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The new england journal of medicine
Clinical Practice
Caren G. Solomon, M.D., M.P.H., Editor Groin Hernias in Adults
Robert J. Fitzgibbons, Jr., M.D., and R. Armour Forse, M.D., Ph.D.
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors’ clinical recommendations.
A 67-year-old man presents with a bulge in his right groin, which he recently noticed while in the shower. He is easily able to push it back completely, but it reappears in- termittently. He says it is not painful and that he has not altered his activity level be- cause of it. Physical examination confirms the presence of a right inguinal hernia. How should his case be managed?
The Clinical Problem
The lifetime risk of development of a groin hernia has been estimated at 27% for men and 3% for women.1 The frequency of surgical correction varies among coun- tries and ranges from 10 per 100,000 population in the United Kingdom to 28 per 100,000 in the United States.2
The word “hernia” is from the Latin word “rupture”; the condition occurs when an organ normally contained in one body cavity protrudes through the lining of that cavity. Groin hernias have three components: the neck, which is the opening in the abdominal wall; the sac, which is formed by the protrusion of the perito- neum through the opening; and the contents — that is, any tissue or organ that protrudes through the neck into the hernia sac (Fig. 1). The abdominal wall in the groin region is composed of the peritoneum, transversalis fascia, internal and external oblique muscles and their aponeurotic structures, subcutaneous tissue, and skin. A failure of the transversalis fascia to prevent the intraabdominal con- tents from protruding through the anatomical area known as the myopectineal orifice of Fruchaud is the final common denominator in the development of all groin hernias (Fig. 2). Groin hernias are inguinal or femoral; inguinal hernias are either direct or indirect. Both direct and indirect hernias protrude above the ingui- nal ligament; a direct hernia is medial to the inferior epigastric vessels, whereas an indirect hernia is lateral. A femoral hernia protrudes below the inguinal ligament and medial to the femoral vessels (Fig. 1 and 2).
Demographics and Risk Factors
Inguinal hernias are more common on the right side than on the left and are 10 times more common in men than in women.3 Indirect inguinal hernias are twice as common as direct hernias. The reported prevalence of inguinal hernias varies widely from study to study; hernia repair is often used as a surrogate. In a study using the Danish national registry, groin hernias were found to be most commonly diagnosed
n engl j med 372;8 nejm.org February 19, 2015
The New England Journal of Medicine
Downloaded from nejm.org at UFPB on October 26, 2016. For personal use only. No other uses without permission. Copyright © 2015 Massachusetts Medical Society. All rights reserved.
Caren G. Solomon, M.D., M.P.H., Editor Groin Hernias in Adults
Robert J. Fitzgibbons, Jr., M.D., and R. Armour Forse, M.D., Ph.D.
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors’ clinical recommendations.
A 67-year-old man presents with a bulge in his right groin, which he recently noticed while in the shower. He is easily able to push it back completely, but it reappears in- termittently. He says it is not painful and that he has not altered his activity level be- cause of it. Physical examination confirms the presence of a right inguinal hernia. How should his case be managed?
The Clinical Problem
The lifetime risk of development of a groin hernia has been estimated at 27% for men and 3% for women.1 The frequency of surgical correction varies among coun- tries and ranges from 10 per 100,000 population in the United Kingdom to 28 per 100,000 in the United States.2
The word “hernia” is from the Latin word “rupture”; the condition occurs when an organ normally contained in one body cavity protrudes through the lining of that cavity. Groin hernias have three components: the neck, which is the opening in the abdominal wall; the sac, which is formed by the protrusion of the perito- neum through the opening; and the contents — that is, any tissue or organ that protrudes through the neck into the hernia sac (Fig. 1). The abdominal wall in the groin region is composed of the peritoneum, transversalis fascia, internal and external oblique muscles and their aponeurotic structures, subcutaneous tissue, and skin. A failure of the transversalis fascia to prevent the intraabdominal con- tents from protruding through the anatomical area known as the myopectineal orifice of Fruchaud is the final common denominator in the development of all groin hernias (Fig. 2). Groin hernias are inguinal or femoral; inguinal hernias are either direct or indirect. Both direct and indirect hernias protrude above the ingui- nal ligament; a direct hernia is medial to the inferior epigastric vessels, whereas an indirect hernia is lateral. A femoral hernia protrudes below the inguinal ligament and medial to the femoral vessels (Fig. 1 and 2).
