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Surgical Management of Inguinal Hernia

Surgical Management of Inguinal Hernia. Prepared for: Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov. Outline of Material. Agency for Healthcare Research and Quality Comparative Effectiveness Review (CER) Process Background Clinical Questions Addressed in the CER

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Surgical Management of Inguinal Hernia

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  1. Surgical Management of Inguinal Hernia Prepared for: Agency for Healthcare Research and Quality (AHRQ) www.ahrq.gov

  2. Outline of Material • Agency for Healthcare Research and Quality Comparative Effectiveness Review (CER) Process • Background • Clinical Questions Addressed in the CER • Clinical Bottom Line: Summary of CER Results • Conclusions • Gaps in Knowledge • Resources for Shared Decisionmaking

  3. Agency for Healthcare Research and Quality (AHRQ) Comparative Effectiveness Review (CER) Development • Topics are nominated through a public process, which includes submissions from health care professionals, professional organizations, the private sector, policymakers, the public, and others. • A systematic review of all relevant clinical studies is conducted by independent researchers, funded by AHRQ, to synthesize the evidence in a report summarizing what is known and not known about the select clinical issue. The research questions and the results of the report are subject to expert input, peer review, and public comment. • The results of these reviews are summarized into a Clinician Research Summary and a Consumer Research Summary for use in decisionmaking and in discussions with patients. The Research Summaries and the full report are available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  4. Strength of Evidence Ratings • The strength of evidence ratings are classified into four broad ratings: AHRQ Methods Guide for Effectiveness and Comparative Effectiveness Reviews. Available at www.effectivehealthcare.ahrq.gov/methodsguide.cfm.Owens DK, Lohr KN, Atkins D, et al. J Clin Epidemiol. 2010 May;63(5):513-23. PMID: 19595577. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  5. Background: Inguinal Hernias in Adults • An inguinal hernia is a protrusion of abdominal contents into the inguinal canal through an abdominal wall defect. • Approximately 4.5 million people in the United States have an inguinal hernia. • Around 500,000 new inguinal hernias are diagnosed annually. • The lifetime risk of inguinal hernia is about 25 percent in males and 2 percent in females. • Inguinal hernia can affect all ages, but the risk for one increases with age. • Approximately 20 percent of hernia cases are bilateral. Abramson JH, et al. J Epidemiol Community Health. 1978;32:59-67. Available at http://www.ncbi.nlm.nih.gov/pubmed/95577.Everhart, JE, ed. Digestive diseases in the United States: epidemiology and impact. Washington, DC: US Government Printing Office, 1994; NIH publication no. 94-1447.Goroll AH, et al. Primary care medicine: office evaluation and management of the adult patient, 5th ed. Philadelphia, Lippincott Williams & Wilkins; 2005:431-434.Nicks BA. Hernias. Medscape Reference: Drugs, Diseases, and Procedures. Last Updated June 6, 2012. Available at http://emedicine.medscape.com/article/775630-overview. Accessed April 30, 2013.Rutkow IM. Surg Clin North Am. 1998;78:941-951. Available at http://www.ncbi.nlm.nih.gov/pubmed/9927978. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  6. Background: Inguinal Hernias in Children • The incidence of inguinal hernia in children ranges from 0.8 to 4.4 percent. • It is 10 times as common in boys as in girls. • It is more common in infants born before 32 weeks’ gestation (13% prevalence) and in infants weighing less than 1,000 grams at birth (30% prevalence). Brandt ML. Pediatric hernias. Surg Clin North Am. 2008 Feb;88(1):27-43, vii-viii. PMID: 18267160. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  7. Direct and Indirect Inguinal Hernias • A direct inguinal hernia protrudes through the inguinal floor—defined by Hesselbach's triangle, the pubic tubercle, the lateral border of the rectus, and the inguinal ligament—and accounts for one-third of all inguinal hernias. • An indirect inguinal hernia protrudes through the internal inguinal ring and may descend through the inguinal canal and accounts for about two-thirds of all inguinal hernias. • Direct hernias typically develop only in adulthood and are more likely to recur than indirect hernias. Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al. JAMA. 2006 Jan 18;295(3):285-92. PMID: 16418463. Simons MP, Aufenacker T, Bay-Nielson M, et al. Hernia. 2009 Aug;13(4):343-403. PMID: 19636493. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  8. Symptoms of Inguinal Hernias • If the hernia is severe enough to restrict blood supply to the intestine, it is termed a strangulated hernia; immediate corrective surgery of this type of hernia is necessary. • Most inguinal hernias, however, are less dangerous, and elective surgery is often performed to correct the defect. • Symptoms include abdominal pain and a lump in the groin area, which is most easily palpated during a cough. • Some inguinal hernias, however, are asymptomatic and are only detected by palpation during a cough. Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al. JAMA. 2006 Jan 18;295(3):285-92. PMID: 16418463. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  9. Surgical Repair of Inguinal Hernias • Surgical repair of inguinal hernias is the most commonly performed general surgical procedure in the United States. • About 770,000 surgical repairs were performed in 2003. • Most repairs (87%) are performed on an outpatient basis. • The primary goals of surgery are to: • Repair the hernia • Minimize the chance of recurrence • Return the patient to normal activities quickly • Improve quality of life • Minimize postsurgical discomfort and the adverse effects of surgery Rutkow IM. Surg Clin North Am. 2003 Oct;83(5):1045-51, v-vi. PMID: 14533902. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm. Zhao G, Gao P, Ma B, et al. Ann Surg. 2009 Jul;250(1):35-42. PMID: 19561484.

