Evidence-based management of groin hernia in primary care--a systematic review.
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BACKGROUND: National clinical guidelines on the surgical management of groin hernia have been published by the Royal College of Surgeons of England. There is also a need for guidance on the management of pre- and post-hernia repair patients in primary care, in areas such as diagnosis, referral and advice on recuperation. OBJECTIVE: The purpose of the present study was to determine best practice in primary care aspects of managing groin hernia in adults, by examination of the evidence base. METHOD: A systematic review of the available evidence was carried out, searching the major electronic databases: Medline, the Cochrane Library, Embase, Assia, Helmis, Cinahl and Psyclit. Key search terms were hern$, inguinal, femoral, groin, truss$, with searches limited to human adult subjects and the English language. RESULTS: Robust research on groin hernia is concerned almost exclusively with the in-patient surgical management of patients undergoing primary elective hernia repair. The areas with which this review was concerned, principally diagnosis, referral and advice about return to work, are areas in which it is more difficult to conduct robustly designed studies. Perhaps because of this, the evidence base on the non-surgical aspects of management is of poor methodological quality, being based primarily on expert opinion, reviews of clinical practice and experience, surveys, descriptive case studies and clinical audits. CONCLUSIONS: As the research in this area is generally of poor quality, strong conclusions are precluded, but it is possible to define best practice in some areas of care. In relation to diagnosis, GPs should distinguish correctly between a femoral and inguinal hernia because of the increased risks of strangulation and incarceration associated with the former. Due to clinical inaccuracy, the identification of whether a hernia is direct or indirect is not a good basis on which to base decision making regarding referral for elective repair. The risks associated with surgical repair are those of the normal range found for any procedure. Decisions about the fitness of patients for surgery in this instance are not procedure specific, and therefore the decisions about elective repair especially in older patients should be considered in terms of quality of life and patient choice rather than increased risks with surgical repair. Further research is required to address the gap in the evidence for the management of groin hernia within the primary care sector. (+info)
Groin hernia surgery: a systematic review.
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BACKGROUND: An extensive volume of clinical research has been undertaken on the use of surgery for groin hernias. For many years there has been a large number of different methods of repairing hernias and, with the introduction of laparoscopic surgery, this has increased further. It is uncertain which method is the best in terms of safety and effectiveness. OBJECTIVES: This review was undertaken to compare the outcomes following different surgical procedures to treat groin hernias in adults. It sought answers to six questions: 1)Which method of surgery (including open procedures and laparoscopic surgery) is the safest and most effective for inguinal hernia repair? 2) Is local anaesthesia a safe and effective alternative to general anaesthesia? 3) Is there a difference in outcome between specialist and non-specialist surgeons? 4) Is day-case as safe and effective as inpatient surgery? 5) Is synchronous bilateral hernia repair as safe and effective as delayed repair? 6) Which method of surgery is the safest and most effective for femoral hernia repair? METHODS: The primary measure of effectiveness used was the proportion of hernia repairs in which there was a recurrence. Secondary outcome measures included complications, post-operative pain, wound infection, time to return to normal activities and/or return to work. A systematic search of the literature (up to February 1996) was undertaken using a variety of approaches. the methodological quality of all prospective comparative studies (45 randomised trials and 26 non-randomised trials/prospective cohort studies) was assessed using a standard checklist. RESULTS: Some of the variation in findings from different studies is likely to be due to methodological differences rather than differences in the effectiveness of the surgical procedures. The main methodological shortcomings of the studies that have been performed are: lack of agreed method for assessing severity of hernias; failure to take confounding into account in non-randomised studies; variation in length of follow-up; poor external validity; lack of objective measures of outcome; and inadequate statistical power. These problems severely limit the conclusions that can be drawn from the literature. (+info)
The use of Mersilene mesh in repair of abdominal wall hernias: a clinical and experimental study.
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Use of synthetic materials in herniplasty has been a controversial issue. In order to determine the influence of Mersilene mesh on the strength of healing abdominal wounds and its effectiveness in repair of hernia, experimental and clinical studies were undertaken. Experimental study included 175 male rats divided into three groups subjected to either: 1) an incision made only through the skin and closed with 3-0 silk sutures; 2) a 2.5 cm midline incision through the musculature and peritoneum closed with 2-0 Mersilene suture; or 3) the same procedure as group 2 with the addition of a Mersilene mesh onlay graft. Bursting strength of abdominal wounds as determined in all groups at intervals. Wounds of the group treated with the mesh exhibited significantly greater (P less than 0.01) bursting strength. Clinical trial consisted of 100 consecutive adult patients in which an onlay graft of Mersilene mesh was used in the hernioplasty. Mesh was used as an adjunct in patients with: 1) large ventral hernias; 2) direct hernias resulting from severely attenuated transversialis fascia; 3) indirect hernias associated with a large internal ring and a weak posterior inguinal wall; or 4) combined direct and indirect hernias. All were followed for a minimum of one year to determine the incidence of complication and rate of recurrence. This study suggests that: 1) Mersilene mesh increases the strength of healing abdominal wounds in rats; and 2) repair of large hernias with Mersilene mesh results in an acceptable morbidity and a lowered rate of recurrence. (+info)
Local or general anesthesia for open hernia repair: a randomized trial.
