Inguinal hernias
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39450.428275.AD (Published 31 January 2008) Cite this as: BMJ 2008;336:269
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Good article, but
Stay your hand until you have read
Turaga et el.Surg Clin N Am 88 (2008) 127–138
Routinely avulse the ilio-inguinal nerve
Enough said.
Competing interests:
None declared
Competing interests: No competing interests
After having discussed in our Departments the Clinical Review published in the BMJ by Jenkins John T and O´Dwyer1 Patrick J. “Inguinal Hernias” we would like to express our own experiences at our centre by using Ambulatory Surgery in patients affected by inguinal hernias avoiding therefore, hospital admissions and minimizing multiple risks that could be derived from the patient’s admission, thus increasing the benefits for a great amount of sick people.
Hernia: Latin word that means breaking, but in Greece means yolk, is defined as the abnormal protrusion of a sack covered of peritoneum, throughout the aponeurotic muscle layer of the abdominal wall. The hernias of the inguinal wall are the commonest dysfunction that requires major surgery. In spite of the frequency of the surgical repair, the surgeons don't achieve the best results and the recurrence indexes are very high2.
Another very important aspect in the treatment of inguinal hernias, at present, is the introduction of the “cost - benefit" concept. The concepts of “ cost due to process", “minimally invasive surgery ", “short stay surgery ", or major ambulatory surgery have a wide application in the surgeries of hernias and all of these concepts have partially been modifying the surgical and anaesthetic procedures in the latest years and by judging the results they are fully acceptable concepts.
A benefit that the patients who have been operated from Inguinal Hernia by means of the elective way in the Service of General Surgery of our hospital, is that of having been operated in an ambulatory way in 98.6% of the cases, representing this figure a total of 864 patients in the year 2007.
References:
1. Jenkins JT, J O´Dwyer P. Inguinal hernias. bmj 2008; 336: 269-72.
2. Goderich Lalán, JM, Groves Forge F. Hernias of the region inguinocrural. About their surgical treatment. Spain: University of Alcalá. Ed. Service of Publications of the U.A.H. 1999.
Competing interests:
None declared
Competing interests: No competing interests
In the Clinical Review on Inguinal Hernias by Jenkins and O’Dwyer,
the authors “recommend that all medically fit patients with an inguinal
hernia should have it repaired”(1) This recommendation is made at the
end of the section dealing with hernias with minimal or no symptoms.
There is no evidence base provided for this statement. Indeed, O’Dwyer et
al. (2) showed that watchful waiting could have a role in the management
of asymptomatic hernias although curiously in that paper concluded that
all hernias should be fixed.
While recurrences have decreased with mesh repair, and are of less
concern than previously, the presence of chronic pain remains an important
adverse outcome following hernia surgery.(1,3) Jenkins and O’Dwyer state
“about 30% of patients when asked ……. report long-term pain or discomfort
at hernia repair site”. The results are different with direct questioning
in the clinic, giving a 10% chronic pain occurrence.(1) Kehlet suggests
that 5%-10% of patients have chronic pain adversely affecting their daily
lives.(3) Other sensory disturbances include hypoesthesia, and
hypoalgesia along with sexual dysfunction which can occur in about 2% of
young men.(3)
During 2007 in an NHS hernia clinic, I saw 265 patients with inguinal
hernias. As Jenkins and O’Dwyer state, about one-third was minimally or
completely asymptomatic. All were offered ‘watchful waiting’ and 67 (25%)
accepted a non-operative watchful waiting approach. There were a
surprising number who terminated the consultation immediately on hearing
of the potential consequences of having an operation.
Why would someone with an asymptomatic inguinal hernia trade that
state for a chance to have chronic pain, hypoesthesia or any degree of
sexual dysfunction? Surely this is a clinical situation for which joint
decision making is appropriate. The patient decides but the surgeon
offers, rather than recommends an operation.
References
1. Jenkins JT, O’Dwyer PJ. Inguinal hernias. BMJ 2008; 336:269-272.
2. O’Dwyer PJ, Norrie J, Alani A, Walker A, Duffy F, Horgan P.
Observation or operation for patients with an asymptomatic inguinal
hernia. Ann Surg 2006; 244:167-73.
3. Kehlet H. Chronic pain after groin repair. Br J Surg 2008;
95:135-6.