  10. Types of Surgical Repair for Inguinal Hernias • Surgical repairs of inguinal hernia generally fall into three categories: • Open repair without a mesh implant (i.e., sutured) • Open repair with a mesh • Laparoscopic repair with a mesh • Several procedures have been employed within each of these categories. • The nearly universal adoption of mesh (except in pediatric cases) means that the most relevant questions about hernia repair involve various mesh procedures. Brandt ML. Surg Clin North Am. 2008 Feb;88(1):27-43, vii-viii. PMID: 18267160. Rutkow IM. Surg Clin North Am. 2003 Oct;83(5):1045-51, v-vi. PMID: 14533902. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  11. Example:Open Mesh-Based Repair of an Inguinal Hernia Before After Mesh

  12. Example: Laparoscopic Mesh-Based Repairof an Inguinal Hernia Laparoscope Small cuts aremade to insertthe tools

  13. Open Mesh-Based Repair of Inguinal Hernias(1 of 2) • Kugel® patch repair: An oval-shaped mesh is held open by a memory recoil ring and inserted behind the hernia defect and held in place with a single suture. • Lichtenstein technique: A tension-free open repair wherein mesh is sutured in front of the hernia defect (anteriorly). • Mesh plug technique: A preshaped mesh plug is introduced into the hernia weakness during surgery and a piece of flat mesh is put on top of the hernia. • Open preperitoneal mesh technique: A tension-free repair wherein mesh is sutured posteriorly. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  14. Open Mesh-Based Repair of Inguinal Hernias(2 of 2) • PROLENE™ Hernia System: A one-piece mesh device constructed of an onlay patch connected to a circular underlay patch by a mesh cylinder. • Read-Rives repair: A tension-free repair wherein mesh is placed just over the peritoneum. • Stoppa technique: A large polyester mesh is interposed in the preperitoneal connective tissue between the peritoneum and the transversalis fascia to prevent visceral sac extension through the myopectineal orifice. • Trabucco technique: A hernia repair procedure that involves placing a single preshaped mesh without using sutures. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  15. Laparoscopic Mesh-Based Repair Procedures for Inguinal Hernias • Intraperitoneal onlay mesh technique: A mesh is placed under the hernia defect intra-abdominally to circumvent a groin dissection. • Totally extraperitoneal technique: The peritoneal cavity is not entered, and a mesh is used to cover the hernia from outside the preperitoneal space. • Transabdominal preperitoneal technique: A laparoscopic repair procedure wherein the surgeon enters the peritoneal cavity, incises the peritoneum, enters the preperitoneal space, and places the mesh over the hernia; the peritoneum is then sutured and tacked closed. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  16. Surgical Mesh Products for Hernia Repair • Surgical mesh products are typically made from polypropylene or polyester. • Other available materials include: • Polytetrafluoroethylene • Polyglactin • Polyglycolic acid • Polyamide Mohamed H, Ion D, Serban MB, et al. J Med Life. 2009 Jul-Sep;2(3):249-53. PMID: 20112467. Robinson TN, Clarke JH, Schoen J, et al. Surg Endosc. 2005 Dec;19(12):1556-60. PMID: 16211441. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  17. Properties of Mesh Products for Hernia Repair • Seven important properties of mesh are: • Withstands physiologic stresses over time • Conforms to the abdominal wall • Mimics normal tissue healing • Resists the formation of bowel adhesions and erosions into visceral structures • Does not induce allergic reaction or foreign body reactions • Resists infection • Is noncarcinogenic Mohamed H, Ion D, Serban MB, et al. J Med Life. 2009 Jul-Sep;2(3):249-53. PMID: 20112467. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  18. Clinical Questions Addressed in theComparative Effectiveness Review • What is the comparative effectiveness of: • Laparoscopic versus open repair in adults with painful hernia (primary, bilateral, and recurrent hernia)? • Different types of repair for the pediatric population? • Surgery versus watchful waiting in adults with a pain-free or minimally symptomatic inguinal hernia? • Different types of open surgery? • Different types of laparoscopic surgery? • Different mesh materials? • Different mesh-fixation approaches? • Is there an association between surgical experience and hernia recurrence? Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  19. Outcomes of Interest • Outcomes • Hernia recurrence • Hospital-related information (length of hospital stay and hospital/office visits) • Return to daily activities • Return to work • Quality of life • Patient satisfaction • Short-term pain (≤1 month after surgery) • Intermediate-term pain (>1 and <6 months after surgery) • Long-term pain (≥6 months after surgery) • Adverse effects • Infection • Perception of a foreign body • Small-bowel perforation/obstruction • Hematoma • Epigastric vessel injury • Urinary retention • Spermatic cord injury • Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  20. Results: Overview of the Patient Population • Patient Population • The typical adult in the studies included in this review was: • A man in his mid 50s • Who was of average weight (median body mass index of 25.3 kg/m2; interquartile rage of 25.0–26.7) • Who had an elective repair of a primary unilateral inguinal hernia • About a quarter of the men worked in physically strenuous jobs; for these men, a durable repair is important to prevent a recurrence. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  21. Results: Overview of Studies Included in the Comparative Effectiveness Review • Total included studies: N = 151 • Open versus laparoscopic repair in adults: • Primary hernias; n = 38 • Bilateral hernias; n = 6 • Recurrent hernias; n = 8 • Open versus laparoscopic high ligation for pediatric hernias; n = 2 • Repair versus watchful waiting in adults with pain-free hernias; n = 2 • Open mesh-based procedures; n = 21 • Laparoscopic procedures; n = 11 • Mesh materials; n = 32 • Fixation methods; n = 23 • Surgical experience and hernia recurrence; n = 32 Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  22. Clinical Bottom Line: Laparoscopic Versus Open Repair of Painful Primary Hernias in Adults—Included Studies • Thirty-eight studies met the inclusion criteria. • The most commonly compared procedures include: • TAPP repair versus Lichtenstein (n = 14) • TEP repair versus Lichtenstein (n = 14) • TAPP repair versus mesh plug (n = 3) • TEP repair versus mesh plug (n = 3) • TAPP repair/TEP repair versus Lichtenstein (n = 4) Abbreviations: TAPP = transabdominal preperitoneal; TEP = totally extraperitoneal Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  23. Clinical Bottom Line: Laparoscopic Versus Open Repair of Painful Primary Hernias in Adults (1 of 2) Abbreviations: 95% CI = 95-percent confidence interval; RR = relative risk; SOE = strength of evidence; SWMD = summary weighted mean difference Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  24. Clinical Bottom Line: Laparoscopic Versus Open Repair of Painful Primary Hernias in Adults (2 of 2) Abbreviations: 95% CI = 95-percent confidence interval; OR = odds ration; SOE = strength of evidence Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  25. Clinical Bottom Line:Surgical Repair of Bilateral Hernias • Patients with bilateral hernias return to work about 2 weeks sooner after laparoscopic (TAPP or TEP) repair versus open (Lichtenstein or Stoppa) repair.Strength of Evidence = Low • Evidence was inconclusive for all other outcomes and adverse effects for laparoscopic versus open repair of bilateral hernias. Abbreviations: TAPP = transabdominal preperitoneal; TEP = totally extraperitoneal Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  26. Clinical Bottom Line: Laparoscopic Versus Open Repair of Recurrent Hernias Abbreviations: 95% CI = 95-percent confidence interval; OR = odds ratio; RR = relative risk; SOE = strength of evidence; SWMD = summary weighted mean difference; TAPP = transabdominal preperitoneal; TEP = totally extraperitoneal Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  27. Open Versus Laparoscopic High Ligation for Pediatric Hernias (Ages 3 Months to 15 Years) • Laparoscopic repair is favored for three outcomes, although some of the differences may not be clinically relevant: • Long-term overall patient/parent satisfaction (difference in satisfaction points = 1.00; 95% CI, 0.47 to 1.53)Strength of Evidence: Low • Length of hospital stay (summary difference = 1 hour; 95% CI, 0.5 to 1.8)Strength of Evidence: Moderate • Long-term cosmesis (difference in satisfaction points = 0.25; 95% CI, 0.12 to 0.38)Strength of Evidence: Low • The time to return to daily activities was equivalent.Strength of Evidence: Low Chan KL, Hui WC, Tam PK. Surg Endosc. 