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Surgical Options for Inguinal Hernia: Comparative Effectiveness Review
Comparative Effectiveness Reviews, No. 70
Investigators: Jonathan Treadwell, PhD, Kelley Tipton, MPH, Olu Oyesanmi, MD, MPH, Fang Sun, MD, PhD, and Karen Schoelles, MD, SM, FACP.
Author Information and AffiliationsStructured Abstract
Objective:
The objective of this study was to comprehensively review the evidence to inform key decisions in the management of inguinal hernia in adults and pediatric patients. These questions include whether to repair a pain-free hernia or “wait and see,” and whether to repair a painful hernia using an open or laparoscopic approach. They also include which procedure to use if an open approach is used; which procedure to use if a laparoscopic approach is used; which type of mesh to use; which mesh fixation method (if any) to use; how experience with laparoscopic repair may be related to the risk of hernia recurrence; for pediatric hernia, whether to surgically explore a possible contralateral hernia or “wait and see”; and for pediatric hernia, whether to repair using an open or laparoscopic approach.
Data Sources:
MEDLINE®, PreMEDLINE, Embase, Cochrane Library, and reference lists. The last search date was November 17, 2011.
Review Methods:
We refined the topic with Key Informants and finalized the protocol with Technical Expert Panel members. We determined the study inclusion criteria as well as the risk-of-bias items a priori. Study information was extracted into tables regarding general information, patient enrollment criteria, baseline characteristics, risk-of-bias items, and data. We performed meta-analysis where appropriate and rated the strength of evidence for major comparisons and outcomes. We discussed applicability by focusing on the population, interventions, and settings of the included studies separately for each clinical question.
Results:
We included 223 publications describing 151 unique studies: 123 were randomized controlled trials (RCTs), 2 were registries, and 26 had other designs (included only for the laparoscopic surgical experience question). The evidence came from international sources; only 10 percent of the studies were conducted exclusively in the United States. The risk of bias was moderate for most outcomes in the RCTs but high in the registries. For painless hernia, evidence was mostly insufficient to permit conclusions, but quality of life at 1 year was better after surgery than watchful waiting. For painful primary hernias in adults, the risk of recurrence was lower after open surgery than after laparoscopy, whereas for recurrent hernia, this risk was lower after laparoscopic repair. Other outcomes, including short-term recovery and long-term pain, favored laparoscopic repair over open repair. Different open repair procedures generally yielded similar results, and transabdominal preperitoneal repair had the same or better outcomes compared with other laparoscopic procedures. Different meshes and fixation approaches often showed similar results. Many studies reported that surgical experience lowers the risk of recurrence after laparoscopic repair, but the data were reported unevenly and do not permit any estimate of the length of the learning curve. For pediatric hernia, no studies have compared surgical exploration for a contralateral hernia with watchful waiting, but comparing laparoscopy versus open high ligation, outcomes generally favored laparoscopy.
Conclusions:
Patients, families, and providers can use this evidence review to improve decisionmaking about inguinal hernia. The applicability of our findings is limited to the types of populations, procedures, and settings in the included studies. The typical patient was a middle-aged man of average weight with primary unilateral inguinal hernia.
Contents
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Results
- Overall Description of Included Studies
- Key Question 1 Pain-free hernia: Does hernia repair differ from watchful waiting in patient-oriented effectiveness outcomes and/or adverse events?
- Key Question 2a Does open hernia repair with a mesh differ from laparoscopic hernia repair with a mesh in patient-oriented effectiveness outcomes and/or adverse events? Primary hernias
- Key Question 2b Does open hernia repair with a mesh differ from laparoscopic hernia repair with a mesh in patient-oriented effectiveness outcomes and/or adverse events? Bilateral hernias
- Key Question 2c Does open hernia repair with a mesh differ from laparoscopic hernia repair with a mesh in patient-oriented effectiveness outcomes and/or adverse events? Recurrent hernias
- Key Question 3 Do different open mesh-based repair procedures (e.g., Lichtenstein repair, mesh plug) differ in patient-oriented effectiveness outcomes and/or adverse events?