Competing interests:
None declared
Competing interests: No competing interests
Jenkins and O’Dwyer quote the NICE technology appraisal TA83 summary
headline that laparoscopic repair is one of the treatment options for
inguinal hernia repair.[1] In fact, the appraisal committee has
specifically recommended laparoscopic surgery as the preferred technique
[see paragraph 4.3.6 of TA83] for bilateral inguinal hernias (because both
sides can be simultaneously repaired with minimum excess morbidity) and
recurrent inguinal hernias (because dissection through the scar tissue of
a failed anterior approach is avoided). The NICE technology appraisal also
concluded that, if re-usable equipment is utilised, laparoscopic hernia
repair is a cost-effective alternative to open repair.
In addition, the authors fail to describe that there are two distinct
and well-recognised laparoscopic techniques for inguinal hernia repair:
transabdominal pre-peritoneal (TAPP) or totally extra-peritoneal (TEP).
One of the criticisms of the laparoscopic approach is that the operating
time is significantly longer than that for the open operation. The NICE
committee states that experienced surgeons take 55 minutes to complete the
laparoscopic TEP operation. With increasing experience, operating time
becomes even less of an issue. The author has maintained a detailed,
prospective database of 82 consecutive laparoscopic TEP repairs performed
personally between August, 2006-February, 2008: the median operating time
was 40 minutes; 32 operations took longer than 30 minutes and 10
operations took longer than one hour.
1. http://www.nice.org.uk/guidance/index.jsp?action=download&o=32923.
Downloaded on 11-2-2008
Competing interests:
None declared
Competing interests: No competing interests
We congratulate Jenkins and O'Dwyer for summarising the management of
hernias, which still remains a contentious issue amongst surgeons.
However, we feel that we should comment on two important points:
On examination, it behoves the surgeon to check the contralateral
side as this impacts on the optimum treatment offered.
Secondly, the review states that prophylactic antibiotics do not
reduce the rate of surgical site infections quoting a paper (1) that had
18 infections from 1230 patients in the antibiotic group versus 38
infections from 1230 patients in those that did not receive antibiotics.
The fact that 5% significance was not met may be explained by an
inadequate sample size which, interestingly, was the conclusion conceded
by the Cochrane review (2) when also examining the effect of antibiotics
in preventing infection in mesh hernia surgery.
References
1 - Aufenacker TJ, Koelemay MJW, Gouma DJ, Simons MP. Systematic
review and meta-analysis of the effectiveness of antibiotic prophylaxis in
prevention of wound infection after mesh repair of abdominal wall hernia.
Br J Surg 2006; 93: 5-10.
2 - Sanchez-Manuel FJ, Seco-Gil JL. Antibiotic prophylaxis for hernia
repair. Cochrane Database Syst Rev 2004;(4):CD003769.
Competing interests:
None declared
Competing interests: No competing interests
Since recurrence rates have been reduced to a few per cent with mesh
repair, chronic pain is the most important long term complication.It
adversely affects daily life for 5-10 per cent of patients3, and pain
related sexual dysfunction occurs in about 2 per cent of young men4.
Most works on chronic post-operative pain has focused on factors related
to surgical technique, but data so far are inconclusive.The laparoscopic
approach might reduce the risk of chronic pain. Non-fixation mesh
techniques may also reduce the risk of chronic pain after open surgery,
possibly by reducing nerve damage2.
Based on the hypothesis that a reduced inflammatory response may reduce
the risk of chronic pain,use of light-weight meshes have been
advocated5.The spontaneous resolution may happen in 50% of patients within
5 years. The pharmacological treatment of chronic pain after hernia repair
has not been established.Gabapentanoids and tricyclics may gave a
role.Surgical intervention with neurectomy and mesh removal should be
reserved for those in whom medical treatment has failed 1,2.
Large multicentric collaborative study is required to find the answer to
this long term problem after repair of an inguinal hernia.
References
1.Jenkins JT, O'Dwyer PJ.Inguinal Hernias. BMJ 2008;336:269-272
2.Kehlet H. Chronic pain after groin hernia repair.BJS 2008;95:135-136
3.Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain:risk factors
and prevention. Lancet 2006;367:1618-1625
4.Aasvang EK, Mohl B,Kehlet H. Ejaculatory pain: a specific postherniotomy
pain syndrome? Anaesthesiology 2007;107:298-304
5.Weyhe D,Belyaev O,Muller C,Meurer K,Bauer KH,Papapostolou G et all.
Improving outcome in hernia repair by the use of light meshes -a
comparison of different implant constructions based on a critical
appraisal of the literature. World J Surg 2007;31:234-244
Competing interests:
None declared
Competing interests: No competing interests
Is inguinal hernia repair perhaps like tonsillectomy used to be?
That is, the surgeon can do the op, so the surgeon does the op? Might
this be a cse of "waste not, want not"?