Demographics and Risk Factors
Inguinal hernias are more common on the right side than on the left and are 10 times more common in men than in women.3 Indirect inguinal hernias are twice as common as direct hernias. The reported prevalence of inguinal hernias varies widely from study to study; hernia repair is often used as a surrogate. In a study using the Danish national registry, groin hernias were found to be most commonly diagnosed
n engl j med 372;8 nejm.org February 19, 2015
The New England Journal of Medicine
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756
at the extremes of life. Among adults, the annual
frequency of groin hernia repair was found to
increase consistently with age, from 0.25% at
18 years of age to 4.2% at 75 to 80 years of age.4
Femoral hernias account for fewer than 5% of
groin hernias; however, 35 to 40% of femoral
hernias are not diagnosed until the patient pres-
ents with strangulation or bowel obstruction, and
mortality is higher in association with emergency
repair than with elective repair.5-7 The incidence
of femoral hernias increases steadily with age and
is higher among patients with recurrent hernias.
Femoral hernias are more common in women
than in men, but a woman with a groin mass is
still 5 times more likely to have an inguinal her-
nia than a femoral hernia; inguinal hernias in
women are almost always indirect.6
In addition to male sex and increased age, a major risk factor for a groin hernia is a family history of groin hernias, which is associated with up to eight times the risk.8,9 Other conditions re- ported to be associated with increased risk include chronic obstructive pulmonary disease, smoking, lower body-mass index, high intraabdominal pres- sure, collagen vascular disease, thoracic or abdomi- nal aortic aneurysm, patent processus vaginalis, history of open appendectomy, and peritoneal dialysis.8 Patients with matrix metalloproteinase (MMP) abnormalities, such as Ehlers–Danlos, Marfan’s, Hurler’s, and Hunter’s syndromes, also have increased risks of having a hernia; consis- tent with these observations is the report of mark- ers of abnormal connective-tissue homeostasis, including an increased type I:type III collagen ratio and increased metalloproteinase activity (in-
In addition to male sex and increased age, a major risk factor for a groin hernia is a family history of groin hernias, which is associated with up to eight times the risk.8,9 Other conditions re- ported to be associated with increased risk include chronic obstructive pulmonary disease, smoking, lower body-mass index, high intraabdominal pres- sure, collagen vascular disease, thoracic or abdomi- nal aortic aneurysm, patent processus vaginalis, history of open appendectomy, and peritoneal dialysis.8 Patients with matrix metalloproteinase (MMP) abnormalities, such as Ehlers–Danlos, Marfan’s, Hurler’s, and Hunter’s syndromes, also have increased risks of having a hernia; consis- tent with these observations is the report of mark- ers of abnormal connective-tissue homeostasis, including an increased type I:type III collagen ratio and increased metalloproteinase activity (in-
creased MMP-2 and MMP tissue inhibitor 2 activ-
ity),10 in association with hernias in the general
population.
Whether heavy lifting is also a risk factor re- mains controversial. A recent systematic review showed data concerning the relationship between occasional heavy lifting, repeated heavy lifting, or a single strenuous lifting episode and the devel- opment of a groin hernia to be inconclusive.11 Of note, weight lifters do not have an increased inci- dence of inguinal hernias.12
Strategies and Evidence
Diagnosis and Evaluation
Symptoms are absent in about a third of patients13 but, when present, include a heavy or dragging sensation, a burning sensation, a sharp pain, or discomfort or pain during coughing, defecation, micturition, exercise, or sexual intercourse. Symp- toms are usually worse by the end of the day and are relieved by lying down or manually reducing the hernia. The sudden onset of severe pain sug- gests strangulation and is a surgical emergency.
