Comparative Effectiveness

New effectiveness review discusses treatment options for inguinal hernia

For painful hernias in adults, the risk of a recurrent hernia after open surgery was less than the risk of recurrence after laparoscopic surgery, according to a research review. However, the review from the Effective Health Care Program of the Agency for Healthcare Research and Quality (AHRQ) did show that for pediatric hernias laparoscopy is generally more effective than surgery for reducing recurrence. The review did not highlight many negative side effects for open surgery versus laparoscopy, but did note that the recovery time for open surgery was generally longer. The review also noted that quality of life after the diagnosis of an inguinal hernia was higher after one year for individuals that chose open surgery or laparoscopy rather than watchful waiting.
These findings can be found in the research review, Surgical Options for Inguinal Hernia. This review adds to AHRQ's growing library of resources on health topics.
To access this review and other materials that explore the effectiveness and risks of treatment options for various conditions, visit the Effective Health Care Program Web site at http://www.effectivehealthcare.ahrq.gov.

Surgical Options for Inguinal Hernia: Comparative Effectiveness Review

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Background

An inguinal hernia is a protrusion of abdominal contents into the inguinal canal through an abdominal wall defect. The lifetime rate of inguinal hernia is 25 percent in males and 2 percent in females.¹ The risk of inguinal hernia increases with age, and the annual incidence is about 50 percent in males by the age of 75 years.² Approximately 10 percent of cases are bilateral.³ In children, the incidence ranges from 0.8 to 4.4 percent.⁴ It is 10 times as common in boys as in girls and also more common in infants born before 32 weeks’ gestation (13-percent prevalence) and in infants weighing less than 1,000 grams at birth (30-percent prevalence).⁴
Surgical repair of hernias is the most commonly performed general surgical procedure in the United States.⁵ In 2003, U.S. surgeons performed an estimated 770,000 surgical repairs⁵ of inguinal hernia. (Note, however, that a more recent study, presently in press, estimates the U.S. prevalence at 600,000 and asserts that approximately 42 percent of males will develop an inguinal hernia in their lifetime.⁶) These repairs are typically performed on an outpatient basis (87 percent in 1996).⁵ Such a large volume of procedures suggests that even modest improvements in patient outcomes would have a substantial impact on population health.⁷
The primary goals of surgery include preventing strangulation, repairing the hernia, minimizing the chance of recurrence, returning the patient to normal activities quickly, and minimizing postsurgical discomfort and the adverse effects of surgery. The various surgeries include a constellation of benefits and risks, which presents some clinical uncertainty in the choice between approaches. Recurrence occurs in approximately 1 to 5 percent of cases.⁸ Balancing all the factors (e.g., recurrence, adverse events, time to return to work [RTW]) is a difficult yet critical process in making the best possible medical decisions.
Surgical procedures for inguinal hernia repair generally fall into three categories: open repair without the use of a mesh implant (i.e., sutured), open repair with a mesh, and laparoscopic repair with a mesh. Within each of these categories, several specific procedures have been employed. Until the 1980s, open suture repair was the standard; however, the resulting tension along the suture line yielded relatively high rates of recurrence and patient discomfort. Nonsutured “tension-free” surgical mesh has gained in popularity, and many specific open procedures are used. One author estimates that in 2003, 93 percent of groin hernia repairs involved the use of a mesh, and of these, about three-fourths involved either a Lichtenstein repair or mesh plug.⁵ In the Lichtenstein procedure, surgeons suture the mesh in front of the hernia defect. Mesh plug repair involves a preshaped mesh plug that surgeons introduce into the hernia weakness during open surgery; they then position a piece of flat mesh on top of the hernia defect. The near-universal adoption of mesh means that the most important questions about hernia repair involve various mesh procedures.
In terms of setting, most hernia surgeries are performed not in specialized hernia centers but by general surgeons who also perform many other types of surgeries.⁹ The laparoscopic surgical repair of inguinal hernia is generally recognized as a highly specialized skill, and patients receiving care from more experienced surgeons may fare better than patients receiving care from less experienced surgeons. This review specifically examines evidence on the association between laparoscopic surgical experience and hernia recurrence (See Key Questions below). The most commonly performed laparoscopic repair procedures are transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair. During TAPP repair, surgeons enter the peritoneal cavity to place a mesh through an incision over the hernia site. With TEP surgery, surgeons do not enter the peritoneal cavity but use a mesh to cover the hernia from outside the peritoneum.
Given the clinical uncertainty, a systematic review of the existing evidence on comparative effectiveness will help inform important medical decisions about surgical options for inguinal hernia. The findings of the review may affect clinical decisions by patients and surgeons, treatment recommendations by professional societies, purchasing decisions by hospitals, and coverage decisions by payers.

full-text:
http://www.ahrq.gov/research/oct12/1012RA27.htm