Disclosures: David C Brooks, MD Nothing to disclose. Richard Turnage, MD Nothing to disclose. Kathryn A Collins, MD, PhD, FACS Nothing to disclose.
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INTRODUCTION — The definitive treatment of all hernias, regardless of their origin or type, is surgical repair . Repair of inguinal or femoral hernia may be the most common operation with over 20 million hernia repairs performed per year worldwide , and over 700,000 in the United States . Urgent/emergent repair is indicated for patients who develop complications (eg, bowel obstruction, bowel perforation) related to an inguinal or femoral hernia. For uncomplicated hernias, the optimal timing of repair (watchful waiting versus immediate) and the optimal technique for repair (open versus laparoscopic) remain controversial.
An overview of the treatment of inguinal and femoral hernias is presented here. The epidemiology, pathogenesis, clinical manifestations, and diagnosis of inguinal and femoral hernias in adults, hernias in children, and other hernias are discussed elsewhere. (See "Classification, clinical features and diagnosis of inguinal and femoral hernias in adults" and "Overview of inguinal hernia in children".)
INDICATIONS FOR REPAIR — Inguinal or femoral hernia repair has minimal short-term morbidity and patients generally have a rapid return to presurgical health. These excellent surgical outcomes, even among elderly individuals (particularly if local anesthesia can be used), have led to recommendations to offer surgical repair to patients with inguinal or femoral hernia who are symptomatic. Historically, recommendations were that the mere presence of a groin hernia was indication for repair due to the perception that complications were common and increased operative morbidity. Two studies conducted at the turn of the century compared watchful waiting to open mesh repair of inguinal hernia. Both studies showed a negligible rate of hernia accidents (acute incarceration with or without strangulation), but there was a measurable progression of symptoms (pain, discomfort) in the watchful waiting group that led to eventual repair. There was no apparent “penalty” for delaying repair until symptoms developed. (See 'Watchful waiting' below.)
Most large randomized trials have included only men; therefore, caution should be used when extrapolating these data and recommendations to women with groin hernias. Femoral hernias may have a higher rate of incarceration, due to anatomy, but we have no data to support repair over watchful waiting in asymptomatic or minimally symptomatic patients
Strangulated/incarcerated hernia — Urgent/emergent hernia repair should be undertaken for patients with symptoms and signs of strangulated hernia (inguinal or femoral), and in those with acutely incarcerated hernia to reduce the risk of subsequent strangulation. In patients with an acutely incarcerated inguinal hernia who do not have signs of strangulation (skin changes, peritonitis), an attempt at reduction is reasonable as long as the patient is accessible for follow-up over the next day or two. Emergency surgery within four to six hours of onset of symptoms may prevent loss of bowel from a strangulated hernia. The clinical manifestations and diagnosis of incarcerated/strangulated inguinal or femoral hernias are discussed elsewhere. (See "Classification, clinical features and diagnosis of inguinal and femoral hernias in adults".)
Symptomatic hernia — Patients who have significant symptoms attributable to a groin hernia should undergo elective hernia repair . For patients with no symptoms but with the risk factors for groin hernia incarceration or strangulation that are discussed below, we suggest hernia repair as soon as feasible. Significant symptoms would include pain on lifting or pain with any type of exertion, inability to manually reduce the hernia, or inability to perform routine activities of daily life because of discomfort or pain. Male patients with minimal symptoms can be safely observed; however, female patients, who have a higher risk for complications, should undergo repair. (See 'Watchful waiting' below.)
From randomized trials and observational studies, the cumulative probability of developing problems such as increasing pain, incarceration, or strangulation, is 2.8 percent at three months, 4.5 to 23 percent at two years, and 31 percent at four years [4-6]. It is often stated that the risk of strangulation is higher for smaller hernia defects, but there is no objective evidence proving this observation. Patients may be more likely to complain of pain with smaller hernia defects. Although it is not possible to identify with a high degree of certainty which hernias will remain uncomplicated versus those that will become symptomatic or incarcerated and/or strangulated, certain factors may increase the likelihood of hernia complications. In a retrospective review of 1034 consecutive patients with a groin hernia, patients requiring emergent hernia repair (n = 63) were significantly more likely than those having elective repair to have a femoral hernia (7.4 versus 2.5 percent), scrotal hernia (32.4 versus 16.2 percent), or recurrent hernia (30.9 versus 16.7 percent) . Of those undergoing emergent repair, 33 patients (52 percent) were not previously known to have a hernia and 5 patients (17 percent) had a known hernia and were being observed.
Femoral hernia — Femoral hernias account for 2 to 4 percent of groin hernias, and are more common in women. Due to the high risk of hernia complications and better outcomes for elective versus emergent hernia repair, long-standing femoral hernias that are asymptomatic may be considered for watchful waiting, while recently identified hernias should be considered for elective repair, even if asymptomatic [1,8].
The Swedish Hernia Register documented 3980 femoral hernia repairs (2524 elective and 1409 emergent) between 1992 and 2006 . Femoral hernia operations accounted for 23 percent of groin hernia operations in women, compared with only 1 percent in men. The repairs were done as emergencies in women 40 percent of the time compared with 28 percent for men. Bowel resection was required in 23 percent of emergent femoral hernia repairs, but in only 0.6 percent of elective repairs. Additionally, the risk of mortality for emergency operations was significantly higher than for elective operations (OR 5.37, 95% CI 3.24-8.91), highlighting the importance of repairing femoral hernias in an elective setting.
