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UPDATES ON THE MANAGEMENT OF INGUINAL HERNIA IN ADULTS.

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Presentation on theme: "UPDATES ON THE MANAGEMENT OF INGUINAL HERNIA IN ADULTS."— Presentation transcript:

1 UPDATES ON THE MANAGEMENT OF INGUINAL HERNIA IN ADULTS

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3 INTRODUCTION  Most common general surgical procedure  Goals  Provide long-lasting closure of pelvic floor defect  Reduce pain  Improve quality of life  Lack of consensus  Optimum repair technique  Prosthetic mesh

4 QUESTIONS?  Should all inguinal hernias be repaired?  What kind of mesh?  Endoscopic approach or open surgery?  TEP vs TAPP?  To fix or not to fix? (In endoscopic approach)

5 MYOPECTINEAL ORIFICE OF FRUCHARD  A single weak point where all groin hernias originate from  Only consists of transversalis fascia  Superior – Conjoint tendon  Inferior – Cooper’s ligament (Pectineal)  Medial – Rectus muscle  Lateral – Illiopsoas muscle

6 ANATOMY

7 QUESTIONS?  S hould all inguinal hernias be repaired?  W hat kind of mesh?  E ndoscopic approach or open surgery?  T EP vs TAPP? o fix or not to fix? (In endoscopic approach)

8 SHOULD ALL HERNIAS BE REPAIRED?  All hernias should be repaired due to risk of incarceration or strangulation

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10 THE EVIDENCE  D efinite indications for surgery include  S trangulation  I ncarceration  S ymptomatic  W hat about asymptomatic or minimally symptomatic patients?

11 THE EVIDENCE AuthorPublished YearStudy SizeFollow upConversion RateHernia Accident Fitzgibbons et al years68%2.4% O’Dwyer et al years72%2.5% Fitzgibbons RJ, Jr, Giobbie-Hurder A, Gibbs JO, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA. 2006;295:285–292 Fitzgibbons RJ Jr, Ramanan B et al. Long-term results of randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg Sep;258(3): O’Dwyer PJ, Norrie J, Alani A, et al. Observation or operation for patients with an asymptomatic inguinal hernia: a randomized clinical trial. Ann Surg. 2006;244:167. Chung L, Norrie J, O’Dwyer P. Long-term follow-up of patientswith a painless inguinal hernia from a randomized clinical trial. Br J Surg. 2011;98:596–599.  Watchful waiting  Safe and acceptable  70% of patients  symptoms will increase  Surgery

12 SHOULD ALL HERNIAS BE REPAIRED?  Current Recommendation  Older men/comorbidities  consider watchful waiting strategy  Younger patients  encourage elective repair

13 QUESTIONS?  S hould all inguinal hernias be repaired?  W hat kind of mesh?  E ndoscopic approach or open surgery?  T EP vs TAPP? o fix or not to fix? (In endoscopic approach)

14 LIGHTWEIGHT VS HEAVYWEIGHT  Lightweight mesh (Large porous mesh)  Weight reduced large pore >1 mm in size  Minimal foreign body reaction  Lighter, more pliable and more comfortable  ↓ Shrinkage  Heavyweight mesh (Small porous mesh)  Closely knitted with small pores less than 1 mm size  ↑ S urface area  ↑ I ntense foreign body reaction  ↑ Shrinkage

15 THE EVIDENCE  3 Meta-analyses (2012): Sajid et al, Uzzaman MM et al, Smietanski M et al  Current Recommendation  Lightweight meshes - ↓ chronic pain and ↓ foreign body feeling (early follow up)  No difference in chronic pain in long term follow up >3 years  Recurrence rate not increased

16 QUESTIONS?  S hould all inguinal hernias be repaired?  W hat kind of mesh?  E ndoscopic approach or open surgery?  T EP vs TAPP? o fix or not to fix? (In endoscopic approach)

17 ENDOSCOPIC APPROACH OR OPEN SURGERY?  P roven benefit for recurrent hernias  I n terms of recurrence and chronic pain  A lso proven beneficial for bilateral hernias  B ut what about primary unilateral inguinal hernias?

