BMJ  2004;328:59-60 (10 January), doi:10.1136/bmj.328.7431.59

Editorial

Treating inguinal hernias

Open mesh Lichtenstein operation is preferred over laparoscopy

Inguinal hernias are common; the lifetime risk for men is 27% and for women 3%.¹ It has been estimated that worldwide over 20 million repairs of inguinal hernia are carried out each year, the specific operation rates varying between countries from around 100-300 per 100 000 population per year.² In the United Kingdom some 100 000 inguinal hernias are repaired each year and in the United States 750 000. In the past decade the outcomes for surgery for inguinal hernia have been improved dramatically by the routine use of prosthetic mesh. Laparoscopic surgery has not affected surgery for inguinal hernia appreciably because of the increased costs and the reluctance of general surgeons to learn this complex procedure to correct a minor abnormality. Improvements in the delivery and quality of inguinal hernia surgery in the future will depend on the development of improved prosthetic mesh materials to reduce the incidence of chronic groin pain, which is now higher than recurrence rates. Furthermore, improvements in the organisation of care should include comprehensive education of patients, clinical nurse specialists, outpatient care for most patients, and greater use of local anaesthesia.

Repair of an asymptomatic bulge in an elderly, unfit man is not mandatory because the risk of strangulation is minimal. For symptomatic hernias in younger men a truss may allow continuation of heavy work with greater comfort while awaiting operation. A truss is an option only if the hernia can be reduced readily and completely and will remain in position despite physical activity or obesity. Patients can wait for surgery relatively safely because the cumulative probability of strangulation for an inguinal hernia is no more than about 2% per year.³ For femoral hernias the risk is much higher—40% of patients are admitted as an emergency with strangulation or incarceration, and it is therefore important to differentiate between these two types of groin hernia. Femoral hernias should be treated urgently.

Five relevant factors should be considered in any evaluation of outcomes of modern day hernia surgery: technical difficulty for the surgeon; overall complication rates and the seriousness of possible complications; rehabilitation both short term and long term, including return to daily activities and work; recurrence rates; and socioeconomic factors, notably cost. Which of these takes precedence has been the subject of numerous clinical trials, meta-analyses, and systematic reviews. A systematic review by the European Union's Hernia Trialists Collaboration reported a threefold reduction in recurrence rates from 4.4% to 1.4% with the use of mesh compared with suture techniques.⁴ The same group published a systematic review comparing laparoscopic with open methods of groin hernia repair and reported that in the hands of experts who practise the technique, laparoscopic repair was associated with less postoperative pain and more rapid return to normal activities. However, laparoscopic repair took longer to perform and was associated with an increased risk of rare but serious complications, such as bladder or bowel perforation and vascular injury.⁵ In several European countries these conclusions are reflected in patterns of surgical practice with up to 95% of surgeons performing open mesh (Lichtenstein) repair and only 5% adopting the more complex, costlier laparoscopic operation, which has less margin for error.^{6 7 8} This view was adopted by the United Kingdom's National Institute for Clinical Excellence, which recommended that open mesh repair should be the preferred surgical procedure for primary inguinal hernia.⁹

After surgery for inguinal hernia patients should be encouraged to return rapidly to normal activities and work. "Take it easy" is the wrong advice.¹⁰ After ambulatory surgery under local anaesthesia patients will usually be relatively pain free at three days, be able to resume normal activities at seven days, and be able to return to work at 10 days. With modern techniques and anaesthesia there is no justification for patients to remain off work for six weeks as previously recommended. Chronic groin pain has been increasingly recognised as a disability experienced by up to 5% of patients, causing notable effects on daily activities including walking, work, sleep, relationships with other people, mood, and general enjoyment of life.¹¹ Strategies to reduce the numbers of patients with chronic groin pain will include specific advice that modifies behavioural attitudes after surgery and technological improvements in mesh design.¹²

Stoppa has been the seminal thinker in developing not only the routine use of mesh for groin hernia surgery but also the concept of placing this into the preperitoneal space covering the myopectineal orifice through which all groin hernias protrude¹³ (figure). These concepts have been fundamental in the development of preperitoneal techniques for repair of recurrent hernias and form the basis for laparoscopic hernia surgery.

The preperitoneal space showing the placement of mesh to cover the myopectineal orifice, encompassing indirect inguinal, direct inguinal, and femoral hernia defects with a wide overlap of mesh to prevent recurrence

 

The open mesh Lichtenstein operation has overcome the problems of technical difficulty and recurrence. Further improvements in inguinal hernia surgery will come about through increased use of outpatient facilities, attention to patient education, improving recovery patterns and new prosthetic materials to enhance long term patient comfort.¹⁴

Derriford Hospital, Plymouth PL6 8DH (andrew.kingsnorth{at}phnt.swest.nhs.uk)

---

Competing interests: None declared.

