PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of bmjclinevidLink to Publisher's site
 
BMJ Clin Evid. 2008; 2008: 0412.
Published online 2008 July 16.
PMCID: PMC2908002

Inguinal hernia

Mr Sanjay Purkayastha, Clinical Research Fellow,# Mr Andre Chow, Senior House Officer,# Mr Thanos Athanasiou, Senior Lecturer and Consultant Surgeon,# Paris P Tekkis, Professor of Colorectal Surgery,# and Ara Darzi, Professor of Surgery and Head of Department#

Abstract

Introduction

The main risk factors for inguinal hernia are male sex and increasing age. Complications of inguinal hernia include strangulation, intestinal obstruction, and infarction. Recurrence can occur after surgery.

Methods and outcomes

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of elective treatments for primary unilateral, primary bilateral, and recurrent inguinal hernia in adults? We searched: Medline, Embase, The Cochrane Library, and other important databases up to September 2007 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations, such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results

We found 24 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions

In this systematic review, we present information relating to the effectiveness and safety of the following interventions: expectant management, open mesh repair, open suture repair, totally extraperitoneal (TEP) laparoscopic repair, and transabdominal preperitoneal (TAPP) laparoscopic repair.

Key Points

The main risk factors for inguinal hernia are male sex and increasing age.

  • Complications of inguinal hernia include strangulation, intestinal obstruction, and infarction. Recurrence can occur after surgery.

The consensus is that surgery is the treatment of choice for inguinal hernia, although few good-quality studies have compared surgery with expectant management.

Open suture repair is a well-established surgical treatment for people with unilateral inguinal hernia, but seems less effective at preventing recurrence, and prolongs recovery, compared with other techniques.

Open suture repair may be associated with longer recovery times compared with open mesh repair or TAPP laparoscopic repair in people with bilateral inguinal hernia.

  • Open mesh repair seems as effective as TEP laparoscopic repair, but may prolong recovery and increase complication rates compared with TAPP laparoscopic repair.

Open suture repair may be associated with an increased recovery time compared with open mesh repair in people with recurrent inguinal hernia.

  • We don't know how open suture repair compares with TEP or TAPP laparoscopic repair in people with recurrent inguinal hernia.
  • TAPP and TEP laparoscopic repair may both reduce recovery time compared with open mesh repair, but complication rates seem to be similar.

About this condition

Definition

Inguinal hernia is an out-pouching of the peritoneum, with or without its contents, which occurs through the muscles of the anterior abdominal wall at the level of the inguinal canal in the groin. It almost always occurs in men because of the inherent weakness of the abdominal wall where the spermatic cord passes through the inguinal canal. A portion of bowel may become caught in the peritoneal pouch and present as a lump in the groin. The hernia may extend into the scrotum and can cause discomfort or ache. Primary hernias relate to the first presentation of a hernia, and are distinct from recurrent hernias. A hernia is described as reducible if it occurs intermittently (e.g., on straining or standing) and can be pushed back into the abdominal cavity, or irreducible if it remains permanently outside the abdominal cavity. Inguinal hernia is usually a long-standing condition and the diagnosis is made clinically, on the basis of these typical symptoms and signs. The condition may occur in one groin (unilateral hernia) or both groins simultaneously (bilateral hernia), and may recur after treatment (recurrent hernia). Inguinal hernias are frequently classified as direct or indirect, depending on whether the hernia sac bulges directly through the posterior wall of the inguinal canal (direct hernia), or whether it passes through the internal inguinal ring alongside the spermatic cord and follows the course of the inguinal canal (indirect hernia). Occasionally, hernia may present acutely because of complications (see prognosis). Clinical experience and consensus suggest that surgical intervention is an effective treatment for inguinal hernia. However, surgery is associated with complications (see outcomes). Therefore, much of this review examines the relative effectiveness and safety of different surgical techniques. None of the studies that we identified distinguished between direct and indirect types of inguinal hernia. Identified studies gave little detail about the severity of hernia among included participants. In general, studies explicitly excluded people with irreducible or complicated hernia, large hernia (extending into the scrotum), or serious comorbidity, and those at high surgical risk (e.g., because of coagulation disorders). In this review, we deal only with non-acute uncomplicated inguinal hernias in adults.

Incidence/ Prevalence

Inguinal hernia is usually repaired surgically in resource-rich countries. Therefore, surgical audit data provide reasonable estimates of incidence. We found one nationally mandated guideline, which reported that in 2001–2002 there were about 70,000 inguinal hernia surgeries performed in England, involving 0.14% of the population, and requiring over 100,000 NHS hospital-bed days. Of these procedures, 62,969 were for the repair of primary hernias and 4939 were for the repair of recurrent hernias. A similar number of inguinal hernia repairs were undertaken in public healthcare settings in England in 2002–2003. In the USA, estimates based on cross-sectional data suggest that about 700,000 inguinal hernia repairs were undertaken in 1993. A national survey of general practices, covering about 1% of the population of England and Wales in 1991–1992, found that about 95% of people presenting to primary-care settings with inguinal hernia were male. It found that the incidence rose from about 11/10,000 person-years in men aged 16 to 24 years to about 200/10,000 person-years in men aged 75 years and over.

Aetiology/ Risk factors

Age and male sex are risk factors. Chronic cough and manual labour involving heavy lifting are conventionally regarded as risk factors because they lead to high intra-abdominal pressure. Obesity has also been suggested as a risk factor.

Prognosis

Strangulation, intestinal obstruction, and infarction are the most important acute complications of untreated hernia, and are potentially life-threatening. National statistics from England found that 5% of primary inguinal hernia repairs were undertaken as emergencies (presumably because of acute complications) in 1998–1999. Older age, longer duration of hernia, and longer duration of irreducibility are thought to be risk factors for acute complications.

Aims of intervention

To prevent recurrence; to alleviate symptoms; to allow return to normal activities; to improve quality of life; to prevent acute hernia complications; to minimise adverse effects of treatment.

Outcomes

Pain (persistent or continuing hernia pain); hernia complications; hospitalisation (hospital stay, operation duration); return to normal activities/work; recurrence; quality of life; adverse effects (seroma; haematoma; numbness; infection; postoperative pain, vascular injury; visceral injury; wound hernia or dehiscence; surgical mortality; and other complications of intervention).

Methods

Clinical Evidence search and appraisal September 2007. The following databases were used to identify studies for this systematic review: Medline 1966 to September 2007, Embase 1980 to September 2007, and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials 2007, Issue 3. Additional searches were carried out using these websites: NHS Centre for Reviews and Dissemination (CRD) — for Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA) — and NICE. We also searched for retractions of studies included in the review. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the contributor for additional assessment, using predetermined criteria to identify relevant studies. Study design criteria for inclusion in this review were: published systematic reviews and RCTs in any language; "open", "open-label", or non-blinded studies were included where blinding was impossible; and containing more than 20 individuals of whom more than 80% were followed up. There was no minimum length of follow-up required to include studies. We also did a search for cohort and cross-sectional studies relating to "expectant management". In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the FDA and the MHRA, which are added to the reviews as required. To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as RRs and ORs. We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table). The categorisation of the quality of the evidence (high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com).

Table
GRADE Evaluation of interventions for Inguinal hernia.

Glossary

Expectant management
A policy of no active intervention.
Low-quality evidence
Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Moderate-quality evidence
Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Open mesh repair
An open operation in which a synthetic mesh is inserted across the posterior wall of the inguinal canal to repair the weakness in the muscles and fascia through which the hernia sac has protruded. Variants include the Lichtenstein and Stoppa procedures. The technique may be performed under local or regional anaesthetic.
Open suture repair
An open operation using sutures to repair the weakness in the muscles and fascia through which the hernia sac has protruded. There are many variants of the technique (e.g., Bassini, McVay, Maloney, and Shouldice procedures). The technique is commonly performed under local or regional anaesthetic.
Short Form 36 (SF-36)
A scale that assesses health-related quality of life across eight domains: limitations in physical activities (physical component); limitations in social activities; limitations in usual role activities due to physical problems; pain; psychological distress and wellbeing (mental health component); limitations in usual role activities because of emotional problems; energy and fatigue; and general health perceptions.
Totally extraperitoneal (TEP) laparoscopic repair
An operation that uses mesh to repair the weakness in the muscles and fascia through which the hernia sac has protruded. This technique does not involve entering the peritoneum with the laparoscope (compare transabdominal preperitoneal [TAPP] laparoscopic repair). The technique is usually performed under general anaesthetic.
Transabdominal preperitoneal (TAPP) laparoscopic repair
An operation that uses mesh to repair the weakness in the muscles and fascia through which the hernia sac has protruded. This technique involves entering the peritoneum with the laparoscope, although the repair itself (done with a mesh) is undertaken anterior to the peritoneum. The technique is usually performed under general anaesthetic.
Very low-quality evidence
Any estimate of effect is very uncertain.

Notes

Disclaimer

The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients. To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.

Contributor Information

Mr Sanjay Purkayastha, Department of Biosurgery and Surgical Technology, Imperial College, St Mary's Hospital, London, UK.

Mr Andre Chow, Department of Biosurgery and Surgical Technology, Imperial College, St Mary's Hospital, London, UK.

Mr Thanos Athanasiou, Department of Biosurgery and Surgical Technology, Imperial College, St Mary's Hospital, London, UK.

Paris P Tekkis, Royal Marsden and Chelsea and Westminster Hospitals, Imperial College , London, UK.

Ara Darzi, Department of Biosurgery and Surgical Technology, Imperial College, St Mary's Hospital, London, UK.

References

1. NICE. Laparoscopic surgery for inguinal hernia repair. September 2004. http://guidance.nice.org.uk/TA83 (last accessed 5 April 2006).
2. Department of Health. Hospital Episode Statistics, England: Financial year 2002–03. http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937 (last accessed 5 April 2006).
3. Rutkow IM, Robbins AW. Demographic, classificatory, and socioeconomic aspects of hernia repair in the United States. Surg Clin North Am 1993;73:413–426. [PubMed]
4. Royal College of General Practitioners. Morbidity statistics from general practice. Fourth national study. London, UK: HMSO, 1995.
5. Rai S, Chandra SS, Smile SR. A study of the risk of strangulation and obstruction in groin hernias. Aust N Z J Surg 1998;68:650–654. [PubMed]
6. 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. [PubMed]
7. 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 2006244:167–173. [PubMed]
8. Scott N, McCormack K, Graham P, et al on behalf of the EU Hernia Trialists Collaboration. Open mesh versus non-mesh for groin hernia repair. In: The Cochrane Library: Issue 3, 2007. Chichester, UK: John Wiley & Sons, Ltd. Search date 2000.
9. Koukourou A, Lyon W, Rice J, et al. Prospective randomized trial of polypropylene mesh compared with nylon darn in inguinal hernia repair. Br J Surg 2001;88:931–934. [PubMed]
10. Prieto-Diaz-Chavez E, Medina-Chavez JL, Gonzalez-Ojeda A, et al. Tension-free hernioplasty versus conventional hernioplasty for inguinal hernia repair. Surg Today 2005;35:1047–1053. [PubMed]
11. Harjai MM, Nagpal BM, Singh P, et al. A prospective randomized controlled study of Lichtenstein's tension free versus modified Bassini repair in the management of groin hernias. Med J Arm For India 2007;63:40–43.
12. Butters M, Redecke J, Koninger J. Long-term results of a randomized clinical trial of Shouldice, Lichtenstein and transabdominal preperitoneal hernia repairs. Br J Surg 2007;94:562–565. [PubMed]
13. Eklund A, Rudberg C, Smedberg S, et al. Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair. Br J Surg 2006;93:1060–1068. [PubMed]
14. Butler RE, Burke R, Schneider JJ, et al. The economic impact of laparoscopic inguinal hernia repair: Results of a double-blinded, prospective, randomized trial. Surg Endosc 2007;21:387–390. [PubMed]
15. McCormack K, Scott NW, Go PMNYH, et al on behalf of the EU Hernia Trialists Collaboration. Laparoscopic techniques versus open techniques for inguinal hernia repair. In: The Cochrane Library: Issue 3, 2007. Chichester, UK: John Wiley & Sons, Ltd. Search date 2002.
16. Wennstrom I, Berggren P, Akerud L, et al. Equal results with laparoscopic and Shouldice repairs of primary inguinal hernia in men. Report from a prospective randomised study. Scand J Surg 2004;93:34–36. [PubMed]
17. 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;9:1–203. Search date 2003; primary sources Medline, Embase, The Cochrane Library, Cinahl, Biosis, Science Citation Index, Web of Science Proceedings, HTA database, Journals@Ovid Full Text, Springerlink, National Research Register, Clinical Trials, Current Controlled Trials, Research Findings Register, conference proceedings, hand searches of references, and contact with experts.
18. Gokalp A, Inal M, Maralcan G, et al. A prospective randomized study of Lichtenstein open tension-free versus laparoscopic totally extraperitoneal techniques for inguinal hernia repair. Acta Chir Belg 2003;103:502–506. [PubMed]
19. Heikkinen T, Bringman S, Ohtonen P, et al. Five-year outcome of laparoscopic and Lichtenstein hernioplasties. Surg Endosc 2004;18:518–522. [PubMed]
20. Wake BL, McCormack K, Fraser C, et al. Transabdominal pre-peritoneal (TAPP) vs totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair. In: The Cochrane Library, Issue 3, 2007. Chichester, UK: John Wiley & Sons, Ltd. Search date 2003.
21. Koninger J, Redecke J, Butters M. Chronic pain after hernia repair: a randomized trial comparing Shouldice, Lichtenstein and TAPP. Langenbecks Arch Surg 2004;389:361–365. [PubMed]
22. Lorenz D, Stark E, Oestreich K, et al. Laparoscopic hernioplasty versus conventional hernioplasty (Shouldice): results of a prospective randomized trial. World J Surg 2000;24:739–746. [PubMed]
23. Berndsen F, Arvidsson D, Enander LK, et al. Postoperative convalescence after inguinal hernia surgery: prospective randomized multicenter study of laparoscopic versus Shouldice inguinal hernia repair in 1042 patients. Hernia 2002;6:56–61. [PubMed]
24. Arvidsson D, Berndsen FH, Larsson LG, et al. Randomized clinical trial comparing 5-year recurrence rate after laparoscopic versus Shouldice repair of primary inguinal hernia. Br J Surg 2005;92:1085–1091. [PubMed]
25. Berndsen FHP, Petersson U, Arvidsson D, et al. Discomfort five years after laparoscopic and Shouldice inguinal hernia repair: a randomised trial with 867 patients. A report from the SMIL study group. Hernia 2007;11:307–313. [PubMed]
26. Anadol ZA, Ersoy E, Taneri F, et al. Outcome and cost comparison of laparoscopic transabdominal preperitoneal hernia repair versus open Lichtenstein technique. J Laparoendosc Adv Surg Tech A 2004;14:159–163. [PubMed]
27. Wellwood J, Sculpher MJ, Stoker D, et al. Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: outcome and cost. BMJ 1998;317:103–110. [Erratum in: BMJ 1998;317:631] [PMC free article] [PubMed]
28. Dedemadi G, Sgourakis G, Karaliotas C, et al. Comparison of laparoscopic and open tension-free repair of recurrent inguinal hernias: a prospective randomized study. Surg Endosc 2006;20:1099–1104. [PubMed]
29. Eklund A, Rudberg C, Leijonmarck CE, et al. Recurrent inguinal hernia: randomized multicenter trial comparing laparoscopic and Lichtenstein repair. Surg Endosc 2007;21:634–640. [PubMed]
2008; 2008: 0412.
Published online 2008 July 16.

