Professional Documents
Culture Documents
EBCPG-management of Adult Inguinal Hernia
EBCPG-management of Adult Inguinal Hernia
l, January-March,2007
PJSSiilll'ilTi
Evidence-BasedClinical Practice Guidelineson the Management of Adult Inguinal
Hernia: Primary Inguinal Hernia, RecurrentInguinal Hernia and Bilateral Inguinal
Hernia
40
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
amongpanel
TechnicalWorking Group
The TWG preparedthe first draft of the manuscript
Members:
which consistedof a summaryof the strongestevidence
RayI. Sarmiento, (Chair)
M.D.,F.P.C.S.
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
M.D.,F.P.C.S.
Nilo C. de los Santos, (Director)
December 7,2005duringthe63'dPCSClinicalCongress
heldat the KamiaRoomof EDSA ShangrilaHotel.The
PanelofExperts:
PSGSBoard of Directorsthen acceptedthe guidelines
on February11,2006.
l. Reynaldo
M. Baclig,M.D.,F.P.C.S.
(CebuEasternVisayasChapter)
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,
CategoryA)
M.D.,F.P.C.S.
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)
CategoryA)
7. JaimeB. Lagunilla,
M.D.,F.P.C.S.
4. The recommendedtechniquesfor openmeshrepair (Northern Mindanao Chapter)
arethe Lichtenstein,
Plugandmeshandthe Prolene 8. ArturoE. Mendoza,
M.D.,F.P.C.S.
HerniaSystem.(Level lB, CategoryA) (CentralLuzonChapter)
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
02 TEP ve.susOpen
L/92 0/92 0.56 7.39 I0.1s, 312.381
Brisbane1996
t't / a8'7 31/5o'7 z5. ad 0.5? [0.32,1.01]
CoalaTrial Gp 1997
o/32 0/32 Not estimable
Denizli1998
r/50 0/50 0.56 ?.39 t0.L5,372.381
Hawaii1996
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
MRCmulticentre
o/59 0/5'l Not estimable
Madrid1997
0/22 o/ 2 3 Not estimable
O u l u2 1 9 9 8
0/89 0/92 Not estimable
Paris1994
3/ 5 r L /4 9 2.L1 2.69 10.31,79.1L)
Paris1997
3/731 6/II6 4.84 0.42 t0.11,1.591
Quebec1998
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)
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
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).
'.:.{
! rrl'/ Tr'*$ld\.trd Feto f)F v",Jei!$)1 tlaio {)R
tf jr.rr,-ditrj!l+f\.
8544 fl :& l}5 ,::,
't t tt'
;*.L;t.,*Jl"ui.,n
,."*o,.,,
",,.,.1i'*,
Source:
McCormackK, ScottNW, Go PMNYH, RossS (EU HerniaTrialistsCollaboration) The Cochrane Database
of
Systematic
Reviews2003,Laparoscopictechniques
versusopentechniquesfor inguinalherniarepair(Review).
Comparisonof Laparoscopic
Techniquesvs. OpenTechniquesin RecurrentInguinalHerniaRepairandRecurrence.
i.xl.d r $.]r3' .: i i
tas" to 36 tn.6r.r,
T,:n:rr e\.*niit 1,i aTr *Dttr*il r. t ; {..:i::r{.,}l:!
i i:j:::t l,rr i1d*r,:{*rrjfryr,:lltr + 1 1 .50,,jf : I tp } i I f t. t" - 3sr.t.*
1*rii ltr $\,*rnll eiif:!::t : c {i;-q r-p $ i:) r{i:;l
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
Outcome title No. of Studies No. of Participants Statistical Method Effect Size
Open
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.
'Llu,Jr
Cnrtrrs Pe'16 0R we|gt{
(r ,l$'i! {.!
ljr !t,sr-f,ld*{ul:1 r,.N at
^l
T. pF vet.r U...r:rF*r,
i nd L,*rlr 1 ?'ili il.i 1 5 F3/u
I13\,.,sx I994 Q/.1 !l/d
t{rlir+lh l alti:r $Jt. r:r.r l.
l..iits{4rin 1 3!irf n/la f,.')
[.1F:.:m'.rtl!::t:.'lr * 1'!']:r.l ft.. S {r./ {i
tlr,resli{{ri 1 1i*n {'/AS l.r I 'j
frt6i.r{.rc trt 1 $tri:l 1.r''14 n/r.3 JS.4!i!
"I*rr{re}e t 9:ilii t.' 10 Lt,. { ?9"fft'
r:r.rldritht i 5ra;'r(rr:i)
hl&l f vr-lil( rj. la { l1 *{|.rrr}.}t }. tJ 1i nnlttrl l
Iril.Jt 1*r hstrirr}*.inr:nvi {hl: * fr nt, dr '* 1 iF = Cr.Qfr). t.." Of*!
jr$l l.Jt {rw'r{ll rtte,:{ :a * I 1a Ifi ,..il::51
Nu!i
'?,rj(1
(r /ilf 15.te to .ls, ::$d.
al 1 :.6 n./ 11 ld 6r:
!i.:) 3g ?.6d t*
'l
{rttil iar{i'd. {::!'l I d!ft. 0[ 4. t: l[
lltdl eveiltJ. " j rl l r e $ t r n * r } t r. lr l{.}r{roll
I{i lDll
fjjE\'c".rr{ i,tnr0l
Comparison
of Laparoscopic
Techniques in BilateralInguinalHerniaRepairandHerniaRecurrence.
vs.OpenTechniques
)j.l.nJl Psl,j {rfi ,/Vegril Prtri (]Fl
'ir f, \ll!-Llrlle,:lit r/ rir! n.it l !3$':!S.:l "*j 1rs."" {:.}
I,l)[ . nq
IS$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,,',,** ''""'
n.".,,1i,,
.'.,1i,i1",
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
vs.Placebo
Antibiotic
in Abdominal Wall Hernia Repair and Wound Infection'
i
SarliL, IuscoDR, Sansebastiano
Source: G, CostiR. Simultaneous
Randomized
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