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l, January-March,2007
Evidence-BasedClinical Practice Guidelineson the Management of Adult Inguinal
Hernia: Primary Inguinal Hernia, RecurrentInguinal Hernia and Bilateral Inguinal

N' Agno' M'D.l

Nilo C. de los SantosoM.D., F.P.C.S.;Ray I. SarmientooM.D.,'F.P'C'S'; Marilou
F'P'C'S'; JosephD'
F.P.C.S.;Dakila P. de los Angeles,M.D., F.P.C.S.;Domingo A. Bongala,M'D'o
F.P.C.S.;for the Philippine Societyof
QuebraloM.D., F.P.C.S.and JoseAntonio M. Salud, M.t,
General SurgeonsInc.

This information,basedon the Philippine Societyof In the Philippines,inguinalherniarepairis one of

G e n e r a l S u r g e o n s( P S G S ) l n c . C l i n i c a l P r a c t i c e the most common surgical proceduresperformed by intendedto assistphysiciansandpatients generalsurgeonsandthe numberis expectedto continue
in the management of adult inguinalhernias'A distinct io risein thefuture'The country'seconomicdevelopment
panel of expertstogetherwith the Technical Working and the rapid westernizationof our lifestylesare major
Group (TWG) developedthe PSGS Clinical Practice factorsexpectedto contributeto the increasedawareness
Guidelines.These guidelinesare given by the PSGS of this condition.
basedon the current scientific evidenceand its views The TWG put in orderthe clinicalquestions'search
concerningacceptedapproachesto treatmentof adult method, levels of evidence,and categories
' he TWG has been
r e c o m m e n d a t i o n sT r e g u l a rly
Theseguidelinesare not proposedto change,but to monitoringthe major sourcesof publications,namely'
assisttheproficiencyandclinicaljudgmentof physicians the Pubmed(Medline) of the U'S' NationalLibrary of
on the managementof patientswith adult inguinal Medicineand The Cochrane
hernia. Eaclr patient's condition must be evaluated
i n d i v i d u a l l y I. t i s i m p o r t a n t o d i s c u s st h e g u i d e l i n e s Level of Eviddnce
andall informationregardingtreatment optionswith tlie
patient. The choiceof a well-informedpatientplaysa I. Evidence from at least one properly designed
g r e a t r o l e i n t h e d e c i s i o n - m a k i n go f t h e s u r g i c a l i.randomized controlledtrial or meta-analysis'
procedure. ll. Evidencefrom at leastone well designedclinical
trial without properrandomization,from prospective
ExecutiveSummary or cohortor case-controlanalyticstudies(preferably
from onecenter),from multipletime-seriesstudies'
The Philippine Society of General Surgeons(PSGS) or from dramaticresultsin uncontrolledexperiments'
of respected authoritieson
Inc. togetherwith the PhilippineCollegeof Surgeons Ill. Evidencefrom opinions
thebasisofclinicalexperiences, studies'
(PCS)haspublishedits Evidence-based ClinicalPractice
Guidelines (EBCPG)on otherimportantgeneralsurgical or reportsof exPertcommittees'
conditions. Fromthenon,numeroushighqualityclinical
trials havebeenpublishedon differentgeneralsurgical Categories of Recommendation
p r o b l e m s . T h e s e p u b l i c a t i o n sh a v e r e s u l t e d i n
consensusby expert panel
rnodificationsin otherclinical practiceguidelines,like CategoryA: At least 7Soh
thosein the United StatesandEurope' present

E B C P G so n t h e M a n a g e m e notf A d u l t I n g u i n a lH e r n i a 4l

C a t e g o r y B : R e c o m m e n d a t i o nw a s s o m e w h a t 7 . A n t i m i c r o b i a l p r o p h y l a x i s i s n o t r o u t i n e l y
controversialand did not meet consensus recommended for electivegroinherniarepairusing
mesh.(Level lA, CategoryA)
CategoryC: Recommendationcausedreal disagreements
TechnicalWorking Group
The TWG preparedthe first draft of the manuscript
which consistedof a summaryof the strongestevidence
RayI. Sarmiento, (Chair)
associatedwith the clinical questionsand suggestedthe
MarilouN. Agno,M.D.,F.P.C.S.
recommendations.The first draft was discussedand
DomingoA. Bongala, M.D., F.P.C.S.
modified by a Panel of Expertscalled togetherby the
DakilaP. de losAngeles,M.D.,F.P.C.S.
PSGSon August3,2005 atthe LubangRoomof EDSA
Joseph D. Quebral,M.D.,F.P.C.S.
ShangrilaHotel. A seconddraft was completedby the
JoseAntonioM. Salud,M.D.,F.P.C.S.
TWG and this was discussedin a Public Forum on
Nilo C. de los Santos, (Director)
December 7,2005duringthe63'dPCSClinicalCongress
heldat the KamiaRoomof EDSA ShangrilaHotel.The
PSGSBoard of Directorsthen acceptedthe guidelines
on February11,2006.
l. Reynaldo
M. Baclig,M.D.,F.P.C.S.
Summary of Recommendations
2. Raymond G. Casipit,M.D.,F.P.C.S.
L The recommendedtreatmentfor inguinal hernia is (CentralLuzonChapter)
mesh repair, either the laparoscopicor the open
3. Dominador M. ChiongJr.,M.D.,F.P.C.S.
method.(Level 1A, CategoryA)
(Metro Manila Chapter)
2. Therecommendedtechniques forlaparoscopicmesh 4. GiovanniA. DelosReyes,M.D.,F.P.C.S.
repairare transabdominalpreperitoneal(TAPP) or (PanayChapter)
total extra preperitoneal(TePP) repair. (Level 1B,
5. RomeoG. Ehcanto,
(Metro Manila Chapter)
3. It is not necessaryto
fixthe meshduringlaparoscopic 6. RamonS. Inso,M.D.,F.P.C.S.
TAPP or TEPP inguinalherniarepair.(Level 1B, (Southern Tagalog Chapter)
7. JaimeB. Lagunilla,
4. The recommendedtechniquesfor openmeshrepair (Northern Mindanao Chapter)
arethe Lichtenstein,
Plugandmeshandthe Prolene 8. ArturoE. Mendoza,
HerniaSystem.(Level lB, CategoryA) (CentralLuzonChapter)