Open mesh repair for unilateral inguinal hernia

Summary

Open mesh repair reduces the risk of recurrence compared with open suture repair , without increasing the rate of surgical complications.

Benefits and harms

Open mesh repair versus expectant management (in people with minimally symptomatic hernia):

We found two RCTs comparing open mesh repair versus expectant management.

Pain

Open mesh repair compared with expectant management (in people with minimally symptomatic hernia) Open mesh repair may be no more effective than expectant management at reducing pain scores (measured by visual analogue pain scores [VAS]) at rest or on movement at 6 to 12 months, or at reducing the proportion of people with pain that limits normal activities at 2 years (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Pain

RCT
720 men; 619 unilateral, 77 recurrent Proportion of people with pain that limited normal activities at 2 years
2.21% with open mesh repair
5.07% with expectant management

Risk difference (RD) 2.88%
95% CI –0.04% to +5.77%
P = 0.52
See further information on studies for discussion of generalisability of results
Not significant

RCT
160 men; 147 unilateral, 4 recurrent Pain (assessed by visual analogue score [VAS]) at rest at 6 months
with open mesh repair
with expectant management

Difference in proportions +7%
95% CI –8 to +22%
P = 0.42
See further information on studies for discussion of generalisability of results
Not significant

RCT
160 men; 147 unilateral, 4 recurrent Pain (assessed by VAS) on movement at 6 months
with open mesh repair
with expectant management

Difference in proportions +11%
95% CI –5 to +26%
P = 0.20
See further information on studies for discussion of generalisability of results
Not significant

RCT
160 men; 147 unilateral, 4 recurrent Pain (assessed by VAS) at rest at 12 months
with open mesh repair
with expectant management

Difference in proportions –2%
95% CI –17 to +12%
P = 0.86
See further information on studies for discussion of generalisability of results
Not significant

RCT
160 men; 147 unilateral, 4 recurrent Pain (assessed by VAS) on movement at 12 months
with open mesh repair
with expectant management

Difference in proportions +8%
95% CI –7 to +23%
P = 0.31
See further information on studies for discussion of generalisability of results
Not significant

Hernia complications

Open mesh repair compared with expectant management (in people with minimally symptomatic hernia) Open mesh repair may be no more effective than expectant management at reducing mortality (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Mortality

RCT
720 men; 619 unilateral, 77 recurrent Mortality
10/356 (3%) with open mesh repair
12/364 (3%) with expectant management

P = 0.70
See further information on studies for discussion of generalisability of results
Not significant

No data from the following reference on this outcome.

Quality of life

Open mesh repair compared with expectant management (in people with minimally symptomatic hernia) We don't know whether open mesh repair is more effective than expectant management at improving quality-of-life scores (as measured by SF-36) (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Quality of life

RCT
720 men; 619 unilateral, 77 recurrent Mean change in physical component score (scale 0–100) of the SF-36 health-related quality-of-life survey (change from baseline) at 2 years
0.13 with open mesh repair
0.29 with expectant management

Difference 0.16
95% CI –1.19 to +1.50
P = 0.79
See further information on studies for discussion of generalisability of results
Not significant

RCT
160 men; 147 unilateral, 4 recurrent SF-36 quality-of-life survey at 6 months
with open mesh repair
with expectant management

Mean difference 8
95% CI 2 to 14
P = 0.0079
See further information on studies for discussion of generalisability of results
Effect size not calculatedopen mesh repair

RCT
160 men; 147 unilateral, 4 recurrent SF-36 quality-of-life survey at 12 months
with open mesh repair
with expectant management

Mean difference 7
95% CI 0 to 14
P = 0.039
See further information on studies for discussion of generalisability of results
Effect size not calculatedopen mesh repair

Hospitalisation

No data from the following reference on this outcome.

Return to normal activities/work

No data from the following reference on this outcome.

Recurrence

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Adverse effects

RCT
720 men; 619 unilateral, 77 recurrent Adverse effects
with open mesh repair
with expectant management

RCT
160 men; 147 unilateral, 4 recurrent Adverse effects
with open mesh repair
with expectant management

Open mesh repair versus open suture repair:

We found one systematic review (search date 2000) and four subsequent RCTs. The systematic review included people with unilateral, bilateral, or recurrent femoral or inguinal hernia. Separate meta-analyses were performed in people with recurrent or bilateral hernia and are presented in this review (see questions on primary bilateral inguinal hernia in adults and recurrent inguinal hernia in adults).

Pain

Open mesh repair compared with open suture repair We don't know how open mesh repair and open suture repair compare at reducing continuing pain at 3 months (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Pain

Systematic review
2393 people
9 RCTs in this analysis
Persisting pain after 3 months
63/1213 (5%) with open mesh repair
84/1180 (7%) with open suture repair

OR 0.68
95% CI 0.47 to 0.98
Results were heterogeneous and influenced by data from one RCT. After adjustment for heterogeneity, difference between groups was not significant; see further information on studies for full details
Small effect sizeopen mesh repair

No data from the following reference on this outcome.

Hospitalisation

Open mesh repair compared with open suture repair Open mesh repair may be marginally more effective than open suture repair at reducing length of hospital stay, but we don't know whether it is more effective at reducing operating time (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Hospital stay

Systematic review
3733 people
17 RCTs in this analysis
Duration of hospital stay
with open mesh repair
with open suture repair

WMR in length of stay: 0.28 days
95% CI 0.22 to 0.35
The difference in hospital stay was small and may be of limited importance to people having surgery
Effect size not calculatedopen mesh repair
Operation duration

RCT
106 people; 100 primary hernias, 6 recurrent hernias Operating time
33 minutes with open mesh repair
49 minutes with open suture repair

P <0.05
See further information on studies for details on generalisability and power
Effect size not calculatedopen mesh repair

RCT
196 men; 216 primary inguinal hernias Time taken for repair
55.34 minutes with open mesh repair
59.34 minutes with open suture repair

P >0.05
See further information on studies for details on generalisability and power
Not significant

No data from the following reference on this outcome.

Return to normal activities/work

Open mesh repair compared with open suture repair We don't know how open mesh repair and open suture repair compare at reducing time to return to normal activity or work (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Return to normal activities/work

Systematic review
1279 people
8 RCTs in this analysis
Time to usual activities after 3 months
with open mesh repair
with open suture repair

HR 0.81
95% CI 0.73 to 0.91
Results were heterogeneous and influenced by data from one RCT. After adjustment for heterogeneity, difference between groups was not significant; see further information on studies for full details
Small effect sizeopen mesh repair

RCT
100 men; 5 bilateral hernias Time to return to normal activity
5.1 weeks with open mesh repair
5.1 weeks with open suture repair

Difference 0 weeks
95% CI –1.6 weeks to +1.6 weeks
See further information on studies for details on generalisability and power
Not significant

RCT
106 people; 100 primary hernias, 6 recurrent hernias Time off work
15 days with open mesh repair
25 days with open suture repair

P <0.01
See further information on studies for details on generalisability and power
Effect size not calculatedopen mesh repair

RCT
196 men; 216 primary inguinal hernias Time to return to work
21.39 days with open mesh repair
28.24 days with open suture repair

P <0.05
See further information on studies for details on generalisability and power
Effect size not calculatedopen mesh repair

No data from the following reference on this outcome.

Recurrence

Open mesh repair compared with open suture repair We don't know how open mesh repair and open suture repair compare at reducing hernia recurrence (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Recurrence

Systematic review
4532 people, predominantly with unilateral hernia
18 RCTs in this analysis
Recurrence
with open mesh repair
with open suture repair

OR 0.37
95% CI 0.26 to 0.51
Moderate effect sizeopen mesh repair

RCT
100 men; 5 bilateral hernias Number of hernia recurrences 4 years
2 with open mesh repair
2 with open suture repair

Significance not assessed
See further information on studies for details on generalisability and power

RCT
106 people; 100 primary hernias, 6 recurrent hernias Recurrence
0/54 (0%) with open mesh repair
1/52 (2%) with open suture repair

P = 0.08
See further information on studies for details on generalisability and power
Not significant

RCT
196 men; 216 primary inguinal hernias Hernia recurrence
5 with open mesh repair
8 with open suture repair

P >0.05
See further information on studies for details on generalisability and power
Not significant

RCT
3-armed trial
280 men with primary inguinal hernias Recurrence
1 with open mesh repair
6 with open suture repair

P = 0.055 for open mesh v open suture repair
See further information on studies for details on generalisability and power
Not significant

Hernia complications

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

Open mesh repair compared with open suture repair Open mesh repair and open suture repair may be associated with a similar risk of surgical complications, such as haematoma, seroma, infection, numbness, and mortality, and a similar risk of postoperative pain (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Mortality

Systematic review
1564 people
6 RCTs in this analysis
Mortality
with open mesh repair
with open suture repair

OR 1.35
95% CI 0.65 to 2.80
Not significant
Haematoma

Systematic review
3072 people
13 RCTs in this analysis
Haematoma
with open mesh repair
with open suture repair

OR 0.93
95% CI 0.68 to 1.26
Not significant

RCT
100 men; 5 bilateral hernias Haematoma
13% with open mesh repair
14% with open suture repair

Reported as not significant
P value not reported
Not significant
Seroma

Systematic review
3045 people
11 RCTs in this analysis
Seroma
with open mesh repair
with open suture repair

OR 1.52
95% CI 0.92 to 2.52
Not significant

RCT
100 men; 5 bilateral hernias Seroma
2% with open mesh repair
4% with open suture repair

Reported as not significant
P value not reported
Not significant
Infection

Systematic review
3516 people
16 RCTs in this analysis
Infection
with open mesh repair
with open suture repair

OR 1.24
95% CI 0.84 to1.84
Not significant

RCT
100 men; 5 bilateral hernias Infection
4% with open mesh repair
2% with open suture repair

Reported as not significant
P value not reported
Not significant
Complications

Systematic review
3508 people
14 RCTs in this analysis
Life-threatening surgical complications
with open mesh repair
with open suture repair

OR 1.00
95% CI 0.20 to 4.95
Not significant

RCT
106 people; 100 primary hernias, 6 recurrent hernias Overall complication rates
7% with open mesh repair
13% with open suture repair

RR 0.57
95% CI 0.17 to 1.77
P = 0.4
Not significant
Numbness

Systematic review
602 people
3 RCTs in this analysis
Persisting numbness after 3 months
with open mesh repair
with open suture repair

OR 0.70
95% CI 0.29 to 1.72
Not significant

RCT
3-armed trial
280 men with primary inguinal hernias Rates of nerve injury leading to numbness
14.5% with open mesh repair
12.2% with open suture repair

Significance not assessed
Postoperative pain

RCT
106 people; 100 primary hernias, 6 recurrent hernias Analgesic requirement (paracetamol dose) first postoperative week
3.9 grams with open mesh repair
5.0 grams with open suture repair

P <0.03
Effect size not calculatedopen mesh repair

RCT
106 people; 100 primary hernias, 6 recurrent hernias Postoperative pain scores (measured using visual analogue scale [0 = no pain; 100 = unbearable pain]) at 14 days
1 with open mesh repair
2 with open suture repair

P <0.01
Effect size not calculatedopen mesh repair

RCT
196 men; 216 primary inguinal hernias Pain score evening of the operative day
6 with open mesh repair
6.08 with open suture repair

P >0.05
Not significant

Open mesh repair versus transabdominal preperitoneal (TAPP) laparoscopic repair:

See option on TAPP laparoscopic repair.

Open mesh repair versus totally extraperitoneal (TEP) laparoscopic repair:

See option on TEP laparoscopic repair.