CONTRAINDICATIONS TO ELECTIVE REPAIR — There are few contraindications to inguinal or femoral hernia repair, provided the procedure can be performed under local anesthesia (with or without sedation). For patients in whom the hernia cannot be repaired using local anesthesia, the main contraindication relates to the type of anesthesia that would be used.
Active infection, which includes any infection from local infection or systemic sepsis, is a contraindication to the placement of prosthetic material, which is usually needed to provide a tension-free repair. (See "Wound infection following repair of abdominal wall hernia".)
Pregnancy — The prevalence of inguinal hernia during pregnancy is overall low and estimated to be 1:2000 . Complications of groin hernia during pregnancy account for <5 percent of intestinal obstructions . In general, elective repair of groin hernia during pregnancy is not recommended; however, if severe discomfort or a hernia complication develops, repair will need to be undertaken during pregnancy.
Expectant management of inguinal hernia during pregnancy is associated with a minimal risk of serious hernia-related complications over the short-term. In one study of hernias in pregnancy, seven women with groin hernias were successfully observed nonoperatively and each had their hernia repaired after delivery . Nonemergent repair should ideally be deferred until after the lax abdominal wall has returned to its baseline (four or more weeks postpartum).
Combined cesarean delivery and hernia repair has been reported, with the goal of minimizing the need for additional hospitalization and anesthetics [9,12]. However, the combined procedure has not been rigorously evaluated.
WATCHFUL WAITING — Although surgery is indicated for most patients with complicated hernia or those with significant symptoms related to the hernia, it may be reasonable to take a more conservative approach in men who have minimal or no symptoms . Because women are at higher risk for hernia complications, in general, they should be offered repair when diagnosed. (See 'Indications for repair' above and 'Gender differences' below.)
The largest study evaluating watchful waiting (the WW trial) randomly assigned 720 men with an inguinal hernia to watchful waiting or open surgical repair (tension-free hernia repair) [5,13]. The men, who were mostly between the ages of 40 and 65, were asymptomatic or had only minimal symptoms, and the hernia remained easily reduced within 6 weeks of initial screening. The following results were noted:
●At two years follow-up, there were no differences between the groups for the primary end points of pain sufficient to limit activity, or change in physical health scores.
●Twenty-three percent of patients in the watchful waiting group had surgery within two years and 31 percent at four years.
●With longer-term follow-up (maximum 11.5 years), the estimated cumulative crossover rates using Kaplan-Meier analysis was 68 percent. Crossover rates were higher for men older than 65 years compared with younger men (79 versus 62 percent). The most common reason for crossover was pain (54.1 percent).
●Significant hernia complications did occur in patients being watched, but were rare with only 0.0018 hernia-related adverse events per patient-year.
●The rate of postoperative complications was not significantly different between patients who were assigned to and received surgical repair compared with those who were assigned to watchful waiting and then crossed over to receive surgical repair (21.7 versus 27.9 percent). At the time of maximum follow-up, a total of three patients required an emergency operation, but there was no mortality.
A smaller study of 160 men, published subsequent to the WW trial, also found no difference in the rate of hernia complications or pain scores between the surgery and watchful waiting groups; however, patients who had immediate surgery responded that their general health had improved at one year, compared with a perception of health decline in the observation group .
These findings suggest that a strategy of watchful waiting rather than elective repair is an option for white, middle-aged male patients with asymptomatic or minimally symptomatic inguinal hernia, provided the patient is aware of the risk of potential hernia complications and understands the need for prompt medical attention if symptoms develop. However, there are insufficient data regarding the risk of watchful waiting in older patients who are at the greatest risk of strangulation, and the risk associated with emergency hernia repair . In addition, it is not clear whether the above studies are generalizable to young individuals, women, other ethnic groups, or other types of hernia.
Negative side effects of trusses — The only nonsurgical therapy for groin hernia in men is a truss. Although the use of a truss may be appropriate in certain situations, we generally discourage their use.
A truss is a device consisting of a strap similar to an athletic supporter with a metal or hard plastic plug that is positioned to lie over the hernia defect. The hard disc or plug applies pressure, maintaining the contents of the hernia in the abdomen.
There are insufficient data to determine the efficacy of trusses for controlling symptoms [15,16]. The truss may potentially lead to harm if the disc impinges on the hernia contents. In addition, prolonged tissue pressure can lead to atrophy of the spermatic cord or fusion to the hernia sac, and atrophy or deterioration of the fascial margins can also occur, complicating surgical repair .
PREOPERATIVE EVALUATION — The diagnosis of inguinal or femoral hernia is based upon clinical grounds in the majority of cases. Prior to hernia repair, the patient should be re-examined to confirm the presence of the hernia. (See "Classification, clinical features and diagnosis of inguinal and femoral hernias in adults".)
The risks and benefits of hernia repair versus watchful waiting, and the potential complications of each approach, should be reviewed with the patient, including the risk of chronic pain. If hernia repair is elected, the benefits and risks of the open and laparoscopic approach should be discussed with the patient [1,15,18-22]. (See 'Open versus laparoscopic inguinal hernia repair' below.)
Medical risk assessment — Much of the preoperative evaluation is directed toward ensuring that the patient is adequately prepared for anesthesia. (See "Preoperative medical evaluation of the healthy patient".)
