Groin Hernias:Do all Need to be Fixed?

Abeezar I Sarela MD FRCS

Groin Hernia RepairWhat are we seeking to achieve?

• Relief of discomfort or pain

Is pain truly due to a hernia?

Chronic groin pain after hernia repair

• Prevention of future complications

?Sudden-onset strangulation is rare

All licensed providers of NHS-funded Unilateral Hip replacements, Unilateral Knee replacements, Groin Hernia Surgery or Varicose Vein Surgery (“Providers”) are expected to invite patients undergoing one of these procedures to complete a preoperative PROMs questionnaires from April 2009 in accordance with this guidance. For non-Foundation Trust NHS Acute Trusts, the PROMs data collection has been given mandatory collection status by the Review

• self-completed questionnaires administered to Patients to assess their self-reported health status before and after certain elective healthcare interventions funded by the NHS.

• provides an indication of the outcomes or quality of care delivered to NHS Patients.

Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open

repair of groin hernia MRC Laparoscopic Groin Hernia Trial Group BJS 2004; 91: 1570–1574

928 patients

Laparoscopic468 patients(TEP 80%)

Open460 patients

• 1994-1997• 27 surgeons in 26

hospital in the UK• Response

– 2 yrs: 70%– 5 yrs: 60%

Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open

repair of groin hernia MRC Laparoscopic Groin Hernia Trial Group BJS 2004; 91: 1570–1574

1 year 5 years

Lap Open Lap Open

Groin Pain

28% 36% 18% 20%

Severe pain

4% 2% 2% 2%

Testis pain

22% 20% 19% 13%

Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open

repair of groin hernia MRC Laparoscopic Groin Hernia Trial Group BJS 2004; 91: 1570–1574

1 year 5 years

Lap Open Lap Open

Numb groin

18% 40% 13% 25%

Numb thigh

14% 11% 10% 9%

Risk factors for long-term pain after hernia surgery

Ann Surg 2006;244:212-219

• Swedish Hernia Registry: 2000

• 10,000 hernia operation

• Exclude: bilateral operations or previous/subsequent contralateral operation

• Eligible: 7000 patients

• Random selection: 3000 patients

• Postal questionnaire (DIBS) - 2003

Risk factors for long-term pain after hernia surgery

Ann Surg 2006;244:212-219

• Comparison with contra-lateral groin– Some pain: 31%– Pain interfering with daily activity: 6%

• Predictors of pain– Young (age below median)– High level of pre-op. pain– Any post-op complication– Open surgery

RCT: Observation or Operation for Patients with an Asymptomatic Inguinal Hernia

O’Dwyer et al. Ann Surg 2006;244:167-173

• Inclusion– Male > 55 years– No pain at rest or movement– Reducible

• Randomization of 160 patients• Operation: Open Lichtenstein repair• Observation: Crossover if pain,

interference with activity, irreducibility• Primary end-point: Pain at one year

RCT: Observation or Operation for Patients with an Asymptomatic Inguinal Hernia

O’Dwyer et al. Ann Surg 2006;244:167-173

• No difference in pain at rest or movement at 12 months (~1/3 in both groups had pain > 2mm on a 10cm VAPS)

• HRQoL (SF36) significantly improved after operation

RCT: Observation or Operation for Patients with an Asymptomatic Inguinal Hernia

O’Dwyer et al. Ann Surg 2006;244:167-173

• Crossovers from observation to operation– 26% at 15 months– Post-op complications

• MI (1 patient; died)• CVA (1 patient)

– Acute presentation: 1 patient

• No serious complications in operation arm• Cost: £400 more per patient in operation

arm

RCT: Observation or Operation for Patients with an Asymptomatic Inguinal Hernia

O’Dwyer et al. Ann Surg 2006;244:167-173

RCT: Observation or Operation for Patients with an Asymptomatic Inguinal Hernia

O’Dwyer et al. Ann Surg 2006;244:167-173

Conclusion: Patients with asymptomatic hernias should be operated because

• Operation does not impact incidence of chronic pain – but short follow-up study