Further information on studies

Generalisability The RCT did not analyse results separately for people with recurrent or bilateral hernias. However, because most people presented with primary unilateral hernia, results are applicable to people with unilateral inguinal hernia. The RCT included men with only minimally symptomatic hernias; hence, these results are applicable only to people with minimal symptoms. Crossover Of note, 23% of men assigned to expectant management received surgical repair because of an increase in hernia-related pain. Self-reported pain scores in this subgroup improved following surgical repair (data not reported). Conversely, 17% of men assigned to operative repair crossed over to expectant management. As-treated analysis Analysis of data based on treatment received found no significant difference between groups in proportion of people with pain that limited normal activity (1.46% with open mesh repair v 3.94% with expectant management; RD 2.88%, 95% CI –0.98% to +5.94%) or in quality-of-life score (+0.66 with open mesh repair v –0.62 with expectant management; difference –1.27, 95% CI –2.98 to +0.44; P = 0.79).

Generalisability The RCT did not analyse results separately for people with recurrent or bilateral hernias. However, because most people presented with primary unilateral hernia, results are applicable to people with unilateral inguinal hernia. The RCT included men with only minimally symptomatic hernias; hence, these results are applicable only to people with minimal symptoms. Crossover In the observation group, 23 men (29%) ended up with surgical repair because of increasing pain (11), hernia size (8), hernia affecting work or leisure (3), or acute presentation (1).

Results adjusted for heterogeneity The systematic review found that the results on continuing postoperative pain and time to return to usual activities were heterogeneous and influenced by the results of one RCT. When the analyses were adjusted for heterogeneity, the results were no longer significant (persisting pain: random effects model; OR 0.86, 95% CI 0.43 to 1.73; time to usual activities: sensitivity analysis excluding 1 RCT; HR 0.89, 95% CI 0.80 to 1.00). The heterogeneous RCT results within the review suggest that the outcome effects may be dependent on factors other than surgical method alone, and may include use of different variants of suturing and mesh repair, participant characteristics, experience of operating surgeons, or methods of outcome measurement among studies.

The RCTs included a small proportion of men with either recurrent or bilateral inguinal hernia, and did not present results separately in men with unilateral hernia. However, the numbers of people with bilateral or recurrent hernias were small, and the number with femoral hernia in the systematic review was negligible. The overall results are therefore applicable to people with unilateral inguinal hernia. The RCTs were small compared with the systematic review, and probably lacked power to detect clinically important differences in recurrence rate between groups.

Comment

Clinical guide:

Most clinicians believe surgical intervention to be the first-line treatment for inguinal hernia. However, there is some (albeit limited) evidence that watchful waiting (expectant management) is a safe option for men with minimally symptomatic or asymptomatic unilateral inguinal hernia. However, if these hernias become symptomatic they should be repaired. There is strong evidence that open mesh repair significantly reduces recurrence rates compared with open suture repair, but there is no significant difference in perioperative complication rates between the two methods.

Substantive changes

Open mesh repair for unilateral inguinal hernia: One RCT comparing open mesh repair versus expectant management added, which found improved health-related quality of life up to one year after operation in men with minimally symptomatic hernias. Two RCTs comparing open mesh repair versus open suture repair added; the first found a reduced time off work with mesh repair, and the second found a lower rate of hernia recurrence with mesh repair. Two RCTs comparing open mesh repair with totally extraperitoneal (TEP) laparoscopic repair added; the first found less analgesic requirement and time off work with TEP laparoscopic repair compared with open mesh repair, but the second found no significant difference. Two RCTs comparing open mesh repair versus transabdominal preperitoneal (TAPP) laparoscopic repair added; the first RCT found that TAPP laparoscopic repair took more time to perform, and the second RCT found reduced nerve damage with TAPP repair. Benefits and harms data enhanced. Categorisation unchanged (Beneficial).

2008; 2008: 0412.
Published online 2008 July 16.

Totally extraperitoneal (TEP) laparoscopic repair for unilateral inguinal hernia

Summary

Totally extraperitoneal (TEP) laparoscopic repair may lead to less pain, faster recovery, and similar recurrence rates compared with open mesh repair, but studies have given inconclusive results.

We found no direct information from RCTs about whether or not TEP laparoscopic repair is better than no active intervention (expectant management).

Benefits and harms

TEP laparoscopic repair versus expectant management:

We found no systematic review, RCTs, or cohort studies of sufficient quality comparing TEP laparoscopic repair versus expectant management.

TEP laparoscopic repair versus open suture repair:

We found one systematic review (search date 2002) and one subsequent RCT comparing TEP laparoscopic repair versus open suture repair. The systematic review excluded people with non-inguinal hernias. Although the review included patients with bilateral and recurrent inguinal hernias, the proportion was small, and the overall results are therefore applicable to people with unilateral inguinal hernia. Separate meta-analyses were performed for recurrent and bilateral hernia and are presented in this review (see questions on primary bilateral inguinal hernia in adults and recurrent inguinal hernia in adults).

Pain

TEP laparoscopic repair compared with open suture repair TEP laparoscopic repair may be more effective than open suture repair at reducing persisting pain at 3 months, but not groin pain at 2 years (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Pain

Systematic review
515 people
2 RCTs in this analysis
Persisting pain after 3 months
with TEP laparoscopic repair
with open suture repair

OR 0.22
95% CI 0.14 to 0.35
Data analysed using fixed-effects model; see further information on studies for full details
Moderate effect sizeTEP laparoscopic repair

RCT
261 people Groin pain after 2 years
14/119 (12%) with TEP laparoscopic repair
8/125 (6%) with open suture repair

P >0.05
Not significant

Hospitalisation

TEP laparoscopic repair compared with open suture repair TEP laparoscopic repair may be marginally more effective than open suture repair at reducing the length of hospital stay (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Hospital stay

Systematic review
1338 people
4 RCTs in this analysis
Length of hospital stay
with TEP laparoscopic repair
with open suture repair

WMD in length of stay: 0.34 days
95% CI 0.22 days to 0.45 days
Effect size not calculated TEP laparoscopic repair

RCT
261 people Median hospital stay
1 day with laparoscopic repair
1 day with open suture repair

Reported as not significant
P value not reported
Not significant

Return to normal activities/work

TEP laparoscopic repair compared with open suture repair TEP laparoscopic repair seems no more effective than open suture repair at reducing the time to return to normal activities (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Return to normal activities/work

Systematic review
94 people
Data from 1 RCT
Time to return to normal activities
with TEP laparoscopic repair
with open suture repair

HR 0.78
95% CI 0.52 to 1.17
Data analysed using fixed-effects model; see further information on studies for full details
Not significant

No data from the following reference on this outcome.

Recurrence

TEP laparoscopic repair compared with open suture repair TEP laparoscopic repair and open suture repair seem equally effective at reducing hernia recurrence (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Recurrence

Systematic review
1519 people
5 RCTs in this analysis
Recurrence
with TEP laparoscopic repair
with open suture repair

OR 0.67
95% CI 0.38 to 1.18
Data analysed using fixed-effects model; see further information on studies for full details
Not significant

RCT
261 people Recurrence after 2 years
5/119 (4%) with TEP laparoscopic repair
0/125 (0%) with open suture repair

P >0.05
Not significant

Hernia complications

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

TEP laparoscopic repair compared with open suture repair TEP laparoscopic repair seems to be associated with a lower rate of superficial infection but a higher rate of seroma than open suture repair. TEP laparoscopic repair and open suture repair seem to be associated with similar rates of haematoma and vascular injury (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Complications (general)

RCT
261 people Complications (general) after 2 years
7 with TEP laparoscopic repair
4 with open suture repair

P value not reported
Not significant
Haematoma

Systematic review
1337 people
3 RCTs in this analysis
Haematoma
with TEP laparoscopic repair
with open suture repair

OR 1.27
95% CI 0.70 to 2.33
Data analysed using fixed-effects model; see further information on studies for full details
Not significant
Injury

Systematic review
1279 people
3 RCTs in this analysis
Vascular injury
with TEP laparoscopic repair
with open suture repair

OR 0.55
95% CI 0.06 to 5.30
Data analysed using fixed-effects model; see further information on studies for full details
Not significant

Systematic review
1098 people
2 RCTs in this analysis
Visceral injury
0 with TEP laparoscopic repair
0 with open suture repair
Seroma

Systematic review
1279 people
3 RCTs in this analysis
Seroma
with TEP laparoscopic repair
with open suture repair

OR 7.65
95% CI 2.33 to 25.09
Data analysed using fixed-effects model; see further information on studies for full details
Large effect sizeopen suture repair
Infection

Systematic review
1279 people
3 RCTs in this analysis
Superficial infection
with TEP laparoscopic repair
with open suture repair

OR 0.14
95% CI 0.03 to 0.61
Data analysed using fixed-effects model; see further information on studies for full details
Large effect sizeTEP laparoscopic repair

Systematic review
1098 people
2 RCTs in this analysis
Deep infection
0 with TEP laparoscopic repair
0 with open suture repair

TEP laparoscopic repair versus open mesh repair:

We found one systematic review (search date 2003) and three subsequent RCTs comparing TEP laparoscopic repair versus open mesh repair. We also found one long-term follow-up of one of the studies included in the review, which pooled results of three RCTs comparing TEP laparoscopic repair, small mesh transabdominal preperitoneal (TAPP) laparoscopic repair, large mesh TAPP laparoscopic repair, and open mesh repair (see further information on studies).

Pain

TEP laparoscopic repair compared with open mesh repair TEP laparoscopic repair seems more effective than open mesh repair at reducing persisting pain and pain at 12 weeks post surgery (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Pain

Systematic review
991 people
4 RCTs in this analysis
Persisting pain
with TEP laparoscopic repair
with open mesh repair

RR 0.77
95% CI 0.64 to 0.94
Data analysed using fixed-effects model; see further information on studies for full details
Small effect sizeTEP laparoscopic repair

RCT
1371 men with primary unilateral hernia Analgesic requirement 12 weeks
with TEP laparoscopic repair
with open mesh repair

P = 0.011
Effect size not calculatedTEP laparoscopic repair

No data from the following reference on this outcome.

Hospitalisation

TEP laparoscopic repair compared with open mesh repair TEP laparoscopic repair may be more effective than open mesh repair at reducing the overall length of hospital stay, but not at reducing the duration of operation or the proportion of people discharged within 24 hours (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Hospital stay

Systematic review
1227 people
8 RCTs in this analysis
Length of hospital stay
with TEP laparoscopic repair
with open mesh repair

WMD –0.12 days
95% CI –0.06 days to –0.18 days
The difference was small
Data analysed using fixed-effects model; see further information on studies for full details
Heterogeneity among RCTs; see further information on studies
Effect size not calculatedTEP laparoscopic repair

RCT
140 people Length of hospital stay
2 days with TEP laparoscopic repair
2 days with open mesh repair

P >0.05
Not significant

RCT
1371 men with primary unilateral hernia Discharge from the hospital within 24 hours
100% with TEP laparoscopic repair
99.1% with open mesh repair

Significance not assessed
Duration of operation

RCT
1371 men with primary unilateral hernia Median duration of operation
55 minutes with TEP laparoscopic repair
55 minutes with open mesh repair

Significance not assessed

RCT
3-armed trial
66 men with primary unilateral hernia Operative times
with TEP laparoscopic repair
with open mesh repair
Absolute results not reported

Significance not assessed

Return to normal activities/work

TEP laparoscopic repair compared with open mesh repair TEP laparoscopic repair may be more effective than open mesh repair at reducing the time to return to normal activities or work (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Return to normal activities/work

Systematic review
836 people
7 RCTs in this analysis
Time to return to normal activities
with TEP laparoscopic repair
with open mesh repair

HR 0.49
95% CI 0.42 to 0.56
Data analysed using fixed-effects model; see further information on studies for full details
Moderate effect sizeTEP laparoscopic repair

RCT
140 people Time to return to work
13 days with TEP laparoscopic repair
18 days with open mesh repair

P <0.05
Effect size not calculatedTEP laparoscopic repair

RCT
1371 men with primary unilateral hernia Median sick leave
7 (range 0–77) with TEP laparoscopic repair
12 (range 0–55) with open mesh repair

P <0.001
Effect size not calculatedTEP laparoscopic repair

RCT
3-armed trial
66 men with primary unilateral hernia Lost work days
with TEP laparoscopic repair
with TAPP laparoscopic repair
with open mesh repair
Absolute results not reported

P among the groups = 0.074

Recurrence

TEP laparoscopic repair compared with open mesh repair TEP laparoscopic repair and open mesh repair seem equally effective at preventing hernia recurrence (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Recurrence

Systematic review
2009 people
13 RCTs in this analysis
Recurrence
with TEP laparoscopic repair
with open mesh repair

RR 1.61
95% CI 0.87 to 2.98
Not significant

RCT
140 people Recurrence median follow-up of 18 months
0 with TEP laparoscopic repair
0 with open mesh repair

P >0.05
Not significant

RCT
1371 men with primary unilateral hernia Recurrence at 3 months
5 with TEP laparoscopic repair
0 with open mesh repair

Significance not assessed

RCT
3-armed trial
66 men with primary unilateral hernia Recurrence within 24 months
1 with TEP laparoscopic repair
0 with open mesh repair

Significance not assessed

Hernia complications

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

TEP laparoscopic repair compared with open mesh repair TEP laparoscopic repair seems to be associated with a lower rate of haematoma and persisting numbness at 1 year, but not of seroma or superficial infection. TEP laparoscopic repair may be more effective than open mesh repair at reducing postoperative pain and analgaesic requirement (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Postoperative complications (general)

RCT
140 people Postoperative complications
17/61 (28%) with TEP laparoscopic repair
16/62 (26%) with open mesh repair