Patients with chronic medical conditions, such as coronary artery disease, pulmonary disease, and diabetes mellitus, should be optimized prior to elective hernia repair. (See "Evaluation of cardiac risk prior to noncardiac surgery" and "Evaluation of preoperative pulmonary risk" and "Perioperative management of blood glucose in adults with diabetes mellitus".)
Identifying risk factors post-herniorrhaphy neuralgia — Preoperative questionnaires may help identify patients at risk for more intense postoperative pain or chronic postsurgical pain due to post-herniorrhaphy neuralgia [23-28]. Preoperative risk factors for neuralgia include younger age, preoperative pain, prior surgery, preoperative sensory disorder, female gender, and recurrent inguinal hernia repair [29-31]. (See "Persistent groin pain following hernia repair and post-herniorrhaphy neuralgia".)
Measures to prevent post-herniorrhaphy neuralgia — Instituting measures to prevent nerve injury during hernia repair and minimize excessive postoperative pain, may decrease the risk of developing post-herniorrhaphy neuralgia. Measures focus on preemptive identification and early aggressive treatment of patients at risk for chronic groin pain, proper tissue handling, the use of lighter-weight mesh for repair, using a laparoscopic approach, and prophylactic neurectomy.
●Preemptive and multimodal analgesia – Intensive preemptive analgesia and longer-term postoperative multimodal analgesia may help minimize postoperative pain, which has been linked to the development of chronic postsurgical pain [29,32]. (See "Management of acute perioperative pain" and "Persistent groin pain following hernia repair and post-herniorrhaphy neuralgia".)
●Choice and placement of mesh – Lighter-weight mesh may induce a less intense inflammatory response, and appears to reduce the risk of chronic pain [33-37]. A systematic review identified 9 trials involving 2310 patients comparing lightweight versus heavyweight mesh for open inguinal hernia repair. A pooled analysis found a lower risk of chronic pain for those treated with lighter-weight mesh relative to heavier mesh (risk ratio (RR) 0.61, 95% CI 0.5-0.74). Partially absorbable and completely absorbable mesh has also been tried . However, there is a concern that lighter-weight mesh may increase the risk for hernia recurrence. In two separate metaanalyses, eliminating mesh fixation during laparoscopic hernia repair did not affect postoperative pain scores [38,39].
●Prophylactic neurectomy – Neurectomy, which refers to division of a nerve, may prevent nerve dysfunction; however, neurectomy leaves an area of relative sensory deprivation on the thigh or hemiscrotum. Some surgeons, but not all, divide the ilioinguinal nerve (ilioinguinal neurectomy) during the course of open, inguinal hernia repair if it appears that the nerve may have become entangled in the mesh or is otherwise at risk for involvement in scar (See "Open surgical repair of inguinal and femoral hernia in adults", section on 'Minimizing post-herniorrhaphy neuralgia'.)
●Surgical approach – With careful attention to the neural anatomy and gentle tissue handling, primary nerve injury can be avoided . Techniques for hernia repair that minimize the potential for nerve damage may include preferentially using a laparoscopic approach . (See 'Favoring a laparoscopic approach' below.)
Choice of anesthesia — Elective surgery for groin hernia is generally performed in an outpatient setting. The choice of anesthesia depends on the type and size of the hernia, approach to repair, and patient and surgeon preferences.
Inguinal or femoral hernia repair can be performed using general, neuraxial (spinal or epidural), or regional anesthesia (peripheral nerve block, local) [42,43]. Local anesthesia, which can be administered as a regional nerve block or subcutaneously with or without conscious sedation, is a popular option for open hernia repair. The main disadvantage of local anesthesia is that it may not provide adequate anesthesia during the repair of large hernias, and particularly those that have resulted in a loss of abdominal domain. General anesthesia can also be used for open hernia repair, but it is generally not favored unless the patient has a compelling desire to be completely anesthetized. Laparoscopic repairs using transabdominal preperitoneal patch (TAPP) or intraperitoneal onlay mesh technique (IPOM) require general anesthesia, which may be contraindicated in some patients, whereas totally extraperitoneal (TEP) repairs are often performed under general anesthesia, but can be also performed under spinal or epidural anesthesia. (See "Overview of anesthesia and anesthetic choices".)
Local anesthesia can be administered as a nerve block of the ilioinguinal and iliohypogastric nerves, or as direct infiltration into the incision site(s). Nerve block may be more difficult to achieve, but has the advantage of not causing significant soft tissue edema. (See "Peripheral nerve block: Techniques", section on 'Ilioinguinal and iliohypogastric nerve block'.)
A randomized trial of local, regional, and general anesthesia in 616 adult patients in 10 hospitals undergoing open inguinal hernia repair found that the use of local anesthesia was superior for pain control in the early postoperative period . Patients who received local anesthesia had less postoperative pain and nausea, shorter time spent in the hospital (3.1 versus 6.2 hours with regional and general anesthesia), and fewer unplanned overnight admissions (3 versus 14 and 22 percent, respectively). Another multicenter, randomized trial compared spinal and local anesthesia in 100 patients undergoing open hernia repair and also found local anesthesia was associated with less postoperative pain, shorter operating time, and fewer overnight stays .
Thromboprophylaxis — Thromboprophylaxis is administered according to the patient’s risk (table 1). Patients who are otherwise healthy, young (<40 years of age), and who have no risk factors do not require pharmacologic thromboprophylaxis. Mechanical thromboprophylaxis may be applied, unless contraindicated (eg, peripheral artery disease), at the surgeon’s discretion. (See "Prevention of venous thromboembolic disease in surgical patients".)