- Key Question 4 Do different laparoscopic mesh-based repair procedures (e.g., transabdominal preperitoneal repair, totally extraperitoneal repair) differ in patient-oriented effectiveness outcomes and/or adverse events?
- Key Question 5 Do different mesh products differ in patient-oriented effectiveness outcomes and/or adverse events?
- Key Question 6 Do different mesh-fixation methods (e.g., no fixation, sutures, glue) differ in patient-oriented effectiveness outcomes and/or adverse events?
- Key Question 7 For each type of laparoscopic mesh repair, what is the association between surgical experience and hernia recurrence?
- Key Question 8 Pediatric patients: For a possible contralateral hernia, does same-operation repair/exploration differ from watchful waiting in patient-oriented effectiveness outcomes and/or adverse events?
- Key Question 9 Pediatric patients: Does open hernia repair without a mesh differ from laparoscopic hernia repair without a mesh in patient-oriented effectiveness outcomes and/or adverse events?
- Discussion
- References
- Glossary of Procedures
- Abbreviations
- Appendix A Search Strategy
- Appendix B Excluded Studies
- Appendix C Evidence Tables
- Appendix D References for Appendixes B and C
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10063. Prepared by: ECRI Institute Evidence-based Practice Center, Plymouth Meeting, PA
Suggested citation:
Treadwell J, Tipton K, Oyesanmi O, Sun F, Schoelles K. Surgical Options for Inguinal Hernia: Comparative Effectiveness Review. Comparative Effectiveness Review No. 70. (Prepared by the ECRI Institute Evidence-based Practice Center under Contract No. 290-2007-10063.) AHRQ Publication No. 12-EHC091-EF. Rockville, MD: Agency for Healthcare Research and Quality. August 2012. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the ECRI Institute Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10063). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
- 1
540 Gaither Road, Rockville, MD 20850; www
.ahrq.gov
- Review Laparoscopic versus open umbilical or paraumbilical hernia repair: a systematic review and meta-analysis.[Hernia. 2017]Review Laparoscopic versus open umbilical or paraumbilical hernia repair: a systematic review and meta-analysis.Hajibandeh S, Hajibandeh S, Sreh A, Khan A, Subar D, Jones L. Hernia. 2017 Dec; 21(6):905-916. Epub 2017 Oct 14.
- [Open mesh technique versus laparoscopic transabdominal preperitoneal (TAPP) approach in inguinal hernia repair. Our experience].[G Chir. 2008][Open mesh technique versus laparoscopic transabdominal preperitoneal (TAPP) approach in inguinal hernia repair. Our experience].Pironi D, Palazzini G, Panarese A, La Gioia G, Vendettuoli M, Romani AM, Filippini A. G Chir. 2008 Nov-Dec; 29(11-12):497-504.
- Initial experience with the use of fibrin sealant for the fixation of the prosthetic mesh in laparoscopic transabdominal preperitoneal hernia repair.[Rozhl Chir. 2005]Initial experience with the use of fibrin sealant for the fixation of the prosthetic mesh in laparoscopic transabdominal preperitoneal hernia repair.Langrehr JM, Schmidt SC, Neuhaus P. Rozhl Chir. 2005 Aug; 84(8):399-402.
- National results after ventral hernia repair.[Dan Med J. 2016]National results after ventral hernia repair.Helgstrand F. Dan Med J. 2016 Jul; 63(7).
- Review Meta-analysis of randomized controlled trials comparing laparoscopic with open mesh repair of recurrent inguinal hernia.[Br J Surg. 2010]Review Meta-analysis of randomized controlled trials comparing laparoscopic with open mesh repair of recurrent inguinal hernia.Karthikesalingam A, Markar SR, Holt PJ, Praseedom RK. Br J Surg. 2010 Jan; 97(1):4-11.
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