Reported as not significant
P value not reported
Not significant
Haematoma

Systematic review
1593 people
9 RCTs in this analysis
Haematoma
with TEP laparoscopic repair
with open mesh repair

RR 0.44
95% CI 0.33 to 0.58
Data analysed using fixed-effects model; see further information on studies for full details
Moderate effect sizeTEP laparoscopic repair

RCT
1371 men with primary unilateral hernia Haematoma
10.5% with TEP laparoscopic repair
12.9% with open mesh repair

P = 0.184
Not significant
Numbness

Systematic review
906 people
4 RCTs in this analysis
Persisting numbness at 1 year
with TEP laparoscopic repair
with open mesh repair

RR 0.67
95% CI 0.53 to 0.86
Data analysed using fixed-effects model; see further information on studies for full details
Small effect sizeTEP laparoscopic repair

RCT
1371 men with primary unilateral hernia Numbness at 3 months
3 patients with TEP laparoscopic repair
22 patients with open mesh repair

P <0.001
Effect size not calculatedTEP laparoscopic repair
Seroma

Systematic review
1609 people
9 RCTs in this analysis
Seroma
with TEP laparoscopic repair
with open mesh repair

RR 0.73
95% CI 0.46 to 1.14
Data analysed using fixed-effects model; see further information on studies for full details
Not significant

RCT
1371 men with primary unilateral hernia Seroma
0.9% with TEP laparoscopic repair
0.8% with open mesh repair

P = 1.00
Not significant
Infection

Systematic review
1749 people
10 RCTs in this analysis
Superficial infection
with TEP laparoscopic repair
with open mesh repair

RR 0.62
95% CI 0.33 to 1.16
Data analysed using fixed-effects model; see further information on studies for full details
Not significant

Systematic review
1056 people Deep infection
with TEP laparoscopic repair
with open mesh repair

RCT
1371 men with primary unilateral hernia Infection
1.45% with TEP laparoscopic repair
0.7% with open mesh repair

P = 0.206
Not significant
Urinary tract discomfort

RCT
1371 men with primary unilateral hernia Urinary tract discomfort
0.95% with TEP laparoscopic repair
1.0% with open mesh repair

P = 1.00
Not significant
Injury

Systematic review
1461 people Vascular injury
with TEP laparoscopic repair
with open mesh repair

Systematic review
1274 people Visceral injury
with TEP laparoscopic repair
with open mesh repair
Postoperative pain

RCT
140 people Need for postoperative analgesia (number of postoperative analgesic injections)
3.7 with TEP laparoscopic repair
4.3 with open mesh repair

P >0.05
Not significant

RCT
140 people Need for postoperative analgesia (days of oral analgesia)
2 days with TEP laparoscopic repair
2 days with open mesh repair

P >0.05
Not significant

RCT
1371 men with primary unilateral hernia Postoperative pain (visual analogue score)
with TEP laparoscopic repair
with open mesh repair

P <0.001
Effect size not calculatedTEP laparoscopic repair

RCT
1371 men with primary unilateral hernia Postoperative analgesic requirement
with TEP laparoscopic repair
with open mesh repair

P <0.001
Effect size not calculatedTEP laparoscopic repair

No data from the following reference on this outcome.

TEP laparoscopic repair versus TAPP laparoscopic repair:

We found one systematic review (search date 2003, 1 RCT, 52 people) and one subsequent RCT.

Hospitalisation

TEP laparoscopic repair compared with TAPP laparoscopic repair We don't know how TEP and TAPP laparoscopic repair compare at reducing duration of operation, time off work, or length of hospital stay (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Hospital stay

Systematic review
52 men
Data from 1 RCT
Length of hospital stay (mean number of days)
4.4 with TEP laparoscopic repair
3.7 with TAPP laparoscopic repair

WMD –0.7 days
95% CI –1.33 days to –0.07 days
P = 0.03
Effect size not calculatedTAPP laparoscopic repair
Duration of operation

Systematic review
52 men
Data from 1 RCT
Duration of operation (minutes)
52.3 with TEP laparoscopic repair
46.0 with TAPP laparoscopic repair

WMD –6.3 minutes
95% CI –12.82 minutes to +0.22 minutes
P = 0.06
Not significant

RCT
3-armed trial
66 men Time for repair
with TEP laparoscopic repair
with TAPP laparoscopic repair
Absolute results not reported

Return to normal activities/work

TEP laparoscopic repair compared with TAPP laparoscopic repair We don't know how TEP and TAPP laparoscopic repair compare at reducing time off work (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Time off work

RCT
3-armed trial
66 men Time off work
with TEP laparoscopic repair
with TAPP laparoscopic repair
with open mesh repair
Absolute numbers not reported

P = 0.074 for among group difference

Recurrence

TEP laparoscopic repair compared with TAPP laparoscopic repair We don't know how TEP and TAPP laparoscopic repair compare at reducing hernia recurrence (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Recurrence

Systematic review
52 men
Data from 1 RCT
Hernia recurrence
0/24 (0%) with TEP laparoscopic repair
1/28 (4%) with TAPP laparoscopic repair

RR 2.59
95% CI 0.11 to 60.69
P = 0.6
Not significant

Pain

No data from the following reference on this outcome.

Hernia complications

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Haematoma

Systematic review
52 men
Data from 1 RCT
Haematoma formation
0/24 (0%) with TEP laparoscopic repair
1/28 (4%) with TAPP laparoscopic repair

RR 2.59
95% 0.11 to 60.69
P = 0.6
Not significant

No data from the following reference on this outcome.

Further information on studies

Analysis of data The review analysed data using the fixed-effects model, as opposed to the random-effects model, and this may have overestimated differences between the two treatments.

The long-term follow-up found that laparoscopic repair significantly reduced the proportion of people with chronic pain at 5 years compared with open mesh repair, although results for TAPP and TEP laparoscopic repair were not reported separately (pain: 0/62 [0%] with TAPP or TEP laparoscopic repair v 4/59 [7%] with open mesh repair; difference –7, 95% CI –10 to –0.4; P = 0.04). It found lower rates of recurrence at 5 years with TEP laparoscopic repair compared with open mesh repair (123 people, 121 followed up; 0/22 [0%] with TEP laparoscopic repair v 2/59 [3%] with open mesh repair, significance not reported).

There were 12 TEP conversions: eight to an open mesh repair, and four to a TAPP laparoscopic procedure. Reasons for conversion included gas leakage, adhesions, bleeding, and anatomical difficulties.

There were two conversions from TEP to an open repair because of technical difficulties.

Analysis of data The review analysed data using the fixed-effects model, as opposed to the random-effects model, and this may have overestimated differences between the two treatments. Hospital stay The review found heterogeneity among RCTs in length of hospital stay for TEP versus open mesh repair. There were greater differences in mean length of stay between different hospitals than between different operative techniques. This may suggest that overall findings reflect differences in healthcare systems as opposed to differences because of types of repair.

Comment

Clinical guide:

TEP laparoscopic repair may lead to less pain and similar recurrence rates compared with open suture and open mesh repair. Complication rates seem to be similar between TEP laparoscopic repair and traditional open methods, although TEP repair was shown to have an increased risk of seroma and reduced risk of superficial infection compared with open suture repair.

Substantive changes

Totally extraperitoneal (TEP) laparoscopic repair for unilateral inguinal hernia: Two RCTs comparing TEP laparoscopic repair with open mesh repair added. The first found less analgesic requirement and time off work with TEP laparoscopic repair, but the subsequent RCT found no significant difference between TEP laparoscopic repair and open mesh repair in lost work days. One systematic review and one subsequent RCT found no significant difference between TEP laparoscopic repair and transabdominal preperitoneal (TAPP) laparoscopic repair. Benefits and harms data enhanced. Categorisation unchanged (Beneficial).

2008; 2008: 0412.
Published online 2008 July 16.

Transabdominal preperitoneal (TAPP) laparoscopic repair for unilateral inguinal hernia

Summary

Transabdominal preperitoneal (TAPP) laparoscopic repair reduces pain and speeds up recovery compared with open mesh repair , but both procedures have similar recurrence rates.

We found no direct information from RCTs about whether or not TAPP laparoscopic repair is better than no active intervention (expectant management).

Benefits and harms

TAPP laparoscopic repair versus expectant management:

We found no systematic review, RCTs, or cohort studies of sufficient quality comparing TAPP laparoscopic repair versus expectant management.

TAPP laparoscopic repair versus open suture repair:

We found one systematic review (search date 2002) and four subsequent RCTs, reported in six publications. The systematic review excluded people with non-inguinal hernias, but it did include a small proportion of people with recurrent or bilateral hernias. The overall results are therefore applicable to people with unilateral inguinal hernia. Separate meta-analyses were performed for recurrent and bilateral hernia, and are presented in this review (see questions on primary bilateral inguinal hernia in adults and recurrent inguinal hernia in adults). One further report of one subsequent RCT reported on discomfort levels; see further information on studies for full details.

Pain

TAPP laparoscopic repair compared with open suture repair TAPP laparoscopic repair seems more effective than open suture repair at reducing persistent pain at 3 months (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Pain

Systematic review
1233 people
8 RCTs in this analysis
Persisting pain after 3 months
with TAPP laparoscopic repair
with open suture repair

OR 0.35
95% CI 0.24 to 0.50
Data analysed using fixed-effects model; see further information on studies for full details
Moderate effect sizeTAPP laparoscopic repair

No data from the following reference on this outcome.

Hospitalisation

TAPP laparoscopic repair compared with open suture repair TAPP laparoscopic repair may be more effective than open suture repair at marginally reducing length of hospital stay (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Hospital stay

Systematic review
1586 people
13 RCTs in this analysis
Length of hospital stay
with TAPP laparoscopic repair
with open suture repair

WMR 0.10 days
95% CI 0.02 days to 0.17 days
The effect on length of hospital stay was slight
Data analysed using fixed-effects model; see further information on studies for full details
Heterogeneity among RCTs; see further information on studies
Effect size not calculatedTAPP laparoscopic repair

No data from the following reference on this outcome.

Return to normal activities/work

TAPP laparoscopic repair compared with open suture repair TAPP laparoscopic repair may be more effective than open suture repair at reducing the time taken to return to usual activities (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Return to normal activities

Systematic review
728 people
7 RCTs in this analysis
Time to usual activities
with TAPP laparoscopic repair
with open suture repair

HR 0.50
95% CI 0.43 to 0.58
Data analysed using fixed-effects model; see further information on studies for full details
Small effect sizeTAPP laparoscopic repair
Duration of sick leave

RCT
1042 people with primary unilateral inguinal hernia Median duration of sick leave
10 days with TAPP laparoscopic repair
14 days with open suture repair

P <0.001
Effect size not calculatedTAPP laparoscopic repair

No data from the following reference on this outcome.

Recurrence

TAPP laparoscopic repair compared with open suture repair We don't know how TAPP laparoscopic repair and open suture repair compare at reducing hernia recurrence (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Recurrence

Systematic review
2259 people
16 RCTs in this analysis
Recurrence
with TAPP laparoscopic repair
with open suture repair

OR 0.45
95% CI 0.28 to 0.72
Data analysed using fixed-effects model; see further information on studies for full details
The review reported a lack of consistency in results for recurrence among the included RCTs (see further information on studies)
Moderate effect sizeTAPP laparoscopic repair

RCT
176 people, 152 unilateral and 24 bilateral inguinal hernias Recurrence rate
2/86 (2%) with TAPP laparoscopic repair
1/90 (1%) with open suture repair

Reported as not significant
P value not reported
The RCT may have lacked power to detect a clinically important difference
Not significant

RCT
1042 people with primary unilateral inguinal hernia Recurrence 3 months
1.2% with TAPP laparoscopic repair
0.6% with open suture repair

P = 0.339
Not significant

RCT
People with primary unilateral inguinal hernia
Further report of reference
Cumulative recurrence rates at 5 years
30/454 (6.6%) with TAPP laparoscopic repair
31/466 (6.7%) with open suture repair

P >0.9
Not significant

RCT
3-armed trial
280 men with primary inguinal hernia Number of recurrences 4 years
1 with TAPP laparoscopic repair
6 with open suture repair

P = 0.055 for TAPP laparoscopic repair versus open suture repair
Not significant

No data from the following reference on this outcome.

Hernia complications

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Haematoma or seroma

Systematic review
2061 people
15 RCTs in this analysis
Haematoma
with TAPP laparoscopic repair
with open suture repair

OR 1.18
95% CI 0.81 to 1.73
Not significant

RCT
176 people, 152 unilateral and 24 bilateral hernias Haematoma and seroma
4% with TAPP laparoscopic repair
3% with open suture repair

Significance not assessed
RCT may have lacked power to detect clinically important differences

RCT
1042 people with primary unilateral inguinal hernia Haematoma and seroma
9.1% with TAPP laparoscopic repair
14.7% with open suture repair

P <0.01
Effect size not calculatedTAPP laparoscopic repair

Systematic review
1424 people
10 RCTs in this analysis
Seroma
with TAPP laparoscopic repair
with open suture repair

OR 1.93
95% CI 1.25 to 2.99
Small effect sizeopen suture repair
Infection

Systematic review
1992 people
12 RCTs in this analysis
Superficial infection
with TAPP laparoscopic repair
with open suture repair

OR 0.47
95% CI 0.21 to 1.04
Not significant

Systematic review
1248 people
7 RCTs in this analysis
Deep infection
with TAPP laparoscopic repair
with open suture repair

OR 0.98
95% CI 0.06 to 15.70
Not significant

RCT
176 people; 152 unilateral and 24 bilateral hernias Wound infection
1% with TAPP laparoscopic repair
2% with open suture repair

Significance not assessed
RCT may have lacked power to detect clinically important differences
Numbness

Systematic review
871 people
5 RCTs in this analysis
Persisting numbness after 3 months
with TAPP laparoscopic repair
with open suture repair

OR 0.20
95% CI 0.09 to 0.43
Moderate effect sizeTAPP laparoscopic repair
Overall complications

RCT
1042 people with primary unilateral inguinal hernia Overall complication rate at 1 week
14.7% with TAPP laparoscopic repair
18.3% with open suture repair

P = 0.113
Not significant
Postoperative pain

RCT
1042 people with primary unilateral inguinal hernia Postoperative pain (determined by self-reporting using a visual analogue scale) in the first week
with TAPP laparoscopic repair
with open suture repair

P <0.001
Effect size not calculatedTAPP laparoscopic repair

RCT
3-armed trial
280 people with primary hernias Absence of postoperative pain
84% with TAPP laparoscopic repair
62% with open suture repair

P <0.001
Effect size not calculatedTAPP laparoscopic repair

No data from the following reference on this outcome.