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OBJECTIVE: To compare patient outcome following repair of a primary groin hernia under local (LA) or general anesthesia (GA) in a randomized clinical trial. SUMMARY BACKGROUND DATA: LA hernia repair is thought to be safer for patients, causes less postoperative pain, cost less, and is associated with a more rapid recovery when compared with the same operation performed under GA. METHODS: All patients presenting to three surgeons during the study period with a primary groin hernia were considered eligible. Outcome parameters measured including tests of vigilance, divided attention, sustained attention, memory, cognitive function, pain, return to normal activity, and costs. RESULTS: Two hundred seventy-nine patients were randomized to LA or GA hernia repair; 276 of these had an operation, with 138 participants in each group. At 6, 24, and 72 hours postoperatively there were no differences in vigilance or divided attention between the groups. Similarly, memory, sustained attention, and cognitive function were not impaired in either group. Although physical activity was significantly impaired at 24 hours, this and return to usual social activities were similar in both groups. While patients in the LA group had significantly less pain on moving, at 6 hours they were less likely to recommend the same operation to someone else. GA hernia repair cost 4% more than the same operation under LA. CONCLUSIONS: There are no major differences in patient recovery after LA or GA hernia repair. Patients should be offered a choice of anesthesia, LA or GA, for repair of their groin hernia. (+info)
A technique for hernia repair.
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After Ryan reported a low recurrence rate in a large series of patients with recurrent inguinal and femoral hernia who were operated upon by a technique developed by Shouldice and later improved, an adaptation of the method was used in a number of difficult cases. In the dissection technique, the transversalis fascia is completely transected from the internal ring to the pubic spine. This exposes a fascial layer which has never before been described as being intentionally used in hernia repair. The method of imbrication with steel wire for suturing also differs from the methods most often used. Use of local anesthesia is another important part of the technique as a whole. (+info)
LOCAL ANESTHESIA FOR HERNIOPLASTY. IMMEDIATE AMBULATION AND RETURN TO WORK: A PRELIMINARY REPORT.
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In 50 cases in which hernioplasty was carried out with atraumatic technique under local anesthesia, the patients walked away from the operating table, then through the corridors, without assistance. They usually drove home the next day and returned to their regular occupations immediately. Few had pain necessitating more than mild analgesia. In a period of follow-up ranging from six months to three years at the time of this report, two patients had recurrence. (+info)
Management of groin hernias in patients with ascites.
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The records of 18 cirrhotic patients with ascites and groin hernias (20 inguinal and one femoral) were retrospectively reviewed. Eleven patients underwent repair of their groin hernias (total of 13 repairs). Ten herniorrhaphies were performed electively, two were performed urgently because of recent difficult reduction, and one was performed emergently for incarceration without strangulation. No major and four minor postoperative complications occurred. There were no perioperative deaths or ascites leaks. Of the 13 hernias in 11 patients undergoing repair, 12 (92%) were available for follow-up. In this group, the 12 groin hernia repairs were followed for a mean of 25 months. One recurrence (8%) occurred 11 months after repair. In this same group of patients, five umbilical hernias were repaired, with three recurrences (60%). From this retrospective study, it appears that serious complications from groin hernias in cirrhotics are not common, and elective repair can usually await control of ascites. Additionally, for appropriately selected patients with ascites, elective inguinal hernia repair can be performed safely, with an acceptable rate of recurrence. (+info)
The diagnosis of femoral hernia.
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The accuracy of diagnosis of femoral hernia in referrals to a district general hospital over a period of 5 years has been studied and related to clinical outcome. A correct diagnosis was made in only 36 of 98 cases (60 urgent, 38 routine) before admission to hospital. A correct pre-operative diagnosis was ultimately made in 85 cases. Four patients, all urgent admissions with incarcerated bowel, died within 30 days of operation. In none of these cases was a correct diagnosis made before admission to hospital. The median length of post-operative stay of urgent admissions was 7 days (range 4-50) when a correct initial diagnosis was made and 10 days (range 4-50) when the initial diagnosis was incorrect (P = 0.07, Mann-Whitney test). When strangulated small bowel was found at operation, 70% of those with an incorrect initial diagnosis (n = 23) required resection, as compared with 20% of those with a correct initial diagnosis (n = 10, P = 0.014, chi 2 with Yates' correction). Femoral hernias are frequently incorrectly diagnosed before hospital admission and this is associated with worsened outcome in urgent cases. (+info)