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Table of Contents
Year : 2018  |  Volume : 1  |  Issue : 3  |  Page : 74-78

Editorial commentary to the paper “A case for open inguinal hernia repair” written by John Morrison

1 Department of Surgery, Emeritus Director, Marienhospital Stuttgart, Stuttgart, Germany
2 Department of Clinical Surgery, Director of Lichtenstein Amid Hernia Clinic, University of California, Los Angeles, California, USA

Date of Submission16-Oct-2018
Date of Acceptance21-Oct-2018
Date of Web Publication19-Nov-2018

Correspondence Address:
Prof. Reinhard Bittner
Department of Surgery, Emeritus Director, Marienhospital Stuttgart, Supperstr.19, 70565, Stuttgart
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_25_18

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How to cite this article:
Bittner R, Chen D. Editorial commentary to the paper “A case for open inguinal hernia repair” written by John Morrison. Int J Abdom Wall Hernia Surg 2018;1:74-8

How to cite this URL:
Bittner R, Chen D. Editorial commentary to the paper “A case for open inguinal hernia repair” written by John Morrison. Int J Abdom Wall Hernia Surg [serial online] 2018 [cited 2023 Jun 9];1:74-8. Available from: http://www.herniasurgeryjournal.org/text.asp?2018/1/3/74/245596

It is with great pleasure, admiration, and appreciation that we reviewed Dr. Morrison's scientific review and editorial “A Case for Open Inguinal Hernia Repair.” With his true expertise of herniology, perspective, and wisdom of over a period of 40 years in surgical practice, there are many important points, observations, admonitions, and advice for the management of inguinal hernia repair. This manuscript both reviews the scientific literature and provides an editorial “State of the Union” of inguinal hernia repair that challenges all herniologists, surgical educators, trainees, and individual surgeons to thoroughly understand the anatomy of the inguinal canal and broaden their armamentarium of techniques to provide high quality, cost-effective surgery with excellent outcomes to patients in a wide variety of settings worldwide.

Dr. Morrison's case provides a balanced, scientific assessment of the range of open tissue, open mesh, open preperitoneal, laparoscopic, and robotic inguinal hernia repairs delineating their relative strengths and weaknesses. Open inguinal hernia repair will remain a cornerstone in the global treatment of this disease for the foreseeable future. The benefits of local anesthesia are undeniable. The necessity for nonmesh-based techniques is absolute. The ability to tailor between a tissue repair, open preperitoneal mesh repair and open anterior mesh repair covering the range of groin hernias absolutely represents the cornerstone of what every hernia specialist would ideally master. The consideration of lowest direct cost is without argument in an era of escalating health-care costs. However, the value comes from more than simple cost calculations. The value is equally dependent on outcomes, and every surgeon will decide for themselves which technique provides the best outcome for their patients in their hands.

The recently released International Guidelines created some controversy with the expanded indication that laparoscopic inguinal hernia repair is recommended for primary unilateral inguinal hernias.[1] The traditional scope had been for bilateral inguinal hernias, recurrences after prior open repair, and for hernia repair in women. The recommendation was based on recurrence rates, a lower incidence of acute and chronic pain, return to work considerations, and technical considerations of simultaneously addressing all types of groin hernia. There are explicit caveats that expertise is required with a known steep learning curve a de facto limitation to adoption and implementation. The equivalency of outcomes for open anterior Lichtenstein repair was also stated with clear benefits in certain circumstances, global locations, and in patients with comorbidities and prior pelvic surgeries. The Shouldice repair was recommended as the best available tissue repair with indications in selected patients. These recommendations were based on not only a few selected studies but on the entire scientific body of evidence available up to 2017 reviewed, prioritized, graded, and then discussed to provided expert perspective on the clinical validity of the science. The source data and resulting statements are based on data and not opinion. They are dynamic and subject to evolve as the literature changes. It is crucial to understand that recommending one technique does not take away from the value, necessity, and importance of another technique - all of these proven techniques have a place in the treatment of this ubiquitous disease.