TAPP laparoscopic repair versus open mesh repair:

We found one systematic review (search date 2003) and four subsequent RCTs. We found a long-term follow-up of one of the studies included in the review, which pooled the results of three RCTs comparing small mesh TAPP laparoscopic repair, large mesh TAPP laparoscopic repair, and totally extraperitoneal (TEP) laparoscopic repair versus open mesh repair (see further information on studies).

Pain

TAPP laparoscopic repair compared with open mesh repair TAPP laparoscopic repair seems more effective than open mesh repair at reducing the proportion of people with persisting pain at 1 year (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Pain

Systematic review
1550 people
8 RCTs in this analysis
Persisting pain at 1 year
with TAPP laparoscopic repair
with open mesh repair

RR 0.72
95% CI 0.56 to 0.88
Data analysed using fixed-effects model; see further information on studies for full details
Small effect sizeTAPP laparoscopic repair

No data from the following reference on this outcome.

Hospitalisation

TAPP laparoscopic repair compared with open mesh repair TAPP laparoscopic repair may be more effective than open mesh repair at reducing the length of hospital stay, but not operative time (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Hospital stay

RCT
50 people Length of hospital stay
1.52 days with TAPP laparoscopic repair
2.24 days with open mesh repair

P <0.05
Effect size not calculatedTAPP laparoscopic repair
Operation duration

RCT
3-armed trial
66 people Time to perform procedure
with TAPP laparoscopic repair
with open mesh repair
Absolute results not reported

Significance not assessed

No data from the following reference on this outcome.

Return to normal activities/work

TAPP laparoscopic repair compared with open mesh repair TAPP laparoscopic repair may be more effective than open mesh repair at reducing the time to return to normal activities, but not in lost work days (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Return to normal activities

Systematic review
1025 people
8 RCTs in this analysis
Time to return to usual activities
with TAPP laparoscopic repair
with open mesh repair

HR 0.66
95% CI 0.58 to 0.75
Data analysed using fixed-effects model; see further information on studies for full details
Small effect sizeTAPP laparoscopic repair
Lost work days

RCT
3-armed trial
66 people Lost work days
with TAPP laparoscopic repair
with TEP laparoscopic repair
with open mesh repair
Absolute results not reported

P = 0.074 for among-group difference
Not significant

No data from the following reference on this outcome.

Recurrence

TAPP laparoscopic repair compared with open mesh repair TAPP laparoscopic repair and open mesh repair seem equally effective at preventing hernia recurrence (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Recurrence

Systematic review
2114 people
15 RCTs in this analysis
Hernia recurrence
with TAPP laparoscopic repair
with open mesh repair

RR 1.18
95% CI 0.69 to 2.02
Data analysed using fixed-effects model; see further information on studies for full details
Not significant

RCT
50 people Recurrence mean follow-up 13.5 months
0 with TAPP laparoscopic repair
0 with open mesh repair

Significance not assessed

RCT
3-armed trial
280 men Recurrence
1 with TAPP laparoscopic repair
1 with open mesh repair

Significance not assessed

No data from the following reference on this outcome.

Hernia complications

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

TAPP laparoscopic repair compared with open mesh repair TAPP laparoscopic repair may be more effective than open mesh repair at reducing the risk of persisting numbness, haematoma, superficial infection, and postoperative pain, but less effective at reducing the risk of seroma (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Haematoma

Systematic review
1677 people
12 RCTs in this analysis
Haematoma
with TAPP laparoscopic repair
with open mesh repair

RR 0.76
95% CI 0.62 to 0.94
Data analysed using fixed-effects model; see further information on studies for full details
Result was heavily influenced by 1 RCT, and the difference was not significant when this trial was removed
Small effect sizeTAPP laparoscopic repair
Seroma

Systematic review
1672 people
12 RCTs in this analysis
Seroma
with TAPP laparoscopic repair
with open mesh repair

RR 1.97
95% CI 1.27 to 3.07
Data analysed using fixed-effects model; see further information on studies for full details
Small effect sizeopen mesh repair
Numbness

Systematic review
1483 people
8 RCTs in this analysis
Numbness
with TAPP laparoscopic repair
with open mesh repair

RR 0.26
95% CI 0.17 to 0.40
Data analysed using fixed-effects model; see further information on studies for full details
Moderate effect sizeTAPP laparoscopic repair

RCT
3-armed trial
66 people Numbness
with TAPP laparoscopic repair
with open mesh repair
Absolute results not reported

Statistical analysis not reported
Infection

Systematic review
1756 people
12 RCTs in this analysis
Infection
with TAPP laparoscopic repair
with open mesh repair

RR 0.41
95% CI 0.26 to 0.44
Data analysed using fixed-effects model; see further information on studies for full details
Result was heavily influenced by 1 RCT, and the difference was not significant when this trial was removed
Moderate effect sizeTAPP laparoscopic repair
Adverse effects (general)

RCT
50 people Adverse effects
with TAPP laparoscopic repair
with open mesh repair
Postoperative pain

RCT
50 people Postoperative pain (0 = least pain; 100 = most severe pain) at 24 hours
20.92 with TAPP laparoscopic repair
37.24 with open mesh repair

P <0.05
Effect size not calculatedTAPP laparoscopic repair

RCT
3-armed trial
280 people with primary hernias Absence of postoperative pain
84% with TAPP laparoscopic repair
68% with open mesh repair

P <0.01
Effect size not calculatedTAPP laparoscopic repair

No data from the following reference on this outcome.

TAPP laparoscopic repair versus TEP laparoscopic repair:

See option on TEP laparoscopic repair.

Further information on studies

A further report of one RCT reported no significant difference between TAPP laparoscopic repair and open suture repair in discomfort levels after five years (9% with TAPP repair v 11% with suture repair; P = 0.12).

Analysis of data The review analysed data using the fixed-effects model, as opposed to the random-effects model, and this may have overestimated differences between the two treatments. Heterogeneity The review reported a lack of consistency in results for recurrence among the included RCTs. Reasons for heterogeneity may include the use of different variants of the surgical techniques, different participant characteristics, differing experience of operating surgeons, or differing methods of outcome measurement among studies. The review also found heterogeneity among RCTs in length of hospital stay. There were greater differences in mean length of stay between different hospitals than between different operative techniques. This may suggest that the overall findings reflect differences in healthcare systems as opposed to differences owing to types of repair.

Analysis of data The review analysed data using the fixed-effects model, as opposed to the random-effects model, and this may have overestimated differences between the two treatments.

The long-term follow-up compared small mesh TAPP laparoscopic repair, large mesh TAPP laparoscopic repair, and totally extraperitoneal (TEP) laparoscopic repair versus open mesh repair. It found that laparoscopic repair significantly reduced the proportion of people with chronic pain at 5 years compared with open mesh repair, although the results for TAPP and TEP laparoscopic repair were not reported separately (pain: 0/62 [0%] with TAPP or TEP laparoscopic repair v 4/59 [7%] with open mesh repair; 95% CI –10 to –0.4; P = 0.04). Pooled results found lower recurrence rates at 5 years with TAPP laparoscopic repair using large mesh compared with open mesh repair, but increased recurrence rates with TAPP laparoscopic repair using a small mesh compared with both other groups (recurrence: 0/20 [0%] with TAPP laparoscopic repair using large mesh v 5/20 [25%] with TAPP laparoscopic repair using a small mesh v 2/59 [3%] with open mesh repair; significance assessment for differences between groups not reported).

Comment

Clinical guide:

TAPP laparoscopic repair reduces pain, but has similar recurrence rates compared with open suture and open mesh repair. Complication rates are similar between TAPP laparoscopic repair and open suture repair. However, TAPP repair reduces the risk of haematoma and superficial infection compared with open mesh repair.

Substantive changes

Transabdominal preperitoneal (TAPP) laparoscopic repair for unilateral hernia: One RCT and one follow-up of a previous RCT comparing TAPP laparoscopic repair with open suture repair added, which found no significant difference in recurrence after 4 years or discomfort after 5 years. Two RCTs comparing open mesh repair versus TAPP laparoscopic repair added; the first found that TAPP laparoscopic repair took more time to perform, and the second found reduced nerve damage with TAPP repair as compared with mesh repair. One systematic review and one subsequent RCT found no significant difference between totally extraperitoneal (TEP) laparoscopic repair compared with TAPP laparoscopic repair. Benefits and harms data enhanced. Categorisation unchanged (Beneficial).

2008; 2008: 0412.
Published online 2008 July 16.

Open suture repair for unilateral inguinal hernia

Summary

Open suture repair is a well-established surgical treatment for people with unilateral inguinal hernia, but seems less effective at preventing recurrence, and prolongs recovery, compared with other techniques.

Benefits and harms

Open suture repair versus expectant management:

We found no systematic review, RCTs, or cohort studies of sufficient quality comparing open suture repair versus expectant management.

Open suture repair versus open mesh repair:

See option on open mesh repair.

Open suture repair versus transabdominal preperitoneal (TAPP) laparoscopic repair:

See option on TAPP laparoscopic repair.

Open suture repair versus TEP laparoscopic repair:

See option on TEP laparoscopic repair.

Further information on studies

None.

Comment

Clinical guide:

Clinical experience and consensus suggest that surgery is effective for primary unilateral inguinal hernia. Open suture repair is a well-established method of management for people with inguinal hernias. However, there is strong evidence to show that open suture repair has an increased recurrence rate when compared with open mesh repair. There is no significant difference in other perioperative complications between the two methods.

Substantive changes

Open suture repair for unilateral inguinal hernia: Two RCTs comparing open mesh repair versus open suture repair added. The first RCT found a reduced time off work, and the subsequent RCT found a lower rate of hernia recurrence, with mesh repair as compared with open suture repair. One RCT found no significant difference in recurrence after 4 years, and one follow-up of a previous RCT found no significant difference in discomfort after 5 years, with TAPP laparoscopic repair as compared with open suture repair. Benefits and harms data enhanced. Categorisation unchanged (Likely to be beneficial).

2008; 2008: 0412.
Published online 2008 July 16.

Expectant management for unilateral inguinal hernia

Summary

We don’t know whether expectant management is better than open suture repair or laparoscopic repair in people with unilateral inguinal hernia because we found no studies.

Benefits and harms

Expectant management versus open mesh repair:

See option on open mesh repair.

Expectant management versus open suture repair or laparoscopic repair:

We found no systematic review, RCTs, or cohort studies of sufficient quality comparing expectant management versus open suture repair or laparoscopic repair.

Further information on studies

None.

Comment

Clinical guide:

Expectant management might be considered a reasonable strategy in people who have only minimally symptomatic hernias, low risk of hernia complications (see prognosis), or high operative risk. Although the only RCTs we found compared expectant management versus open mesh repair, the results may be applicable to comparisons of other surgical management strategies.

Substantive changes

Expectant management for unilateral inguinal hernia: One RCT comparing open mesh repair versus expectant management added, which found improved health-related quality of life up to one year after operation in people with minimally symptomatic hernias. Benefits and harms data enhanced. Categorisation unchanged (Unknown effectiveness).

2008; 2008: 0412.
Published online 2008 July 16.

Open mesh repair for bilateral inguinal hernia

Summary

Open mesh repair seems to be as effective as totally extraperitoneal (TEP) laparoscopic repair , but may prolong recovery and increase complication rates compared with transabdominal preperitoneal (TAPP) laparoscopic repair .

We found no clinically important results from RCTs or cohort studies about open mesh repair compared with no active intervention (expectant management).

Benefits and harms

Open mesh repair versus expectant management:

We found two RCTs comparing open mesh repair versus expectant management in people with primary, recurrent, and bilateral hernias; the majority had primary unilateral hernias. However, groups were not analysed separately and it is uncertain whether the results are applicable to a subset of people with primary bilateral hernias.

Open mesh repair versus open suture repair:

We found one systematic review (search date 2000).

Hospitalisation

Open mesh repair compared with open suture repair We don't know how open mesh and open suture repair compare at decreasing length of hospital stay (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Hospital stay

Systematic review
46 people with bilateral inguinal hernia
2 RCTs in this analysis
Length of hospital stay
with open mesh repair
with open suture repair

WMD 1.52 days
95% CI 0.70 days to 2.33 days
See further information on studies for discussion of clinical relevance of results
Effect size not calculatedopen mesh repair

Recurrence

Open mesh repair compared with open suture repair We don't know how open mesh and open suture repair compare at reducing hernia recurrence (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Recurrence

Systematic review
46 people with bilateral inguinal hernia
2 RCTs in this analysis
Recurrence
with open mesh repair
with open suture repair

OR 0.70
95% CI 0.05 to 9.60
See further information on studies for discussion of clinical relevance of results
Not significant

Pain

No data from the following reference on this outcome.

