title: European Hernia Society guidelines on the treatment of inguinal hernia in adult patients Discomfort five years after laparoscopic and Shouldice inguinal hernia repair: a randomised trial with 867 patients. A report from the SMIL study group EFFECT OF EARLY RETURN TO WORK AFTER ELECTIVE REPAIR OF INGUINAL HERNIA: CLINICAL AND FINANCIAL CONSEQUENCES AT ONE YEAR AND THREE YEARS Factors associated with postoperative complications and hernia recurrence for patients undergoing inguinal hernia repair: a report from the VA Cooperative Hernia Study Group. Quality assessment of 26 304 herniorrhaphies in Denmark: a prospective nationwide study Hernia surgery in a defined population: a prospective three year audit. Body Mass Index and Groin Hernia: A 34-Year Follow-up Study in Swedish Men Intra-abdominal pressure increases during exhausting back extension in humans Psychological risk factors for chronic post-surgical pain after inguinal hernia repair surgery: a prospective cohort study. Nerve Management and Chronic Pain After Open Inguinal Hernia Repair: A Prospective Two Phase Study Randomized trial comparing the Prolene® Hernia System, mesh plug repair and Lichtenstein method for open inguinal hernia repair Short convalescence after inguinal herniorrhaphy with standardised recommendations: duration and reasons for delayed return to work. Randomized clinical trial comparing 5‐year recurrence rate after laparoscopic versus Shouldice repair of primary inguinal hernia Early return to work after repair of a unilateral inguinal hernia
abstract: The European Hernia Society ( EHS ) is proud to present the EHS Guidelines for the Treatment of  Inguinal Hernia in Adult Patients . The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare . They have been developed by a Working Group consisting of expert surgeons with representatives of 14 country members of the EHS . They are evidence -based and , when necessary , a consensus was reached among all members . The Guidelines have been review ed by a Steering Committee . Before finalisation , feedback from different national hernia societies was obtained . The  Appraisal of Guidelines for REsearch and Evaluation ( AGREE ) instrument was used by the Cochrane Association to vali date the Guidelines . The Guidelines can be used to adjust local protocol s , for training purpose s and quality control . They will be revised in 2012 in order to keep them up date d. In between revisions , it is the intention of the Working Group to provide every year , during the EHS annual congress , a short up date of new high-level evidence ( r and omised controlled trials [ RCTs ] and meta-analyses ) . Developing guidelines leads to questions that remain to be answered by specific research . Therefore , we provide recommendations for further research that can be performed to raise the level of evidence concerning certain aspects of inguinal hernia treatment . In addition , a short summary , specifically for the general practitioner , is given . In order to increase the practical use of the Guidelines by consultants and residents , more details on the most important surgical techniques , local infiltration anaesthesia and a patient information sheet is provided . The most important challenge now will be the implementation of the Guidelines in daily surgical practice . This remains an important task for the EHS . The establishment of an EHS school for teaching inguinal hernia repair surgical techniques , including tips and tricks from experts to overcome the learning curve ( especially in endoscopic repair ) , will be the next step . Working together on this project was a great learning experience , and it was worthwhile and fun . Cultural differences between members were easily overcome by educating each other , respecting different views and always coming back to the principles of evidence -based medicine . The members of the Working Group would like to thank the EHS board for their support and especially Ethicon for sponsoring the many meetings that were needed to finalise such an ambitious project Background In recent years long-term discomfort  after inguinal hernia surgery has become an issue of great concern to hernia surgeons . Long-term results on discomfort from large r and omised studies are sparse . Methods One-thous and one-hundred and eighty-three patients were r and omised in a multicentre trial with the primary aim of comparing recurrence rates after laparoscopic TAPP and Shouldice repair . Evaluating late discomfort and its possible risk factors were