Antibiotics — Whether to routinely administer prophylactic antibiotics to all patients undergoing elective inguinal or femoral hernia repair or only to those at risk for mesh infection remains controversial [45-50]. Uncomplicated hernia surgery is considered clean surgery, and although antibiotics are not recommended for clean procedures, antimicrobial prophylaxis may be warranted for patients undergoing hernioplasty (ie, tension-free hernia repair with mesh) (table 2) [50,51]. On the other hand, the incidence of infection in untreated patients is low, and not eliminated by prophylaxis. Further, most infections are superficial and can be cleared by judicious use of oral antibiotics. Thus, some clinicians may opt to avoid prophylaxis. If prophylaxis is chosen, a single dose of an appropriate antibiotic (table 2) should be given within one hour of the incision [52,53]. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults" and "Control measures to prevent surgical site infection following gastrointestinal procedures in adults".)
An updated Cochrane review (2012) identified 17 randomized trials comparing antibiotic prophylaxis with placebo for open inguinal hernia repair; six trials were performed in those who did not have mesh placement (herniorrhaphy) and 11 trials in patients with mesh (hernioplasty) . Overall, there was a significantly decreased risk for surgical site infection (SSI) in the treated group compared with control (3.1 versus 4.5 percent; odds ratio [OR] 0.64, 95% CI 0.50-0.82). In the herniorrhaphy (ie, no mesh) subgroup, the statistical significance was borderline, whereas in the hernioplasty (ie, with mesh) subgroup, antibiotic prophylaxis showed a significant reduction of SSI compared with the control group (2.4 versus 4.2 percent; OR 0.56; 95% CI 0.38-0.81). These results, and the low incidence of SSI and increasing problems with antibiotic resistance, argue against routine antibiotic prophylaxis for hernias that will be repaired primarily (ie, without mesh). It is important to note that most hernia surgical site infections are minor and generally respond to a brief course of antibiotics. (See "Overview of complications of inguinal and femoral hernia repair", section on 'Superficial wound infection'.)
Patients undergoing urgent or emergent inguinal or femoral hernia repair should be treated according to the nature of the complication (eg, bowel perforation, bowel ischemia). For inguinal or femoral hernia complicated by bowel obstruction or perforation, broad empiric antimicrobial coverage should be initiated (table 2) and narrowed based on intraoperative culture results, as soon as feasible, according to antibiotic sensitivity analysis.
When surgical site infection does occur, skin flora is most commonly isolated (ie, aerobic gram-positive organisms; aerobic streptococci, staphylococci, and enterococci) . Thus, when antibiotic prophylaxis is given, we use a single dose of a cephalosporin administered within hour one of the incision. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)
Complicated hernias — Patients with complications related to inguinal and femoral hernia should be treated to manage symptoms and other problems associated with bowel obstruction, or perforation. This may include fluid therapy, nasogastric decompression, and antimicrobial therapy, which are discussed in detail elsewhere. (See "Overview of management of mechanical small bowel obstruction in adults".)
TENSION-FREE REPAIR — Successful hernia repair depends upon a tension-free closure, which may be performed as an open or laparoscopic procedure and is typically achieved with placement of mesh. While open repair can be performed with or without mesh, laparoscopic repair necessarily requires mesh placement. Based upon large database reviews and metaanalyses of randomized trials that have shown reduced recurrence rates for tension-free mesh repair [1,2,41,55-58], we agree with various hernia society guidelines that recommend a tension-free mesh technique (open or laparoscopic) over techniques that are known to generate tension (ie, most primary approximation repairs) [1,18,59]. Another advantage of tension-free mesh repair is less short-term pain and discomfort allowing the patient to return to normal activities more rapidly . (See "Open surgical repair of inguinal and femoral hernia in adults", section on 'Mesh versus non-mesh repair'.)
Open versus laparoscopic inguinal hernia repair — There is no strong consensus as to whether the optimal approach for inguinal and femoral hernia repair should be open or laparoscopic, and the issue continues to be debated [18,59,60]. The repair approach differs relative to the hernia defect. With the laparoscopic approach, the repair is posterior to the hernia defect, whereas for the open approach, it is anterior to the hernia defect (except Kugel repair and plug and patch repair). An open approach may be the best approach for primary, unilateral inguinal hernia repair, but in general, the approach used to repair groin hernia should be the one the surgeon is most comfortable with and most experienced performing. In certain clinical situations, an open or laparoscopic approach may be preferred. When performed by surgeons experienced with each technique, the incidence of recurrent hernia is similar, provided a tension free-repair has been used. (See 'Favoring open approach' below and 'Favoring a laparoscopic approach' below.)
●Open repair techniques – Open techniques for inguinal hernia repair include tension-free mesh repairs such as the Lichtenstein (our preferred), plug and patch, and Kugel (preperitoneal) repairs, and nonmesh primary tissue approximation repairs such as the Shouldice, Bassini, and McVay repairs [56,61-65]. Although the Shouldice repair does not incorporate mesh, it is regarded by some as a tension-free repair. Specific techniques used to perform open groin hernia repair, outcomes, and the choice of open technique are discussed in detail elsewhere. (See "Open surgical repair of inguinal and femoral hernia in adults", section on 'Hernia repair techniques'.)
