et al. J Clin
  Epidemiol. 2010 May63(5)513-23. PMID 19595577.
• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

5
Background Inguinal Hernias in Adults

• An inguinal hernia is a protrusion of abdominal
  contents into the inguinal canal through an
  abdominal wall defect.
• Approximately 4.5 million people in the United
  States have an inguinal hernia.
• Around 500,000 new inguinal hernias are diagnosed
  annually.
• The lifetime risk of inguinal hernia is about 25
  percent in males and 2 percent in females.
• Inguinal hernia can affect all ages, but the risk
  for one increases with age.
• Approximately 20 percent of hernia cases are
  bilateral.

• Abramson JH, et al. J Epidemiol Community Health.
  19783259-67. Available at http//www.ncbi.nlm.ni
  h.gov/pubmed/95577.Everhart, JE, ed. Digestive
  diseases in the United States epidemiology and
  impact. Washington, DC US Government Printing
  Office, 1994 NIH publication no. 94-1447.Goroll
  AH, et al. Primary care medicine office
  evaluation and management of the adult patient,
  5th ed. Philadelphia, Lippincott Williams
  Wilkins 2005431-434.Nicks BA. Hernias.
  Medscape Reference Drugs, Diseases, and
  Procedures. Last Updated June 6, 2012. Available
  at http//emedicine.medscape.com/article/775630-ov
  erview. Accessed April 30, 2013.Rutkow IM. Surg
  Clin North Am. 199878941-951. Available at
  http//www.ncbi.nlm.nih.gov/pubmed/9927978.
• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

6
Background Inguinal Hernias in Children

• The incidence of inguinal hernia in children
  ranges from 0.8 to 4.4 percent.
• It is 10 times as common in boys as in girls.
• It is more common in infants born before 32
  weeks gestation (13 prevalence) and in infants
  weighing less than 1,000 grams at birth (30
  prevalence).

• Brandt ML. Pediatric hernias. Surg Clin North Am.
  2008 Feb88(1)27-43, vii-viii. PMID 18267160.
• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

7
Direct and Indirect Inguinal Hernias

• A direct inguinal hernia protrudes through the
  inguinal floordefined by Hesselbach's triangle,
  the pubic tubercle, the lateral border of the
  rectus, and the inguinal ligamentand accounts
  for one-third of all inguinal hernias.
• An indirect inguinal hernia protrudes through the
  internal inguinal ring and may descend through
  the inguinal canal and accounts for about
  two-thirds of all inguinal hernias.
• Direct hernias typically develop only in
  adulthood and are more likely to recur than
  indirect hernias.

• Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et
  al. JAMA. 2006 Jan 18295(3)285-92. PMID
  16418463.
• Simons MP, Aufenacker T, Bay-Nielson M, et al.
  Hernia. 2009 Aug13(4)343-403. PMID 19636493.
• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

8
Symptoms of Inguinal Hernias

• If the hernia is severe enough to restrict blood
  supply to the intestine, it is termed a
  strangulated hernia immediate corrective surgery
  of this type of hernia is necessary.
• Most inguinal hernias, however, are less
  dangerous, and elective surgery is often
  performed to correct the defect.
• Symptoms include abdominal pain and a lump in the
  groin area, which is most easily palpated during
  a cough.
• Some inguinal hernias, however, are asymptomatic
  and are only detected by palpation during a cough.

• Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et
  al. JAMA. 2006 Jan 18295(3)285-92. PMID
  16418463.
• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

9
Surgical Repair of Inguinal Hernias

• Surgical repair of inguinal hernias is the most
  commonly performed general surgical procedure in
  the United States.
• About 770,000 surgical repairs were performed in
  2003.
• Most repairs (87) are performed on an outpatient
  basis.
• The primary goals of surgery are to
• Repair the hernia
• Minimize the chance of recurrence
• Return the patient to normal activities quickly
• Improve quality of life
• Minimize postsurgical discomfort and the adverse
  effects of surgery

• Rutkow IM. Surg Clin North Am. 2003
  Oct83(5)1045-51, v-vi. PMID 14533902.
• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.
• Zhao G, Gao P, Ma B, et al. Ann Surg. 2009
  Jul250(1)35-42. PMID 19561484.

10
Types of Surgical Repair for Inguinal Hernias

• Surgical repairs of inguinal hernia generally
  fall into three categories
• Open repair without a mesh implant (i.e.,
  sutured)
• Open repair with a mesh
• Laparoscopic repair with a mesh
• Several procedures have been employed within each
  of these categories.
• The nearly universal adoption of mesh (except in
  pediatric cases) means that the most relevant
  questions about hernia repair involve various
  mesh procedures.

