Inguinal Hernia in the 21st Century: An Evidence-Based Review

The treatment of inguinal hernias has been undergoing metamorphosis over the last 30 years. The techniques for surgical repair have been shifting from tissue- and suture-based repairs to mesh-based reinforcement of the hernia defect. There has been considerable time spent discussing the merits and demerits of laparoscopic repairs as compared with open mesh repairs. The research landscape has been shifting from following recurrence rates, to determining cost-effectiveness, complication rates, rates of chronic pain, and time to return to normal activity. It is becoming difficult to find areas of common ground among surgeons who are whetted to 1 repair technique or another with the exclusion of other techniques. Some generalizations have become clear over the last 30 years. The Shouldice hernia repair is the preferred tissue-based repair with regard to recurrence. The Lichtenstein tension-free hernia repair with mesh is an easy to learn, simple, and effective repair that can be mastered by clinicians and provide the recurrence and complication rates that are presented in the literature from specialty centers. In addition, the use of local anesthetic allows this repair to be used in the sickest of our patients with little increased risk. The laparoscopic hernia repair has been refined and polished over the last 10 years. The recurrence rates are more variable and this is likely due to the skill required to affect an adequate repair; there appears to be a significant learning curve. However, once skilled in this technique, the surgeon can provide his/her patient with the benefits of decreased pain and decreased length of time required to get back to work or full activity. Some decisions surrounding inguinal hernia repair are still clouded by personal preference. The use of antibiotics, the type of anesthetic used, and the manner in which the mesh is attached in a repair will be analyzed and recommendations will be offered. It will likely be years until a consensus on these topics will be reached and implemented across our profession. It is also likely that the setting of the specialized hernia center is different from the small town hospital with surgeons practicing a variety of general surgery procedures. The increased description of settings outside academic or specialty hospitals is helping to clarify what can be expected realistically by patients in the general population. The VA population is becoming better described, but individual practitioners should follow their outcomes in a prospective manner to assess if they are matching described rates of recurrence and complication. Ultimately, the decision of a style of inguinal hernia repair and the specifics of the operation are left to the individual surgeon and selection of a procedure should be made in consultation with the patient. A broad training in inguinal hernia anatomy and tissue-based repair provides options in patients who have relative contraindications for mesh. Open mesh techniques allow an effective repair to be made in patients with compromised tissue strength and comorbid diseases. Laparoscopic repairs are useful for recurrent hernias, bilateral hernias, and athletic or pain-prone individuals. Practitioners, as they leave their training, must understand how to tailor their operative treatment of inguinal hernia to provide their patient with the best chance of a durable repair, with the least risk of complication, and to do this in the most cost-effective way possible. The question can be asked: Which hernia repair should I use? This was addressed by an editorial in the British Medical Journal by Kirk. He argues: "In my experience outstanding and thoughtful surgeons who devise new techniques attribute their success to the method. They are too modest. Their colleagues know that it is not the particular method that brings success but the enthusiasm for perfection and painstaking skill with which it is accomplished. If I develop a hernia I shall not worry about the method of repair but who is carrying it out."¹⁶⁹. Similarly, a discussion about the merits of mesh in hernia repair can be tempered with the comments of Zimmerman: "Prostheses, whatever their value, cannot replace a full knowledge of the underlying anatomy and pathology of hernia, or substitute for the exercise of time honored principles of surgical technique."¹⁷⁰. In the end, the general surgeon must take nearly 150 years of improvements in inguinal hernia repair and select an appropriate repair, with appropriate materials, for an individual patient. This should be based on the surgeon's training and skills. Ultimately, the individual record of the surgeon's past results should be the litmus test as to whether a correct technique has been selected.