18 THE EVIDENCE – META-ANALYSIS AuthorJournalStudiesPatient no.Repair typeRecurrenceChronic painComplicationsReturn to Work (days) EU Hernia Trialist (2002) Hernia254165Lap vs LichtensteinNo differenceLap < OpenMore serious Cx in lapN/A Memon (2003) British Journal of Surgery Lap vs OpenNo differenceN/ALap < Open NICE Guidelines (2004) Lap vs Open mesh repairNo differenceLap < OpenNo differenceLap < Open Schmedt (2005) Surgical Endoscopy Lap vs OpenNo differenceLap < Open More serious Cx in lap Lap < Open Kuhry (2007) (Systemic review) Surgical Endoscopy TEP vs OpenNo differenceN/ANo differenceLap < Open O’Reilly (2012) Annals of Surgery Lap vs OpenLap > OpenLap < OpenNo differenceN/A Koning (2013) PLOS ONE135404TEP vs LichtensteinNo difference N/A European Hernia Society Guidelines (2009/2014) Hernia8 (FU >48mths) 2399Lap vs LichtensteinNo difference N/A

19 WHAT DOES THIS ALL MEAN?  Difficult to interpret  Heterogeneity of the studies  Open repair included studies performing Bassini, Shouldice etc  Discrepancy in laparoscopic experience Bassini Shouldice Master Techniques in Surgery: Hernia. Jones B Daniel

20 BEST OPTIONS FOR PRIMARY UNILATERAL HERNIA REPAIR  Current Recommendation  Open Lichtenstein and laparoscopic hernioplasty  No difference between recurrence rate  Possible ↓ acute and chronic pain in laparoscopic hernioplasty

21 QUESTIONS?  S hould all inguinal hernias be repaired?  W hat kind of mesh?  E ndoscopic approach or open surgery?  T EP vs TAPP? o fix or not to fix? (In endoscopic approach)

22 TEP OR TAPP?  TEP = Totally extraperitoneal technique  TAPP = Transabdominal pre-peritoneal technique  What’s the difference?

23 Zollinger’s Atlas of Surgical Operations 9 th Edition

24 Master Techniques in Surgery: Hernia. Jones B Daniel

25 TEP Hernia Surgery Simplified. Kuber, Sachin

26 TEP Master Techniques in Surgery: Hernia. Jones B Daniel

27 TEP Master Techniques in Surgery: Hernia. Jones B Daniel

28 TEP Hernia Surgery Simplified. Kuber, Sachin

29 TAPP Hernia Surgery Simplified. Kuber, Sachin

30 TAPP Master Techniques in Surgery: Hernia. Jones B Daniel

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34 TEP OR TAPP?  C C ochrane Review 2005  I nsufficient data  M ost were non-randomized studies  C onclusion back then: No differences between TEP and TAPP  W hat is the conclusion now, 10 years later?

35 TEP VS TAPP  Systemic Review by Bracale et al (2012)  Indirect comparison  Operative time  Post-op complications  Post-op pain  Recurrence  TEP and TAPP were equivalent Bracale U, Melillo P, Pignata G, et al. Which is the best laparoscopic approach for inguinal hernia repair: TEP or TAPP? A systematic review of the literature with a network meta-analysis. Surg Endosc 2012;26(12):3355–66.

36 TEP VS TAPP  Two RCTs – Gong et al (2011) and Bansal et al (2012)  Chronic pain  Quality of life  Return to normal activities  Recurrence  TEP and TAPP were comparable Gong K, Zhang N, Lu Y, Zhu B, Zhang Z, Du D, Zhao X, Jiang H (2011) Comparison of the open tension-free mesh-plug, transabdominal preperitoneal (TAPP), and totally extraperitoneal (TEP) laparoscopic techniques for primary unilateral inguinal hernia repair: a prospective randomized controlled trial. Surg Endosc 25:234–239 Bansal VK, Misra MC, Babu D, et al. A prospective, randomized comparison of long-term outcomes: chronic groin pain and quality of life following totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) laparoscopic inguinal hernia repair. Surg Endosc 2013;27(7):2373–82.