• Brandt ML. Surg Clin North Am. 2008
  Feb88(1)27-43, vii-viii. PMID 18267160.
• Rutkow IM. Surg Clin North Am. 2003
  Oct83(5)1045-51, v-vi. PMID 14533902.
• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

11
ExampleOpen Mesh-Based Repair of an Inguinal
Hernia
12
Example Laparoscopic Mesh-Based Repairof an
Inguinal Hernia
Laparoscope
Small cuts aremade to insertthe tools
13
Open Mesh-Based Repair of Inguinal Hernias(1 of
2)

• Kugel patch repair An oval-shaped mesh is held
  open by a memory recoil ring and inserted behind
  the hernia defect and held in place with a single
  suture.
• Lichtenstein technique A tension-free open
  repair wherein mesh is sutured in front of the
  hernia defect (anteriorly).
• Mesh plug technique A preshaped mesh plug is
  introduced into the hernia weakness during
  surgery and a piece of flat mesh is put on top of
  the hernia.
• Open preperitoneal mesh technique A tension-free
  repair wherein mesh is sutured posteriorly.

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

14
Open Mesh-Based Repair of Inguinal Hernias(2 of
2)

• PROLENE Hernia System A one-piece mesh device
  constructed of an onlay patch connected to a
  circular underlay patch by a mesh cylinder.
• Read-Rives repair A tension-free repair wherein
  mesh is placed just over the peritoneum.
• Stoppa technique A large polyester mesh is
  interposed in the preperitoneal connective tissue
  between the peritoneum and the transversalis
  fascia to prevent visceral sac extension through
  the myopectineal orifice.
• Trabucco technique A hernia repair procedure
  that involves placing a single preshaped mesh
  without using sutures.

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

15
Laparoscopic Mesh-Based Repair Procedures for
Inguinal Hernias

• Intraperitoneal onlay mesh technique A mesh is
  placed under the hernia defect intra-abdominally
  to circumvent a groin dissection.
• Totally extraperitoneal technique The peritoneal
  cavity is not entered, and a mesh is used to
  cover the hernia from outside the preperitoneal
  space.
• Transabdominal preperitoneal technique A
  laparoscopic repair procedure wherein the surgeon
  enters the peritoneal cavity, incises the
  peritoneum, enters the preperitoneal space, and
  places the mesh over the hernia the peritoneum
  is then sutured and tacked closed.

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

16
Surgical Mesh Products for Hernia Repair

• Surgical mesh products are typically made from
  polypropylene or polyester.
• Other available materials include
• Polytetrafluoroethylene
• Polyglactin
• Polyglycolic acid
• Polyamide

• Mohamed H, Ion D, Serban MB, et al. J Med Life.
  2009 Jul-Sep2(3)249-53. PMID 20112467.
• Robinson TN, Clarke JH, Schoen J, et al. Surg
  Endosc. 2005 Dec19(12)1556-60. PMID 16211441.
• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

17
Properties of Mesh Products for Hernia Repair

• Seven important properties of mesh are
• Withstands physiologic stresses over time
• Conforms to the abdominal wall
• Mimics normal tissue healing
• Resists the formation of bowel adhesions and
  erosions into visceral structures
• Does not induce allergic reaction or foreign body
  reactions
• Resists infection
• Is noncarcinogenic

• Mohamed H, Ion D, Serban MB, et al. J Med Life.
  2009 Jul-Sep2(3)249-53. PMID 20112467.
• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

18
Clinical Questions Addressed in theComparative
Effectiveness Review

• What is the comparative effectiveness of
• Laparoscopic versus open repair in adults with
  painful hernia (primary, bilateral, and recurrent
  hernia)?
• Different types of repair for the pediatric
  population?
• Surgery versus watchful waiting in adults with a
  pain-free or minimally symptomatic inguinal
  hernia?
• Different types of open surgery?
• Different types of laparoscopic surgery?
• Different mesh materials?
• Different mesh-fixation approaches?
• Is there an association between surgical
  experience and hernia recurrence?