While Dr. Morrison's case for open inguinal hernia repair is thoughtful and compelling, we thought it appropriate and potentially more necessary to present the data and a perspective to make “a case for Laparoendoscopic inguinal hernia repair” as a fundamental and essential technique that should be equally disseminated and universally taught. The reality remains that after over 30 years of implementation and refinement, despite excellent results, outcomes, and standardization of technique, the penetrance of laparoscopic repair remains globally low. The “learning curve” in comparison to the Shouldice or Lichtenstein operation is indeed considered to be steeper. However, as laparoscopy has become a basic skill in general surgery, the essential skills to perform a laparoendoscopic hernia operation have become more ubiquitous and can be highly standardized. In our experience, residents start early in their training as was the case with open repairs. When the technique is strictly standardized and the training well-structured, there is no significant “learning curve” with regard to morbidity and recurrence rate with the only variability being operative time.[2] With respect to operation time, after 50 TAPP repairs trainees reached the level of experienced surgeons.

Insofar, the “difficult learning curve” is not the main problem for the slow and uneven spread of this new technique globally. It is remarkable that currently in Germany and New Zealand about 60% of the inguinal hernias are operated using laparoendoscopic technique, in Denmark more than 50%, in the Netherlands more than 40%, in the United States around 20%, and in South Europe (Italy, Spain, and Greece) <10%. The reasons for these discrepancies are many fold – cultural, economic, logistic, hierarchical structure in hospitals, private or public insurance, type of hospital, different payor systems, different teaching and training systems, along with the availability of expertise. When compared to the direct costs of open repair, the equipment is expensive and difficult to afford not only in low-resource countries. However, decreasing the cost of laparoscopic equipment and widespread availability has made these tools ubiquitous in most operating rooms worldwide.

While laparoscopic cholecystectomy has been more universally adopted with rapid global dissemination, laparoscopic hernioplasty is more complex as the operation is both ablative and reconstructive demanding more surgical skills. Furthermore, laparoendoscopic inguinal hernia repair carries a higher risk of visceral injury entering the abdominal cavity in TAPP repairs or a difficult extraperitoneal dissection with a higher risk of vascular injury in TEP repairs. After having thoroughly weighed the benefits against the above outlined technical difficulties and risks of MIS (Minimal Invasive Surgery), many surgeons continue to recommend open surgery. However, according to the current literature, the two most recommended open techniques, Shouldice and open anterior mesh repair, have specific disadvantages in comparison to MIS.[1] It is true that in the Shouldice Hospital in Toronto excellent results are achieved with a reported recurrence rate around 1.1%.[3] However, a manuscript from the Ontario Association of General Surgeons (OAGS) noted that these outcomes may not be universally applicable due to selection bias and a skewed up-to-date comparison. Notably, patients operated on at the Shouldice Hospital are younger, wealthier, and healthier when compared to the average hernia patient population. In this analysis, Malik et al. report that about 10% of the patients presenting to the Shouldice Hospital are rejected for various reasons. However, according to the OAGS, this number may be underestimated as the selection process at Shouldice has a significant emphasis on ideal body weight with many patients self-excluded owing to failure to achieve weight loss requirements not mentioned in that study.

Perhaps the most significant critique of the Shouldice outcomes data from the OAGS is that in a significant percentage of the patients, the follow-up time was too short.[4] The duration of follow-up is the crucial point for evaluating the recurrence rate, especially after a tissue-based Shouldice repair. Similarly, in the German database Herniamed, the follow-up time is only 1 year after surgery; therefore, any statement about recurrence rates is debatable. We know from one of the most established Shouldice clinics in Germany (University Hospital Aachen under the leadership of Professor V. Schumpelick) that after 2 years, the published recurrence rate was 0% in patients with a resected cremaster muscle and 2.6% in patients with cremasteric preservation.[5] However, after 10 years, the recurrence rate after Shouldice repair was 11%.[6] Contrasting favorably to these results, in a well-performed follow-up study 5 years after TAPP (follow-up rate 85%) with clinical examination of 952 patients who were consecutively operated during a 1-year period, a recurrence rate of 0.4% and a rate of chronic pain (visual analog scale >6) of 0.59% was reported.[7] A systematic review of the studies included in the Cochrane Database (6 randomized controlled trials [RCTs]) reported a recurrence rate of 3.6% after Shouldice repair but only 0.8% after a mesh-based repair (odds ratio 3.80, 95% confidence interval 1.99–7.26).[8] However, as the authors concede, the quality of the papers analyzed in the Cochrane Review is low.