secondary objectives , and are reported here . The patients were clinical ly examined after 1 and 5 years , and answered question naires 2 and 3 years postoperation . Results Of 1,068 operated patients , 867 were eligible for analysis after 5 years ( 81.2 % ) . The percentage of patients experiencing discomfort of any kind were 8.5 % in the TAPP group and 11.4 % ( p = 0.156 ) in the Shouldice group . Although discomfort was usually mild it was severe for 0.2 and 0.7 % , respectively . Severe pain the first postoperative week was a risk factor for late discomfort in the Shouldice group ( OR 2.25 , P = 0.022 ) but not in the TAPP group . No other risk factor for late discomfort was found . Conclusion There was no difference between late discomfort at five-year follow-up after laparoscopic TAPP and Shouldice repair .  Discomfort was mostly mild and pain during the first postoperative week was a prognostic variable for late discomfort in Shouldice patients Since January , 1976 , male patients undergoing elective unilateral inguinal herniorrhaphy have been included in a trial to see whether early return to normal activity is associated with an increased recurrence rate and to investigate economic consequences . By June , 1981 , 500 patients had been review ed at one year . 2 patients had defaulted . The first 200 patients had been examined at one year and three years . Recurrence was assessed independently , and recurrences were found of which the patient was unaware . The acceptable definition of recurrence was need for reoperation or a truss . The overall recurrence rate at one year was 3.9 % . At three years no further recurrences were detected in the first 200 patients . There was no difference in the recurrence rate for those in the " early " group with 8 recurrences in a total of 246 patients and 10 recurrences in 245 patients in the control group . the median inactivity period in the " early " group was 48 days , compared with 65 days in the control . This differences of 17 days is significant ( p=0.001 ) . The self-employed " early " group returned to work in a median of 31 days . One-third of workers were losing a median of pounds 31 per week ( range pounds 3- pounds 200 ) . Patients can return to normal activity sooner after inguinal herniorrhaphy than has been advised without increasing the recurrence rate at one year and three years and with considerable monetary benefit to one-third of workers BACKGROUND We sought to determine perioperative variables predictive of complications or recurrence for patients undergoing surgical repair of inguinal hernias . PATIENTS AND METHODS Using data from the Veterans Affairs trial , regression analyses were utilized to identify perioperative factors significantly associated with complications ( overall , short-term and long-term ) , long-term pain , and to develop a risk model for recurrence . RESULTS Recurrent and scrotal hernias were predictors for short term and overall complications , regardless of technique . Older age and higher Mental Component Score of the SF-36 were associated with higher risk of long term complications in the open group while prostatism and increased body mass index were the significant predictors in the laparoscopic group . Long-term pain complaints decreased as patient age increased in both groups . Patient and surgeon factors were predictive of recurrence but varied greatly depending on surgical technique . CONCLUSIONS Regardless of technique , scrotal and recurrent hernias were associated with a greater risk of complications and younger patients had more long-term pain . Predictors of recurrence vary based on surgical technique BACKGROUND Groin hernia repair is one of the most frequent operations , but there is no consensus about surgical or anaesthetic technique . Furthermore , no nationwide studies have been done . Our aim was to investigate outcome results of groin hernia surgery to improve quality of treatment . METHODS We prospect ively recorded 26304 groin hernia repairs done in Denmark from Jan 1 , 1998 , to June 30 , 2000 , in a nationwide Danish hernia data base . FINDINGS 93 % of all groin herniorrhaphies done in Denmark in the 30 months of the study were recorded in the data base . Kaplan-Meier estimates of reoperation rates 30 months after anterior mesh repair and laparoscopic repair were significantly lower than after sutured posterior wall repairs in primary inguinal hernia ( 2.2 % and 2.6 % vs 4.4 % ; p<0.0001 ) . Reoperation rates were also lower with anterior mesh repair ( 6.1 % ; p<0.0001 ) and laparoscopic repair ( 3.4 % ; p<0.0001 ) than with sutured posterior wall repair ( 10.6 % ) after recurrent hernia . Use of Lichtenstein mesh repair  increased from 33 % in January , 1998 , to 62 % in June , 2000 , whereas use of laparoscopic repair remained constant at about 5 % . Kaplan-Meier estimates of reoperation rates were 2.8 % in the first 15 months and 1.6 % in the second ( p=0.03 ) . For elective repairs , only 59 % of patients were treated on an outpatient basis , and only 18 % had local anaesthesia . INTERPRETATION Mesh repairs have a lower reoperation rate than conventional open repairs . Systematic prospect i ve recording of treatment and outcome variables in a national clinical data base improved the overall quality of surgical care . However , there is a large potential for cost savings and more efficient patient care with extended use of mesh techniques , outpatient surgery , and local anaesthesia OBJECTIVE To establish a register of  inguinal hernia surgery  that allows audit and analyses of data from several centres . DESIGN Prospect i ve recording of data on a common protocol . SETTING Eight Swedish hospitals . SUBJECTS All groin hernia operations done for patients over 15 years old from January 1992 to December 1994 . MAIN OUTCOME MEASURES Methods of repair , postoperative complications including mortality , day surgery rate , and reoperations for recurrence . RESULTS During the three years studied 4879 hernia operations were undertaken in 4474 patients .  Postoperative mortality within 30 days of operation for emergency and elective hernia repairs was 3.5 % and 0.07 % , respectively . Of all herniorrhaphies 798 ( 16 % ) were done for recurrences , 142 of these after operations between 1992 and 1994 . At 24 months 4 % of all operations had been redone because of recurrences with highly significant variations among hospitals ranging from 1.5 % to 6.7 % . Postoperative complications within 30 days after operation , direct hernia , recurrent hernia , and the use of absorbable sutures were associated with an increased risk of reoperation . CONCLUSIONS A quality register recorded voluntarily can identify significant interhospital differences in outcome as well as variables associated with an increased risk of reoperation , thereby raising quality awareness and facilitating the process of improvement Objective :  Inguinal  hernias are very common disorders , especially in men , with inguinal herniorrhaphy being one of the most frequently performed general surgical procedures in men . Theoretically , obesity might increase the risk of groin hernia by increasing intra-abdominal pressure . The objective of the present study was to investigate whether overweight and obesity in middle age could significantly predict future groin hernia  in men . Summary Background Data : Design : Prospect i ve cohort study ; Setting : General population of men living in Gothenburg , Sweden ; Participants : A community-based sample of 7483 men aged 47 to 55 years were followed-up from baseline ( 1970–1973 ) for a maximum of 34 years . Main Outcome Measures : A diagnosis of groin hernia according to the Swedish hospital discharge register . Results : A total of 1017 men ( 13.6 % ) were diagnosed with groin hernia .  An inverse relationship was found between body mass index ( BMI ) and risk of groin hernia . With each BMI unit ( 3–4 kg ) , the relative risk for groin hernia decreased by 4 % ( P < 0.0001 ) . Compared with men of normal weight , obese men had a 43 % lower risk ( P = 0.0008 , 95 % confidence interval 21%–59 % ) . Heavy smokers demonstrated a 26 % lower risk for groin hernia ( P = 0.003 , 95 % confidence interval 10%–39 % ) . Diabetes , high physical activity , and blood pressure were not associated with groin hernia . Entering other variables potentially associated with groin hernia , as age , BMI , smoking , and serum cholesterol , in a multivariable analysis left the risk estimates for BMI and smoking virtually unchanged . Conclusions : In a large community-based sample of middle-aged men overweight and obesity were associated with a lower risk for groin hernia during an extended follow-up . Obesity , in comparison with normal weight , reduced the risk of groin hernia by 43 % . A reduced risk of groin hernia was also noted in heavy smokers . Obviously , hernia may be more easily detected in lean men but a true protective effect can not be excluded Abstract . The aim of this study was to investigate in humans the effect of maintained spinal load on the intra-abdominal pressure ( IAP ) , low back kinematics and trunk muscle activity . This study consisted of two endurance tests for the low back muscles performed 3 weeks apart . Nine healthy subjects participated in the study . In the first test ( upright-test ) , the subject had to pull with the back muscles at a constant force in an upright position , and in the second test ( incline-test ) , the subject had to resist a constant forward pulling force while st and ing with a 45 ° inclination of the back in relation to vertical .  