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

19
Outcomes of Interest

• Outcomes
• Hernia recurrence
• Hospital-related information (length of hospital
  stay and hospital/office visits)
• Return to daily activities
• Return to work
• Quality of life
• Patient satisfaction
• Short-term pain (1 month after surgery)
• Intermediate-term pain (gt1 and lt6 months after
  surgery)
• Long-term pain (6 months after surgery)

• Adverse effects
• Infection
• Perception of a foreign body
• Small-bowel perforation/obstruction
• Hematoma
• Epigastric vessel injury
• Urinary retention
• Spermatic cord injury

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

20
Results Overview of the Patient Population

• Patient Population
• The typical adult in the studies included in this
  review was
• A man in his mid 50s
• Who was of average weight (median body mass index
  of 25.3 kg/m2 interquartile rage of 25.026.7)
• Who had an elective repair of a primary
  unilateral inguinal hernia
• About a quarter of the men worked in physically
  strenuous jobs for these men, a durable repair
  is important to prevent a recurrence.

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

21
Results Overview of Studies Included in the
Comparative Effectiveness Review

• Total included studies N 151
• Open versus laparoscopic repair in adults
• Primary hernias n 38
• Bilateral hernias n 6
• Recurrent hernias n 8
• Open versus laparoscopic high ligation for
  pediatric hernias n 2
• Repair versus watchful waiting in adults with
  pain-free hernias n 2
• Open mesh-based procedures n 21
• Laparoscopic procedures n 11
• Mesh materials n 32
• Fixation methods n 23
• Surgical experience and hernia recurrence n 32

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

22
Clinical Bottom Line Laparoscopic Versus Open
Repair of Painful Primary Hernias in
AdultsIncluded Studies

• Thirty-eight studies met the inclusion criteria.
• The most commonly compared procedures include
• TAPP repair versus Lichtenstein (n 14)
• TEP repair versus Lichtenstein (n 14)
• TAPP repair versus mesh plug (n 3)
• TEP repair versus mesh plug (n 3)
• TAPP repair/TEP repair versus Lichtenstein (n 4)

Abbreviations TAPP transabdominal
preperitoneal TEP totally extraperitoneal

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

23
Clinical Bottom Line Laparoscopic Versus Open
Repair of Painful Primary Hernias in Adults (1 of
2)
Outcome Surgery Favored Calculated Differences (95 CI) SOE
Hernia recurrence Open surgery RR 1.43 (1.15 to 1.79) 2.49 recurrence after open versus 4.46 recurrence after laparoscopy Low
Length of hospital stay Approximate equivalence Summary difference in means -0.33 days (-0.52 to -0.14) Low
Return to normal daily activities Laparoscopic SWMD in days -3.9 (-5.6 to -2.2) High
Return to work Laparoscopic SWMD in days -4.6 (-6.1 to -3.1) High
Abbreviations 95 CI 95-percent confidence
interval RR relative risk SOE strength of
evidence SWMD summary weighted mean difference

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

24
Clinical Bottom Line Laparoscopic Versus Open
Repair of Painful Primary Hernias in Adults (2 of
2)
Outcome Surgery Favored Calculated Differences (95 CI) SOE
Long-term pain Laparoscopic OR 0.61 (0.48 to 0.78) Moderate
Epigastric vessel injury Open OR 2.1 (1.1 to 3.9) Low
Hematoma Laparoscopic OR 0.70 (0.55 to 0.88) Low
Wound infection Laparoscopic OR 0.49 (0.33 to 0.71) Moderate
Abbreviations 95 CI 95-percent confidence
interval OR odds ration SOE strength of
evidence

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

25
Clinical Bottom LineSurgical Repair of
Bilateral Hernias

• Patients with bilateral hernias return to work
  about 2 weeks sooner after laparoscopic (TAPP or
  TEP) repair versus open (Lichtenstein or Stoppa)
  repair.Strength of Evidence Low
• Evidence was inconclusive for all other outcomes
  and adverse effects for laparoscopic versus open
  repair of bilateral hernias.

Abbreviations TAPP transabdominal
preperitoneal TEP totally extraperitoneal

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

26
Clinical Bottom Line Laparoscopic Versus Open
Repair of Recurrent Hernias
Outcome Surgery Favored Results (95 CI) SOE
Return to daily activities Laparoscopic SWMD -7.4 days (-11.4 to -3.4) High
Long-term pain Laparoscopic OR 0.24 (0.08 to 0.74) Moderate
Re-recurrence rates Laparoscopic (TAPP or TEP) RR 0.82 (0.70 to 0.96) 7.5 for laparoscopic vs. 12.3 for open repair Low
Abbreviations 95 CI 95-percent confidence
interval OR odds ratio RR relative risk
SOE strength of evidence SWMD summary
weighted mean difference TAPP transabdominal
preperitoneal TEP totally extraperitoneal