Hernia complications

No data from the following reference on this outcome.

Return to normal activities/work

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Haematoma

Systematic review
46 people with bilateral inguinal hernia
2 RCTs in this analysis
Haematoma
with open mesh repair
with open suture repair

OR 0.47
95% CI 0.08 to 2.83
See further information on studies for discussion of clinical relevance of results
Not significant
Seroma

Systematic review
46 people with bilateral inguinal hernia
2 RCTs in this analysis
Seroma
with open mesh repair
with open suture repair

OR 7.30
95% CI 0.36 to 146.00
See further information on studies for discussion of clinical relevance of results
Not significant

Open mesh repair versus totally extraperitoneal (TEP) laparoscopic repair:

See option on TEP laparoscopic repair.

Open mesh repair versus transabdominal preperitoneal (TAPP) laparoscopic repair:

See option on TAPP laparoscopic repair.

Further information on studies

Methodological limitations The meta-analyses were based on limited data, so the incidence of several clinically important outcomes could not be estimated. Similarly, many of the RCTs lacked power to detect clinically important differences in outcomes. Confidence intervals were wide, and the lack of significance for these results should not be taken to imply a lack of clinically important difference between surgical techniques. Time to return to normal activities The review found no significant difference between both techniques in time to return to normal activities, persisting pain after 3 months (time to normal activities: 1 RCT, 10 people, HR 1.47, 95% CI 0.43 to 5.09; pain: 1 RCT, 10 people, OR 12.18, 95% CI 0.22 to 665.00). However, the number of people in the RCT was below the minimum criteria for reporting in this Clinical Evidence review.

Comment

Clinical guide:

There have been few studies comparing open mesh repair with open suture repair in patients with primary bilateral inguinal hernia. However, results from primary unilateral inguinal hernia may be applicable to this group of people.

Substantive changes

Open mesh repair for bilateral inguinal hernia: One RCT comparing open mesh repair with expectant management added, which found insufficient data in the small proportion of people with bilateral inguinal hernias. Benefits and harms data enhanced. Categorisation unchanged (Likely to be beneficial).

2008; 2008: 0412.
Published online 2008 July 16.

Open suture repair for bilateral inguinal hernia

Summary

Open suture repair may be associated with longer recovery times compared with open mesh repair or transabdominal preperitoneal (TAPP) laparoscopic repair in people with bilateral inguinal hernia.

We found no clinically important results from RCTs or cohort studies about open suture repair compared with no active intervention (expectant management).

Benefits and harms

Open suture repair versus expectant management:

We found no systematic review, RCTs, or cohort studies of sufficient quality comparing open suture repair versus expectant management.

Open suture repair versus open mesh repair:

See option on open mesh repair.

Open suture repair versus totally extraperitoneal (TEP) laparoscopic repair:

See option on TEP laparoscopic repair.

Open suture repair versus transabdominal preperitoneal (TAPP) laparoscopic repair:

See option on TAPP laparoscopic repair.

Further information on studies

None.

Comment

Clinical guide:

Clinical experience and consensus suggest that surgical intervention is an effective treatment for bilateral inguinal hernia. Open suture repair is a well-established surgical technique.

Substantive changes

No new evidence

2008; 2008: 0412.
Published online 2008 July 16.

Totally extraperitoneal (TEP) laparoscopic repair for bilateral inguinal hernia

Summary

TEP laparoscopic repair seems to be as effective as open mesh repair .

We found no clinically important results from RCTs or cohort studies about TEP laparoscopic repair compared with no active intervention (expectant management), open suture repair , or transabdominal preperitoneal (TAPP) laparoscopic repair in people with bilateral inguinal hernia.

Benefits and harms

Totally extraperitoneal (TEP) laparoscopic repair versus expectant management:

We found no systematic review, RCTs, or cohort studies of sufficient quality comparing TEP laparoscopic repair versus expectant management.

TEP laparoscopic repair versus open mesh repair:

We found one systematic review (search date 2003).

Pain

TEP laparoscopic repair compared with open mesh repair We don't know how TEP laparoscopic repair and open mesh repair compare at reducing persisting pain (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Pain

Systematic review
74 people
2 RCTs in this analysis
Persisting pain
with TEP laparoscopic repair
with open mesh repair

RR 0.97
95% CI 0.62 to 1.52
See further information on studies for discussion of clinical relevance of results
Not significant

Return to normal activities/work

TEP laparoscopic repair compared with open mesh repair We don't know how TEP laparoscopic repair and open mesh repair compare at decreasing the time taken to return to normal activities (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Return to normal activities

Systematic review
73 people
3 RCTs in this analysis
Time to usual activities
with TEP laparoscopic repair
with open mesh repair

HR 0.79
95% CI 0.47 to 1.32
See further information on studies for discussion of clinical relevance of results
Not significant

Recurrence

TEP laparoscopic repair compared with open mesh repair We don't know how TEP laparoscopic repair and open mesh repair compare at reducing recurrence (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Recurrence

Systematic review
110 people
3 RCTs in this analysis
Recurrence
with TEP laparoscopic repair
with open mesh repair

RR 4.44
95% CI 0.52 to 38.01
See further information on studies for discussion of clinical relevance of results
Not significant

Hernia complications

No data from the following reference on this outcome.

Hospitalisation

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Haematoma

Systematic review
72 people
2 RCTs in this analysis
Haematoma
with TEP laparoscopic repair
with open mesh repair

RR 2.17
95% CI 0.57 to 8.24
See further information on studies for discussion of clinical relevance of results
Not significant
Seroma

Systematic review
71 people
2 RCTs in this analysis
Seroma
with TEP laparoscopic repair
with open mesh repair

RR 0.58
95% CI 0.12 to 2.91
See further information on studies for discussion of clinical relevance of results
Not significant
Infection

Systematic review
71 people
2 RCTs in this analysis
Superficial infection
with TEP laparoscopic repair
with open mesh repair

RR 0.39
95% CI 0.02 to 9.07
See further information on studies for discussion of clinical relevance of results
Not significant
Numbness

Systematic review
71 people
2 RCTs in this analysis
Numbness
with TEP laparoscopic repair
with open mesh repair

RR 1.05
95% CI 0.49 to 2.22
See further information on studies for discussion of clinical relevance of results
Not significant

TEP laparoscopic repair versus open suture repair:

We found one systematic review (search date 2002, 4 RCTs, 97 patients) comparing TEP laparoscopic repair with open suture repair. The RCTs within the review examined different outcome measures with heterogeneous results. The systematic review concluded that there was insufficient evidence to compare the effects of TEP laparoscopic repair versus open suture repair on time to return to usual activities, recurrence, persisting pain after 3 months, or harms.

TEP laparoscopic repair versus TAPP laparoscopic repair:

We found no systematic reviews or RCTs that compared TEP laparoscopic repair with TAPP laparoscopic repair in bilateral inguinal hernias.

Further information on studies

The meta-analyses were based on few data. Therefore, the incidence of several clinically important outcomes could not be estimated. Similarly, many of the RCTs lacked power to detect clinically important differences in outcomes. Confidence intervals were wide, and the lack of significance for these results should not be taken to imply a lack of clinically important difference between surgical techniques.

Comment

Clinical guide:

There is limited evidence showing no significant difference in persisting pain or recurrence between TEP laparoscopic repair and open mesh repair. There are insufficient data to compare TEP laparoscopic repair and open suture repair.

Substantive changes

No new evidence

2008; 2008: 0412.
Published online 2008 July 16.

Transabdominal preperitoneal (TAPP) laparoscopic repair for bilateral inguinal hernia

Summary

TAPP laparoscopic repair may be associated with shorter recovery times compared with open suture repair in people with bilateral inguinal hernia.

TAPP laparoscopic repair may shorten recovery and decrease complication rates compared with open mesh repair .

Benefits and harms

TAPP laparoscopic repair versus expectant management:

We found no systematic review, RCTs, or cohort studies of sufficient quality comparing TAPP laparoscopic repair versus expectant management.

TAPP laparoscopic repair versus open mesh repair:

We found one systematic review (search date 2003) comparing TAPP laparoscopic repair with open mesh repair.

Pain

TAPP laparoscopic repair compared with open mesh repair We don't know how TAPP laparoscopic repair and open mesh repair compare at reducing persistent pain (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Pain

Systematic review
86 people
3 RCTs in this analysis
Persisting pain
with TAPP laparoscopic repair
with open mesh repair

RR 0.80
95% CI 0.45 to 1.45
See further information on studies for discussion of clinical relevance of results
Not significant

Hospitalisation

TAPP laparoscopic repair compared with open mesh repair We don't know how TAPP laparoscopic repair and open mesh repair compare at reducing length of hospital stay (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Hospital stay

Systematic review
107 people
6 RCTs in this analysis
Length of hospital stay
with TAPP laparoscopic repair
with open mesh repair

WMD –0.18 days
95% CI –0.38 days to +0.02 days
See further information on studies for discussion of clinical relevance of results
Not significant

Return to normal activities/work

TAPP laparoscopic repair compared with open mesh repair TAPP laparoscopic repair may be more effective than open mesh repair at reducing the time taken to return to normal activities (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Return to normal activities

Systematic review
87 people
6 RCTs in this analysis
Time to normal activities
with TAPP laparoscopic repair
with open mesh repair

HR 0.51
95% CI 0.32 to 0.81
See further information on studies for discussion of clinical relevance of results
Small effect sizeTAPP laparoscopic repair

Recurrence

TAPP laparoscopic repair compared with open mesh repair We don't know how TAPP laparoscopic repair and open mesh repair compare at reducing hernia recurrence (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Recurrence

Systematic review
152 people
7 RCTs in this analysis
Recurrence
with TAPP laparoscopic repair
with open mesh repair

RR 2.02
95% CI 0.52 to 7.83
See further information on studies for discussion of clinical relevance of results
Not significant

Hernia complications

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

TAPP laparoscopic repair compared with open mesh repair TAPP laparoscopic repair may be associated with a lower risk of persisting numbness and superficial infection compared with open mesh repair, but may be associated with a similar risk of haematoma or seroma (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Haematoma

Systematic review
140 people
6 RCTs in this analysis
Haematoma
with TAPP laparoscopic repair
with open mesh repair

RR 0.76
95% CI 0.35 to 1.65
See further information on studies for discussion of clinical relevance of results
Not significant
Seroma

Systematic review
140 people
6 RCTs in this analysis
Seroma
with TAPP laparoscopic repair
with open mesh repair

RR 2.62
95% CI 0.92 to 7.48
See further information on studies for discussion of clinical relevance of results
Not significant
Numbness

Systematic review
96 people
4 RCTs in this analysis
Persisting numbness
with TAPP laparoscopic repair
with open mesh repair

RR 0.23
95% CI 0.06 to 0.94
See further information on studies for discussion of clinical relevance of results
Moderate effect sizeTAPP laparoscopic repair
Infection

Systematic review
140 people
6 RCTs in this analysis
Superficial infection
with TAPP laparoscopic repair
with open mesh repair

RR 0.26
95% CI 0.09 to 0.72
See further information on studies for discussion of clinical relevance of results
Moderate effect sizeTAPP laparoscopic repair

TAPP laparoscopic repair versus open suture repair:

We found one systematic review (search date 2002).

Pain

TAPP laparoscopic repair compared with open suture repair We don't know how TAPP laparoscopic repair and open suture repair compare at reducing persisting pain at 3 months (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Pain

Systematic review
63 people
2 RCTs in this analysis
Persisting pain at 3 months
with TAPP laparoscopic repair
with open suture repair

OR 0.38
95% CI 0.10 to 1.43
See further information on studies for discussion of clinical relevance of results
Not significant

Hospitalisation

TAPP laparoscopic repair compared with open suture repair We don't know how TAPP laparoscopic repair and open suture repair compare at reducing length of hospital stay (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Hospital stay

Systematic review
97 people
4 RCTs in this analysis
Length of hospital stay
with TAPP laparoscopic repair
with open suture repair

WMD –0.05 days
95% CI –0.17 days to +0.07 days
See further information on studies for discussion of clinical relevance of results
Not significant

Return to normal activities/work

TAPP laparoscopic repair compared with open suture repair TAPP laparoscopic repair may be more effective than open suture repair at reducing time taken to return to normal activities (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Return to normal activities

Systematic review
59 people
3 RCTs in this analysis
Time to return to normal activities
with TAPP laparoscopic repair
with open suture repair

OR 0.52
95% CI 0.31 to 0.88
See further information on studies for discussion of clinical relevance of results
Small effect sizeTAPP laparoscopic repair

Hernia complications

No data from the following reference on this outcome.

Recurrence

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

TAPP laparoscopic repair compared with open suture repair TAPP laparoscopic repair and open suture repair may be associated with similar rates of adverse effects (haematoma, seroma, superficial infection, and visceral injury) (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Haematoma

Systematic review
97 people
4 RCTs in this analysis
Haematoma
with TAPP laparoscopic repair
with open suture repair

OR 1.26
95% CI 0.37 to 4.29
See further information on studies for discussion of clinical relevance of results
Not significant
Seroma

Systematic review
82 people
3 RCTs in this analysis
Seroma
with TAPP laparoscopic repair
with open suture repair

OR 0.85
95% CI 0.24 to 3.04
See further information on studies for discussion of clinical relevance of results
Not significant
Infection

Systematic review
97 people
4 RCTs in this analysis
Superficial infection
with TAPP laparoscopic repair
with open suture repair

OR 0.97
95% CI 0.08 to 11.59
See further information on studies for discussion of clinical relevance of results
Not significant
Injury

Systematic review
82 people
3 RCTs in this analysis
Visceral injury
with TAPP laparoscopic repair
with open suture repair

OR 5.16
95% CI 0.09 to 286.00
See further information on studies for discussion of clinical relevance of results
Not significant

TAPP laparoscopic repair versus TEP laparoscopic repair:

See option on TEP laparoscopic repair.

