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Inguinal hernia

Inguinal hernias are protrusions of abdominal cavity contents through an area of the abdominal wall, commonly referred to as the groin, and known in anatomic language as the inguinal area or the myopectineal orifice. They are very common and their repair is one of the most frequently performed surgical operations. They usually arise as a consequence of the descent of the testis from the abdomen into the scrotum during early fetal life, and are therefore far more commonly seen in men than women. They present as painless bulges in the groin area that can become more prominent when coughing, straining, or standing up. The bulge commonly disappears on lying down. more...

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The presence of pain, or the inability to "reduce" the bulge back into the abdomen, usually indicates the onset of complications.

As the hernia progresses, contents of the abdominal cavity, such as the intestine, can descend into the hernia and run the risk of being strangulated within the hernia, causing an intestinal obstruction. If the blood supply of the portion of the intestine that is caught in the hernia is compromised, gut ischemia and gangrene can result, with serious consequences. The time of occurrence of complications is not predictable; some hernias can remain static for years, others can progress rapidly from the time of onset. Therefore, provided there are no serious co-existing medical problems, patients are advised to get the hernia repaired surgically at the earliest convenience after a diagnosis is made. Emergency surgery for complications such as obstruction and strangulation carry much higher risk than planned, "elective" procedures.

Despite the profusion of medical technology that is now available, the diagnosis of inguinal hernia rests on the history given by the patient and the physician's findings on examination of the groin. No tests are needed to confirm the problem.

Surgical correction of inguinal hernia is a simple operation that is now done in most places as an ambulatory or "day surgery" procedure. A workable technique of repairing hernia was first described by Bassini in the 1800s; the Bassini technique was a "tension" repair, one in which the edges of the defect are simply sewn back together without any reinforcement or prosthesis. Although tension repairs are no longer the standard of care due to their high recurrence rates, long recovery period and severe post-operative pain, a few tension repairs are still in use today; these include the Shouldice and the Cooper's/McVay repair.

Almost all repairs done today are open "tension-free" repairs that involve the placement of a synthetic mesh to strengthen the inguinal region; some popular techniques include the Lichtenstein repair (flat mesh patch placed on top of the defect), Plug and Patch (mesh plug placed in the defect and covered by a Lichtenstein-type patch), Kugel (mesh device placed behind the defect), and Prolene Hernia System (2-layer mesh device placed over and behind the defect). The meshes used are typically made from polypropylene or polyester, although some companies market Teflon meshes and partially absorbable meshes. The operation is typically performed under local anesthesia, and patients go home within a few hours of surgery, often requiring no medication beyond over-the-counter pain relievers such as aspirin or acetaminophen. Patients are encouraged to walk and move around immediately post-operatively, and can usually resume all their normal activities within a week or two of operation. Recurrence rates are very low - one percent or less compared with over 10% for a tension repair.

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Laparoscopic versus open mesh repair of inguinal hernia
From British Medical Journal, 5/1/99 by James Wellwood

EDITOR--Our paper on hernia repair produced much correspondence.[1 2] In response to the letter from Notaras we agree that patients unfit for general anaesthetic, and therefore not suitable for laparoscopic repair, would be suitable for local anaesthetic, and this is how we would treat them. We do not agree that the reduced pain after laparoscopic repair, the improved quality of life, and the faster return to work and other activities are unimportant to the patient. Our view that these constitute important improvements from the patients' perspective is borne out by our table showing patient satisfaction (table 6).

Rose et al point out the absence of serious complications in any of our patients. We state in our discussion that our trial was not powered to detect a difference in serious but rare complications. Good training is essential to avoid these. We have not experienced such complications (vascular injury, gut injury, etc) in over 1000 laparoscopic repairs. Figure 3 in our paper was coloured erroneously in the published article and an erratum has been printed. It shows that the patients having unilateral and bilateral laparoscopic repairs (unbroken lines) returned to normal activities more quickly than either the patients who had unilateral open repair or those who had bilateral open repairs (broken lines).

We congratulate Kark et al on their figures for return to work after open mesh repair. It is only fair to point out that their patients are self paying and may be under more pressure to return to work. They may also have a younger average age. We agree with Taylor et al that the hospital cost of laparoscopic repair may be reduced, and we have stated this at the end of the article.

Anayanwu and O'Riordan are concerned that trainees and consultants may not have a standardised surgical technique, but this is not the case. The operating technique was standardised and the surgeon designated before randomisation. We do not feel it was possible to blind surgeons, patients, and assessors in our trial as informed consent included the description of wounds and their position and the use of local anaesthetic for the open repair only. Can the authors tell us how blinding could have been achieved?

On the issue of whether observational studies are less biased than unblinded clinical trials, most of our outcomes were measured by questionnaires completed by the patients and did not require professional judgment.

In answer to Kernick and Reinhold, costing the difference between the treatments in recovery times (and hence in healthy time at work or undertaking other activities) is an area of methodological controversy.[3] However, we did present information on recovery times that would facilitate an estimate of differential productivity costs. The question of the relative cost effectiveness of the procedures has also been raised. We did not address this in the paper. Such an analysis requires assessment of the extent to which any additional cost of laparoscopic repair (and our sensitivity analysis showed this to be sensitive to the use of disposables with the procedure) is justified by an overall improvement in outcome. This requires outcomes to be valued on a single dimension and in generic units that can be compared with other uses of healthcare resources. Future research is currently being planned to address this question.

James Wellwood Consultant surgeon Whipps Cross Hospital, London E11 1NR

Mark Sculpher Senior research fellow Centre for Health Economics, University of York, York YO1 5DD

David Stoker Consultant surgeon North Middlesex Hospital, London N18 1QX dlstoker1@aol.com

[1] Wellwood J, Sculpher MJ, Stoker D, Nicholls GJ, Geddes C, Whitehead A, et al. Randomised controlled trial of laparoscopic versus open mesh repair of inguinal hernia: outcome and cost. BMJ 1998;317:103-10. (11 July.)

[2] Correspondence. Laparoscopic versus open mesh repair of inguinal hernia. BMJ 1999;318:189-91. (16 January.)

[3] Gold MR, Siegel JE, Russell LB, Weinstein MC. Cost effectiveness in health and medicine. New York, NY: Oxford University Press, 1996.

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