5. The recommendedtreatmentfor recurrentinguinal 9. WilliamL. Olalia,M.D., F.P.C.S.

herniais meshrepair,eitherthe laparoscopic
or the (Metro Manila Chapter)
openmethod.(Level 1A, CategoryA)
10.ReyMelchorF. Santos, M.D.,F.P.C.S.
(Metro Manila Chapter)
6. The recommendedtreatmentfor bilateral inguinal
herniais meshrepair,eitherthe laparoscopic
or the I 1 .J e s uV
s . V a l e n c i aM, . D . ,F . P . C . S .
openmethod.(Level 1A, CategoryA) (Metro Manila Chapter)
42 PJSSVof.62,No. l, January-March,2007

Acknowledgment 3 . Hernia recurrencedata were basedon the methods

usedin individualtrials'Mean or
of ascertainment
JohnsonandJolrnson, Philippinessupportedthis project mediandurationof follow-r-rprangedfrom 6 weeks
o f G e n e r aSl u r g e o n s , l n cT.h e to 36 months.
o f t h e P h i l i p p i n eS o c i e t y
sponsoringcompanyin no way influencedthe outcome A
a. Adult-Age of participants greater or equal to l6
o f t h e s eg u i d e l i n e s . years. Subjects' ages ranged from 16-85 years
( m e d i a no f 5 2 . 3 ) .
5. TAPP (transabdominalpreperitoneal) a
The TWG usedcombinedMESH terms and free text laparoscopic herniatechniquein whiclrtheperitoneal
searches of databases from PubMed,CochraneLibrary cavity is traversedand an incision is madeover tlre
a n d t h e P h i l i p p i n eJ o u r n a l o f S u r g i c a l S p e c i a l t i e s peritoneumto exposethe preperitonealspaceover
( P J S S )t o r e t r i e v et i t l e s . O n l y r e l e v a n tt i t l e s w e r e ihe inguinal area for mesli on lay placement'The
selected for full-text retrieval by norninal group peritoneumis then approximated(with staplesor
suturing)to coverthe meshprosthesis'
techniqueand appraisedby the groupfor eligibility of
tlre retrievedstudies.A total of 252 journaltitles were -
6 . TEPP/TePP/TEP (totally extraperitoneal) a
retrieved,13full texttitles were used forthe guidelines.
l a p a r o s c o p i ca p p r o a c h w h e r e i n t h e r e i s n o
The Levelsof Evidenceusedwas basedon the Oxford penetrationinto the peritonealcavity' The working
M e d i c i n e L e v e l s o f
Centre for Evidence-Based spaceis preperitonealand is createdby inflating a
E v i d e n c eM. ay 2001. balloon or by blunt dissectioninto the preperitoneal
Outcome measures used in these Guidelines were space to expose the inguinal area. The mesh is
hernia recurrenceas the primary outcomeand duration placed on lay into the preperitonealspace'
of operation (rninutes), hematoma, seroma, wound/
- intraperitonealon lay mesh repair is a
superficialinfection,seriouscomplications(rnesh/deep 7 . IPOM
infection. vascularinjury, visceral injury), length of l a p a r o s c o p i tce c h n i q u ew h e r e a c o m p o s i t em e s h
postoperativehospital stay (days), time to return to is placecl to cover the hernia defect without
normal activities,pain persistingat least> 3 months, d i s s e c t i o n o f t h e p r e p e r i t o n e a ls p a c e ' T h e
meshis anchoredto the abdominalcavity over the
and numbnessat least> 3 montlls,as the secondary
'Lichtensteinrepair(LR)/openon-lay/openflat mesh
Operational Definitions - a mesh trimmed to fit the inguinal floor and
securedby sutures.
I . Persistingpain was defined as groin pain of any
severity(inclLrdingtesticular)persistingat oneyear 9 . Mesh plug repair(MPR)/plug and mesh a two part
afterthe operation,or at the closesttime point to one meshprosthesis, one as a plug (sutured)and one as
year provided this was at least three months after flat mesh anteriorto it (unsutured)'
10. ProleneHerniaSystem(PHS)- circularmeshand a
2. Persisting numbnessincluded paresthesia, flat meshthat is connectedby a tubular meshacting
dysesthesia and discomfortpersistingat one year as one unit where the flat portion is placedanterior,
afterthe operation,or at the closesttime pointto one the tubular portion into the inguinal canal and the
year provided this was at least three months after circular portion is placed posterior to the
sLlrgery. transversalisfascia or preperitoneally'
E B C P G so n t h e M a n a g e m e notf A d u l t I n g u i n a lH e r n i a 43