●Laparoscopic repair techniques – The two main laparoscopic inguinal hernia repairs are the totally extraperitoneal (TEP) and transabdominal properitoneal patch (TAPP) repairs , and each is regarded as tension-free and require the use of mesh. The intraperitoneal onlay mesh technique (IPOM) is an uncommonly used technique that has fallen out of favor. Laparoscopic techniques, outcomes, and the choice of laparoscopic technique are discussed in detail elsewhere. (See "Laparoscopic inguinal and femoral hernia repair in adults", section on 'Laparoscopic repair approaches'.)
Multiple systematic reviews of randomized trials have generally agreed that although laparoscopic repair is associated with less postoperative pain and quicker return to normal activities (including work), but it can take longer to perform and may be associated with a higher recurrence rate and other rare, but serious complications [66-79]. The largest, multicenter trial randomly assigned 1983 patients to open mesh or laparoscopic mesh repair . Patients treated laparoscopically had less pain on the day of surgery and at two weeks, and returned to work one day earlier. However, laparoscopic repair resulted in significantly more recurrences at two years (10.1 versus 4.9 percent) and complications (39 versus 33.4 percent) including more life-threatening complications (1.1 versus 0.1 percent). A significantly higher incidence of recurrence was found for laparoscopic repair of primary hernia compared with open repair (10.1 versus 4.0 percent) but similar recurrence rates were found for the treatment of recurrent hernias (10.0 versus 14.1 percent). Patients were older (average age 58) and less healthy (only 34 percent were ASA class I) than the general population. Some earlier trials found lower recurrence rates for laparoscopic repair compared with open repair ; however, open repairs in these studies were not necessarily tension-free repairs (ie, with mesh) as was performed in the large multicenter trial .
Favoring open approach — The following may favor an open approach to groin hernia repair.
●Prior pelvic surgery – For those with an abdominal incision or surgery in the preperitoneal space (eg, prostatectomy), an open approach may be favored. Prior mesh placement in the preperitoneal space also makes a laparoscopic approach much more difficult. Although TAPP repair is feasible, TEP repair is more difficult. TAPP or TEP repair has been performed after prostatectomy, but laparoscopic repair was found in observational studies to have a higher incidence of morbidity and longer operative time compared with open repair [83,84].
●Infection – Active infection is a contraindication to mesh placement. An open repair may be an option for patients with remote infection in whom repair cannot be deferred, or in those with an infected mesh graft. The management of infected or recurrent hernia is discussed elsewhere. (See "Wound infection following repair of abdominal wall hernia".)
●Complicated inguinal or femoral hernia – Although a laparoscopic approach is theoretically possible for nearly all inguinal hernias, including incarcerated or strangulated hernias , laparoscopic repair of complicated hernias may be fraught with technical difficulties [76,86]. We repair all strangulated hernias using an open approach, and in spite of several case series documenting successful laparoscopic repairs of acutely incarcerated inguinal hernia , we also use an open approach for incarcerated hernias to minimize the risk of bowel injury. If bowel perforation has occurred due to strangulation and necrosis, the placement of mesh is contraindicated, precluding laparoscopic repair.
●Large scrotal hernia – Large scrotal hernia (>3 cm) represents a relative contraindication for laparoscopic repair because of the difficulty in managing and reducing a large indirect inguinal hernia sac .
Favoring a laparoscopic approach — The following may favor a laparoscopic approach to groin hernia repair:
●Bilateral hernias – Three small, randomized trials have compared the laparoscopic with open approach for bilateral inguinal hernia [87-89]. Each study showed less postoperative pain and a more rapid recovery to normal activities with a laparoscopic approach and a similar recurrence rate for both techniques. The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom advocates laparoscopic repair for bilateral hernia repair . The advantages of bilateral hernia repair by a laparoscopic approach may include:
•Both hernias can be accessed through the same incision, which improves the cosmetic result.
•A single large piece of mesh can be used with a laparoscopic TEP repair, reducing costs and potentially reducing the risk of direct recurrence medially .
•A laparoscopic approach allows exploration of the contralateral groin in patients with contralateral groin pain but where there remains uncertainty regarding the presence of a contralateral hernia .
It is important to note, however, that bilateral open tension-free mesh repairs can be also be performed simultaneously . Prior to the development of tension-free open hernia repair, bilateral inguinal hernias were repaired one side at a time, which has led some surgeons to conclude that bilaterality should be an absolute indication to laparoscopic repair.
●Recurrent hernia – Many surgeons feel that recurrent hernias, particularly those that recur after an anterior mesh repair, are best addressed via a laparoscopic technique [68,72]. The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom also advocates laparoscopic repair for recurrent hernias . The rationale for this argument is that recurrent hernia repair is optimal if performed in a previously undissected tissue plane. As with primary repair, a laparoscopic approach is associated with faster recovery, less postoperative pain, and fewer complications [89,94-96]. A meta-analysis of four small randomized trials found no significant differences between the laparoscopic and open approach for recurrence, chronic pain, or complications .
●Femoral hernia – For open repair of femoral hernia, the floor of the inguinal canal must be opened to gain access to a femoral canal. The laparoscopic approach (TEP or TAPP) is more direct and is better for identifying occult femoral hernia. In an audit of patients undergoing laparoscopic recurrent hernia repair following initial open Shouldice or Lichtenstein repair, 10 percent of recurrent hernias that were presumed to be inguinal were femoral . In a Swedish Registry study of emergency femoral hernia repair, a preperitoneal approach (laparoscopic or open) was associated with a lower rate of recurrence .