The same is true with the laparoscopic comparison study by Sajid et al. cited by Dr. Morrison, for example, of the 10 RCTs, 9 had no power calculation and no intention to treat analysis, 7 had no blinding, and 6 had no or inadequate allocation concealment.[9] The authors admit that although their conclusion is based on the summated outcome of ten randomized, controlled trials, it should be considered with caution because the of the poor quality of the majority of included trials, for example, only 2 of 10 studies had adequate mesh size, 5 were undersized, and 3 studies did not mention mesh size. Corresponding to the studies published by Li et al.[10],[11] cited by Dr. Morrison, an earlier systematic comparison of endoscopic techniques with the Shouldice repair showed that these MIS techniques had significant advantages in terms of the following parameters: total morbidity, hematoma, nerve injury, and pain-associated parameters such as time to return to work, and chronic groin pain.[12]

Universal to performing successful inguinal hernia repair and achieving excellent outcomes is proper and standardized technique. Dr. Morrison emphasizes “that laparoscopic repair of a primary inguinal hernia involves detailed anatomical knowledge of the pelvic floor anatomy especially the course of the major blood vessels, the spermatic cord and the course of the groin nerves.” With open surgery, the same considerations are essential, but the inguinal nerves are directly inherent to the repair and are potentially at higher risk for injury. In a meta-analysis of RCTs that examined chronic pain, endoscopic operations resulted in a cumulative incidence of inguinal paresthesia of 7/840 (0.8%) in comparison to 41/827 (5.0%) after Shouldice repair (P < 0.00001 (0.22 [0. 12–0.39]). Furthermore, the studies that compared endoscopic with open non-Shouldice techniques also reported significantly fewer nerve lesions after endoscopic operation: 15/397 (3.8%) versus 78/398 (19.6%), P < 0.00001 (0.15 [0.09–0.24]).[12] Similar results were reported in a meta-analysis which compared laparoscopy with open mesh techniques. This analysis showed that inguinal or scrotal paresthesia was seen after endoscopic operations with a cumulative incidence of 76 of 1948 cases (3.9%) versus 159 of 1976 (8.0%) after Lichtenstein repair (P < 0.00001) (0.46 [0.35, 0.61]).

A meta-analysis that compared endoscopic with open non-Lichtenstein mesh techniques also reported significantly fewer symptoms of nerve lesions after endoscopic operations (74 of 660 [11.2%] vs. 153 of 633 [24.2%]) (P < 0.0000l) (0.35 [0.26, 0.47]).[13] When comparing open preperitoneal mesh repair with laparoendoscopic repair, there is no doubt that MIS repair is advantageous due to the 8-fold enlargement of the operating field and more direct and precise visualization of the critical structures of the myopectineal orifice. A clear view of the posterior anatomy of the groin as well as of the pathology of the hernia is essential for safe dissection, recognition, and prevention of complications. In open preperitoneal mesh repair, instead of unmistakably recognizing all the structures and layers visually, the surgeon relies on tactile sensation and experience. While some surgeons may have excellent personal outcomes, no studies are needed to understand that the latter is especially difficult in obese patients, aberrant anatomy, and with small incisions. More importantly, with open preperitoneal repair, the essential concepts of standardization and reproducibility of inguinal hernia repair technique are impossible.