Results is a meta-analysis of forty-onerandomizedcontroltrials

( R C T s ) i n v o l v i n g 7 1 6 1 p a r t i c i p a n t sc o m p a r i n g
1. What is the recommendedtreatment for inguinal laparoscopictechniquesversus open techniquesfor
hernia? inguinalhernia repair.Theoutcomeshowsthefollowing:
operation times for laparoscopicrepair were longer,
The recommendedtreatmentfor inguinalherniais rnesh therewas a higherrisk of rare seriouscomplicationsin
repair,the laparoscopic orthe openmethod.(Level I A, laparoscopicrepair,returnto usualactivitieswas faster
CategoryA) in laparoscopicrepair,lesspersistingpain andnumbness
in laparoscopicrepair, hernia recurrencewas less
McCormackK, ScottNW, Go PMNYH and RossS common in laparoscopicrepair than open non-mesh
(EU HerniaTrialistsCollaboration)in 2003rreviewed repair but not different to open mesh methods and a
laparoscopictechniquesversus open techniquesfor reducedrecurrenceofaround 30-50percentwas related
i n g u i n a l h e r n i a r e p a i r . T h i s w a s p u b l i s h e di n t h e to the use of mesh rather than the method of meslr
CochraneDatabaseof SystematicReviews2003.This placement.

Comparisonof Clinical Outcomesof LaparoscopicversusOpen Techniquesfor Inguinal Hernia Repair

Outcome No. of Studies No. of Participants StatisticalMethod Effect Size

Duration of operation
(minutes) JI 6482 (Fixed)95%CI
WeightedMeanDifference 14.81[ 1 3 . 9 81, 56 4 ]
Vascularinjury zo 5256 PetoOddsRatio95%CI |.38[0.44,4.29]
Visceral injury 22 4914 PetoOddsRatio95%CI s.76lr.s3,2r.681
Time to return to
usualactivities(days) 20 2608 PetoOddsRatio95%CI 0.s6[0.s1,0.61]
Persistingpain 2l 4500 PetoOddsRatio95%CI 0.54[0.46, 0.641
Persistingnumbness 16 3043 PetoOddsRatio95%CI 0.38[0.29, 0.49]
Hernia recurrence 39 oo4z PetoOddsRatio95%CI 0 . 8 1 [ 0 . 611. 0
, 8]

Source:Scott NW, McCormack K, Graham P, Go PMNYH, RossSJ, Grant AM on behalf d the EU Hernia Trialists Collaboration.
Laparoscopictechniquesvs. open techniquesfor inguinal hernia repair. The CochraneDatabaseofSystematicReviews,2005, Issue2

2. lf laparoscopic mesh repair is the preferred rateof postoperativepain and returnto physicalactivity.
technique for inguinal hernias, what is the A total of 86 patients were randomized in the study,
recommendedlaparoscopictechnique? Shouldice(n:34), TAPP (n=28)or TPP(n=24),Results
showedthat therewas no significantdifferencebetween
Therecommended mesh tlre three groups for postoperativepain and return to
techniquesfor laparoscopic
repairaretransabdominalpreperitoneal(TAPP) or total physicalactivity.
extra preperitoneal(TePP).(Level lB, CategoryA)
LeopoldoSarli,et al.3in December1997publishedin
SchrenkP, WoisetschlagedR, RiegerR, and Wayan the Journal of Surgery Laparoscopyand Endoscopy a
W2 in November1996publishedin the British Journal prospective comparison ofTAPP andIPOMtechniques, in
of Surgerya prospectiverandomizedtrial comparing laparoscopichernia repair alnong I l5 patients. Mean
transabdominalpreperitoneal,total preperitoneal or follow-up of patients was 32 months after the IPOM
Shouldicetechniquefor inguinal hernia repair on the procedureand a mean follow-up of 28 months, after the
44 PJSSVol. 62,No. 1, January-March'2007

Hernia Recurrence Comparing Laparoscopic versus Open Techniques for Inguinal Hernia Repairs.
Treatment Control Peto OR Weight Peto OR
Study o/o
n/N n/N 95% cl 95olo Cl
or sub<ategory

01 TAPP Ecus Open

6/49 4 .63 0.46 [0.12, L.8r)
Aarberg 1 996
r/ 42 o/44 ?.?5 t0.15,39O.961
Adelaide 1994
2/52 o/56 1.1t- 8.14 to-50, 132.O61
Ancona 1998
7/5A a/5'7 1-26 LA-L4, 366.O'71
Bangkok 1998
o/ao o/160 Not estimable
Berlin 1996
7/94 3/rao 2.AA o-66 [0.08, 5.25]
Bietigheim 1998
3/ 62 2 -71 3.31 t0.a5,24.20)
Bydgoszcz 1998
o/2s o/30 Not estimable
Caen 1998
Not estimabl-e
Hawaii '1994 o/5L o/49
o/20 o/ra Not estimable
Kokkola 1997
2/IIO s/89 3 . ' 76 0.33 f0.o'7, r.491
Linkopin 1 997
r/2a o/3a 9.15 t0.18, 469.981
Linz 1 996
o/15 o/'76 Not estimable
MRCmulticentre 1999
1/48 22 / A'7 0.29 t0-13,0.641
Maastricht 1998
6/42 3. 60 4.t2 la.88,19.321
Maastricht 1999
a/11 3.96 2.'11 tA-62, Lr.a4l
Michigan l99T
4/r38 3/130 L-26 lO.2A,5.6Al
Nyborg 1 999
o/24 2/29 1.09 0.16 []
Omaha 1996
r/sE a/66 8.48 t0.71,430.911
Oxford 1995
l/s6 2.13 lo-22, 20-951
Parma 1997
3 / 20'7 t1 / 446 9.'70 o.42 1o.16,1.081
scuR l999
o/54 o/48 Not estimable
Stuttgart 1995
3.06 4.83 [0.90,25.4L)
Tampere 1998 t / J !