●Prevention of post-herniorrhaphy neuralgia – Laparoscopic repair appears to be associated with less chronic groin pain [98-104]. A metaanalysis of 14 trials found a significantly decreased risk of chronic groin pain following laparoscopic inguinal hernia repair versus open inguinal hernia (relative risk [RR] 0.66, 95% CI 0.51-0.97) . When comparing different types of laparoscopic hernia repair, the difference was attributable to repairs performed using transabdominal preperitoneal (TAPP) laparoscopic repair (RR 0.66, 95% CI 0.50-0.97). There was no significant difference in the occurrence of chronic groin pain between totally extraperitoneal (TEP) laparoscopic repair and open inguinal hernia repair (RR 0.81, 95% CI 0.45-1.44). Other measures to limit the potential for post-herniorrhaphy neuralgia are discussed above. (See 'Measures to prevent post-herniorrhaphy neuralgia' above.)
●Laparoscopic hernia repair may be particularly beneficial for patients with jobs that require physical activity (eg, manual labor), given advantages such as reduced postoperative pain, and early return to normal activity.
Cost considerations — Cost-effectiveness studies weighing the reduced cost of a shortened hospitalization versus the increased costs of operating time, equipment expenditures and complications have found an overall cost benefit for open hernia repair compared with laparoscopic repair [105-109]. However, a sensitivity analysis in one study showed that there are specific situations in which laparoscopic repair may be a viable alternative, such as when reusable equipment is employed .
Gender differences — Groin hernias are uncommon in females, with less than 8 percent of the repairs performed in women [8,110-112]. Hernias are more likely to be femoral in location and to present with incarceration or strangulation in women compared with men . Women also have a higher incidence of recurrent hernia than men . (See "Classification, clinical features and diagnosis of inguinal and femoral hernias in adults", section on 'Epidemiology' and "Classification, clinical features and diagnosis of inguinal and femoral hernias in adults", section on 'Femoral hernia'.)
●For male patients with primary, unilateral or bilateral hernia, a tension-free mesh repair, either open (Lichtenstein repair, plug and patch) or laparoscopic is preferred.
●In female patients, laparoscopic repair has important advantages such as allowing identification and repair of occult hernias; however, women are more likely to have had prior surgery in the preperitoneal space contraindicating a totally extraperitoneal (TEP) approach. For uncomplicated hernias, an open, anterior approach, particularly for small femoral hernias, is less invasive overall and provides excellent outcomes.
MORBIDITY AND MORTALITY — Minor complications of inguinal and femoral hernia repair are relatively common and include seroma/hematoma formation. More significant complications such as chronic postoperative pain, post-herniorrhaphy neuralgia, and hernia recurrence can occur and depend upon the site of the hernia and type of repair. (See "Persistent groin pain following hernia repair and post-herniorrhaphy neuralgia" and "Overview of complications of inguinal and femoral hernia repair".)
Mortality within 30 days of groin hernia surgery for both sexes is 0.1 percent in elective settings [7,110], but increases significantly when emergency operation is needed ranging from 2.8 to 3.1 percent [110,113], and are even higher when bowel resection is needed . Significant factors associated with increased mortality factors in emergency settings are female gender and increasing age . In one study, mortality after emergent hernia repair increased from 1 percent for those 60 to 69 years of age, to 5 percent in those 70 to 79 years of age, further increasing to 16 percent for those 80 to 89 years of age .
A study of the Swedish Hernia Registry found increased mortality rates for femoral hernia repair . Mortality associated with femoral hernias was 0.16 percent in elective and 9.8 percent in emergency cases. Compared with inguinal hernia, femoral hernias showed an increased 30-day standardized mortality ratio (6.81 versus 1.29 in men and 7.16 versus 2.82 in women) . The higher mortality rate in women is due to the greater proportion of femoral hernias, emergencies, and older age in women compared with men.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
●Basics topics (see "Patient information: Inguinal and femoral (groin) hernias (The Basics)")
SUMMARY AND RECOMMENDATIONS
●The definitive treatment of all hernias, regardless of their origin or type, is surgical repair. Patients with complications (acute incarceration, ischemia, obstruction) related to inguinal or femoral hernia should undergo urgent/emergent hernia repair. (See 'Indications for repair' above.)
●For male patients with moderate to severe symptoms related to inguinal hernia, we recommend repair rather than watchful waiting (Grade 1B). For minimally symptomatic patients with inguinal hernia, we suggest elective surgical repair (Grade 2A). (See 'Indications for repair' above and 'Watchful waiting' above.)
●For patients with femoral hernia, regardless of gender or symptoms, we suggest elective repair rather than watchful waiting (Grade 2B). Femoral hernia is associated with an increased risk for complications and higher mortality following emergent repair. (See 'Femoral hernia' above.)
●Male patients with minimal or no symptoms who wish to avoid surgery can reasonably be treated with watchful waiting provided they are counseled of the very low risk of hernia complications (incarceration and strangulation) and understand the need for prompt medical attention should symptoms of these complications occur. Trusses are associated with negative consequences and should not be used to manage symptoms related to inguinal hernia. (See 'Watchful waiting' above.)
