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Experts evaluate strategies for management of recurrent inguinal hernias

Thursday, October 16 2008 | Comments
Evidence Grade 0 What's This?
By Courtneay Parsons

The optimal approach to managing recurrent inguinal hernias remains a controversial topic, but a successful strategy must consider the primary repair performed, the patient's presentation, and the experience of the surgeon, according to experts who discussed the merits of watchful waiting, open repair, and laparoscopic techniques.

The debate surrounding the management of recurrent inguinal hernias has revolved almost exclusively around the type of surgical approach to use. However, there is at least some evidence to suggest that a strategy of watchful waiting might be appropriate for asymptomatic or minimally symptomatic patients, according to Dr. Robert Fitzgibbons of Creighton University Medical Center in Omaha, NE.

In evaluating the benefits of a watchful waiting strategy, Dr. Fitzgibbons noted that the likelihood of hernia recurrence generally increases with each operation a patient undergoes. Additionally, data suggest that a cautious wait-and-see approach is acceptable from a cost perspective.

Virtually all of the evidence to support this strategy for the management of recurrent inguinal hernias has been extrapolated from findings in patients who underwent primary hernia repair, he added. Dr. Fitzgibbons cited a randomized controlled trial of 753 patients who received either a Lichtenstein repair or a watchful waiting strategy. This analysis showed no significant differences in levels of pain or physical function. In addition, a secondary analysis of these data showed no differences between individuals who had surgery within 6 months and those who delayed surgery in terms of operation times, complications, recurrence rates, or patient satisfaction; delaying surgery also seemed to be safe, with an accident (strangulation or bowel obstruction) rate of 0.0018 event per patient-year.

Regarding the surgical approaches to treatment, there is evidence to support open-repair approaches, even in the era of laparoscopic surgery, according to Dr. Samir Awad with the Baylor College of Medicine in Houston, TX. He cited multiple studies published during the last 8 years that have shown various open-repair approaches to be safe, effective, and easier to learn than laparoscopic techniques.

One of the more recent studies cited by Dr. Awad was a randomized, multicenter trial of 147 patients with recurrent inguinal hernias (Eklund A, et al. Surg Endosc 2007;21:634-640.). The trial, which compared laparoscopic (transabdominal preperitoneal patch [TAPP]) and Lichtenstein repairs for recurrent inguinal hernias showed no significant between-group differences in the long-term rates of chronic pain or hernia recurrence.

However, Dr. George Ferzli with the Lutheran Medical Center in Brooklyn, NY, and Dr. Quan-Yang Duh with the University of California, San Francisco, argued in favor of a laparoscopic rather than an open-repair approach and emphasized the use of both TAPP and total extraperitoneal (TEP) hernia repair.

Advantages associated with laparoscopic surgery include less postoperative pain as well as an earlier return to work and daily activities, Dr. Ferzli noted. In addition, TAPP has the potential to identify bilateral disease as well as other concurrent hernias in that the technique allows for full visualization of the area.

With respect to re-recurrence rates, the benefits of laparoscopic surgery are slightly less straightforward, Dr. Ferzli added, particularly since the likelihood of any recurrence after laparoscopic repair is strongly linked with the skill level of the surgeon.

To further evaluate the issue of re-recurrence rates with laparoscopic versus open repair, Dr. Duh highlighted 2 recent studies. The first study (Bisgaard T, et al. Ann Surg 2008;247:707-711.) showed a lower re-operation rate with laparoscopic surgery (versus open repair) following primary Lichtenstein repair, and a trend toward a lower operation rate after primary repair with nonmesh or non-Lichtenstein mesh, but there was no significant difference between laparoscopic and open repair following primary laparoscopic repair.

The second study (Neumayer L, et al. N Engl J Med 2004;350:1819-1827.) suggested the 2-year recurrence rate after primary repair was higher with laparoscopic than with open mesh repair (10.1% vs 4.0%), but recurrence rates were similar between the 2 groups after recurrent hernia repair (10.0% vs 14.1%). Interestingly, Dr. Duh noted, the recurrence rate for hernias increased from the primary surgery to the subsequent surgery with open-mesh repair (from 4.0% to 14.1%). By contrast, when the hernia was managed laparoscopically, the risk of recurrence did not increase from the first to the second procedure (approximately 10% for both).

Regarding differences in the 2 laparoscopic approaches, Dr. Duh conceded that there are no randomized trials comparing TAPP and TEP hernia repair, such that the choice of one over another is often a matter of personal preference. While TAPP affords a more complete view of the anatomy, TEP allows the surgeon to treat the hernia without going into the abdomen, a particular advantage for patients with previous abdominal operations.

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