WARC Journal Club: Inguinal Hernia

de Goede B, et al. Watchful Waiting Versus Surgery of Mildly Symptomatic or Asymptomatic Inguinal Hernia in Men Aged 50 Years and Older: A Randomized Controlled Trial. Ann Surg. 2018 Jan;267(1):42-49.

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RESULTS: Between January 2006 and August 2012, 528 patients were enrolled, of whom 496 met the inclusion criteria: 234 were assigned to elective repair and 262 to watchful waiting. The mean pain/discomfort score at 24 months was 0.35 [95% confidence interval (CI) 0.28-0.41)] in the elective repair group and 0.58 (95% CI 0.52-0.64) in the watchful waiting group. The difference of these means (MD) was -0.23 (95% CI -0.32 to -0.14). In the watchful waiting group, 93 patients (35·4%) eventually underwent elective surgery and 6 patients (2·3%) received emergent surgery for strangulation/incarceration. Postoperative complication rates and recurrence rates in these 99 operated individuals were comparable with individuals originally assigned to the elective repair group (8.1% vs 15.0%; P = 0.106, 7.1% vs 8.9%; P = 0.668, respectively).

CONCLUSIONS: Our data could not rule out a relevant difference in favor of elective repair with regard to the primary endpoint. Nevertheless, in view of all other findings, we feel that our results justify watchful waiting as a reasonable alternative compared with surgery in men aged 50 years and older.

Bessa SS, et al. Results of prosthetic mesh repair in the emergency management of the acutely incarcerated and/or strangulated groin hernias: a 10-year study. Hernia. 2015 Dec;19(6):909-14.

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RESULTS: The present study included 234 patients. Their age ranged from 16 to 85 years with a mean of 55.9 ± 17.7 years. The hernia was indirect inguinal in 201 patients (85.9%), direct inguinal in 5 patients 5 (2.1%), hernia of canal of nuck in 13 patients (5.6%) and femoral in 15 patients (6.4%). Thirty patients (12.8%) had recurrent hernias. Resection-anastomosis of non-viable small intestine was performed in 32 patients (13.7%). There were 5 perioperative mortalities (2.1%). Complications were encountered in 41 patients (17.5%) and included wound infection in 14 patients (6%), scrotal hematoma in 9 patients (3.8%), chest infection in 8 patients (3.4%), deep vein thrombosis in 2 patients (0.9%), transient deterioration of liver function in 11 patients (4.7%) and mesh infection in 1 patient (0.5%). Follow-up duration ranged from 6 to 120 months with a mean of 62.5 ± 35.3 months. Two recurrences (0.9%) were encountered throughout the study period.

CONCLUSIONS: The use of prosthetic mesh repair in the emergency management of the acutely incarcerated and/or strangulated groin hernias is safe. The presence of non-viable intestine cannot be regarded as a contraindication for prosthetic repair.

Youssef T, El-Alfy K, Farid M. Randomized clinical trial of Desarda versus Lichtenstein repair for treatment of primary inguinal hernia. Int J Surg. 2015 Aug; 20:28-34.

Full-text for Emory users.

RESULTS: During 2-year follow up, one recurrence was detected in each group (P = 0.99). Chronic groin pain was experienced by 5.6% and 4.2% of patients from Desarda and Lichtenstein groups respectively (P = 0.68). There was no significant statistical difference in mean postoperative VAS scores for pain at the five time points between the two study groups. There was significantly shorter operating time and earlier return to normal gait in favor of Desarda repair. Foreign body sensation was not different between the two groups.

CONCLUSION: Successful inguinal hernia treatment without mesh implantation can be achieved using Desarda repair, as it is effective as the standard Lichtenstein procedure. Shorter operating time, early return to normal gait and lower cost (no mesh) are potential benefits of Desarda repair. The suitability of Desarda repair for patients found to have thin, weak or divided external oblique aponeurosis intraoperatively needs further evaluation.

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