37 TEP OR TAPP  Current Recommendation  Both TEP and TAPP provide favorable outcomes  Decision based on surgeon’s preference and expertise

38 QUESTIONS?  S hould all inguinal hernias be repaired?  W hat kind of mesh?  E ndoscopic approach or open surgery?  T EP vs TAPP? o fix or not to fix? (In endoscopic approach)

39 TRIANGLE OF PAIN CORONA MORTIS Master Techniques in Surgery: Hernia. Jones B Daniel TRIANGLE OF DOOM

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41 Master Techniques in Surgery: Hernia. Jones B Daniel

42 TYPES OF FIXATION  Traumatic mesh fixation  Endoscopic staplers  Atraumatic mesh fixation  Fibrin/tissue glue Hernia Surgery Simplified. Kuber, Sachin

43 MESH FIXATION VS NO FIXATION – META-ANALYSES AuthorJournalStudiesPatient no.Repair typeRecurrencePost-op PainComplicationsChronic pain Tam KW et al (2010) World Journal of Surgery 6932TEPNo difference N/A Tang YJ et al (2011) Surgical Endoscopy6772TEPNo difference N/A Sajid MS et al (2012) International Journal of Surgery 81386TEP (one study with TAPP) No difference

44 TAPP  Only one RCT comparing mesh fixation and no fixation  502 patients  Median follow up of 16 months  No statistical difference  Operative time  Chronic pain  Recurrence Smith AI, Royston CM, Sedman PC (1999) Stapled and nonstapled laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair. A prospective randomized trial. Surg Endosc 13(8):804–806

45 TO FIX OR NOT TO FIX  Current Recommendation  Traumatic mesh fixation in TEP is unnecessary in most cases

46 CONCLUSION  Should all inguinal hernias be repaired?  What kind of mesh?  Endoscopic approach or open surgery?  TEP vs TAPP?  To fix or not to fix? (In endoscopic approach)

47 THE END

48 THE IDEAL MESH  Not physically modified by body tissue fluids  Chemically inert  Flexible and moldable  Not causing hypersensitivity  Resistant to mechanical strain over long time  Should not cause foreign body inflammation or allergic reactions  High tensile strength  Capable of being fabricated in the form required  Can be sterilized  Noncarcinogenic  Should not prone to bacterial seeding and infection  Barrier to adhesion  Cost-effective  Readily available

49 MOST COMMON MATERIALS USED  Polypropylene  Ie. Prolene, Marlex  Polyester  Ie. Dacron, Mersilene

50 WHAT MATERIAL?  No evidence on what type of material is better.

51 ATRAUMATIC MESH FIXATION VS MECHANICAL FIXATION

52 ATRAUMATIC FIXATION VS MECHANICAL FIXATION  Comparable results  Recurrence, operative time, post-operative complications and length of hospital stay.  Two RCTs (Lovisetto F et al (2007) and Olmi S (2007)  Decreased post-operative pain for glue fixation  No meta-analyses to compare - Lau H (2005) Fibrin sealant vs. mechanical stapling for mesh fixation during endoscopic extraperitoneal inguinal hernioplasty: a randomized prospective trial. Ann Surg 242(5):670–675 - Lovisetto F, Zonta S, Rota E, Mazzilli M, Bardone M, Bottero L, Faillace G, Longoni M (2007) Use of human fibrin glue (Tissucol) vs. staples for mesh fixation in laparoscopic transabdominal preperitoneal hernioplasty: a prospective, randomized study. Ann Surg 245(2):222– Olmi S, Scaini A, Erba L, Guaglio M, Croce E (2007) Quantification of pain in laparoscopic transabdominal preperitoneal (TAPP) inguinal hernioplasty identifies marked differences between prosthesis fixation systems. Surgery 142(1):40–46. - Boldo E, Armelles A, Perez de Lucia G, Martin F, Aracil JP, Miralles JM, Martinez D, Escrig J (2008) Pain after laparoscopic bilateral hernioplasty: early results of a prospective randomized double-blind study comparing fibrin vs. staples. Surg Endosc 22(5):1206– Fortelny RH, Petter-Puchner AH, May C, Jaksch W, Benesch T, Khakpour Z, Redl H, Glaser KS (2012) The impact of atraumatic fibrin sealant vs. staple mesh fixation in TAPP hernia repair on chronic pain and quality of life: results of a randomized controlled study. Surg Endosc 26(1):249–254.