The IAP , rate of perceived exertion and electromyogram ( EMG ) from the erector spinae , iliocostalis lumborum , rectus abdominus and the external and internal oblique muscles were measured using surface electrodes . There was no significant difference in endurance time between the two tests . Both tests showed a significant increase in EMG amplitude with time for all muscles except the erector spinae muscle . A decrease in the median frequency for the erector spinae muscle was found indicating fatigue , and since no increase in EMG amplitude was found a decrease in force output from the muscle must be assumed . The IAP increased significantly during both tests . There was a considerable variation between the subjects in the size of this development , but the pattern was the same for all subjects . In conclusion it was found that trunk extension until exhaustion initiates an increase in the activity of the abdominal muscles and an increase in the IAP as the low back muscles become fatigued A significant proportion of patients experience chronic post-surgical pain ( CPSP ) following inguinal hernia surgery .  Psychological models are useful in predicting acute pain after surgery , and in predicting the transition from acute to chronic pain in non-surgical context s. This is a prospect i ve cohort study to investigate psychological ( cognitive and emotional ) risk factors for CPSP  after inguinal hernia surgery . Participants were asked to complete question naires before surgery and 1 week and 4 months after surgery . Data collected before surgery and 1 week after surgery were used to predict pain at 4 months . Psychological risk factors assessed included anxiety , depression , fear-avoidance , activity avoidance , catastrophizing , worry about the operation , activity expectations , perceived pain control and optimism .  The study included 135 participants ; follow-up question naires were returned by 119 ( 88.1 % ) and 115 ( 85.2 % ) participants at 1 week and 4 months after surgery respectively . The incidence of CPSP ( pain at 4 months ) was 39.5 % . After controlling for age , body mass index and surgical variables ( e.g. anaesthetic , type of surgery and mesh type used ) , lower pre-operative optimism was an independent risk factor for CPSP at 4 months ; lower pre-operative optimism and lower perceived control over pain at 1 week after surgery predicted higher pain intensity at 4 months . No emotional variables were independently predictive of CPSP . Further research should target these cognitive variables in pre-operative psychological preparation for surgery Introduction : This prospect i ve cohort study involved 781 elective primary inguinal hernia operations performed on 736 patients at the Hernia Centre of Reinbek Hospital from April 2000 to April 2002 . Material and Methods : Small hernias were fixed by the Shouldice repair , and large defects by the Lichtenstein repair with conventional polypropylene mesh .  Pain was assessed before the operation , on day 0 , 1 , 2 , 7 , 6 months and 5 years after the operation by the visual analogue scale ( VAS ) . The follow-up was 90.1 % after 6 months and 82.6 % after 5 years . Chronic pain ( CP ) was assessed in relation to preoperative pain , nerve anatomy and intraoperative nerve management . The anatomy of the iliohypogastric nerve ( IHN ) , ilioinguinal nerve ( IIN ) , and genital branch of the genitofemoral nerve ( GB ) before and after surgery was recorded in every operation . Results : The preoperative pain rate was 41.0 % . The CP and sensory disorder rate after 6 months were 16.4 % and 15.9 , respectively . The only independent significant parameters for CP after 6 months were preoperative pain ( P < 0.002 ) and sensory disorder of the groin after 6 months ( P < 0.0001).After 5 years 16.1 % of patients reported pain and 20.3 % sensory disorder of the groin . Independent significant predictors of CP were : Preoperative pain ( P < 0.024 ) , IIN neurolysis in Lichtenstein repair ( = IIN mobilization from its