Inguinal hernias are diagnosed by means of a physical examination disclosing a visible bulge or an easily palpable mass on straining with an examining finger in the external ring. Differen- tiating an indirect from a direct inguinal hernia is unnecessary, because it does not affect treat- ment. It is not always possible to differentiate an inguinal hernia from a more worrisome femoral hernia during physical examination.5,14 Imaging studies are required only in cases in which there are typical symptoms in the absence of physical
Whether heavy lifting is also a risk factor re- mains controversial. A recent systematic review showed data concerning the relationship between occasional heavy lifting, repeated heavy lifting, or a single strenuous lifting episode and the devel- opment of a groin hernia to be inconclusive.11 Of note, weight lifters do not have an increased inci- dence of inguinal hernias.12
Strategies and Evidence
Diagnosis and Evaluation
Symptoms are absent in about a third of patients13 but, when present, include a heavy or dragging sensation, a burning sensation, a sharp pain, or discomfort or pain during coughing, defecation, micturition, exercise, or sexual intercourse. Symp- toms are usually worse by the end of the day and are relieved by lying down or manually reducing the hernia. The sudden onset of severe pain sug- gests strangulation and is a surgical emergency.
Inguinal hernias are diagnosed by means of a physical examination disclosing a visible bulge or an easily palpable mass on straining with an examining finger in the external ring. Differen- tiating an indirect from a direct inguinal hernia is unnecessary, because it does not affect treat- ment. It is not always possible to differentiate an inguinal hernia from a more worrisome femoral hernia during physical examination.5,14 Imaging studies are required only in cases in which there are typical symptoms in the absence of physical
Clinical Practice
Key Clinical Points
Groin Hernias in Adults
-
Groin hernias are much more common in men than in women.
-
Patients with symptoms of acute incarceration and strangulation require emergency surgery.
-
Watchful waiting is a safe approach for asymptomatic male patients with inguinal hernia, but data from
randomized trials suggest that the majority of men will ultimately be referred for surgery, primarily
because of pain, within 10 years.
-
For an uncomplicated unilateral inguinal hernia, open repair has the advantages of potentially being
performed under local anesthesia and incurring lower initial costs; laparoscopic repair results in less
postoperative pain and an earlier return to normal activities, but it requires general anesthesia routinely
and carries a small risk of major intraabdominal injury.
-
Femoral hernias occur more often in women than in men, are associated with much higher risk of
strangulation, and can be difficult to distinguish from inguinal hernias; watchful waiting is not
recommended in women.
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758
n engl j med 372;8 nejm.org February 19, 2015
The New England Journal of Medicine
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The New England Journal of Medicine
Downloaded from nejm.org at UFPB on October 26, 2016. For personal use only. No other uses without permission. Copyright © 2015 Massachusetts Medical Society. All rights reserved.
findings, to rule out an occult hernia or other con-
dition. Ultrasonography is relatively inexpensive
and avoids the use of radiation, but its accuracy is
operator-dependent.15 Computed tomography and
magnetic resonance imaging (MRI) are alterna-
tives; MRI provides the best anatomic detail and
has the highest sensitivity and specificity.16,17
The differential diagnosis varies according to the clinical presentation. In the case of a groin mass thought to be a hernia, other possible causes include lymphadenopathy, a soft-tissue tumor, or an abscess. Possible causes of scrotal masses in- clude a hydrocele or a testicular tumor. In the case of a patient with symptoms consistent with a groin hernia but without a mass, possible causes (other than occult hernia) include epididymitis, local musculoskeletal abnormalities (e.g., arthri- tis of the hip, osteitis pubis, or tenosynovitis), nerve-root compression, and renal calculi. Athletes can have unusual syndromes that result in symp- toms suggestive of a hernia; these include athletic pubalgia, femoral acetabular impingement, and adductor longus tendinopathy.
The differential diagnosis varies according to the clinical presentation. In the case of a groin mass thought to be a hernia, other possible causes include lymphadenopathy, a soft-tissue tumor, or an abscess. Possible causes of scrotal masses in- clude a hydrocele or a testicular tumor. In the case of a patient with symptoms consistent with a groin hernia but without a mass, possible causes (other than occult hernia) include epididymitis, local musculoskeletal abnormalities (e.g., arthri- tis of the hip, osteitis pubis, or tenosynovitis), nerve-root compression, and renal calculi. Athletes can have unusual syndromes that result in symp- toms suggestive of a hernia; these include athletic pubalgia, femoral acetabular impingement, and adductor longus tendinopathy.