53 MESH OR NON-MESH  Not much controversy  Many studies have documented a 50-75% reduction rates with the addition of mesh to an inguinal hernia repair  With mesh  Most studies report recurrence rates in the 2-5% range with long-term follow up  Lower rates of chronic pain - EU Hernia Trialists Collaboration. Mesh compared with non-mesh methods of open groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000;87(7):854–9. - Scott NW, McCormack K, Graham P, et al. Open mesh versus non-mesh for repair of femoral and inguinal hernia. Cochrane Database Syst Rev 2002;(4): - EU Hernia Trialists Collaboration. Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials. Ann Surg 2002;235(3):322–32. - Amato B, Moja L, Panico S, et al. Shouldice technique versus other open techniques for inguinal hernia repair. Cochrane Database Syst Rev 2012;(4): - Grant AM, EU Hernia Trialists Collaboration. Open mesh versus non-mesh repair of groin hernia: meta-analysis of randomised trials based on individual patient data. Hernia 2002;6(3):130–6.

54 CONTRALATERAL DISSECTION: HOW FAR?  The incidence of incipient unsuspected contralateral hernia is %  Laparoscopic hernia repair (TAPP) has a major advantage of allowing the surgeon to explore the site contralateral to the clinically diagnosed hernia without any additional dissection steps  In TEP- Advantages and disadvantages  Recommendations  The systemic exploration of the contralateral side using the TEP technique is controversial. Further studies are needed

55 WHAT IS THE MOST COST-EFFECTIVE OPERATION?  From the perspective of the hospital, an open mesh procedure is the most cost- effective operation in primary unilateral hernias  From a socioeconomic perspective, an endoscopic procedure is probably the most cost-effective approach for patients who participate in the labour market.  Conclusions with respect to cost issues should be interpreted with care since local expertise, the used instrumentation (disposable vs reusable instruments, type of anaesthesia) and local health care/insurance issues (eg. Day surgery vs overnight stay, public vs private hospital setting) play a role to determine direct costs  Sociocultural differences with respect to work resumption increase the difficulty in interpretation when evaluating total costs

56 ANTIBIOTICS  In open mesh repair in low risk patients and a low incidence of wound infection, antibiotic prophylaxis does not significantly reduce the number of wound infections  In the presence of high incidence of wound infection (>5%) there is a significantly benefit of antibiotic prophylaxis. NNT 22  (Class IA evidence)  European Hernia Society Guidelines Update 2014

57 ILIOINGUINAL NERVE  Prophylactic resection of the ilioinguinal nerve does not reduce the risk of chronic pain after open hernia surgery  Level IA evidence  A more recent meta-analysis of all RCTs on preservation vs routine division of the ilioinguinal nerve during open mesh repair for the prevention of chronic pain showed no difference at 6 and at 12 months  Chen CS, Lee HC, Liang HH, Kuo LJ, Wei PL, Tam KW (2012) Preservation vs. division of ilioinguinal nerve on open mesh repair of inguinal hernia: a meta-analysis of randomized controlled trials. World J Surg

58 CHRONIC PAIN  Evidence from two RCTs show that chronic pain diminishes over time  In a 10 year follow up study of an RCT including 300 patients comparing mesh vs non-mesh repair for a primary inguinal hernia  Incidence of pain 6 months postoperatively was between 10-15%  None of the patients suffered from persistent pain and discomfort interfering with daily activity  Another RCT comparing endoscopic TEP vs Lichtenstein repair in 1370 patients  21.7% had chronic pain at 1 year  18.8% chronic pain at 5 years

59 MESH DEVICES  PHS and Plug and Patch (mesh plug) result in comparable outcome (recurrence and chronic pain) as the Lichtenstein technique (1-4 year follow up)

60 COMPARISON BETWEEN POLYESTER AND POLYPROPYLENE  Small RCTs have shown similar results in regards to postoperative pain and quality of life  Amount of chronic pain was similar too