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

27
Open Versus Laparoscopic High Ligation for
Pediatric Hernias (Ages 3 Months to 15 Years)

• Laparoscopic repair is favored for three
  outcomes, although some of the differences may
  not be clinically relevant
• Long-term overall patient/parent satisfaction
  (difference in satisfaction points 1.00 95
  CI, 0.47 to 1.53)Strength of Evidence Low
• Length of hospital stay (summary difference 1
  hour 95 CI, 0.5 to 1.8)Strength of Evidence
  Moderate
• Long-term cosmesis (difference in satisfaction
  points 0.25 95 CI, 0.12 to 0.38)Strength of
  Evidence Low
• The time to return to daily activities was
  equivalent.Strength of Evidence Low

• Chan KL, Hui WC, Tam PK. Surg Endosc. 2005
  Jul19(7)927-32. PMID 15920685. ? Koivusalo AI,
  Korpela R, Wirtavuori K, et al. Pediatrics. 2009
  Jan123(1)332-7. PMID 19117900. ? Treadwell J,
  Tipton K, Oyesanmi O, et al. AHRQ Comparative
  Effectiveness Review No. 70. Available at
  www.effectivehealthcare.ahrq.gov/inguinal-hernia.c
  fm.

28
Clinical Bottom Line Pain-Free Primary
HerniasRepair Versus Watchful Waiting in Adults

• Mesh repair may improve a patients overall
  health status at 12 months more than watchful
  waiting (difference in mean SF-36 scores 7.3
  95 CI, 0.4 to 14.3).Low strength of evidence
• There is not enough information to know if there
  are differences in adverse effects.

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

29
Comparative Effectiveness of Open Mesh-Based
Repair Procedures

• Twenty-one studies were included.
• The most commonly compared procedures were
• Lichtenstein versus mesh plug (n 7)
• Lichtenstein versus the PROLENE Hernia System
  (PHS n 5)
• Lichtenstein versus the open preperitoneal mesh
  technique (n 3)
• Mesh plug versus the PHS (n 2)
• Lichtenstein versus the Kugel Mesh Patch (n 2)
• Studies were typically conducted between 2000 and
  2010.

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

30
Comparative Effectiveness of Open Mesh-Based
Repair ProceduresLichtenstein Versus Mesh Plug

• Rates of recurrence were approximately
  equivalent.Strength of Evidence Moderate
• Patients who have the Lichtenstein repair may
  return to work about 4 days earlier (95 CI, 1 to
  7).Strength of Evidence Moderate
• Lichtenstein repair is associated with lower
  rates of seroma than mesh plug repair (OR 0.39
  95 CI 0.16 to 0.94).Strength of Evidence
  Moderate

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

31
Comparative Effectiveness of Other Open
Mesh-Based Repair Procedures

• Short-term pain outcomes were similar for these
  open repair procedures
• Mesh plug versus the PROLENE Hernia System (PHS)
  Strength of Evidence Moderate
• Lichtenstein versus the PHS
  Strength of Evidence
  Moderate
• Lichtenstein versus open preperitoneal mesh
  Strength of Evidence Low
• Lichtenstein versus the Kugel Mesh Patch
  Strength of Evidence
  Low
• Intermediate-term pain was also similar for
  Lichtenstein versus Kugel Mesh Patch repair.
  Strength of Evidence Low

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

32
Comparative Effectiveness of Laparoscopic Repair
ProceduresTAPP Versus TEP

• Transabdominal preperitoneal (TAPP) repair may
  offer a 1.4-day earlier return to work however,
  this may not be clinically significant.Strength
  of Evidence Moderate
• Short-term pain outcomes were similar.Strength
  of Evidence Moderate
• Intermediate-term and long-term pain outcomes
  were similar.Strength of Evidence Low
• Research on comparative adverse effects between
  TAPP and totally extraperitoneal repairs was
  inconclusive for hematoma, urinary retention, and
  wound infection.

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

33
Comparative Effectiveness of Mesh Materials

• Hernia recurrence occurred at similar rates with
  polypropylene mesh versus combination
  materials.Strength of Evidence Moderate
• Long-term pain after surgery was similar for
  standard polypropylene mesh when compared with
  biologic mesh or light-weight polypropylene
  mesh.Strength of Evidence Low
• Evidence on comparative adverse effects for the
  different types of mesh materials was
  inconclusive.
• Descriptions of the combination-material mesh
  analyzed for this outcome can
• be found in the full report.