References

1. Primatesta P, Goldacre MJ. Inguinal hernia repair: incidence of elective and emergency surgery, readmission and mortality. Int J Epidemiol 1996;25: 835-9.[Abstract/Free Full Text]
2. Kingsnorth AN, LeBlanc KA. Management of abdominal hernias. 3rd ed. London, New York: Edward Arnold, 2003: 40-7.
3. Gallegos NC, Dawson J, Jarvis M, Hobsley M. Risk of strangulation in groin hernias. Br J Surg 1991;78: 1771-3.
4. EU Hernia Trialists Collaboration. Mesh compared with non-mesh methods of open groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000;87: 854-9.[CrossRef][ISI][Medline]
5. EU Hernia Trialists Collaboration Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized trials Br J Surg 2000;87: 860-7.[CrossRef][ISI][Medline]
6. Beattie PK, Foley RJE, Callam MJ Future of laparoscopic inguinal hernia surgery Br J Surg 2002;87: 1727-8.[CrossRef]
7. Schoots IG, van Dijkman D, Butzelaar RMJM, van Geldere D, Simons MP Inguinal hernia repair in the Amsterdam Region 1994-1996 Hernia 2001;5: 37-40.[CrossRef][Medline]
8. Bay-Nielsen M, Kehlet H, Strand L, Malmstrom J, Andersen FH, Wara P, et al Quality assessment of 26,304 herniorrhaphies in Denmark: a prospective nationwide study. Lancet 2001;358: 1124-8.[CrossRef][ISI][Medline]
9. National Institute for Clinical Excellence. Guidance on the use of laparoscopic surgery for inguinal hernias: London: NICE, 2001. (Technology appraisal guidance No.18.)
10. Shulman AG, Amid PK, Lichtenstein IL. Returning to work after herniorrhaphy. BMJ 1994;309: 216-7.[Free Full Text]
11. Page B, Paterson C, Young D, O'Dwyer PJ. Pain from primary inguinal hernia and the effect of repair on pain. Br J Surg 2002;89: 1315-8.[CrossRef][ISI][Medline]
12. Junge K, Klinge U, Rosch R, Klosterhalfen B, Schumpelick V. Functional and morphologic properties of a modified mesh for inguinal hernia repair. World J Surg 2002;26: 1472-80.[CrossRef][ISI][Medline]
13. Stoppa RE. Wrapping the visceral sac into a bilateral mesh prosthesis in groin hernia repair. Hernia 2003;7: 2-12.[Medline]
14. Kingsnorth AN, Bowley DMG, Porter C. A prospective study of 1000 hernias: results of the Plymouth Hernia Service. Ann R Coll Surg Engl 2003;85: 18-22.[CrossRef][ISI][Medline]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Relevant Articles

Treating inguinal hernias: Editorial does not tell the whole story...

Emilie Øberg and Jacob Rosenberg
BMJ 2004 328: 403. [Extract] [Full Text]

Treating inguinal hernias: ... and is misleading

Paul M Peyser
BMJ 2004 328: 403-404. [Extract] [Full Text]

This article has been cited by other articles:

• Ribeiro, B. (2004). Randomized Controlled Trial of Preservation or Elective Division of Ilioinguinal Nerve on Open Inguinal Hernia Repair With Polypropylene Mesh--Invited Critique. Arch Surg 139: 759-759 [Full text]  
• Oberg, E., Rosenberg, J. (2004). Treating inguinal hernias: Editorial does not tell the whole story.... BMJ 328: 403-403 [Full text]  
• Peyser, P. M (2004). Treating inguinal hernias: ... and is misleading. BMJ 328: 403-404 [Full text]  

Rapid Responses:

Read all Rapid Responses

Poor solutions for poor surgery.

Richard G Fiddian-Green
bmj.com, 11 Jan 2004 [Full text]

Misleading account

Paul M Peyser
bmj.com, 14 Jan 2004 [Full text]

Not the whole truth.

Emilie Oeberg, et al.
bmj.com, 19 Jan 2004 [Full text]

Treating Inguinal Hernias

Peter A Jones, et al.
bmj.com, 21 Jan 2004 [Full text]

Hernia repairs must be able to be performed economically Worldwide. Cost counts.

Nick J Barwell
bmj.com, 21 Jan 2004 [Full text]

Misleading title - 'Lichtenstein opearation is preferred over Laparoscopy'

Amir Nisar
bmj.com, 22 Jan 2004 [Full text]

Is Laparoscopic Hernia repair very expansive?

Amir Nisar
bmj.com, 22 Jan 2004 [Full text]

Inguinal Hernias

James Wellwood
bmj.com, 23 Jan 2004 [Full text]

Convincing Picture of Preperitoneal hernia repair

Amir Nisar
bmj.com, 25 Jan 2004 [Full text]

The Elusive Inguinal Hernia Repair

Abd H Mat Sain
bmj.com, 15 Aug 2005 [Full text]