●For patients with uncomplicated inguinal and femoral hernia, we recommend tension-free hernia repair, which typically requires the use of mesh, rather than repairs that are known to produce tension (ie, most primary approximations repairs) (Grade 1B). For complicated hernias, the approach depends upon whether there are contraindications to the placement of mesh, and, for recurrent hernia, the nature of the prior repair. (See 'Tension-free repair' above and 'Complicated hernias' above and "Recurrent inguinal and femoral hernia".)
●The approach used to repair groin hernia should be the one the surgeon is most comfortable with and most experienced performing. In certain clinical situations, an open or laparoscopic approach may be preferred. (See 'Open versus laparoscopic inguinal hernia repair' above.)
•An open approach may be preferred over a laparoscopic approach for patients with prior surgery involving the preperitoneal space, primary inguinal hernia, large hernias, scrotal hernias, and when infection is a concern (ie, mesh contraindicated). (See 'Favoring open approach' above.)
•A laparoscopic approach to hernia repair may be preferred over an open approach for bilateral hernia, recurrent hernia where prior repair was an open anterior repair, and femoral hernia. (See 'Favoring a laparoscopic approach' above.)
●For patients undergoing elective inguinal or femoral hernia repair requiring mesh placement (eg, laparoscopic, Lichtenstein), we recommend prophylactic antibiotics (Grade 1B). Although prophylactic antibiotics may not be routinely needed for all patients undergoing elective inguinal or femoral hernia repair, a growing body of evidence supports antibiotic prophylaxis prior to elective hernia repairs that use mesh. (See 'Antibiotics' above.)
- Rosenberg J, Bisgaard T, Kehlet H, et al. Danish Hernia Database recommendations for the management of inguinal and femoral hernia in adults. Dan Med Bull 2011; 58:C4243.
- Bay-Nielsen M, Kehlet H, Strand L, et al. Quality assessment of 26,304 herniorrhaphies in Denmark: a prospective nationwide study. Lancet 2001; 358:1124.
- Schumpelick V, Treutner KH, Arlt G. Inguinal hernia repair in adults. Lancet 1994; 344:375.
- Gallegos NC, Dawson J, Jarvis M, Hobsley M. Risk of strangulation in groin hernias. Br J Surg 1991; 78:1171.
- 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.
- O'Dwyer PJ, Norrie J, Alani A, et al. Observation or operation for patients with an asymptomatic inguinal hernia: a randomized clinical trial. Ann Surg 2006; 244:167.
- Abi-Haidar Y, Sanchez V, Itani KM. Risk factors and outcomes of acute versus elective groin hernia surgery. J Am Coll Surg 2011; 213:363.
- Dahlstrand U, Wollert S, Nordin P, et al. Emergency femoral hernia repair: a study based on a national register. Ann Surg 2009; 249:672.
- Ochsenbein-Kölble N, Demartines N, Ochsenbein-Imhof N, Zimmermann R. Cesarean section and simultaneous hernia repair. Arch Surg 2004; 139:893.
- Mayer IE, Hussain H. Abdominal pain during pregnancy. Gastroenterol Clin North Am 1998; 27:1.
- Buch KE, Tabrizian P, Divino CM. Management of hernias in pregnancy. J Am Coll Surg 2008; 207:539.
- Gabriele R, Conte M, Izzo L, Basso L. Cesarean section and hernia repair: simultaneous approach. J Obstet Gynaecol Res 2010; 36:944.
- Fitzgibbons RJ Jr, Ramanan B, Arya S, et al. Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg 2013; 258:508.
- Hernández-Irizarry R, Zendejas B, Ramirez T, et al. Trends in emergent inguinal hernia surgery in Olmsted County, MN: a population-based study. Hernia 2012; 16:397.
- McIntosh A, Hutchinson A, Roberts A, Withers H. Evidence-based management of groin hernia in primary care--a systematic review. Fam Pract 2000; 17:442.
- Cheek CM, Williams MH, Farndon JR. Trusses in the management of hernia today. Br J Surg 1995; 82:1611.
- Burns E, Whitley A. Trusses. BMJ 1990; 301:1319.
- Simons MP, Aufenacker T, Bay-Nielsen M, et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2009; 13:343.
- Bittner R, Arregui ME, Bisgaard T, et al. Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)]. Surg Endosc 2011; 25:2773.
- Carter J, Duh QY. Laparoscopic repair of inguinal hernias. World J Surg 2011; 35:1519.
- Rattner DW. Physicians' choice for their own hernia repairs. J Laparoendosc Adv Surg Tech A 2000; 10:75.
- Winslow ER, Quasebarth M, Brunt LM. Perioperative outcomes and complications of open vs laparoscopic extraperitoneal inguinal hernia repair in a mature surgical practice. Surg Endosc 2004; 18:221.
- Callesen T, Bech K, Kehlet H. Prospective study of chronic pain after groin hernia repair. Br J Surg 1999; 86:1528.
- Macrae WA. Chronic pain after surgery. Br J Anaesth 2001; 87:88.
- Perkins FM, Kehlet H. Chronic pain as an outcome of surgery. A review of predictive factors. Anesthesiology 2000; 93:1123.
- Bay-Nielsen M, Perkins FM, Kehlet H, Danish Hernia Database. Pain and functional impairment 1 year after inguinal herniorrhaphy: a nationwide questionnaire study. Ann Surg 2001; 233:1.
- Poobalan AS, Bruce J, Smith WC, et al. A review of chronic pain after inguinal herniorrhaphy. Clin J Pain 2003; 19:48.
