Guidelines

Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society)

R. Bittner • M. A. Montgomery • E. Arregui • V. Bansal • J. Bingener •
T. Bisgaard • H. Buhck • M. Dudai • G. S. Ferzli • R. J. Fitzgibbons •
R. H. Fortelny • K. L. Grimes • U. Klinge • F. Koeckerling • S. Kumar •
J. Kukleta • D. Lomanto • M. C. Misra • S. Morales-Conde • W. Reinpold • J. Rosenberg • K. Singh • M. Timoney • D. Weyhe • P. Chowbey

Received: 5 September 2014 / Accepted: 19 September 2014
Ó The Author(s) 2014. This article is published with open access at Springerlink.com and Other Interventional Techniques

Introduction

Guidelines are the bridge between science and clinical practice [1]. Science is a dynamic process and it is con- tinuously evolving. Consequently, there is a continual development of new insights necessitation updates of existing guidelines. For this update, the authors concen- trated on studies with level of 1 and 2 evidence. All ref- erences are marked with the level of evidence, according to the Oxford classification. In general ‘‘Recommendation Grade D’’ does not constitute a recommendation, but in some instances it is shown in the text to indicate lack of quality data. We recommended all readers to download the original statements and recommendations [2], for fully appreciation of the Update Guidelines on Laparoscopic Hernia Surgery.

Updates should include issues that were not yet suffi- ciently covered in the original guidelines or those which have gained increased clinical importance. For this reason, the Update includes four new chapters: single port surgery, convalescence, costs and training. The update process was started in March 2013. All the authors were requested to commence revision of their chapters between January 2009 and September 30th 2013. An Update Consensus Confer- ence was held on October 23–26, 2013 in Windhoek/ Namibia, following which, the first versions of the updates were presented to the delegates and extensively discussed. Based on these discussions the definite update was formulated and circulated for approval by all the involved experts.

References (in parentheses graduation of evidence)

  • Eccles M, Mason J (2001) How to develop cost-con- scious guidelines. Health Technol Assess 5(16):1–69. Reviews

  • Bittner R, Arregui ME, Bisgaard T, Dudai M, Ferzli GS, Fitzgibbons RJ, Fortelny RH, Klinge U, Kocker- ling F, Kuhry E, Kukleta J, Lomanto D, Misra MC, Montgomery A, Morales-Conde S, Reinpold W, Rosenberg J, Sauerland S, Schug-Pass C, Singh K, Timoney M, Weyhe D, Chowbey P (2011) Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treat- ment of inguinal hernia [International Endohernia Society (IEHS)]. Surg Endosc 25(9):2773–284

Results & Conclusions: Evaluating and comparing the data on functioning of the 3 devices leads to the conclusion that the MNS is the one device that addresses the mentioned optimal requirements. The MNS device enable the average surgeon performing easily and precisely Lap Hernia repair, potentially reducing recurrences and the cost of the procedure by dramatically cutting on the operating time.

Chapter 16: Sportsman hernia—diagnosis and treatment

Salvador Morales-Conde/Moshe Dudai, Reinhard Bittner

Search terms: Sportsmen HERNIA, Sport hernia, Athletes hernia, Athletes Pubalgia, Groin injury/treatment, Surgery,

Technique, Repair, Surgical finding, Imaging, Pathology, Diagnosis, Etiology, Results, Complications

Search machines

PubMed; Medline.

Publications

Three new papers level 1 and 2 were identified.

Diagnostic procedures

One new, supplementary statement.

Level 2B

CT scan has high accuracy in detecting posterior wall deficiency (PWD. (new)

No new recommendations.

Indication for surgery

New statements—identical to previous except state- ments below.

Level 1B

Surgery (endoscopic placement of retropubic mesh) is more efficient than conservative therapy for the treatment of sportsman’s hernia. (stronger evidence).

In Sportsman’s hernia the results of surgical repair to the posterior inguinal wall are excellent. (stronger evidence).

For conservative treatment the use of radiofrequency denervation of both ilio-inguinal nerve and inguinal ligament in the treatment of refractory Sportsman’s Hernia is safe and efficacious at least in the short term, and is superior to anesthetic/steroid injection. (new).

New recommendations—identical to previous except recommendations below.

Grade A

Endoscopic placement of retropubic mesh must be considered a serious option for Sportsman hernia. (stronger evidence).

For conservative treatment of refractory Sportsman’s hernia, radiofrequency denervation of both ilio-inguinal nerve and inguinal ligament must be considered, in the short term, an alternative to anesthetic/steroid injection. (new).

Comments

One paper with level of evidence 2 has been published since 2009 based on the diagnostic procedures of sports- men hernias [1]. Regarding treatment two level 1 studies are available: Comin [2] has published a study comparing radiofrequency denervation of both the ilio-inguinal nerve and inguinal ligament to desensitize the groin region and enable the athlete to become pain-free. This therapy was compared with local anesthetics (Bupivacaine) and steroid (Trimacinolone) injection, showing that the use of radio- frequency denervation is safe and efficacious at least in the short term, being superior to unaesthetic/steroid injection.

Regarding surgery, Paajanen et al. [3] compared con- servative treatment to endoscopic mesh repair on 60 patients with a diagnosis of chronic groin pain and sus- pected sportsman’s hernia. Operative repair was more effective than non-operative treatment to decrease chronic groin pain after 1 month and up to 12 months of follow-up. Of the 30 athletes who underwent operation, 90 % returned to sports activities after 3 months of convalescence com- pared to 27 % of the 30 athletes in the non-operative group.

References (in parentheses graduation of evidence)

1. Garvey JF (2012) Computed tomography scan diag- nosis of occult hernia. Hernia 16:307–314. (2B)

2. Comin J, Obaid H, Lammers G, Moore J, Wotherspoon M, Connell D (2013) Radiofrequency denervation of the inguinal ligament for the treatment of ‘Sportsman’s Hernia’: a pilot study. Br J Sports Med 47:380–386. (1B)

3. Paajanen H, Brinck T, Hermunen H, Airo I (2011) Laparoscopic surgery for chronic groin pain in athletes is more effective than nonoperative treatment: a randomized clinical trial with magnetic resonance imaging of 60 patients with sportsman’s hernia (ath- letic pubalgia). Surgery 150:99–107. (1B)

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