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

34
Comparative Effectiveness of Fixation Methods

• After laparoscopic surgery, hernia recurrence
  rates were similar for tacks or staples versus no
  fixation. Strength of Evidence Moderate
• Mesh fixed with sutures versus glue during open
  or laparoscopic surgery had similar
• Recurrence ratesStrength of Evidence Moderate
• Long-term pain outcomesStrength of Evidence Low
• Mesh fixed with fibrin glue during transabdominal
  preperitoneal repair resulted in less long-term
  pain than when the mesh was fixed with
  staples.Strength of Evidence Moderate
• Data on adverse effects were either missing or
  inconclusive.

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm

35
Association Between Laparoscopic Surgical
Experience and Hernia Recurrence

• Thirty-two studies reported on this association.
• The length of the learning curve for TEP or TAPP
  repair could not be estimated due to problems
  associated with not accounting for followup time,
  not accounting for the evolution of procedures
  over time, and selective outcome reporting.
• Generally, the risk of recurrence decreases when
  a more experienced surgeon performs a repair, but
  there were not enough congruent studies to
  perform a meta-analysis.
• Abbreviations TAPP transabdominal
  preperitoneal TEP totally extraperitoneal

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

36
Conclusions Patient Population

• The typical adult in the studies included in this
  review was a man in his mid 50s, of average
  weight (median body mass index, 25.3 kg/m2
  interquartile range, 25.026.7), who had an
  elective repair of a primary unilateral inguinal
  hernia.
• It is unclear how these results apply to
• Women
• Men of other age groups
• About a quarter of the men with hernias worked in
  physically strenuous jobs for these men, a
  durable repair is important to prevent a
  recurrence.

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

37
Conclusions Laparoscopic Versus Open Repair of
Inguinal Hernias in Adults

• Laparoscopic repair of an inguinal hernia is
  associated with
• Faster recovery times
• Less risk of long-term pain
• A lower risk of another hernia recurrence after a
  previous recurrence
• Open hernia repair may be associated with
• Fewer internal injuries
• Lower recurrence rates in the context of primary
  inguinal hernia

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

38
Conclusions Watchful Waiting Versus Repair for
Pain-Free Inguinal Hernias

• Low-strength evidence suggests that choosing to
  repair a pain-free hernia with a Lichtenstein or
  tension-free mesh repair over watchful waiting
  may improve quality of life.
• However, this finding may not be applicable to
  other types of repair procedures (e.g.,
  laparoscopic repair).
• The evidence on adverse effects was inconclusive.

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

39
Conclusions Mesh Material and Fixation Methods

• Research found most of the meshes or fixation
  methods to be equivalent in their effectiveness
  and risk of adverse effects with only a few
  exceptions.

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

40
Gaps in Knowledge

• How the surgeon's experience influences surgical
  outcomes such as recurrence and pain
• The comparative effectiveness and adverse effects
  of laparoscopic repair versus watchful waiting
  for pain-free or minimally symptomatic inguinal
  hernias in adults
• The comparative effectiveness and adverse effects
  of contralateral exploration/repair versus
  watchful waiting in the pediatric population
• More evidence on several outcomes related to the
  comparisons of mesh products and fixation methods
  including recurrence rates, perception of a
  foreign body, long-term pain, and infection rates
• Clarification in future studies of whether the
  population includes emergent as well as elective
  surgeries and whether or not the findings apply
  equally to both populations

• Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
  Comparative Effectiveness Review No. 70.
  Available at www.effectivehealthcare.ahrq.gov/ingu
  inal-hernia.cfm.

41
Shared Decisionmaking What To Discuss With Your
Patients

• If repair or watchful waiting is the right
  decision for their pain-free or minimally
  symptomatic inguinal hernia
• How to choose between open or laparoscopic
  surgery if the option is available
• What to expect from open or laparoscopic repair
  as far as outcomes and adverse effects, including
  the risk of long-term chronic pain
• What to do if the hernia recurs

42
Resource for Patients

• Surgery for an Inguinal Hernia, A Review of the
  Research for Adults is a free companion to this
  continuing medical education activity. It can
  help patients talk with their health care
  professionals about the decisions involved with
  the care and maintenance of an inguinal hernia.
• It provides information about
• Types of operative treatments
• Current evidence of effectiveness and harms
• Questions for patients to ask their doctor