r/34 3/33 2 .14 0.34 (0.05, 2.s3)

Toumai 1996
o/21 0-55 6-16 I0.L2,3L6.611
utm 1993
o/50 2/44 1.11 0.13 t0. oL, 2.061
Whipps Cross 1994
r /200 L/200 1.00 t0.06,16.041
Whipps Cross 1998
:136 o. E0 trl. 55/ i. .l-61
Subtotal (95o/oCl) 1113
Total ewnts: 53 (Treatment),71 (Control)
Testfor hatorogeneity: Chiz= 37.31,df = 20 (P = O.01)' 12= 46.40/o
Test for o\,€rall elfect. Z = 1.1I (P = 0.23)

02 TEP ve.susOpen
L/92 0/92 0.56 7.39 I0.1s, 312.381
t't / a8'7 31/5o'7 z5. ad 0.5? [0.32,1.01]
CoalaTrial Gp 1997
o/32 0/32 Not estimable
r/50 0/50 0.56 ?.39 t0.L5,372.381
a/ 2 4 0/34 Not estimable
L i n z1 9 9 6
1999 1/ 2 8 5 0/211 3.8? 1.L9 tL.62, 3r.891
o/59 0/5'l Not estimable
0/22 o/ 2 3 Not estimable
O u l u2 1 9 9 8
0/89 0/92 Not estimable
3/ 5 r L /4 9 2.L1 2.69 10.31,79.1L)
3/731 6/II6 4.84 0.42 t0.11,1.591
Woodville1996 2/41 0/55 1.10 8.95 f0.55, L46.3'7)
subrotal (950/0cl) :t.3iIi 1 . 38
r 38.69 0.89 [0.56,1..43]
Total e\ents: 34 (Treatment),38 (Control)
Test for heterogeneity:Chi'z= 17.16,dt = 6 (P = 0.009), 12= 65.0olo
Test for orerall etled: Z= 0.47 (P = 0.64)

03 Miscellaneous Laparoscopic rersus Open

0 0 t,loL esLimabl.j
Subtotal(95% Cl)
Total events:0 (Treatment),0 (Control)
Test for heterogeneity:not applicable
Test for overalleffect: not applicable

Total (95% Cl) :j148 3504 1r)0.00

Total e\ents: 87 (Treatment),109 (Control)
Test for heterogeneity:Chi2= 54.61,dl = 27 (P = 0.001), 12= 50.60/o
Test for o\Erall effect: z = 1.22 (P -- o.22\
0 . 0 0 10 . 0 1 0 . 1 1 10 100 1000
Favcurstreatment Fa\ curs control

Source:ScottNW, McCormackK, GrahamP, Go PMNYH, RossSJ,GrantAM on behalfof theEU HerniaTrialists

techniquesvs. opentechniquesfor inguinalherniarepair.The CochraneDatabaseof
Systematic 2005,Issue2
E B C P G s o n t h e M a n a g e m e n to f A d u l t I n g u i n a l H e r n i a 45

TAPP procedure.Resultsshowedthatneuralgiasoccurred showedthat therewas no statisticaldifferencein the

in 3 TAPP and 1I casesof IPOMp < 0.05 andrecurrencesincidenceof recurrence: 0 in 263 nonstapled patients
occurred in no casesof TAPP and in 8 casesof IPOM :
and 3 in 273 stapledpatientschi-square(p 0.09).
(p5 0.01). Similarly,therewasnosignificant in operative
time,port-sitehernia,chronicpainor neuralgiabetween
3. Is fixation of the mesh necessaryin laparoscopic the two groups.
4. If openmeshrepairowhat is the recommended
It is not necessary to securethe mesh during technique?
laparoscopic TAPP or TEPPinguinalherniarepair.
(Level1 B, CategoryA) Therecommended techniquefor openmeshrepair
is the Lichtenstein,plugandmeshor ProleneHernia
Moreno-Egea, et al.ain December2004published System.(Level 1B,CategoryA)
in theArchivesof Surgerya randomized clinicaltrial of
fixationvs.nonfixationof meshin totalextraperitoneal ScottNW, McCormack,GrahamP, Go PMNYH,
inguinalhernioplasty. A total of 170 patientswere RossSJ, and GrantAM6 on behalfof the EU Hernia
assigned andfollowed-upfor 36 +12 months.Results TrialistCollaboratiorr in 2005publishedin TheCochrane
showedthattherewereno significantdifferences with Collaboration a reviewon openrneshversusnonmesh
regardto operatingtime, morbidity or recurrencesrepairfor groin hernia.The aim of the reviewwas to
(p<.001). evaluate meshtechniques in theopensurgicalrepairof
SmithAI, et al.5in 1999published in theJournalof groinhernias.Theopenflat mesh(Lichtenstein) repair
SurgicalEndoscopya prospectiverandomizedtrial was comparedwith plug and rnesh(plug and patch)
c o m p a r i n gs t a p l e da n d n o n s t a p l e dl a p a r o s c o p i crepair.Resultsshowedthattherewasinsufficierrtdata
transabdominal preperitoneal (TAPP)inguinalhernia to reliablyaddress differenttypesof openmeshrepair,
repair.A total of 502 patientswere randomized: 263 particularlyflat meshandplug andmeshrepairbut it
werenonstapled and273 werestapledrepairs.Patients seemed between
thattherewasno significantdifference
werefollowed-up for a medianof 16months.Results thetwo techniques.

Comparisonof Flat Mesh vs. Plug and Mesh.