natural bed and nerve preservation ; P < 0.002 ) , CP after 6 months ( P < 0.006 ) and a sensory disorder after 5 years ( P < 0.0001 ) . Eleven of 12 patients with relevant CP ( VAS > 3 ) after 5 years had had a  Lichtenstein repair with IIN neurolysis . The CP population of preoperative pain free patients changed with time : 65 % of the patients with CP after 6 months were pain free after 5 years , and 69 % of the patients with CP after 5 years were asymptomatic after 6 months . Conclusion : Mesh contact with a nerve removed from its natural bed may cause chronic long-term pain . The combination of IIN neurolysis and the Lichtenstein repair should be avoided Most surgeons favour the use of a mesh for open inguinal hernia repair as it has a low recurrence rate . Procedures used most frequently are the Lichtenstein method  , mesh plug repair and the Prolene ® Hernia System . The choice of technique may be influenced by the effects on postoperative pain and quality of life OBJECTIVE To provide a detailed description of post-herniorrhaphy convalescence . DESIGN Prospect i ve , descriptive , consecutive question naire case series . SETTING Public university hospital , Denmark . PATIENTS 100 consecutive patients treated for inguinal hernia . INTERVENTION Elective open inguinal herniorrhaphy under local anaesthesia . One day convalescence for light/moderate and three weeks for strenuous physical activity was recommended . MAIN OUTCOME MEASURE Duration of absence from work or main recreational activity . RESULTS Overall median absence ( including the day of operation ) was 6 days ( interquartile range 1 - 16 ) . For unemployed patients it was 1 day ( 0 - 7 ) , for patients with a light or moderate workload 6 days ( 3 - 12 ) , and for those with a heavy workload 25 days ( 21 - 37 ) . Among the 64 patients , who did not follow the recommendations , pain was contributory in 33 and advice from the general practitioner in 12 . Pain was the main cause of impairment of activities of daily living . CONCLUSION Well-defined recommendations for convalescence may , together with improved management of postoperative pain , shorten convalescence ; they are essential in the evaluation of effects of different surgical techniques of herniorrhaphy on convalescence The Shouldice technique is the ‘ gold st and ard ’ of open non‐mesh hernia repair . The aim of this study was to compare 5‐year recurrence rates  after Shouldice and laparoscopic transabdominal preperitoneal patch ( TAPP ) repair for primary inguinal hernia Ninety‐seven Royal Naval and Royal Marine officers and ratings undergoing repair of a unilateral inguinal hernia were r and omized postoperatively into two groups : A , those who returned to full working duties  21 days after operation ; B , those who returned to light duties 21 days after operation and to full duties at 3 months . Patients were review ed at 3 and 12 months . One patient was withdrawn because of the development of late sepsis . Two patients in group B developed a recurrence of hernia within 1 year . No patient who returned to full duties at 21 days was unable to do any duty assigned to him . In a concurrent trial 119 male civilian patients were treated in the same hospital under identical conditions . All patients were review ed 21 days after operation and were r and omized into two groups : C , those advised to return to work immediately ; D , those given no advice . Patients in group C returned to work in a mean of 38 days ( range 14–96 days ) , whereas those in group D returned in a mean of 71 days ( range 14–280 days ) . There was no recurrence of hernia in either group within the review period . It is concluded that there is no contraindication to resuming physical work 3 weeks after the uncomplicated repair of a unilateral inguinal hernia , and that active encouragement shortens the interval before return to work
target: There is insufficient epidemiologic evidence to draw meaningful conclusions about ( i ) the existence of causal associations between specific occupational mechanical exposures and the development of inguinal hernia , and ( ii ) the influence of these exposures on prognosis after inguinal hernia repair with respect to hernia recurrence and persistent pain
background: OBJECTIVES The aim of this review was to evaluate the epidemiologic evidence for ( i ) a causal effect of occupational mechanical exposures on incidence of inguinal hernia , and ( ii ) a prognostic effect of such exposures on hernia recurrence and persistent pain after inguinal hernia repair .