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On the basis of this meta-analysis, the HerniaSurge Group recommends the Shouldice technique in non-mesh inguinal hernia repair [ 1 ]. Non-mesh repair for inguinal hernia can be suggested in cases where the patient refuses a mesh, after shared decision making with the patient, or in low-resource settings with non-availability of meshes [ 1 ]. To replace the standard flat mesh in the Lichtenstein technique is strongly not recommended [ 1 ]. Furthermore, in open inguinal hernia repair, there is insufficient evidence to favor preperitoneal mesh repair over Lichtenstein repair [ 1 ].


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For comparison of the best open technique with the laparo-endoscopic techniques transabdominal preperitoneal patch plasty TAPP and totally extraperitoneal patch plasty TEP , five meta-analyses are available [ 14 , 15 , 16 , 17 , 18 ]. No difference in the recurrence rates was found; however, a lower incidence of wound infection, an earlier return to normal activities or work, and a lesser incidence of chronic pain syndrome could be detected [ 17 ]. Two meta-analyses comparing only TEP and one comparing only TAPP with the Lichtenstein technique could not deliver sufficient evidence to determine the greater effectiveness of one over the other technique [ 19 , 20 , 21 ].

In a prospectively documented registry-based study comparing 10, Lichtenstein repairs with 6, TEP repairs in primary unilateral inguinal hernias in men [ 22 ], no difference in recurrence rate, complication-related reoperation rate, and chronic pain rate requiring treatment was detected in a multivariable analysis.

When comparing TEP and TAPP with the Lichtenstein technique, a registry-based, propensity score-matched comparison of 57, patients with primary unilateral inguinal hernia repair revealed significantly less postoperative complications, complication-related reoperations, pain at rest, and pain on exertion in favor of TEP and TAPP [ 23 ]. TEP showed disadvantages in terms of intraoperative complications [ 23 ].

On the basis of the existing evidence, the HerniaSurge Group recommends a laparo-endoscopic technique for male patients with primary unilateral inguinal hernia because of lower postoperative pain incidence and comparable complication-related reoperations, provided that a surgeon with specific and sufficient expertise is available. However, there are patient and hernia characteristics that warrant the Lichtenstein technique as first choice [ 1 ].

Meta-analyses and registry studies comparing the laparo-endoscopic techniques TEP and TAPP demonstrate comparable outcomes [ 23 , 24 , 25 , 26 , 27 ]. The International Guidelines recommend that more studies be performed researching the value of tissue repair in certain patient categories like small lateral hernias in young patients [1]. Also more evidence is needed to support management in women and certain specific types like occult and potential bilateral inguinal hernia [1]. Since a generally accepted technique suitable for all inguinal hernias does not exist, surgeons should provide both an anterior and a posterior approach option [ 1 ].

A tailored approach in inguinal hernia repair should distinguish between the following clinical situations: primary unilateral inguinal hernia in men and in women, primary bilateral inguinal hernia in men and in women, primary scrotal inguinal hernia, primary inguinal hernia after previous pelvic and lower abdominal surgery radical prostatectomy, cystectomy, vascular surgery, low anterior resection of the rectum, previous gynecological operations, and ascites , severe cardiac or pulmonary risk factors requiring local or spinal anesthesia, recurrent inguinal hernia, and emergency surgery for incarcerated or strangulated inguinal hernia [ 28 ].

On the basis of the existing evidence [ 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ] for male patients with primary unilateral inguinal hernia repair fig. The guidelines recommended the best open mesh technique Lichtenstein as an alternative [ 1 , 5 , 6 , 7 , 8 , 9 ]. No systematic review or randomized controlled trials specifically address groin hernia repair in women fig. In a systematic review and meta-analysis of observational studies concerning patient-related risk factors for recurrence, female sex was found to be a significant risk factor for recurrence after inguinal hernia surgery [ 29 ].

A study from the Danish Hernia Database demonstrated a fold greater incidence of femoral hernias after inguinal hernia repair compared with spontaneous incidence [ 30 ]. These femoral recurrences occurred earlier than inguinal recurrences, suggesting that they were possibly femoral hernias overlooked at the primary operation [ 30 ]. All femoral recurrences occurred after a previous open anterior operation [ 31 ].


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Laparoscopic repair of a femoral hernia reduces the risk of reoperation for a recurrence compared with open repair [ 32 ]. In women with a groin hernia, a femoral hernia should always be excluded by laparoscopy or by open exploration of the preperitoneal space [ 33 ]. Therefore, all guidelines [ 1 , 5 , 6 , 7 , 8 , 9 ] strongly recommend a laparo-endoscopic repair TEP, TAPP in women with groin hernias, provided that expertise is available.

The only alternative is the careful exclusion of a femoral hernia by opening the transversalis fascia during an open anterior procedure and conversion to a preperitoneal mesh technique if a femoral hernia is found fig. Two prospective randomized trials compared laparoscopic versus open mesh repair in bilateral inguinal hernia fig. Laparoscopic bilateral inguinal hernia repair was significantly quicker as well as less painful and allowed an earlier return to work. Other comparative studies found additional advantages in terms of postoperative complications and hospital stay in favor of the laparoscopic approach [ 36 , 37 , 38 ].

Although high-level evidence is missing, it seems self-evident since the advantages of laparo-endoscopic repair faster recovery, lower risk of chronic pain, and cost-effectiveness increase when performing two hernia repairs via the same three keyhole incisions [ 1 ]. In all guidelines a strong recommendation is given that primary bilateral inguinal hernias should be repaired laparo-endoscopically, provided surgeons with specific expertise and sufficient resources are available [ 1 , 5 , 6 , 7 , 8 , 9 ].