Outcome Title Numberof Studies No. of Participants StatisticalMethod Effect Size

Duration of operation (mins) 2 220 Weighted Mean Difference 4.4sU..6s,7.2s)

(Fixed) 95% CI
Hematoma 2 111 Peto Odds Ratio 95% CI 1.04[0.06,16.s8]
Seroma 2 221 Peto Odds Ratio 95% CI 1.00[0.06,16.27]
Wound/superficial infection 2 221 Peto Odds Ratio 95% CI 3.s3[0.60,20.62]
Length ofstay (days) I 141 Weighted Mean Difference -0.07[-0.21,
(Fixed) 95% CI
Time to return to usual activities 2 2t4 Peto Odds Ratio 95% CI 1.09
Pain 0 0 Peto Odds Ratio 95% CI Not estimable
Numbness 0 0 Peto Odds Ratio 95% CI Not estimable
Recurrence 2 214 Peto Odds Ratio 95% CI 0 . 1 4[ 0 . 0 1 , 1 . 3 2 ]

Source:Scott NW, McCormack K, Graham P, Go PMNYH, RossSJ, Grant AM on behalf of the EU Hernia Trialists Collaboration.
Laparoscopictechniquesvs. open techniquesfor inguinal hernia repair. The CochraneDatabaseofSystematicReviews,2005, Issue2
46 PJSSVof. 62, No. l, January-March,2007

Niejhuijs SW, Van Oort I, Keemers-Gels ME, 5 . W h a t i s t h e r e c o m m e n d e d t r e a t m e n t f o r

StrobbeLJA andRosman C.7in January 2005published recurrent inguinal hernia?
in theBritishJournalof Surgerya randomized clinical The recommendedtreatmentfor recurrentinguinal
trial comparing the Prolene Hernia System (PHS), herniais meshrepair,eitherlaparoscopic or openmethod'
meshplug repair(MPR) andLichtensteinmethodfor (Level I A, CategoryA)
openinguinalherniarepair.A total of 334 patients Mc Cormack K, Scott NW, Go PMNYH, Ross S,
w e r ea l l o c a t ebdl i n d l y ,1 1I t o P H S ,1 1 3t o M P R a n d and Grant AMr on behalf of the EU Hernia Trialists
I l0 to Lichtenstein. The aim was to comparethe 3 Collaboration published in 2003 in The Cochrane
techniques of openmeshrepair.Shortand longterm Databaseof SystematicReviews a study comparing
r e s u l t s( 2 w e e k s ,3 m o n t h sa n d a t 1 5 m o n t h s laparoscopicrepair versus open repair for recurrent
postoperative follow up)weredetermined. Outcomes hernias.Twelve RCTs were included and subgroup
were postoperative pain and qualityof life. Results analysis on recurrent hernias was conducted'Results
s h o w e dt h a t p a t i e n t sr e p o r t e dn o d i f f e r e n c ei n showed the following: duration of operation was
postoperative painin thethreetypesof herniarepair in sighificantly longer for laparoscopicapproach but
the 1" l4 daysandmeanamountof paracetamol used hematoma,visceralinjury, persistingpain, persisting
per day was 1.9,1.6and l.8 grnafterPHS,MPR and numbness,seroma, and wound/superficial infection,
Lichtenstein repair,respectively. In conclusion, there hernia recurrencewere all comparable.Length of stay
wasnoclinicallysignificant difference in postoperative in the hospitalwas significantlyshorterfor laparoscopic
painandqualityof life amongthethreetypesof mesh approach and time to return to usual activities was
herniarepair. significantly faster for laparoscopicapproach'

Comparison of Laparoscopic vs. Open Repair for Recurrent Hernias

Outcome Title No. of Studies No. of Participants StatisticalMethod Effect Size

Duration of the operation (minutes) 14 448 Weighted Mean Difference r4.3r110.77,r7.851

(Fixed) 95% CI

Hematoma li 383 Peto Odds Ratio 95% CI 0 . 6 0[ 0 . 3 4 , 1 . 0 6 ]

Seroma 11 379 Peto Odds Ratio 95% CI | .39l0.67,2.901

Wound/superficial infection 11 383 Peto Odds Ratio 95% CI 0 . 5 0[ 0 . 1 7 , 1 . 4 6 ]

Mesh/deep infection 9 358 Peto Odds Ratio 95% CI 0 . 2 2[ 0 . 0 0 , 1 3 . 5 4 ]

Vascular injury 10 312 Peto Odds Ratio 95% CI Not estimable

Visceral injury 9 306 Peto Odds Ratio 95% CI 5.4710.10,293.681

Length ofstay (days) 12 367 Weighted Mean Difference 0 . 0 r[ - 0 . 1 3 , 0 . 1 5 ]

(Fixed) 95o/oCI

Time to return to usual activities(days) 11 262 Peto Odds Ratio 95% CI 0 . 6 0[ 0 . 4 6 , 0 . 7 8 ]

Persistingpain 9 331 Peto Odds Ration 95% CI 0 . 9 0[ 0 . 5 0 , 1 . s 9 ]

Persisting numbness 9 332 Peto Odds Ratio 95% CI 0 . 7 9[ 0 . 3 9 , 1 . 6 1 ]

Hernia recurrence t2 Peto oddsRatio 95% CI 1.04t0.45,2.431

Source: McCormack K, Scott NW, Go PMNYH, Ross S (EU Hernia Trialists Collaboration) The Cochrane Database of Systemattc
Reviews 2003, Laparoscopic techniques versus open techniquesfor inguinal hernia repair (Review)
E B C P G so n t h e M a n a g e m e notf A d u l t I n g u i n a lH e r n i a 47

Comparison of Laparoscopic vs. Open Repair for Recurrent Hernias and Time to Return to Usual Activities (days).
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't t tt'
McCormackK, ScottNW, Go PMNYH, RossS (EU HerniaTrialistsCollaboration) The Cochrane Database
versusopentechniquesfor inguinalherniarepair(Review).