Competing interests:
Member of West Sussex PPIF
Competing interests: No competing interests
The advice to offer surgery to all fit patients with asymptomatic
inguinal herniae would seem to conflict with some of the evidence.
A case can be made for watchful waiting, which is less costly and
avoids the risks associated with surgery.
Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al. Watchful
waiting vs repair of inguinal hernia in minimally symptomatic men: a
randomized clinical trial. JAMA 2006;295:285–92.
Competing interests:
None declared
Competing interests: No competing interests
Strangulated hernia causing sudden unexpected death-A major concern. Re: Inguinal hernias
Strangulated hernia causing sudden unexpected death-A major concern.
Dr. Azzard Comrie, Senior Medical officer, Hargreaves Memorial Hospital, Mandeville, Manchester, Jamaica, WI (www.hargreaveshospital.com) and Prof. Dr.Jogenananda Pramanik, Executive Dean, Career Abroad Institute School of Medicine, 32, Hargreaves Avenue, Mandeville, Manchester, Jamaica, WI.(www.caisom.org)
We read the clinical review on Inguinal Hernias by Jenkins and O’Dwyer,
and sincerely applauded their insightful recommendation that all medically fit patients with an inguinal hernia should have it repaired (1) Inguinal hernias account for 75% of abdominal wall hernias, with a lifetime risk of 27% in men and 3% in women.(1)
An inguinal hernia isn't necessarily dangerous always. However, if it doesn't improve on its own, or if patients aren't able to push the hernia in, the contents of the hernia can be trapped (incarcerated) in the abdominal wall. An incarcerated hernia can become strangulated, which cuts off the blood flow to the tissue that's trapped and can lead to life-threatening complications.
Excruciating pain due to ischaemic changes in entrapped gastrointestinal tissue may endanger life causing neurogenic shock. If surgical interventions are delayed, toxic materials from strangulated gut may spread and cause further deterioration of the patient’s overall general condition. Such irreversible complications may often ensue sudden unexpected death in elderly patients.
Less expensive watchful waiting under periodic evaluation, may be a popular endeavour among young patients with inguinal hernia to postpone surgical interventions and also to differ certain uncomfortable postoperative events like sexual dysfunction. (2, 6)
However, repair of inguinal hernia is one of the most common operations in general surgery, with rates ranging from 10 per 100 000 of the population in the United Kingdom to 28 per 100 000 in the United States (1).
Ironically, there is no definite sign for early detection of strangulation of herniated tissue in inguinal hernia and therefore, it seems difficult for patients or their relatives to ascertain when to terminate “watchful waiting period” and decide to seek surgical procedures for remote rural area patients in particular. (3) A third of patients scheduled for surgery have no pain, and severe pain is uncommon (1.5% at rest and 10.2% on movement) (1)
Moreover, there are reports about postoperative death of strangulated inguinal hernia patients who most commonly report for lifesaving surgical intervention late. (4) Postoperative mortality after elective and emergency surgery for inguinal hernia has also been reported (5).
Sudden unwitnessed, unexpected deaths when the bodies are found in public places require a complete and meticulous medico-legal autopsy to ascertain the cause and manner of death to avoid further unnecessary investigations by the legal authorities (7, 8).
References:
1. Jenkins JT, O’Dwyer PJ. Inguinal hernias. BMJ 2008; 336:269-272.
2. O’Dwyer PJ, Norrie J, Alani A, Walker A, Duffy F, Horgan P.
Observation or operation for patients with an asymptomatic inguinal
hernia. Ann Surg 2006; 244:167-73.
3.Fitzgibbons RJ, 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 randomised clinical trial.JAMA2006;295:285-92.
CrossRefPubMedWeb of ScienceGoogle Scholar
4.Haapaniemi S, Sandblom G, Nilsson E. Mortality after elective and emergency surgery for inguinal and femoral hernia. Hernia1999;4:205-8.
Google Scholar
5. McGugan E, Burton H, Nixon SJ, Thompson AM. Deaths following hernia surgery: room for improvement. J R Coll Surg Edinb2000;45:183-6.
PubMedWeb of ScienceGoogle Scholar
6. Kehlet H. Chronic pain after groin repair. Br J Surg 2008;
95:135-6.
7. T.B.Curling: Strangulated Hernia in Old People; Lond J Med 1850; s2-2:507 doi: https://doi.org/10.1136/bmj.s2-2.18.507
8. Menezes RG et al. Sudden unexpected death due to strangulated inguinal hernia. Med Leg J. 2016 Jun;84(2):101-4. doi: 10.1177/0025817216629848. Epub 2016 Feb 2.
Competing interests: No competing interests