2005 Jul;19(7):927-32. PMID: 15920685.  Koivusalo AI, Korpela R, Wirtavuori K, et al. Pediatrics. 2009 Jan;123(1):332-7. PMID: 19117900.  Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  28. Clinical Bottom Line: Pain-Free Primary Hernias—Repair Versus Watchful Waiting in Adults • Mesh repair may improve a patient’s overallhealth status at 12 months more than watchful waiting (difference in mean SF-36 scores = 7.3; 95% CI, 0.4 to 14.3).Low strength of evidence • There is not enough information to know if there are differences in adverse effects. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  29. Comparative Effectiveness of Open Mesh-Based Repair Procedures • Twenty-one studies were included. • The most commonly compared procedures were: • Lichtenstein versus mesh plug (n = 7) • Lichtenstein versus the PROLENE™ Hernia System (PHS; n = 5) • Lichtenstein versus the open preperitoneal mesh technique (n = 3) • Mesh plug versus the PHS (n = 2) • Lichtenstein versus the Kugel® Mesh Patch (n = 2) • Studies were typically conducted between 2000 and 2010. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  30. Comparative Effectiveness of Open Mesh-Based Repair Procedures—Lichtenstein Versus Mesh Plug • Rates of recurrence were approximately equivalent.Strength of Evidence: Moderate • Patients who have the Lichtenstein repair may return to work about 4 days earlier (95% CI, 1 to 7).Strength of Evidence: Moderate • Lichtenstein repair is associated with lower rates of seroma than mesh plug repair (OR = 0.39; 95% CI 0.16 to 0.94).Strength of Evidence: Moderate Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  31. Comparative Effectiveness of Other Open Mesh-Based Repair Procedures • Short-term pain outcomes were similar for these open repair procedures: • Mesh plug versus the PROLENE™ Hernia System (PHS) Strength of Evidence: Moderate • Lichtenstein versus the PHS Strength of Evidence: Moderate • Lichtenstein versus open preperitoneal mesh Strength of Evidence: Low • Lichtenstein versus the Kugel® Mesh Patch Strength of Evidence: Low • Intermediate-term pain was also similar for Lichtenstein versus Kugel Mesh Patch repair. Strength of Evidence: Low Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  32. Comparative Effectiveness of Laparoscopic Repair Procedures—TAPP Versus TEP • Transabdominal preperitoneal (TAPP) repair may offer a 1.4-day earlier return to work; however, this may not be clinically significant.Strength of Evidence: Moderate • Short-term pain outcomes were similar.Strength of Evidence: Moderate • Intermediate-term and long-term pain outcomes were similar.Strength of Evidence: Low • Research on comparative adverse effects between TAPP and totally extraperitoneal repairs was inconclusive for hematoma, urinary retention, and wound infection. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  33. Comparative Effectiveness of Mesh Materials • Hernia recurrence occurred at similar rates with polypropylene mesh versus combination materials.*Strength of Evidence: Moderate • Long-term pain after surgery was similar for standard polypropylene mesh when compared with biologic mesh or light-weight polypropylene mesh.Strength of Evidence: Low • Evidence on comparative adverse effects for the different types of mesh materials was inconclusive. *Descriptions of the combination-material mesh analyzed for this outcome can be found in the full report. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  34. Comparative Effectiveness of Fixation Methods • After laparoscopic surgery, hernia recurrence rates were similar for tacks or staples versus no fixation. Strength of Evidence: Moderate • Mesh fixed with sutures versus glue during open or laparoscopic surgery had similar: • Recurrence ratesStrength of Evidence: Moderate • Long-term pain outcomesStrength of Evidence: Low • Mesh fixed with fibrin glue during transabdominal preperitoneal repair resulted in less long-term pain than when the mesh was fixed with staples.Strength of Evidence: Moderate • Data on adverse effects were either missing or inconclusive. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm

  35. Association Between Laparoscopic Surgical Experience and Hernia Recurrence • Thirty-two studies reported on this association. • The length of the learning curve for TEP or TAPP repair could not be estimated due to problems associated with not accounting for followup time, not accounting for the evolution of procedures over time, and selective outcome reporting. • Generally, the risk of recurrence decreases when a more experienced surgeon performs a repair, but there were not enough congruent studies to perform a meta-analysis. Abbreviations: TAPP = transabdominal preperitoneal; TEP = totally extraperitoneal Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  36. Conclusions: Patient Population • The typical adult in the studies included in this review was a man in his mid 50s, of average weight (median body mass index, 25.3 kg/m2; interquartile range, 25.0–26.7), who had an elective repair of a primary unilateral inguinal hernia. • It is unclear how these results apply to: • Women • Men of other age groups • About a quarter of the men with hernias worked in physically strenuous jobs; for these men, a durable repair is important to prevent a recurrence. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  37. Conclusions: Laparoscopic Versus Open Repair of Inguinal Hernias in Adults • Laparoscopic repair of an inguinal hernia is associated with: • Faster recovery times • Less risk of long-term pain • A lower risk of another hernia recurrence after a previous recurrence • Open hernia repair may be associated with: • Fewer internal injuries • Lower recurrence rates in the context of primary inguinal hernia Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  38. Conclusions: Watchful Waiting Versus Repair for Pain-Free Inguinal Hernias • Low-strength evidence suggests that choosing to repair a pain-free hernia with a Lichtenstein or tension-free mesh repair over watchful waiting may improve quality of life. • However, this finding may not be applicable to other types of repair procedures (e.g., laparoscopic repair). • The evidence on adverse effects was inconclusive. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  39. Conclusions: Mesh Material and Fixation Methods • Research found most of the meshes or fixation methods to be equivalent in their effectiveness and risk of adverse effects with only a few exceptions. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  40. Gaps in Knowledge • How the surgeon's experience influences surgical outcomes such as recurrence and pain • The comparative effectiveness and adverse effects of laparoscopic repair versus watchful waiting for pain-free or minimally symptomatic inguinal hernias in adults • The comparative effectiveness and adverse effects of contralateral exploration/repair versus watchful waiting in the pediatric population • More evidence on several outcomes related to the comparisons of mesh products and fixation methods including recurrence rates, perception of a foreign body, long-term pain, and infection rates • Clarification in future studies of whether the population includes emergent as well as elective surgeries and whether or not the findings apply equally to both populations Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.

  41. Shared Decisionmaking: What To Discuss With Your Patients • If repair or watchful waiting is the right decision for their pain-free or minimally symptomatic inguinal hernia • How to choose between open or laparoscopic surgery if the option is available • What to expect from open or laparoscopic repair as far as outcomes and adverse effects, including the risk of long-term chronic pain • What to do if the hernia recurs

  42. Resource for Patients • Surgery for an Inguinal Hernia, A Review of the Research for Adults is a free companion to this continuing medical education activity. It can help patients talk with their health care professionals about the decisions involved with the care and maintenance of an inguinal hernia. • It provides information about: • Types of operative treatments • Current evidence of effectiveness and harms • Questions for patients to ask their doctor

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