Local anesthesia may be the best treatment option for analgesia in inguinal hernia repair; however, what the patients want is the best operation. Considering intra- and post-operative complication rates, acute and chronic pain, time of recovery, recurrence rates and cosmesis, and the laparoendoscopic techniques which require general anesthesia have advantages compared to open repairs done under local anesthesia. In a recently published RCT comparing TEP with Lichtenstein in local anesthesia, the authors conclude, “The present data justify recommending TEP (in general anesthesia) as the procedure of choice in the surgical treatment of primary inguinal hernia.”[14] Today, with proper preparation, selection, and performance, general anesthesia may be safely performed compared to local anesthesia even in older and comorbid patients.[15],[16],[17] Our own experience confirms the results published in the literature. In a series of 952 patients consecutively operated for inguinal hernia, in 98.02%, a TAPP was successfully performed, and only three patients (0.3%) needed repair under local anesthesia.[7]

While the financial and resource arguments are salient especially in the developing world, the argument that laparoendoscopic surgery does not belong in the daily routine in these countries is also short-sighted. In our personal opinion, it is unethical to exclude the so-called “low resource,” “under-developed,” or “rural countries” from the modern developments in surgery. In our experience, teaching open mesh-based techniques and minimally invasive surgery in developing countries in Latin America, Asia, and Africa, we have seen that surgeons will always benefit from standardized training, access to advancing technology, and a greater understanding of inguinal anatomy from both an anterior and posterior approach. We have trained surgeons in underserved countries on low-cost MIS repair with reusable equipment and minimal waste allowing for surgery to be performed with little additional cost aside from the mesh. We have also learned from our colleagues and have been introduced to tremendous innovation with local techniques, indigenous balloons, and operative tricks that are developed to make these operations practical and sustainable. In countries, where patients require their physical abilities for subsistence, infection rates are higher, and pain and disability directly impact not just quality of life, but livelihood, the benefits of MIS repair are even greater. While the challenges of implementation and dissemination are even more daunting in these countries, as with all technology, the potential for exponential advancement is promising. One way to bridge this divide might be the foundation of Hernia Centers of Excellence in these countries serving as lighthouses guiding surgeons to become familiar with the newest techniques and to help them do the best for their patients.

Putting aside considerations of anesthesia, cost, learning curve, and potential morbidity, a well performed, minimally invasive laparoscopic or robotic posterior approach provides an ideal inguinal hernia repair addressing all variants of inguinal and femoral hernia simultaneously. Dr. Morrison coins this the “single utilitarian approach” - an appropriate term as this belies the greatest benefit of laparoscopic repair. With appropriate training, understanding of the posterior anatomy, and provided resources and expertise are available, almost all hernias can be repaired in a safe, standardized, methodical way with benefits to patients with respect to low recurrence rates, lower rates of chronic pain, faster return to activity and employment, and negligible infection risk. In an era of advancing technology, improved surgical tools, enhanced optics, and refined prosthetic materials, there is undeniable progress with regards to inguinal hernia surgery. We agree that all advances especially those with consideration of materials, products, increased costs, and accompanying potential conflicts of interest should be thoroughly studied, scientifically critiqued, and impartially judged - be it novel tissue techniques, mesh, laparoscopic tools, or robots. This is our responsibility to the science of medicine. We would, however, take a less cynical view of the influence of industry, acknowledge their role in the progress in our field and medicine as a whole, and reflect on the primacy of the doctor–patient relationship and our individual commitment to our Hippocratic Oath to do the greatest good without harm. Each surgeon is a clinician and scientist and was trained to think critically. We each individually decide what is best for our patients based on the reality of our geographic location, resources, circumstance, and personal outcomes. Surgeons do not blindly follow marketing or guidelines - they interpret the data, critically appraise the validity, decide what is best for their patients, and reassess and adjust based on real-world experience and outcomes. This is our responsibility to our patients and to the art of medicine. The case for open repair remains compelling, valid, and universal but as Dr. Morrison has made very clear, our focus should be less about the superiority of any one modality and more about standardization and perfection of our chosen inguinal hernia repair technique toward the benefit of our patient.