• Operation improves sense of well-being

• Delay in operation pre-disposes to increased risk of post-operative complications - unsupported

RCT: Watchful Waiting versus Repair of Inguinal Hernia in Minimally Symptomatic Men

Fitzgibbons et al. JAMA. 2006;295(3):285-292

• Inclusion– Men > 18 years– Absence of pain limiting activity– Chronic irreducibility

• Randomization of 724 patients

• End-points: Pain and QoL at 2 years

RCT: Watchful Waiting versus Repair of Inguinal Hernia in Minimally Symptomatic Men

Fitzgibbons et al. JAMA. 2006;295(3):285-292

• No significant difference in pain interfering with activity in patients assigned to operation (2.2%) vs. waiting (5.1%)– Both groups had less pain at 2 years than at

baseline– For crossovers, significant decrease in pain

after operation

• No significant difference in HRQoL (SF36)– Crossovers had significantly greater

improvement than assigned operation

RCT: Watchful Waiting versus Repair of Inguinal Hernia in Minimally Symptomatic Men

Fitzgibbons et al. JAMA. 2006;295(3):285-292

• Crossovers from waiting to operation: 23%– Beyond 2 years: 4% crossover/year– One acute event (no obstruction) < 2 years– One acute event (obstruction) > 2 years– No difference in complications after assigned

vs. crossover operations

• Crossover from assigned operation to waiting: 17%

RCT: Watchful Waiting versus Repair of Inguinal Hernia in Minimally Symptomatic Men

Fitzgibbons et al. JAMA. 2006;295(3):285-292

Conclusion• A strategy of watching waiting is an

acceptable option and should be offered to men with asymptomatic or minimally symptomatic hernias– Does this apply to the elderly, infirm,

incapable?– Does size of the hernia matter?– What about women?

Mortality after groin hernia surgeryAnn Surg 2007;245:656-660

• Standardized mortality ratio (SMR) = observed/expected death within 30 days for surgery adjusted for age and gender

• No increase in SMR after elective surgery, even in older patients

• SMR increased 6-9X after emergency op.

• SMR increased 20X after emergency op. with bowel resection

Mortality after groin hernia surgeryAnn Surg 2007;245:656-660

• Swedish Hernia Registry: 1992-2004• 1,08,000 patients• Femoral hernias

– Men (1%) vs. Women (22%)– Older patients than inguinal hernias

• Emergency operations– Inguinal (5%) vs. Femoral (36%)– Bowel resection: Inguinal (5%) vs. Femoral (23%)– Men (5%) vs. Women (17%)– Significantly older than elective patients

• Older patients are more likely to need emergency surgery than young patients

• Women are more likely to need emergency surgery than men

• Increased risk of post-operative mortality after emergency surgery

• The elderly are not at increased risk of mortality after elective surgery

Repeated Groin Hernia RecurrencesAnn Surg 2009;249:516-518

• Swedish Hernia Registry: 1992-2006

• Recurrent hernia repair: 17,000/142,000

• Cumulative risk of re-operation– After first recurrence: 7.5%– After second recurrence: 10%– After third recurrence: 13%– After fourth recurrence: 16.5%

• Risk of re-operation is significantly lower if– Laparoscopic TEP repair– High volume surgeon

Re-recurrence after operation for recurrent inguinal hernia

Ann Surg 2008;247:707-711

• Danish Hernia Database: 1998-2005• Primary elective operations: 67,000

– Lichtenstein (70%); other open (26%); laparoscopic (4%)

• Re-operation: 3%• Re-re-operation: 9%• Cumulative re-operation rate was

significantly lower for laparoscopic repair vs. any open repair

Recurrence after Lichtenstein repair – should laparoscopic TEP repair be the accepted standard of care?

Limited data for treatment of recurrences after laparoscopic repair or open non-Lichtenstein repair