In a registry-based comparison of 6, unilateral and 2, bilateral inguinal hernia repairs in the TEP technique, a significantly higher intraoperative bladder injury as well as complication-related reoperation rate constitute a difference in the perioperative outcome between unilateral and bilateral TEP [ 39 ]. Comparing 10, TAPP procedures for unilateral and 4, for bilateral inguinal hernia repair, multivariable analysis confirmed a highly significant difference to the disadvantage of bilateral TAPP due to an increased complication-related reoperation rate [ 40 ].

Based on these results, prophylactic operation of the healthy other groin should not be performed [ 39 ]. In the guidelines of the EAES, scrotal hernias are classified as being a complex condition [ 9 ]. For scrotal hernia, only highly experienced laparo-enoscopic hernia surgeons should opt for a minimally invasive technique [ 7 , 8 , 9 , 28 ]. The challenge in scrotal hernia repair is to ensure complete dissection of the large hernia sac from the inguinal canal and scrotum [ 7 , 8 , 28 ].

Failure to remove a large part of the hernia sac will generally result in persistent seroma formation [ 7 , 8 , 28 ]. Endoscopic control of bleeding during scrotal hernia repair often is also very difficult when dissecting the hernia sac from the spermatic cord structures [ 7 , 8 , 28 ]. Therefore, there is a higher incidence of postoperative secondary hemorrhage and hematoma [ 7 , 8 , 28 ].

Accordingly, the EHS guidelines recommend the open mesh technique as the procedure of choice for scrotal hernia [ 5 , 6 , 28 ].

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In these very complex situations fig. Following major lower abdominal and pelvic surgery, HerniaSurge and the EHS therefore recommend the open-mesh technique Lichtenstein [ 1 , 5 , 6 , 28 ]. The open mesh approach also presents the least risk in the presence of liver cirrhosis with ascites or for patients on peritoneal dialysis [ 28 ]. Based on the recommendations of HerniaSurge and the EHS, the open mesh technique Lichtenstein under local anesthesia is the preferred technique when general anesthesia is not possible for patients with an American Society of Anesthesiologists ASA score III or IV because of cardiac or pulmonary risk factors fig.

HerniaSurge states that when compared with general anesthesia, local anesthesia is associated with faster mobilization, earlier hospital discharge, lower hospital and total healthcare costs, and fewer complications such as urinary retention and early postoperative pain [ 1 ]. However, when surgeons inexperienced in its use are to administer local anesthesia, more hernia recurrences might result [ 1 , 41 ]. When compared with regional anesthesia, local anesthesia is associated with earlier hospital discharge, lower hospital and total healthcare costs, and a lower incidence of urinary retention [ 1 ].

In a more recent prospective randomized trial comparing TEP under general anesthesia with Lichtenstein using local anesthesia in patients, patients operated with TEP experienced less long-term postoperative pain and less limitation in their ability to exercise [ 42 ]. In another prospective randomized trial with 72 patients, Lichtenstein repair under local anesthesia was as good as TEP under general anesthesia [ 43 ].

In a study randomly dividing 60 male patients with unilateral inguinal hernia into a group of Lichtenstein repair under local anesthesia and a group with spinal anesthesia, the time spent in local anesthesia was higher [ 44 ]. Intraoperative pain was higher in local anesthesia than with spinal anesthesia. There was no difference in postoperative pain. Postoperative complications occurred more often in the spinal anesthesia group [ 44 ].

A comparable study randomly divided 50 patients with Lichtenstein repair to local or spinal anesthesia [ 45 ]. The authors concluded that tension-free mesh repair of inguinal hernias under local anesthesia is simple, safe, and cost-effective, with very low rates of complications and a speedy discharge [ 45 ].

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In patients with a symptomatic inguinal hernia and higher risk of general anesthesia due to cardiac or pulmonary comorbidities, Lichtenstein repair in local or spinal anesthesia is recommended. Local anesthesia seems to come along with less complications than spinal anesthesia.

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Additionally, many patients with cardiac complications regularly take thrombocyte aggregation inhibitors, thus increasing the risk of bleeding and complications from spinal anesthesia. Therefore, the decision between local and spinal anesthesia should be made based on patient-related factors. The rate of recurrent inguinal hernias fig. In the largest [ 46 ] of five meta-analyses [ 46 , 47 , 48 , 49 , 50 ] comparing laparo-endoscopic versus open repair of recurrent hernias following previous open non-mesh and mesh procedures, the minimally invasive technique was associated with less wound complications and a faster recovery to normal activity, whereas the re-recurrence rate was comparable between these two methods.

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In a registry-based study comparing TEP and TAPP for recurrent inguinal hernia repair, the results concerning intraoperative complications, complication-related reoperations, re-recurrences, pain at rest, pain on exertion, or chronic pain requiring treatment were equivalent [ 51 ]. Accordingly, all guidelines [ 1 , 5 , 6 , 7 , 8 , 9 ] recommend recurrent inguinal hernia repair following previous open surgery in the TEP or TAPP technique, since the operation is performed in an anatomic layer between the peritoneum and the abdominal wall in which no previous dissection has been performed [ 1 , 5 , 6 , 7 , 8 , 9 , 28 ].

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A laparo-endoscopic approach for recurrence following a previous TEP or TAPP calls for widespread experience of minimally invasive inguinal hernia surgery and is also classified as constituting a complex situation [ 1 , 5 , 6 , 7 , 8 , 9 , 28 ]. It looks like cookies are disabled in your browser.

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