Comparisonof Laparoscopic
Techniquesvs. OpenTechniquesin RecurrentInguinalHerniaRepairandRecurrence.

,f,' .r:rlri.r){rld}i;trr. Y 6'5r& ,:r gg9 cl

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l,]r !:.rtirsll dril*r:tt rj.rl alig{{.::!tjti:

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i i:j:::t l,rr i1d*r,:{*rrjfryr,:lltr + 1 1 .50,,jf : I tp } i I f t. t" - 3sr.t.*
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t,.0!11 flar 0.1

fe\:.irurs tr**mEd fa?$'Jr$.,trjfit.dl

Source: McCormack K, Scott NW, Go PMNYH, Ross S @U Hernia Trialists Collaboration) The Cochrane Database of
SystematicReviews 2003, Laparoscopic techniquesversus open techniquesfor inguinal hernia repair @eview)
48 PJSSVol.62,No. 1, January-March,2007

6. What is the recommendedtreatment for bilateral prospective randomized trial of laparoscopic

inguinal hernia? (transabdominalpreperitoneal)vs open (mesh) repair
for bilateralandrecurrentinguinalhernia.A total of 120
The recommended treatmentfor bilateralinguinal patientswith bilateralor recurrenthernias,42 recurrent
hernia is mesh repair, either laparoscopicor open. and70 bilateral.Sevenwereboth bilateralandrecurrent'
(Level l, CategoryA) Primary outcome was postoperativepain and the
secondary outcomes:well-being,post-opmobilization,
ScottNW, McCormackK, GrahamP, Go PMNYH, return to work. recurrencerate, chronic pain and
Ross SJ, and Grant AM8 on behalf of the EU Hernia complications. Results showed that there was
Trialists Collaborationpublishedin 2005 a study on differencein termsofrecurrence,incidenceof hematoma
laparoscopic techniques vs.opentechniques for inguinal and othercomplications.
analysisof bilateralherniaswas done.No significant Comparisonof LaparoscopicTechniquesvs. Open Mesh Techniques
differencesin recurrencerate.incidenceof hematoma, in Bilateral Inguinal Hernia Repair and Hernia Recurrence'
seroma.length of hospital stay, persistingpain and (+) Recurrence (-) Recurrence
n u m b n e s sb e t w e e n l a p a r o s c o p i ca n d o p e n m e s h
procedures werefound.Laparoscopic meshprocedures Laparoscopic A 55
Open I 59
had a longerdurationof operation,attd seemed to have
a h i g h e r i n c i d e n c eo f v i s c e r a l i n j u r y . L i k e w i s e , p = 0 . 3 5 1N S
laparoscopic meshprocedures had slightlylesswound/
superficialinfectionand shortertime to returtrto usual Estimate 9s%cr
activities. 3.068 -0.s32,34.332
Mahon D, Decadt B and Rhodes Me in 2003 ARI 0.051 - 0 . 0 2t 1
o 0.123
p u b l i s h e di n t h e J o u r n a l o f S u r g i c a l E n d o s c o p ya NNH 20.000 8 t o 4 8

Comparisonof Laparoscopicvs, Open (BilateralHernias)

Outcome title No. of Studies No. of Participants Statistical Method Effect Size

Duration of the operation(minutes) A

168 Weighted Mean Difference 1 2 . r 2 1. 9
78 , r 6 . 2 6 J
(Fixed) 95% CI

Hematoma 11 266 Peto Odds Ratio 95% CI 1 . 3 8[ 0 . 6 7 , 2 . 8 3 ]

Seroma 10 250 Peto Odds Ratio 95% CI 1 . 2 4 1 0 . s 6 ,s2). 7
Wound/ superficial infection 11 265 Peto Odds Ratio 95% CI 0 . 2 7[ 0 . 1 0 , 0 , 7 5 ]
v 4)LUr4r lruurj 8 185 Peto Odds Ratio 95% CI Not estimable
Visceraiinjury 9 232 Peto Odds Ratio 95% CI 5.16[0.09 ,286.571
292 Weighted Mean Difference -0.09 [0.19,0.01]
Length ofstay (days) 13
(Fixed) 95% CI
Time to retum to usual activities(days) r1 2t'7 Peto Odds Ratio 95% CI 0.s9[0.44,0.1e1
Persistingpain 7 223 Peto Odds Ration 95% CI 0 . 7 0[ 0 . 3 8 , 1 . 3 0 ]
Persistingnumbness 8 228 Peto Odds Ratio 95% CI 0 . 5 6[ 0 . 2 4 , 1 . 3 1 ] o
Hernia recurrence t2 227 Peto oddsRatio 95% CI 1 . 3 6[ 0 . s 5 , 3 . 3 7 ]

Source:Scott NW, McCormack, Graham P, Go PMNYH, RossSJ, Grant AM on behalf of the EU Hernia Trialist Collaboration
meshversusnon mesh for groin hernia repair @eview) The CochraneCollaborationThe CochraneLtbrary 2005, Issue2
E B C P G so n t h e M a n a g e m e notf A d u l t I n g u i n a lH e r n i a 49

Comparison of Laparoscopic Techniques vs. Open Techniques in Bilateral Inguinal Hernia Repair.
Cnrtrrs Pe'16 0R we|gt{
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Source:ScottNW, McCormack, Openmesh