61 REFERENCES Fitzgibbons RJ, Jr, Giobbie-Hurder A, Gibbs JO, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA. 2006;295:285– 292 Fitzgibbons RJ Jr, Ramanan B et al. Long-term results of randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg Sep;258(3): O’Dwyer PJ, Norrie J, Alani A, et al. Observation or operation for patients with an asymptomatic inguinal hernia: a randomized clinical trial. Ann Surg. 2006;244:167. Chung L, Norrie J, O’Dwyer P. Long-term follow-up of patientswith a painless inguinal hernia from a randomized clinical trial. Br J Surg. 2011;98:596–599. Sajid MS, Leaver C, Baig MK, Sains P (2012) Systematic review and meta-analysis of the use of lightweight vs. heavyweight mesh in open inguinal hernia repair. Br J Surg 99(1):29–37. Uzzaman MM, Ratnasingham K, Ashraf N (2012) Meta-analysis of randomized controlled trials comparing lightweight and heavyweight mesh for Lichtenstein inguinal hernia repair. Hernia. Smietanski M, Smietanska IA, Modrzejewski A, Simons MP, Aufenacker TJ (2012) Systematic review and meta-analysis on Heavy and lightweight polypropylene mesh in Lichtenstein inguinal hernioplasty. Hernia 16(5):519–528 Nikkolo C, Murruste M, Vaasna T, Seepter H, Tikk T, Lepner U (2012) 3-year results of randomised clinical trial comparing lightweight mesh with heavyweight mesh for inguinal hernioplasty. Hernia 16(5):555–559. Smietanski M, Bury K, Smietanska IA, Owczuk R, Paradowski T (2011) 5-year results of a randomised controlled multi-centre study comparing heavy-weight knitted vs. low-weight, nonwoven polypropylene implants in Lichtenstein hernioplasty. Hernia 15(5):495–501. Bury K, Smietanski M (2012) 5-year results of a randomized clinical trial comparing a polypropylene mesh with a poliglecaprone and polypropylene composite mesh for inguinal hernioplasty. Hernia 16(5):549–553.

62 REFERENCES Treadwell J, Tipton K, Oyesanmi O, et al. Surgical options for inguinal hernia: comparative effectiveness review. Comparative effectiveness review No. 70 (Prepared by the ECRI Institute evidence-based Practice Center under Contract No ) AHRQ publication No. 12-EHC091-EF. Rockville (MD): Agency for Healthcare Research and Quality; 2012 McCormack K, Wake BL, Fraser C, et al. Transabdominal pre-peritoneal (TAPP) versus totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair: a systematic review. Hernia 2005;9(2):109–14. Bittner R, Arregui ME, Bisgaard T, et al. Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal Hernia [International Endohernia Society (IEHS)]. Surg Endosc 2011;25:2773–843. Wake BL, McCormack K, Fraser C, et al. Transabdominal pre-peritoneal (TAPP) vs totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair. Cochrane Database Syst Rev 2005;(1):CD McCormack K, Wake B, Perez J, et al. Laparoscopic surgery for inguinal hernia repair: systematic review of effectiveness and economic evaluation. Health Technol Assess 2005;9(14):1– 203, iii–iv. Shah NR, Mikami DJ, Cook C, et al. A comparison of outcomes between open and laparoscopic surgical repair of recurrent inguinal hernias. Surg Endosc 2011;25(7):2330–7. Sevonius D, Gunnarsson U, Nordin P, et al. Recurrent groin hernia surgery. Br J Surg 2011;98(10):1489–94. Bignell M, Partridge G, Mahon D, et al. Prospective randomized trial of laparoscopic (transabdominal preperitoneal-TAPP) versus open (mesh) repair for bilateral and recurrent inguinal hernia: incidence of chronic groin pain and impact on quality of life: results of 10 year follow-up. Hernia 2012;16(6): 635–40. Gopal SV, Warrier A. Recurrence after groin hernia repair-revisited. Int J Surg 2013;11(5):374–7.