Management
A strangulated hernia, which results in intestinal ischemia, requires emergency surgery. The patient presents with a tense, exquisitely tender groin mass and may have signs of sepsis (e.g., fever, tachycardia, hypotension, vomiting, and confu- sion). Incarceration (i.e., a state in which a hernia cannot be reduced) is not synonymous with stran- gulation; many patients with chronically irreduc- ible hernias have no symptoms. Careful exami- nation of the groin should be performed for any patient presenting with a bowel obstruction. In contrast to other causes of bowel obstruction, hernias causing this complication are almost always associated with complete obstruction and cannot be managed conservatively. Unless an ob- structed hernia is treated expeditiously, progres- sion to strangulation is inevitable.
Asymptomatic or Minimally Symptomatic Hernias
Regardless of the type of hernia, symptomatic pa- tients should be offered repair to improve quality
A strangulated hernia, which results in intestinal ischemia, requires emergency surgery. The patient presents with a tense, exquisitely tender groin mass and may have signs of sepsis (e.g., fever, tachycardia, hypotension, vomiting, and confu- sion). Incarceration (i.e., a state in which a hernia cannot be reduced) is not synonymous with stran- gulation; many patients with chronically irreduc- ible hernias have no symptoms. Careful exami- nation of the groin should be performed for any patient presenting with a bowel obstruction. In contrast to other causes of bowel obstruction, hernias causing this complication are almost always associated with complete obstruction and cannot be managed conservatively. Unless an ob- structed hernia is treated expeditiously, progres- sion to strangulation is inevitable.
Asymptomatic or Minimally Symptomatic Hernias
Regardless of the type of hernia, symptomatic pa- tients should be offered repair to improve quality
The new england journal of medicine
Rectus abdominis
muscle
Inguinal
ligament
Transversus
abdominis
muscle
Inferior epigastric vessels
Anatomy of a groin hernia
AB
Femoral
vessels
Neck
Internal inguinal ring
External inguinal ring Superior pubic ramus (with Cooper’s ligament) Spermatic vessels Vas deferens
C
Contents
Sac
|
|
Figure 1. Types of Hernia and Hernia Anatomy from an Anterior Perspective.
|
Clinical Practice
Transversus
abdominis muscle
Rectus
abdominis
muscle
Inferior epigastric
vessels
Transversus abdominis aponeurotic arch
A
B
C
Transversus abdominis aponeurotic arch
A
B
C
Internal
spermatic
vessels
Inguinal
ligament
Superior
pubic ramus
(with Cooper’s
-
A Indirect inguinal
hernia
-
B Direct inguinal
hernia
-
C Femoral hernia
ligament)
Vas
deferens
Iliac vessels
Mesh covering the myopectineal orifice
Mesh
A
B
C
B
C
Figure 2. Anatomy of the Groin from an Intraabdominal Perspective.
Groin hernias occur through the myopectineal orifice, which is bordered by the arch formed by the termination of the aponeurotic fibers
of the transversus abdominis muscle cranially, the rectus abdominis muscle medially, the iliopsoas muscle laterally, and the superior pu- bic ramus with attached Cooper’s ligament inferiorly. In the inset, a mesh prosthesis is shown covering the entire myopectineal orifice, as one would see in a laparoscopic inguinal herniorrhaphy.
Groin hernias occur through the myopectineal orifice, which is bordered by the arch formed by the termination of the aponeurotic fibers
of the transversus abdominis muscle cranially, the rectus abdominis muscle medially, the iliopsoas muscle laterally, and the superior pu- bic ramus with attached Cooper’s ligament inferiorly. In the inset, a mesh prosthesis is shown covering the entire myopectineal orifice, as one would see in a laparoscopic inguinal herniorrhaphy.