In an ideal surgical world, every general surgeon would learn a perfect tissue repair, a perfect anterior mesh-based repair, a perfect posterior mesh-based repair, and a minimally invasive technique if resources permit. This would allow for tailoring to choose the best operative repair for the individual patient and circumstance. Tailoring in daily practice, however, is difficult if not impossible because preoperatively the precise determination of the hernia type (e.g., direct or indirect, size of the defect, weak or strong connective tissue, underlying collagen disorder) is not reliable. The crux of the issue is that the burden of hernia disease is great and represents the most high-volume case and the bread and butter of the caseload for general surgeons. Most hernias are not repaired by a hernia specialist with proficiency in several techniques. They are fixed by surgeons who care about their patients, want good outcomes, a low incidence of recurrence and chronic pain, low complications rates, reproducibility, and value within the constraints of their geographic and socioeconomic circumstance.

In this sense, most surgeons do seek the “single utilitarian approach” that Dr. Morrison describes, and in real-life practice most pick their one preferred technique. A standardized, technically performed open modified Lichtenstein repair, will serve a surgeon well in almost every circumstance with high reproducibility. A standardized, technically well-performed laparoscopic repair provided expertise and resources are available will serve a surgeon well in almost every circumstance with high reproducibility. A standardized, technically well-performed Shouldice repair, will serve a surgeon well in many but not all circumstances and the learning curve, unfortunately, has also limited widespread adoption. When we consider this reality, as a whole for the community of general surgeons, a recommendation to choose at least one standardized technique that covers all variations of hernia and perfect this technique to maximize personal outcomes will do the greatest good for the greatest number of patients and serve surgeons well in their career.

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HerniaSurge Group. International guidelines for groin hernia management. Hernia 2018;22:1-65.  Back to cited text no. 1
Bökeler U, Schwarz J, Bittner R, Zacheja S, Smaxwil C. Teaching and training in laparoscopic inguinal hernia repair (TAPP): Impact of the learning curve on patient outcome. Surg Endosc 2013;27:2886-93.  Back to cited text no. 2
Malik A, Bell CM, Stukel TA, Urbach DR. Recurrence of inguinal hernias repaired in a large hernia surgical specialty hospital and general hospitals in Ontario, Canada. Can J Surg 2016;59:19-25.  Back to cited text no. 3
Vinden C. Apples and oranges. Can J Surg 2016;59:E4-5.  Back to cited text no. 4
Töns C, Klinge U, Kupczyk-Joeris D, Rötzscher VM, Schumpelick V. Controlled study of cremaster resection in shouldice repair of primary inguinal hernia. Zentralbl Chir 1991;116:737-43.  Back to cited text no. 5
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Amato B, Moja L, Panico S, Persico G, Rispoli C, Rocco N, et al. Shouldice technique versus other open techniques for inguinal hernia repair. Cochrane Database Syst Rev 2012;4:CD001543. doi: 10.1002/14651858.CD001543.pub4. Review.  Back to cited text no. 8
Sajid MS, Caswell J, Singh KK. Laparoscopic versus open preperitoneal mesh repair of inguinal hernia: An integrated systematic review and meta-analysis of published randomized controlled trials. Indian J Surg 2015;77:1258-69.  Back to cited text no. 9
Li J, Wang X, Feng X, Gu Y, Tang R. Comparison of open and laparoscopic preperitoneal repair of groin hernia. Surg Endosc 2013;27:4702-10.  Back to cited text no. 10
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Bittner R, Sauerland S, Schmedt CG. Comparison of endoscopic techniques vs shouldice and other open nonmesh techniques for inguinal hernia repair: A meta-analysis of randomized controlled trials. Surg Endosc 2005;19:605-15.  Back to cited text no. 12
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Westin L, Wollert S, Ljungdahl M, Sandblom G, Gunnarsson U, Dahlstrand U, et al. Less pain 1 year after total extra-peritoneal repair compared with lichtenstein using local anesthesia: Data from a randomized controlled clinical trial. Ann Surg 2016;263:240-3.  Back to cited text no. 14
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