Further information on studies

The meta-analyses were based on few data. Therefore, the incidence of several clinically important outcomes could not be estimated. Similarly, many of the results lacked power to detect clinically important differences in outcomes. Confidence intervals were wide, and the lack of significance for these results should not be taken to imply a lack of clinically important difference between techniques.

Comment

Clinical guide:

There is limited evidence to suggest that TAPP laparoscopic repair reduces the time taken to return to normal activities compared with open mesh repair or open suture repair. The limited evidence found no significant difference in recurrence rates between TAPP laparoscopic repair and open mesh repair. However, no evidence was found comparing the recurrence rates between TAPP laparoscopic repair and open suture repair.

Substantive changes

No new evidence

2008; 2008: 0412.
Published online 2008 July 16.

Expectant management for bilateral inguinal hernia

Summary

We found no direct information from RCTs or cohort studies about expectant management in the treatment of people with bilateral inguinal hernia.

Benefits and harms

Expectant management versus open suture repair, open mesh repair, or laparoscopic repair:

We found no systematic review, RCTs, or cohort studies of sufficient quality comparing expectant management versus open suture repair, open mesh repair, or laparoscopic repair.

Further information on studies

None.

Comment

Clinical guide:

Expectant management might be considered a reasonable strategy in people who have only mild symptoms, low risk of hernia complications (see prognosis), or high operative risk. However, we found no reliable evidence about the benefits and risks of expectant management compared with surgery.

Substantive changes

No new evidence

2008; 2008: 0412.
Published online 2008 July 16.

Open mesh repair for recurrent inguinal hernia

Summary

Open mesh repair may be associated with a decreased recovery time compared with open suture repair in people with recurrent inguinal hernia.

Benefits and harms

Open mesh repair versus expectant management:

We found no systematic reviews, RCTs, or cohort studies of sufficient quality comparing open mesh repair versus expectant management in recurrent inguinal hernia alone. We found two RCTs comparing open mesh repair with expectant management in people with primary, recurrent, and bilateral hernias; the majority had primary unilateral hernias. However, groups were not analysed separately, and it is uncertain whether the results of these RCTs are applicable to a subset of people with recurrent hernias. Both RCTs had one person in the expectant management group who required surgical repair due to an acute exacerbation of a hernia. However, it is not known if these were people with unilateral, bilateral, or recurrent hernias.

Open mesh repair versus open suture repair:

We found one systematic review (search date 2000).

Pain

Open mesh repair compared with open suture repair We don't know how open mesh repair and open suture repair compare at reducing persistent pain at 3 months (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Pain

Systematic review
49 people
2 RCTs in this analysis
Persisting pain after 3 months
with open mesh repair
with open suture repair

OR 1.05
95% CI 0.19 to 5.82
See further information on studies for discussion of clinical relevance of results
Not significant

Hospitalisation

Open mesh repair compared with open suture repair Open mesh repair may be more effective than open suture repair at marginally reducing the length of hospital stay (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Hospital stay

Systematic review
59 people
2 RCTs in this analysis
Length of hospital stay
with open mesh repair
with open suture repair

WMR 0.41 days
95% CI 0.07 to 0.75
The effect was described as small
See further information on studies for discussion of clinical relevance of results
Effect size not calculatedopen mesh repair

Return to normal activities/work

Open mesh repair compared with open suture repair We don't know how open mesh repair and open suture repair compare at reducing time taken to return to normal activities (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Return to normal activities

Systematic review
33 people
2 RCTs in this analysis
Time to return to usual activities
with open mesh repair
with open suture repair

HR 0.88
95% CI 0.44 to 1.74
See further information on studies for discussion of clinical relevance of results
Not significant

Recurrence

Open mesh repair compared with open suture repair We don't know how open mesh repair and open suture repair compare at reducing further hernia recurrence (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Further recurrence

Systematic review
59 people
2 RCTs in this analysis
Further recurrence
with open mesh repair
with open suture repair

OR 1.79
95% CI 0.39 to 8.23
See further information on studies for discussion of clinical relevance of results
Not significant

Hernia complications

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Mortality

Systematic review
People with inguinal hernia Mortality
with open mesh repair
with open suture repair

OR 0.07
95% CI 0 to 1.28
See further information on studies for discussion of clinical relevance of results
Not significant
Haematoma

Systematic review
People with inguinal hernia Haematoma
with open mesh repair
with open suture repair

OR 0.98
95% CI 0 to 16.53
See further information on studies for discussion of clinical relevance of results
Not significant
Infection

Systematic review
People with inguinal hernia Superficial infection
with open mesh repair
with open suture repair

OR 5.29
95% CI 0.10 to 289.31
See further information on studies for discussion of clinical relevance of results
Not significant

Systematic review
People with inguinal hernia Life-threatening visceral or vascular injury/deep infection
with open mesh repair
with open suture repair

OR 1.47
95% CI 0.08 to 25.46
See further information on studies for discussion of clinical relevance of results
Not significant
Numbness

Systematic review
People with inguinal hernia Numbness
with open mesh repair
with open suture repair

OR 1.73
95% CI 0.29 to 10.16
See further information on studies for discussion of clinical relevance of results
Not significant

Open mesh repair versus totally extraperitoneal (TEP) laparoscopic repair:

See option on TEP laparoscopic repair.

Open mesh repair versus transabdominal preperitoneal (TAPP) laparoscopic repair:

See option on TAPP laparoscopic repair.

Further information on studies

Many of the results lacked power to detect clinically important differences in outcomes. Confidence intervals were wide, and the lack of significance for these results should not be taken to imply a lack of clinically important difference between surgical techniques.

Comment

Clinical guide:

There is little evidence comparing open mesh repair with open suture repair in people with recurrent inguinal hernia. The limited evidence suggests no significant difference in recurrence between the two groups. In the authors' experience, open mesh repair tends to be used more frequently than open suture repair for recurrent inguinal hernia. This is likely to be secondary to the experience with primary inguinal hernia, where open mesh repair has been demonstrated to have lower recurrence rates than open suture repair.

Substantive changes

Open mesh repair for recurrent inguinal hernia: One RCT comparing open mesh repair with expectant management added, which found insufficient data in the small proportion of people with recurrent inguinal hernias. Benefits and harms data enhanced. Categorisation unchanged (Likely to be beneficial).

2008; 2008: 0412.
Published online 2008 July 16.

Open suture repair for recurrent inguinal hernia

Summary

Open suture repair may be associated with an increased recovery time compared with open mesh repair in people with recurrent inguinal hernia.

We don't know how open suture repair compares with totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) laparoscopic repair in people with recurrent inguinal hernia.

We found no clinically important results from RCTs or cohort studies about open suture repair compared with no active intervention (expectant management), or about open suture repair compared with TEP laparoscopic repair, in people with recurrent inguinal hernia.

Benefits and harms

Open suture repair versus expectant management:

We found no systematic review, RCTs, or cohort studies of sufficient quality comparing open suture repair versus expectant management.

Open suture repair versus open mesh repair:

See option on open mesh repair.

Open suture repair versus totally extraperitoneal (TEP) laparoscopic repair:

See option on TEP laparoscopic repair.

Open suture repair versus transabdominal preperitoneal (TAPP) repair:

See option on TAPP laparoscopic repair.

Further information on studies

None.

Comment

Clinical guide:

Open suture repair is a well-established method of management for people with inguinal hernias, based on clinical experience and consensus.

Substantive changes

No new evidence

2008; 2008: 0412.
Published online 2008 July 16.

Totally extraperitoneal (TEP) laparoscopic repair for recurrent inguinal hernia

Summary

We don't know how TEP laparoscopic repair compares with open suture repair in people with recurrent inguinal hernia.

TEP laparoscopic repair may reduce recovery time compared with open mesh repair , but complication rates seem to be similar.

We found no clinically important results from RCTs or cohort studies about TEP laparoscopic repair compared with no active intervention (expectant management), open suture repair, or transabdominal preperitoneal (TAPP) laparoscopic repair in people with recurrent inguinal hernia.

Benefits and harms

TEP laparoscopic repair versus expectant management:

We found no systematic review, RCTs, or cohort studies of sufficient quality comparing TEP laparoscopic repair versus expectant management.

TEP laparoscopic repair versus open mesh repair:

We found one systematic review (search date 2003) and one subsequent RCT.

Pain

TEP laparoscopic repair compared with open mesh repair We don't know how TEP laparoscopic repair and open mesh repair compare at reducing persistent pain (very low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Pain

Systematic review
122 people
2 RCTs in this analysis
Persisting pain
with TEP laparoscopic repair
with open mesh repair

RR 0.90
95% CI 0.59 to 1.38
See further information on studies for discussion of clinical relevance of results
Not significant

No data from the following reference on this outcome.

Hospitalisation

TEP laparoscopic repair compared with open mesh repair We don't know how TEP laparoscopic repair and open mesh repair compare at reducing the length of hospital stay (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Hospital stay

Systematic review
88 people
2 RCTs in this analysis
Length of hospital stay
with TEP laparoscopic repair
with open mesh repair

WMD +0.24
95% CI –0.45 to +0.93
See further information on studies for discussion of clinical relevance of results
Not significant

RCT
3-armed trial
82 men with recurrent inguinal hernia Length of hospital stay
18.5 hours with TEP laparoscopic repair
20.4 hours with open mesh repair

P = 0.172
Not significant

Return to normal activities/work

TEP laparoscopic repair compared with open mesh repair TEP laparoscopic repair may be more effective than open mesh repair at reducing the time taken to return to normal activities (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Return to normal activities

Systematic review
97 people
3 RCTs in this analysis
Time to return to usual activities
with TEP laparoscopic repair
with open mesh repair

HR 0.55
95% CI 0.35 to 0.89
See further information on studies for discussion of clinical relevance of results
Small effect sizeTEP laparoscopic repair

RCT
3-armed trial
82 men with recurrent inguinal hernia Time to return to usual activities
13 days with TEP laparoscopic repair
20 days with open mesh repair

P = 0.001
Effect size not calculatedTEP laparoscopic repair

Recurrence

TEP laparoscopic repair compared with open mesh repair We don't know how TEP laparoscopic repair and open mesh repair compare at reducing further hernia recurrence (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Further recurrence

Systematic review
127 people
2 RCTs in this analysis
Further recurrence
with TEP laparoscopic repair
with open mesh repair

RR 1.08
95% CI 0.57 to 2.05
See further information on studies for discussion of clinical relevance of results
Not significant

RCT
3-armed trial
82 men with recurrent inguinal hernia Recurrence within 3 years
2/26 (8%) with TEP laparoscopic repair
5/32 (16%) with open mesh repair

Significance not assessed

Hernia complications

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

TEP laparoscopic repair compared with open mesh repair TEP laparoscopic repair may be more effective than open mesh repair at reducing postoperative pain or the occurrence of haematoma, and may be associated with a similar risk of seroma or persisting numbness (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Haematoma

Systematic review
117 people
2 RCTs in this analysis
Haematoma
with TEP laparoscopic repair
with open mesh repair

RR 0.29
95% CI 0.13 to 0.66
See further information on studies for discussion of clinical relevance of results
Moderate effect sizeTEP laparoscopic repair
Seroma

Systematic review
117 people
2 RCTs in this analysis
Seroma
with TEP laparoscopic repair
with open mesh repair

RR 0.60
95% CI 0.14 to 2.51
See further information on studies for discussion of clinical relevance of results
Not significant
Numbness

Systematic review
117 people
2 RCTs in this analysis
Persisting numbness
with TEP laparoscopic repair
with open mesh repair

RR 1.22
95% CI 0.63 to 2.35
See further information on studies for discussion of clinical relevance of results
Not significant
Perioperative complications

RCT
3-armed trial
82 men with recurrent inguinal hernia Perioperative complications (bleeding, haematoma, and infection)
3/26 (12%) with TEP laparoscopic repair
12/32 (38%) with open mesh repair

P = 0.026
Effect size not calculatedTEP laparoscopic repair
Postoperative pain

RCT
3-armed trial
82 men with recurrent inguinal hernia Postoperative pain (median pain score measured on a visual analogue scale: 1, no pain to 10, worst possible pain) 24 hours
1 with TEP laparoscopic repair
4 with open mesh repair

P = 0.001
Effect size not calculatedTEP laparoscopic repair

RCT
3-armed trial
82 men with recurrent inguinal hernia Pain (median pain score measured on a visual analogue scale: 1, no pain to 10, worst possible pain) 20 days
0 with TEP laparoscopic repair
2 with open mesh repair

P = 0.001
Effect size not calculatedTEP laparoscopic repair

RCT
3-armed trial
82 men with recurrent inguinal hernia Duration of analgesic requirement
1.8 days with TEP laparoscopic repair
3.2 days with open mesh repair

P = 0.001
Effect size not calculatedTEP laparoscopic repair

TEP laparoscopic repair versus open suture repair:

We found no RCTs comparing TEP laparoscopic repair with suture repair in recurrent inguinal hernias.

TEP laparoscopic repair versus TAPP laparoscopic repair:

We found no systematic reviews or RCTs that compared TEP laparoscopic repair with TAPP laparoscopic repair in recurrent inguinal hernias.

Further information on studies

The meta-analyses comparing TEP laparoscopic repair versus open surgery for people with recurrent hernia were based on few data. Therefore, the incidence of several clinically important outcomes, particularly complications, could not be estimated. Similarly, many of the results lacked power to detect clinically important differences in outcomes. Confidence intervals were wide, and the lack of significance for these results should not be taken to imply a lack of clinically important difference between surgical techniques.