of life. However, the results of two randomized
trials comparing prompt repair with a strategy of
watchful waiting for asymptomatic or minimally
symptomatic inguinal hernias have argued against
routine repair.18,19 One of these, a single-center
randomized trial from the United Kingdom in-
volving 160 patients, showed no significant dif-
ference between groups in pain scores and a
minimal difference in scores on the 36-Item Short
Form Health Survey at 1 year.18 In a larger mul-
ticenter trial from North America (involving 720
patients), there was no significant difference at
2 years in pain or quality of life between the
group that underwent surgery and the group that
did not.19 In both studies, approximately one
quarter of patients assigned to watchful waiting
crossed over to surgery (by 15 months in the first
and by 2 years in the second), primarily because
of increasing pain; the delay did not affect the
frequency of operative complications.20 The inci-
dence of an acute presentation was very low (a total
of 3 patients in both studies combined, and 2 of
the 3 patients had the hernia reduced and re-
paired electively), and there was no mortality or
increased morbidity with watchful waiting as
compared with prompt repair.
Both studies have recently been updated with longer-term follow-up data.21,22 The estimated fre- quency of crossover to surgery from the watchful- waiting group was 72% by 7.5 years in the U.K. trial and 68% by 10 years in the North American trial; most crossovers to surgery were a result of increasing pain. In the subset of men who un- derwent randomization after 65 years of age in the original North American study, 79% were predicted to need surgery. The logical conclusion is that watchful waiting is safe but only delays the inevitable surgery. Concern that watchful waiting would result in greater complication rates as a result of increasing severity of coexisting condi- tions and larger fascia defects in cases where surgery was later performed was not borne out.20 Because the patients in both studies had pre- sented to their physicians with concerns about
Both studies have recently been updated with longer-term follow-up data.21,22 The estimated fre- quency of crossover to surgery from the watchful- waiting group was 72% by 7.5 years in the U.K. trial and 68% by 10 years in the North American trial; most crossovers to surgery were a result of increasing pain. In the subset of men who un- derwent randomization after 65 years of age in the original North American study, 79% were predicted to need surgery. The logical conclusion is that watchful waiting is safe but only delays the inevitable surgery. Concern that watchful waiting would result in greater complication rates as a result of increasing severity of coexisting condi- tions and larger fascia defects in cases where surgery was later performed was not borne out.20 Because the patients in both studies had pre- sented to their physicians with concerns about
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their hernias, the results may not be generaliz-
able to the larger group of patients with asymp-
tomatic hernias and no concerns. Another im-
portant caveat is that these results apply only to
inguinal hernias and not to femoral hernias, be-
cause of the higher risks of serious complications
with the latter. Surgical repair is routinely rec-
ommended for women because of their higher
incidence of femoral hernias and the difficulty
in accurately differentiating them from inguinal
hernias by means of physical examination.6,23-26
Surgical Treatment
Hernia repair is performed as either an open pro- cedure or a laparoscopic procedure. Open repairs are divided into two types: tension-free repair with the use of a prosthetic mesh (usually polypropyl- ene) or sutured repair. A Cochrane meta-analysis strongly supported the superiority of prosthetic- mesh repairs over sutured repairs, reporting a 50 to 75% lower risk of hernia recurrence, a lower risk of chronic postherniorrhaphy groin pain, and an earlier return to work.27 The Lichtenstein tension-free repair or one of its modifications (e.g., “plug and patch”) is the most commonly performed repair of all types in the United States. Sutured repairs are generally limited to unique indications such as an infected or contaminated field where the use of a prosthesis might be con- traindicated. One type of sutured repair (the Shouldice repair) is still used in certain specialty clinics but requires a complex dissection that is not easily mastered without specialized training; in general practice, the hernia recurrence rate as- sociated with this type of repair is higher than with mesh techniques.28
Laparoscopic Inguinal Hernia Repair
The laparoscopic method uses the preperitoneal space behind the musculofascial elements of the groin area to place a prosthesis over the entire myopectineal orifice. The preperitoneal space may be entered directly through the abdomen by mak- ing an incision in the peritoneum (transabdomi- nal preperitoneal technique). Alternatively, one can avoid the abdomen by dissecting the space between the peritoneum and the muscular ele- ments, with or without the aid of a dissecting balloon (totally extraperitoneal repair) (Fig. 3).
