The hernia repair method associated with the lowest recurrence rate is the:
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.
A sliding hernia:
Inguinal hernias may compress adjacent nerves, leading to generalized pressure, localized sharp pain, and referred pain. Pressure or heaviness in the groin is a common complaint, especially at the conclusion of the day or following prolonged activity. Sharp pain tends to indicate an impinged nerve and may not be related to the extent of physical activity performed by the patient. Neurogenic pain may be referred to the scrotum, testicle, or inner thigh. Questions should be directed to elicit and characterize extrainguinal symptoms. A change in bowel habits or urinary symptoms may indicate a sliding hernia consisting of intestinal contents or involvement of the bladder within the hernia sac.
A 45 year old man presented to the emergency department with colicky abdominal pain, vomiting, and a painful groin lump. On examination he had a pulse of 110 beats/min and temperature of 37.8°C. There was marked abdominal distension, high pitched bowel sounds, and an erythematous, tender mass in the left groin above and medial to the pubic tubercle. A plain abdominal radiograph was taken in the emergency department (figure below).
Plain abdominal radiograph showing evidence of small bowel obstruction.
What is the next step in management?
Nil by mouth, nasogastric tube, and intravenous drip. The history is consistent with small bowel obstruction secondary to an irreducible inguinal hernia—above and medial to the pubic tubercle. Figure above shows a loop of small bowel leading towards the position of an inguinal hernia. The concern here is that the bowel is ischaemic and is at risk of perforation, which would put the patient at risk. Initial management should aim to prepare the patient for emergency operation.
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