GrahamP, Go PMNYH, RossSJ,GrantAM on behalfof theEU HerniaTrialistCollaboration
versusnon meshfor groinherniarepair(Review)The CochraneCollaboration Library2005,Issue2.

of Laparoscopic
Techniques in BilateralInguinalHerniaRepairandHerniaRecurrence.
)j.l.nJl Psl,j {rfi ,/Vegril Prtri (]Fl
'ir f, \ll!-Llrlle,:lit r/ rir! l !3$':!S.:l "*j 1rs."" {:.}

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ntragrtrt:{rt l'ii:11:1 l ./l 'it ;:fi fli ir.. ?3 {r:) s'$- l.€'. !:!:l
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Jtili 1*r $r'rirnJt r:ti*{:t .I ," lr $t} lF ". l, (r:i)

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ir :;l I s. h*l r::rilQeri*{1" nf,l {$pli{,,ttil,t
T*!i liir !:r-ar{'ll 'itltitl r,,r:if.t{tfr!'c$lill

I:) ) M1$f*ll.r.$.) L.ittrrrlr'rsc sFi:i

: : : \r t { d i t r'l$tti.'::.1 I
i,rt{l .F,..r,.d} l: ( l '.;d"reit), 1 : }{ i : l r . i t r r l t j
i t li i or l1{ gr,:rtf:ii€{i,.' f rtt $trDliiitf ,lt
I i. * lrtt ,]i4:r,11 Ait.r{ l: r}.:i .}l}ttll:,,!Ijij:

I,l)[ . nq
IS$l r\.di.)i: l1 aTres.lm*rlli. i \.:.,irtrrdl)
i.f!t 1ri h'3.iEf{IrjnfBii. r:}ri: = l: 1 1. dl ,, J {r' t: s 9} ;tx.
" {1.1}j,
i4ti ta,! {,,verill ijr!rc,:1 ll -.. {' i:j] | i: * 0 :!lr I

""l'.':::l,*1i,,',,** ''""'
Source: Scott NW, McCormack, Graham P, Go PMNYH, Ross SJ, Grant AM on behalf of the EU Hernia Trialist Collaboration Open mesh
versusnon mesh for groin hernia repair (Review) The Cochrane Collaboration The Cochrane Llorary 2005, Issue 2
50 2007
PJSSVol.62,No. l, January-lllarch'

Sarli L, IuscoDR, Sansebastiano C, Costi Rain hernia. The aim was to determine whether systemic
2001published in theJournalof SurgeryLaparoscopyantibiotic prophylaxispreventedwound infection after
andEndoscopy a prospective randomized studyof open repairof abdominalwall herniawith rnesh.The incidence
tension-free versuslaparoscopic approach in therepair of infection after groin herniarepair was 3 8 (3.0 %) of
of bilateralinguinalhernias.A total of 43 low risk 1277inthe placebogroupand l8 (l -5 %) of 1230in the
patientswererandomized with a blindenvelope system, antibiotic group. Antibiotic prophylaxis did not
singlesurgeon withadequate experience in laparoscopic significantly reduce the incidence of infection: odds
p r e p e r i t o n e a"lb i k i n i m e s h " ( T A P P ) v s . o p e n ratio0.54(95 %CI0.24to I .21);numberneededto treat
Lichtenstein hernioplasty. Therewasno differencein was74. The numberof deepinfectionswas six (0 '6 %)
operating time,95 +l- 32.3min vs.99 +l- 28.3min,no in the placebogroup and three (0'3 %) in the antibiotic
intraoperative complications for both,the intensityof prophylaxisgroup: odds ratio 0.50 (95 YoCl 0.12 to
postoperative painwasgreaterin the ogengroupat 24 2.09). Antibiotic prophylaxis did not prevent the
hours,48hoursand7 daysaftersurgery (p= 0.001) with occurrenceofwound infection after groin herniasurgery'
a greater consumption of painmedication amongthese
patients(p<0.05).Only I asymptomatic recurrence
(43%) wasdiscovered in theopengroup. ofProphylactic
Comparisons in MeshRepairs
in Abdominal Wall Hernia Repair and Wound Infection'

Prophylaxis Placebo OR (95%CI)

Median (25th-75thpercentile) Visual Analog Scale for Pain for
Laparoscopicvs Open Herniorrhaphy.
Superficial infection t8/1230 38/12770.s4(0.24,r.2l)
Deeo infections 3/ 1230 7/1277 o.50(0.12,
Time point Laparoscopic(n=20) Open (n=23)

| (1-2) 1(1-2) ns*' NNT = 74

6 hrspost-op 3 (2-s) 4 (2-6) ns*
12hrs 3 (2-4) 4 (2-6) ns* Source:Aufenacker, T. J, Koelemay, M.J'W, Gouma, D'J, and
24hrs 1(1-3) 4 (2-6) 0.001 S i m o n s , M . P . S y s t e m a t i c r e v i e w a n d m e t a - a n a l y s i so f t h e
48 hrs I (1-3) 3 (2-s) 0 . 0 0I effectiveness of antibiotic prophylaxis in prevention o[ wound
infection after mesh repair of abdominal wall hernia. Br J Surg 2005;
zs* not significant 93:5-10