Laparoscopic herniorrhaphy results in less pain initially, an earlier return to normal activities, and easier repair of recurrent hernias that have
Surgical Treatment
Hernia repair is performed as either an open pro- cedure or a laparoscopic procedure. Open repairs are divided into two types: tension-free repair with the use of a prosthetic mesh (usually polypropyl- ene) or sutured repair. A Cochrane meta-analysis strongly supported the superiority of prosthetic- mesh repairs over sutured repairs, reporting a 50 to 75% lower risk of hernia recurrence, a lower risk of chronic postherniorrhaphy groin pain, and an earlier return to work.27 The Lichtenstein tension-free repair or one of its modifications (e.g., “plug and patch”) is the most commonly performed repair of all types in the United States. Sutured repairs are generally limited to unique indications such as an infected or contaminated field where the use of a prosthesis might be con- traindicated. One type of sutured repair (the Shouldice repair) is still used in certain specialty clinics but requires a complex dissection that is not easily mastered without specialized training; in general practice, the hernia recurrence rate as- sociated with this type of repair is higher than with mesh techniques.28
Laparoscopic Inguinal Hernia Repair
The laparoscopic method uses the preperitoneal space behind the musculofascial elements of the groin area to place a prosthesis over the entire myopectineal orifice. The preperitoneal space may be entered directly through the abdomen by mak- ing an incision in the peritoneum (transabdomi- nal preperitoneal technique). Alternatively, one can avoid the abdomen by dissecting the space between the peritoneum and the muscular ele- ments, with or without the aid of a dissecting balloon (totally extraperitoneal repair) (Fig. 3).
Laparoscopic herniorrhaphy results in less pain initially, an earlier return to normal activities, and easier repair of recurrent hernias that have
previously undergone open repair, and it allows
treatment of bilateral hernias through the same
skin incisions.29,30 The risks of common surgical
complications are similar for laparoscopic and
open repair; complications include wound seroma
or hematoma (approximately 7 to 8% risk),15
wound infection (approximately 1% risk),15 tes-
ticular complications (approximately 0.7% risk),30
and complications related to the mesh — for ex-
ample, contraction, erosion, and infection. How-
ever, laparoscopic repair is associated with a
small risk of life-threatening vascular or visceral
injury (0.9 and 1.8 per 1000 procedures, respec-
tively31). Whereas laparoscopic repair requires gen-
eral anesthesia, open repair can be performed
under local anesthesia (although registry data
from Europe indicate that local anesthesia is
used in only about 10% of cases32); the possibil-
ity of using local anesthesia is a particular ad-
vantage in older patients who require repair and
have serious coexisting medical conditions. Lap-
aroscopic herniorrhaphy is more expensive, but
the costs of the procedure may be offset by an
earlier return to daily function and work.33 A
Cochrane meta-analysis including 41 random-
ized trials showed no significant difference in
recurrence rates between open mesh and laparo-
scopic repairs.29 However, other studies, includ-
ing a recent large cohort study34 and a more re-
cent meta-analysis including 27 randomized trials,
have revealed a significantly higher risk of recur-
rence of primary hernias after laparoscopic re-
pair as compared with open repair35 (reoperation
rates in the cohort study, 4.1% vs. 2.1%). No sig-
nificant difference between the two types of pro-
cedures has been noted in recurrence rates after
repair of recurrent hernias.34,36 Numerous studies
have shown that the most important factor in-
fluencing the outcome of laparoscopic hernior-
rhaphy is the experience of the surgeon.34,37 The
learning curve for laparoscopy is steep; inexpe-
rienced surgeons have poorer results with higher
rates of complication and recurrence. The num-
ber of procedures required for a surgeon to be-
come proficient is not clearly defined.
Areas of Uncertainty
Now that the rate of hernia recurrence has de- creased dramatically with the widespread adop- tion of prosthetic repairs, chronic postherniorrha- phy groin pain (defined as pain lasting >3 months)
Areas of Uncertainty
Now that the rate of hernia recurrence has de- creased dramatically with the widespread adop- tion of prosthetic repairs, chronic postherniorrha- phy groin pain (defined as pain lasting >3 months)
The new england journal of medicine
760
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Clinical Practice
|
A
Rectus abdominis
muscle
Preperitoneal
space
The dissection balloon is inserted through an intraumbilical incision into the preperitoneal space.