Comment

Clinical guide:

There is limited evidence to show that TEP laparoscopic repair reduces the time taken to return to normal activities, and postoperative haematoma, compared with open mesh repair. We found no significant difference in recurrence rates between the two methods.

Substantive changes

No new evidence

2008; 2008: 0412.
Published online 2008 July 16.

Transabdominal preperitoneal (TAPP) laparoscopic repair for recurrent inguinal hernia

Summary

We don't know how TAPP laparoscopic repair compares with open suture repair in people with recurrent inguinal hernia.

We found no clinically important results from RCTs or cohort studies about TAPP laparoscopic repair compared with no active intervention (expectant management), or TAPP laparoscopic repair in people with recurrent inguinal hernia.

Benefits and harms

TAPP laparoscopic repair versus expectant management:

We found no systematic review, RCTs, or cohort studies of sufficient quality comparing TAPP laparoscopic repair versus expectant management.

TAPP laparoscopic repair versus open mesh repair:

We found one systematic review (search date 2003) and two subsequent RCTs.

Pain

TAPP laparoscopic repair compared with open mesh repair We don't know how TAPP laparoscopic repair and open mesh repair compare at reducing persistent pain (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Pain

Systematic review
164 people
4 RCTs in this analysis
Persisting pain
with TAPP laparoscopic repair
with open mesh repair

RR 1.00
95% CI 0.54 to 1.85
See further information on studies for discussion of clinical relevance of results
Not significant

RCT
147 patients with recurrent inguinal hernia Frequency of chronic pain over 5 years
with TAPP laparoscopic repair
with open mesh repair
Absolute results not reported

Reported as not significant
P value not reported
Not significant

No data from the following reference on this outcome.

Hospitalisation

TAPP laparoscopic repair compared with open mesh repair TAPP laparoscopic repair seems as effective as open mesh repair at reducing the hospital stay (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Hospital stay

Systematic review
198 people
6 RCTs in this analysis
Length of hospital stay
with TAPP laparoscopic repair
with open mesh repair

WMD +0.02 days
95% CI –0.13 days to +0.17 days
See further information on studies for discussion of clinical relevance of results
Not significant

RCT
3-armed trial
82 men with recurrent inguinal hernia Length of hospital stay
18.6 hours with TAPP laparoscopic repair
20.4 hours with open mesh repair

P = 0.206
Not significant

No data from the following reference on this outcome.

Return to normal activities/work

TAPP laparoscopic repair compared with open mesh repair TAPP laparoscopic repair seems more effective than open mesh repair at reducing the time to return to usual activities and the need for sick leave (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Return to normal activities

Systematic review
121 people
6 RCTs in this analysis
Time to return to usual activities
with TAPP laparoscopic repair
with open mesh repair

HR 0.60
95% CI 0.41 to 0.87
See further information on studies for discussion of clinical relevance of results
Small effect sizeTAPP laparoscopic repair

RCT
3-armed trial
82 men with recurrent inguinal hernia Time to return to normal activities
14 days with TAPP laparoscopic repair
20 days with open mesh repair

P = 0.001
Effect size not calculatedTAPP laparoscopic repair
Need for sick leave

RCT
147 patients with recurrent inguinal hernia Need for sick leave at the end of 3 weeks
5% with TAPP laparoscopic repair
35% with open mesh repair

P <0.001
Effect size not calculatedTAPP laparoscopic repair

Recurrence

TAPP laparoscopic repair compared with open mesh repair TAPP laparoscopic repair seems as effective as open mesh repair at reducing further hernia recurrence (moderate-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Further recurrence

Systematic review
199 people
6 RCTs in this analysis
Further recurrence
with TAPP laparoscopic repair
with open mesh repair

RR 1.32
95% CI 0.53 to 3.31
See further information on studies for discussion of clinical relevance of results
Not significant

RCT
3-armed trial
82 men with recurrent inguinal hernia Rates of recurrence within 3 years
2/24 (8%) with TAPP laparoscopic repair
5/32 (16%) with open mesh repair

Significance not assessed

RCT
147 patients with recurrent inguinal hernia Cumulative recurrence rates at 5 years
12/73 (19%) with TAPP laparoscopic repair
12/74 (18%) with open mesh repair

Reported as not significant
P value not reported
Not significant

Hernia complications

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Haematoma

Systematic review
190 people
5 RCTs in this analysis
Haematoma
with TAPP laparoscopic repair
with open mesh repair

RR 1.07
95% CI 0.51 to 2.21
See further information on studies for discussion of clinical relevance of results
Not significant

RCT
147 patients with recurrent inguinal hernia Haematoma at 1 week
7% with TAPP laparoscopic repair
22% with open mesh repair
Absolute numbers not reported

P = 0.009
Effect size not calculatedTAPP laparoscopic repair

RCT
3-armed trial
82 men with recurrent inguinal hernia Haematoma
4/24 (17%) with TAPP laparoscopic repair
12/32 (38%) with open mesh repair
Seroma

Systematic review
186 people
5 RCTs in this analysis
Seroma
with TAPP laparoscopic repair
with open mesh repair

RR 1.45
95% CI 0.75 to 2.82
See further information on studies for discussion of clinical relevance of results
Not significant

RCT
147 patients with recurrent inguinal hernia Seroma at 1 week
0% with TAPP laparoscopic repair
1% with open mesh repair

P = 0.5
Not significant

RCT
147 patients with recurrent inguinal hernia Seroma at 3 months
1% with TAPP laparoscopic repair
0% with open mesh repair

P = 0.504
Not significant
Infection

Systematic review
190 people
5 RCTs in this analysis
Superficial infection
with TAPP laparoscopic repair
with open mesh repair

RR 0.60
95% CI 0.24 to 1.54
See further information on studies for discussion of clinical relevance of results
Not significant

RCT
147 patients with recurrent inguinal hernia Infection at 1 week
1% with TAPP laparoscopic repair
3% with open mesh repair
Absolute numbers not reported

P = 0.975
Not significant

RCT
3-armed trial
82 men with recurrent inguinal hernia Infection
0/24 (0%) with TAPP laparoscopic repair
1/32 (3%) with open mesh repair
Injury

Systematic review
113 people
4 RCTs in this analysis
Visceral injury
with TAPP laparoscopic repair
with open mesh repair

RR 2.18
95% CI 0.10 to 46.92
See further information on studies for discussion of clinical relevance of results
Not significant
Postoperative pain

RCT
3-armed trial
82 men with recurrent inguinal hernia Median postoperative pain (assessed by visual analogue scale [VAS]: 1, no pain; 10, worst possible pain) at 24 hours
1 with TAPP laparoscopic repair
4 with open mesh repair

P = 0.001
Effect size not calculatedTAPP laparoscopic repair

RCT
3-armed trial
82 men with recurrent inguinal hernia Median postoperative pain (assessed by VAS: 1, no pain; 10, worst possible pain) at up to 20 days
0 with TAPP laparoscopic repair
2 with open mesh repair

P = 0.001
Effect size not calculatedTAPP laparoscopic repair

RCT
3-armed trial
82 men with recurrent inguinal hernia Duration of analgesic requirement
1.9 days with TAPP laparoscopic repair
3.2 days with open mesh repair

P = 0.004
Effect size not calculatedTAPP laparoscopic repair

RCT
147 patients with recurrent inguinal hernia Postoperative pain (combined VAS index) in first week
125 mm with TAPP laparoscopic repair
165 mm with open mesh repair

P = 0.019
Effect size not calculatedTAPP laparoscopic repair
Numbness

Systematic review
172 people
5 RCTs in this analysis
Persisting numbness
with TAPP laparoscopic repair
with open mesh repair

RR 0.33
95% CI 0.10 to 1.14
See further information on studies for discussion of clinical relevance of results
Not significant
Bleeding

RCT
3-armed trial
82 men with recurrent inguinal hernia Bleeding
1/24 (4%) with TAPP laparoscopic repair
2/32 (6%) with open mesh repair
Perioperative complications

RCT
3-armed trial
82 men with recurrent inguinal hernia Perioperative complications (included bleeding, haematoma, and infection)
3/24 (13%) with TAPP laparoscopic repair
12/32 (38%) with open mesh repair

P = 0.038
Effect size not calculatedTAPP laparoscopic repair

TAPP laparoscopic repair versus open suture repair:

We found one systematic review (search date 2002).

Pain

TAPP laparoscopic repair compared with open suture repair We don't know how TAPP laparoscopic repair and open suture repair compare at reducing persisting pain after 3 months (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Pain

Systematic review
53 people
2 RCTs in this analysis
Persisting pain after 3 months
with TAPP laparoscopic repair
with open suture repair

OR 0.18
95% CI 0 to 9.42
See further information on studies for discussion of clinical relevance of results
Not significant

Hospitalisation

TAPP laparoscopic repair compared with open suture repair We don't know how TAPP laparoscopic repair and open suture repair compare at reducing length of hospital stay (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Hospital stay

Systematic review
92 people
4 RCTs in this analysis
Length of hospital stay
with TAPP laparoscopic repair
with open suture repair

WMD +0.08 days
95% CI –0.25 days to +0.41 days
See further information on studies for discussion of clinical relevance of results
Not significant

Return to normal activities/work

TAPP laparoscopic repair compared with open suture repair We don't know how TAPP laparoscopic repair and open suture repair compare at reducing time to return to normal activities (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Return to normal activities

Systematic review
57 people
3 RCTs in this analysis
Time to return to usual activities
with TAPP laparoscopic repair
with open suture repair

HR 0.70
95% CI 0.41 to 1.20
See further information on studies for discussion of clinical relevance of results
Not significant

Recurrence

Compared with open suture repair We don't know how TAPP laparoscopic repair and open suture repair compare at reducing further hernia recurrence (low-quality evidence).

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Further recurrence

Systematic review
93 people
4 RCTs in this analysis
Further recurrence
with TAPP laparoscopic repair
with open suture repair

OR 0.31
95% CI 0.04 to 2.26
See further information on studies for discussion of clinical relevance of results
Not significant

No data from the following reference on this outcome.

Hernia complications

No data from the following reference on this outcome.

Quality of life

No data from the following reference on this outcome.

Adverse effects

Ref (type)PopulationOutcome, InterventionsResults and statistical analysisEffect sizeFavours
Haematoma

Systematic review
93 people
4 RCTs in this analysis
Haematoma
with TAPP laparoscopic repair
with open suture repair

OR 1.70
95% CI 0.42 to 6.84
See further information on studies for discussion of clinical relevance of results
Not significant
Seroma

Systematic review
93 people
4 RCTs in this analysis
Seroma
with TAPP laparoscopic repair
with open suture repair

OR 2.14
95% CI 0.21 to 22.16
See further information on studies for discussion of clinical relevance of results
Not significant
Infection

Systematic review
93 people
4 RCTs in this analysis
Superficial infection
with TAPP laparoscopic repair
with open suture repair

OR 0.18
95% CI 0 to 9.42
See further information on studies for discussion of clinical relevance of results
Not significant

Systematic review
68 people
2 RCTs in this analysis
Deep infection
with TAPP laparoscopic repair
with open suture repair

OR 0.15
95% CI 0 to 7.71
See further information on studies for discussion of clinical relevance of results
Not significant
Numbness

Systematic review
53 people
2 RCTs in this analysis
Persisting numbness
with TAPP laparoscopic repair
with open suture repair

OR 0.16
95% CI 0.02 to 1.70
See further information on studies for discussion of clinical relevance of results
Not significant
Vascular or visceral injury

Systematic review
93 people
4 RCTs in this analysis
Vascular or visceral injury
0 with TAPP laparoscopic repair
0 with open suture repair

TAPP laparoscopic repair versus TEP laparoscopic repair:

See option on TEP laparoscopic repair for recurrent inguinal hernia.

Further information on studies

The meta-analyses comparing laparoscopic versus open surgery for people with recurrent hernia were based on few data. Therefore, the incidence of several clinically important outcomes, particularly complications, could not be estimated. Similarly, many of the RCTs lacked power to detect clinically important differences in outcomes. Confidence intervals were wide, and the lack of significance for these results should not be taken to imply a lack of clinically important differences between surgical techniques.

Comment

Clinical guide:

There is weak evidence to show that TAPP laparoscopic repair reduces the time taken to return to normal activities compared with open mesh repair. However, this evidence shows no difference between the two groups for persisting pain, further recurrence, or other perioperative complications.

Substantive changes

TAPP laparoscopic repair for recurrent inguinal hernia: One RCT added, which found no significant difference in recurrence rates or chronic pain between TAPP laparoscopic repair and open mesh repair, but decreased postoperative pain and sick leave in the TAPP group. Benefits and harms data enhanced. Categorisation unchanged (Likely to be beneficial).

2008; 2008: 0412.
Published online 2008 July 16.

Expectant management for recurrent inguinal hernia

Summary

We found no direct information from RCTs or cohort studies about expectant management in the treatment of people with recurrent inguinal hernia.

Benefits and harms

Expectant management versus open suture repair, open mesh repair, or laparoscopic repair:

We found no systematic review, RCTs, or cohort studies of sufficient quality comparing expectant management versus open suture repair, open mesh repair, or laparoscopic repair.

Further information on studies

None.

Comment

Clinical guide:

Expectant management might be considered a reasonable strategy in people who have only mild symptoms, low risk of hernia complications (see prognosis), or high operative risk. However, we found no reliable evidence about the benefits and risks of expectant management compared with surgery.

Substantive changes

No new evidence


Articles from BMJ Clinical Evidence are provided here courtesy of BMJ Publishing Group