63 REFERENCES Yang J, Tong da N, Yao J, et al. Laparoscopic or lichtenstein repair for recurrent inguinal hernia: a meta-analysis of randomized controlled trials. ANZ J Surg 2013;83(5):312–8. Simons MP, Aufenacker ET, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2009; 13:343–403. Bittner R, Arregui ME, Bisgaard T, et al. Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal Hernia [International Endohernia Society (IEHS)]. Surg Endosc 2011;25:2773–843. McCormack K, Wake BL, Fraser C, et al. Transabdominal pre-peritoneal (TAPP) versus totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair: a systematic review. Hernia 2005;9(2):109–14. Sajid MS, Ladwa N, Kalra L, et al. A meta-analysis examining the use of tackerfixation versus no-fixation of mesh in laparoscopic inguinal hernia repair. Int J Surg 2012;10(5):224–31. Tolver MA, Rosenberg J, Juul P, et al. Randomized clinical trial of fibrin glue versus tacked fixation in laparoscopic groin hernia repair. Surg Endosc 2013; 27(8):2727–33. Kaul A, Hutfless S, Le H, et al. Staple versus fibrin glue fixation in laparoscopic total extraperitoneal repair of inguinal hernia: a systematic review and metaanalysis. Surg Endosc 2012;26(5):1269–78. Fortelny RH, Petter-Puchner AH, Glaser KS, et al. Use of fibrin sealant (Tisseel/Tissucol) in hernia repair: a systematic review. Surg Endosc 2012;26(7):1803–12. Sajid MS, Ladwa N, Kalra L, et al. A meta-analysis examining the use of tacker mesh fixation versus glue mesh fixation in laparoscopic inguinal hernia repair. Am J Surg 2013;206(1):103– 11. Lau H (2005) Fibrin sealant vs. mechanical stapling for mesh fixation during endoscopic extraperitoneal inguinal hernioplasty: a randomized prospective trial. Ann Surg 242(5):670–675 Lovisetto F, Zonta S, Rota E, Mazzilli M, Bardone M, Bottero L, Faillace G, Longoni M (2007) Use of human fibrin glue (Tissucol) vs. staples for mesh fixation in laparoscopic transabdominal preperitoneal hernioplasty: a prospective, randomized study. Ann Surg 245(2):222–231.

64 REFERENCES Olmi S, Scaini A, Erba L, Guaglio M, Croce E (2007) Quantification of pain in laparoscopic transabdominal preperitoneal (TAPP) inguinal hernioplasty identifies marked differences between prosthesis fixation systems. Surgery 142(1):40–46. Boldo E, Armelles A, Perez de Lucia G, Martin F, Aracil JP, Miralles JM, Martinez D, Escrig J (2008) Pain after laparoscopic bilateral hernioplasty: early results of a prospective randomized double-blind study comparing fibrin vs. staples. Surg Endosc 22(5):1206–1209. Fortelny RH, Petter-Puchner AH, May C, Jaksch W, Benesch T, Khakpour Z, Redl H, Glaser KS (2012) The impact of atraumatic fibrin sealant vs. staple mesh fixation in TAPP hernia repair on chronic pain and quality of life: results of a randomized controlled study. Surg Endosc 26(1):249–254. Bansal VK, Misra MC, Babu D, et al. A prospective, randomized comparison of long-term outcomes: chronic groin pain and quality of life following totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) laparoscopic inguinal hernia repair. Surg Endosc 2013;27(7):2373–82. Bracale U, Melillo P, Pignata G, et al. Which is the best laparoscopic approach for inguinal hernia repair: TEP or TAPP? A systematic review of the literature with a network meta-analysis. Surg Endosc 2012;26(12):3355–66. EU Hernia Trialists Collaboration. Mesh compared with non-mesh methods of open groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000;87(7):854–9. Scott NW, McCormack K, Graham P, et al. Open mesh versus non-mesh for repair of femoral and inguinal hernia. Cochrane Database Syst Rev 2002;(4): EU Hernia Trialists Collaboration. Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials. Ann Surg 2002;235(3):322–32. Amato B, Moja L, Panico S, et al. Shouldice technique versus other open techniques for inguinal hernia repair. Cochrane Database Syst Rev 2012;(4): Grant AM, EU Hernia Trialists Collaboration. Open mesh versus non-mesh repair of groin hernia: meta-analysis of randomised trials based on individual patient data. Hernia 2002;6(3):130-6.


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