Transversalis
fascia
Peritoneum
Intestine
Pubic
bone
Bladder
|
|
B
Preperitoneal
space
The dissection balloon is inflated, expanding the preperitoneal space. The expanded space is maintained with insufflation during hernial repair. |
|
Figure 3. Laparoscopic Totally Extraperitoneal Herniorrhaphy.
The creation of a preperitoneal working space for a laparoscopic totally extraperitoneal herniorrhaphy with the use of a dissecting balloon is shown. Some surgeons prefer to perform the dissection directly, to avoid the expense of the disposable dissecting balloon. |
has emerged as the most important postoperative
issue reported by patients, in that it is both dis-
tressing to patients and poorly understood by
— and the subject of controversy among — her-
nia surgeons. Although the incidence varies
widely in the literature (1.5 to 54%38,39), the
consensus is that approximately 10% of patients
who have undergone an inguinal herniorrhaphy
have some chronic pain, and in 2 to 4% it inter-
feres with daily living.30 Whether this complica-
tion is less likely after laparoscopic repair than
after open repair remains controversial.30,38 Pain
has been attributed to one or more of the follow-
ing factors: damaged or trapped nerves (neuro-
pathic) or scar tissue or a reaction to the pros-
thetic material (nociceptive); however, the exact
mechanisms are unknown. Because the pain
resolves within 6 months in about a third of
cases, antiinflammatory medication is a reason-
able initial treatment. In patients with persistent
pain, strategies for treatment have included
mesh and suture excision, neurectomy, and neu-
roma excision, but there is wide variation in the
reported rates of improvement after these inter-
ventions in case series.40,41 Rigorous studies are
needed to clarify the efficacy of various treat-
ment strategies. Postherniorrhaphy pain should
be discussed as part of informed consent.
There is a paucity of information to guide the management of groin hernias in women. A par- ticular concern in women is their higher fre- quency of femoral hernias, with the attendant
There is a paucity of information to guide the management of groin hernias in women. A par- ticular concern in women is their higher fre- quency of femoral hernias, with the attendant
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high risks of strangulation, as well as the poten-
tial misdiagnosis of femoral hernias as inguinal
hernias. The Lichtenstein operation, unless spe-
cifically modified (i.e., by opening the inguinal
floor to look below the inguinal ligament at the
femoral canal), will miss a femoral hernia. Indeed,
a large study of more than 6000 women from
Sweden showed a rate of femoral-hernia recur-
rence that was much higher than that among
men, especially after the repair of a direct her-
nia; because direct hernias are extremely rare in
woman, this observation suggests that the femo-
ral hernia was actually missed during the index
operation.6 Thus, many experts recommend lapa-
roscopic repair (which results in coverage of the
entire myopectineal orifice) (Fig. 2, inset) for all
women with groin hernias.6,14,30,42 However, a
modified Lichtenstein operation, attaching the
inferior edge of the prosthesis to Cooper’s liga-
ment instead of the inguinal ligament, can
achieve the same coverage.
The use of a truss (hernia belt) for a groin hernia in men is controversial. Data to determine whether their use prevents hernia complications are lacking.
Guidelines
Guidelines for the management of inguinal her- nias have been published by the U.K. National In- stitute for Health and Care Excellence,25 the Eu- ropean Hernia Society,30 the Society for Surgery of the Alimentary Tract,43 the Danish Hernia Database,24 the International Endohernia Society,44 and the Agency for Healthcare Research and
The use of a truss (hernia belt) for a groin hernia in men is controversial. Data to determine whether their use prevents hernia complications are lacking.
Guidelines
Guidelines for the management of inguinal her- nias have been published by the U.K. National In- stitute for Health and Care Excellence,25 the Eu- ropean Hernia Society,30 the Society for Surgery of the Alimentary Tract,43 the Danish Hernia Database,24 the International Endohernia Society,44 and the Agency for Healthcare Research and
Quality.26 The current recommendations are gen-
erally consistent with these guidelines.