SarliL, IuscoDR, Sansebastiano
Source: G, CostiR. Simultaneous
Repairof BilateralInguinalHernias:A Prospective, Sanchez-Manuel FJ and Seco-GilJL'l in 2004
StudyofOpen,Tension-Free versusLaparoscopic for herniarepair.This
Approach.Surg reviewedantibioticprophylaxis
LaparoscEndoscPercutan Tech2001.ll(4):262-267. of Systematic
wa's.published in theCochrane Database
Reviewsin June2004.Theobjectiveof this systematic
7. Is antimicrobial prophylaxis recommended for review was to clarify the effectiveness of antibiotic
elective groin hernia surgery? prophylaxisin reducing postoperative wound infection
rates in electiveopen inguinal hernia repair. Eight
A n t i m i c r o b i a lp r o p h y l a x i si s n o t r o u t i n e l y randomizedclinical trials were identified.Three of
recommended for electivegroin herniasurgeryusing t h e m u s e d p r o s t h e t i cm a t e r i a lf o r h e r n i a r e p a i r
mesh.(LevelI A, CategoryA) (hernioplasty) whereasthe remainingstudiesdid not
(herniorraphy). Pooledand subgroupanalysiswere
AufenackerTJ, KoelemayMJW, GoumaDJ and conducted depending on whetherprostheticmaterial
SimonsMPr0in 2005published in theBritishJournalof wasusedor not.'Thetotal numberof patientsincluded
Surgery a systematicreview and meta-analysisof the wasZg0T (treatment group:142l, controlgroup:I 486)'
of antibioticprophylaxisin prevention
effectiveness of Overallinfectionrateswere2.88percentand4 '3 percent
woundinfectionafter meshrepairof abdominalwall in the prophylaxisand control groups,respectively
E B C P G so n t h e M a n a g e m e notf A d u l t I n g u i n a lH e r n i a 5l

(OR0.65,95%Cl0.35 - I .21).(Thesubgroup of patients SchrenkP, Woisetschlaged R, RiegerR, Wayan W. Prospective

randomized trial comparingpostoperative pain andreturnto physical
with herniorrhaphy had infectionratesof 3.78percent activity after transabdominalpreperitoneal,total preperitonealor
and4.87percentin theprophylaxis andcontrolgroups, Shouldicetechniquefor inguinalherniarepair,Br J Surg 1996;
respectively(OR0.84,95%U 0.53- L34).Thesubgroup 83(ll):1563-1566.
3. SarliL, IuscoDR, Sansebastiano G. CostiR. Simultaneous repairof
of patientswith hernioplasty hadinfectionratesof 1.2 bilateralinguinalhernias: A prospective, randornized studyofopen,
percentand3.3 percentin the prophylaxisandcontrol tension-free versuslaparoscopic approach.Surg LaparoscEndosc
groups,respectively (OR 0.28,95%U 0.02 - 3.14). Percutan Tech200I : 11(4): 262-267 .
Moreno-Egea, et al. Randonrized clinical trial of fixation vs.
Basedon theresultsof thismeta-analysis, therewasno nonfixationof meshin total extraperitoneal inguinalhernioplasty.
clearevidence thatroutineadministration of antibiotic Arch Surg2004;139(12): 1376-1379.
SmithAI, et al. Stapledandnonstapled laparoscopic transabdominal
prophylaxis for electiveinguinalherniarepairreduced preperitoneal (TAPP)inguinalherniarepair.A prospective randomized
infectionrates. trial. SurgEndosc1999;l3(8): 804-806.
o . ScottNW, McCormack, GrahamP, Go PMNYH,RossSJ,GrantAM
on behalfoftheEU HerniaTrialistCollaboration Opennresltversus
nonmeshfor groinherniarepair(Review) TheCochrane Collaboration
ComparisonsofProphylacticAntibioticvs. Placeboin Open Inguinal TheCochrane Library2005,Issue2.
Hernia Repair and Wound Infection. NiejhuijsSW,vanOortI, Keemers-Gels ME, Strobbe LJA,Rosman C.
Randomized clinical trial comparingthe ProleneHerniaSystem,
Prophylaxis(%) Control(%) OR (95%CI) meshplug repairand Lichtenstein methodfor openinguinalhernia
r e p a i rB. r J S u r g2 0 0 5 :9 2 ( l ) : 3 3 - 3 8 .
0verall ScottNW, McCormackK, GrahamP, Go PMNYH, RossSJ,Grant
infectionrate 41/1421(2.88) 64/1486(4.3) 0 , 6 5 ( 0 . 3 51, . 2 1 ) AM on behalfoftheEU HerniaTrialistsCollaboration. Laparoscopic
techniques vs.opentechniques for inguinal herniarepair.TheCochrane
Herniorrhaphy 35/924(3.78) 46/943(4.87) 0.84(0.s3, 1.34) Database of Systematic Reviews, 2005,tssue2.
9 . MahonD, DecadtB, RhodesM. Prospective randomized trial of
Herniopiasty 5/373(t.2) t8/420(3.3) 0.28(0.02,3.r4) laparosoopic (transabdominal preperitoneal) vs. open(mesh)repair
for bilateraland recurrentinguinalhernia.SurgEndosc2003; l7:
Source:Sanchez-ManuelFJ and Seco-GilJL. Antibiotic Prophylaxis r386-1390,
for hernia repair (Review) The Cochrane Collaboration The l 0 AufenackerTJ, KoelemayMJW, Gouma DJ and Simons MP.
Cochrane Library 2004, Issue I Systematic reviewandmeta-analysis of theeffectiveness of antibiotic
prophylaxis in prevention of wound infectionaftermeshrepairof
abdominal wall hernia.Br J Surg2005;93: 5-l 0.
ll Sanchez-Manuel FJ and Seco-GilJL. Antibiotic prophylaiisfor
References herniarepair(Review)The CochraneCollaboration The Cochrane

l. McCormack K, ScottNW, Co PMNYH,RossS (EU HerniaTrialists

Reviews2003; 5-6, 43-46.