Surgery>>>>>Inguinal Hernias
Question 16#

The hernia repair method associated with the lowest recurrence rate is the:

a. Lichtenstein tension-free repair
b. Open elective tissue-based repair
c. Bassini technique
d. Shouldice repair

Correct Answer is A

Comment:

The incidence of recurrence is the most -cited measure of postoperative outcome following inguinal hernia repair. In evaluating the various available techniques, other salient signifiers of outcome include complication rates, operative duration, hospital stay, and quality of life. The following section summarizes the evidence-based outcomes of the various approaches to inguinal hernia repair. 

Among tissue repairs, the Shouldice operation is the most commonly performed technique, and it is most frequently executed at specialized centers. A 2012 meta-analysis from the Cochrane Database demonstrated significantly lower rates of hernia recurrence (odds ratio [OR] 0.62, confidence interval [CI] 0.45-0.85) in patients undergoing Shouldice operations when compared with other open tissue-based methods. In experienced hands, the overall recurrence rate for the Shouldice repair is about 1%. Although it is an elegant procedure, its meticulous nature requires significant technical expertise to achieve favorable outcomes, and it is associated with longer operative duration and longer hospital stay. One study found the recurrence rate for Shouldice repairs decreased from 9.4 to 2.5% after surgeons performed the repair six times. Compared with mesh repairs, the Shouldice technique resulted in significantly higher rates of recurrence (OR 3.65, CI 1 .79-7.47); however, it is the most effective tissue-based repair when mesh is unavailable or contraindicated.

Hernia recurrence is drastically reduced as a result of the Lichtenstein tension-free repair. Compared with open elective tissue-based repairs, mesh repair is associated with fewer recurrences (OR 0.37, CI 0.26-0.51) and with shorter hospital stay and faster return to usual activities. In a multiinstitutional series, 3019 inguinal hernias were repaired using the Lichtenstein technique, with an overall recurrence rate of 0.2%. Among other tension-free repairs, the Lichtenstein technique remains the most commonly performed procedure worldwide. Meta-analysis demonstrates no significant differences in outcomes between the Lichtenstein and the plug and patch techniques; however, intra-abdominal plug migration and erosion into contiguous structures occurs in approximately 6% of cases. The Stoppa technique results in longer operative duration than the Lichtenstein technique. Nevertheless, postoperative acute pain, chronic pain, and recurrence rates are similar between the two methods. Perhaps the most compelling advantage of the Lichtenstein technique is that nonexpert surgeons rapidly achieve similar outcomes to their expert counterparts. Guidelines issued by the European Hernia Society recommend the Lichtenstein repair for adults with either unilateral or bilateral inguinal hernias as the preferred open technique.