Conclusions and Recommendations
This 67-year-old man presents with a history and physical-examination results consistent with an inguinal hernia. Imaging studies are not indi- cated. Watchful waiting is an acceptable strate- gy, although data from randomized trials pre- dict that, given his age (>65 years), he has an 80% chance of requiring surgical hernia repair for evolving symptoms. If surgery is performed, an open conventional prosthetic inguinal herni- orrhaphy would be recommended by most sur- geons; however, a laparoscopic herniorrhaphy performed by an experienced surgeon is also an acceptable option. The laparoscopic operation would be expected to result in less pain and an earlier return to normal activities, but the differ- ences would probably be modest for this uncom- plicated unilateral hernia; at the same time, it would carry a risk (albeit a small one) of a seri- ous vascular or visceral injury. If the patient were a woman, surgery would be recommended rou- tinely, given the greater concern for a femoral hernia and the greater associated risk of com-
plications.
No potential conflict of interest relevant to this article was
reported.
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
We thank Maarten Simons, M.D., Ph.D., coordinator and lead
author of the European Hernia Society guidelines on the treat- ment of inguinal hernia in adult patients, and Marc Miserez, M.D., for their review of an earlier version of the manuscript.
Conclusions and Recommendations
This 67-year-old man presents with a history and physical-examination results consistent with an inguinal hernia. Imaging studies are not indi- cated. Watchful waiting is an acceptable strate- gy, although data from randomized trials pre- dict that, given his age (>65 years), he has an 80% chance of requiring surgical hernia repair for evolving symptoms. If surgery is performed, an open conventional prosthetic inguinal herni- orrhaphy would be recommended by most sur- geons; however, a laparoscopic herniorrhaphy performed by an experienced surgeon is also an acceptable option. The laparoscopic operation would be expected to result in less pain and an earlier return to normal activities, but the differ- ences would probably be modest for this uncom- plicated unilateral hernia; at the same time, it would carry a risk (albeit a small one) of a seri- ous vascular or visceral injury. If the patient were a woman, surgery would be recommended rou- tinely, given the greater concern for a femoral hernia and the greater associated risk of com-
plications.
No potential conflict of interest relevant to this article was
reported.
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
We thank Maarten Simons, M.D., Ph.D., coordinator and lead
author of the European Hernia Society guidelines on the treat- ment of inguinal hernia in adult patients, and Marc Miserez, M.D., for their review of an earlier version of the manuscript.
The new england journal of medicine
762
n engl j med 372;8 nejm.org February 19, 2015
The New England Journal of Medicine
Downloaded from nejm.org at UFPB on October 26, 2016. For personal use only. No other uses without permission. Copyright © 2015 Massachusetts Medical Society. All rights reserved.
The New England Journal of Medicine
Downloaded from nejm.org at UFPB on October 26, 2016. For personal use only. No other uses without permission. Copyright © 2015 Massachusetts Medical Society. All rights reserved.
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Copyright © 2015 Massachusetts Medical Society.
35. O’Reilly EA, Burke JP, O’Connell PR. A meta-analysis of surgical morbidity and recurrence after laparoscopic and open repair of primary unilateral inguinal her- nia. Ann Surg 2012;255:846-53.
36. Li J, Ji Z, Li Y. Comparison of laparo- scopic versus open procedure in the treat- ment of recurrent inguinal hernia: a me- ta-analysis of the results. Am J Surg 2014; 207:602-12.
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Copyright © 2015 Massachusetts Medical Society.
Clinical Practice
Clique aqui >>>> Anatomia inguinal CIRÚRGICA
Clique aqui >>>> Cirurgia Vídeolaparoscópica de hérnia inguinal
MENSAGENS PARA GUARDAR
- CONHECER A ANATOMIA DA REGIÃO INGUINAL
- RECONHECER A IMPORTÂNCIA DO EXAME FÍSICO E OS FATORES DE RISCO PARA O SURGIMENTO DE HÉRNIAS DA PAREDE ABDOMINAL
- IDENTIFICAR OS TIPOS PRINCIPAIS DE HÉRNIA INGUINAL
- COMPREENDER AS INDICAÇÕES DE TRATAMENTO CIRÚRGICO
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