- Condon RE. Groin pain after hernia repair. Ann Surg 2001; 233:8.
- Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet 2006; 367:1618.
- Kalliomäki ML, Meyerson J, Gunnarsson U, et al. Long-term pain after inguinal hernia repair in a population-based cohort; risk factors and interference with daily activities. Eur J Pain 2008; 12:214.
- Poobalan AS, Bruce J, King PM, et al. Chronic pain and quality of life following open inguinal hernia repair. Br J Surg 2001; 88:1122.
- Fränneby U, Sandblom G, Nordin P, et al. Risk factors for long-term pain after hernia surgery. Ann Surg 2006; 244:212.
- O'Dwyer PJ, Kingsnorth AN, Molloy RG, et al. Randomized clinical trial assessing impact of a lightweight or heavyweight mesh on chronic pain after inguinal hernia repair. Br J Surg 2005; 92:166.
- Schopf S, von Ahnen T, von Ahnen M, Schardey H. Chronic pain after laparoscopic transabdominal preperitoneal hernia repair: a randomized comparison of light and extralight titanized polypropylene mesh. World J Surg 2011; 35:302.
- Chowbey PK, Garg N, Sharma A, et al. Prospective randomized clinical trial comparing lightweight mesh and heavyweight polypropylene mesh in endoscopic totally extraperitoneal groin hernia repair. Surg Endosc 2010; 24:3073.
- Sajid MS, Leaver C, Baig MK, Sains P. Systematic review and meta-analysis of the use of lightweight versus heavyweight mesh in open inguinal hernia repair. Br J Surg 2012; 99:29.
- Markar SR, Karthikesalingam A, Alam F, et al. Partially or completely absorbable versus nonabsorbable mesh repair for inguinal hernia: a systematic review and meta-analysis. Surg Laparosc Endosc Percutan Tech 2010; 20:213.
- Teng YJ, Pan SM, Liu YL, et al. A meta-analysis of randomized controlled trials of fixation versus nonfixation of mesh in laparoscopic total extraperitoneal inguinal hernia repair. Surg Endosc 2011; 25:2849.
- Tam KW, Liang HH, Chai CY. Outcomes of staple fixation of mesh versus nonfixation in laparoscopic total extraperitoneal inguinal repair: a meta-analysis of randomized controlled trials. World J Surg 2010; 34:3065.
- Alfieri S, Amid PK, Campanelli G, et al. International guidelines for prevention and management of post-operative chronic pain following inguinal hernia surgery. Hernia 2011; 15:239.
- EU Hernia Trialists Collaboration. Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials. Ann Surg 2002; 235:322.
- Nordin P, Zetterström H, Gunnarsson U, Nilsson E. Local, regional, or general anaesthesia in groin hernia repair: multicentre randomised trial. Lancet 2003; 362:853.
- Young DV. Comparison of local, spinal, and general anesthesia for inguinal herniorrhaphy. Am J Surg 1987; 153:560.
- van Veen RN, Mahabier C, Dawson I, et al. Spinal or local anesthesia in lichtenstein hernia repair: a randomized controlled trial. Ann Surg 2008; 247:428.
- Mazaki T, Mado K, Masuda H, Shiono M. Antibiotic prophylaxis for the prevention of surgical site infection after tension-free hernia repair: a Bayesian and frequentist meta-analysis. J Am Coll Surg 2013; 217:788.
- Sanabria A, Domínguez LC, Valdivieso E, Gómez G. Prophylactic antibiotics for mesh inguinal hernioplasty: a meta-analysis. Ann Surg 2007; 245:392.
- Li JF, Lai DD, Zhang XD, et al. Meta-analysis of the effectiveness of prophylactic antibiotics in the prevention of postoperative complications after tension-free hernioplasty. Can J Surg 2012; 55:27.
- Aufenacker TJ, Koelemay MJ, Gouma DJ, Simons MP. Systematic review and meta-analysis of the effectiveness of antibiotic prophylaxis in prevention of wound infection after mesh repair of abdominal wall hernia. Br J Surg 2006; 93:5.
- Moon V, Chaudry GA, Choy C, Ferzli GS. Mesh infection in the era of laparoscopy. J Laparoendosc Adv Surg Tech A 2004; 14:349.
- Yin Y, Song T, Liao B, et al. Antibiotic prophylaxis in patients undergoing open mesh repair of inguinal hernia: a meta-analysis. Am Surg 2012; 78:359.
- Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL. Antibiotic prophylaxis for hernia repair. Cochrane Database Syst Rev 2012; 2:CD003769.
- Fry DE. Surgical site infections and the surgical care improvement project (SCIP): evolution of national quality measures. Surg Infect (Larchmt) 2008; 9:579.
- Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, et al. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004; 38:1706.
- Sanchez VM, Abi-Haidar YE, Itani KM. Mesh infection in ventral incisional hernia repair: incidence, contributing factors, and treatment. Surg Infect (Larchmt) 2011; 12:205.
- Scott NW, McCormack K, Graham P, et al. Open mesh versus non-mesh for repair of femoral and inguinal hernia. Cochrane Database Syst Rev 2002; :CD002197.
- EU Hernia Trialists Collaboration. Mesh compared with non-mesh methods of open groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000; 87:854.
- Eklund AS, Montgomery AK, Rasmussen IC, et al. Low recurrence rate after laparoscopic (TEP) and open (Lichtenstein) inguinal hernia repair: a randomized, multicenter trial with 5-year follow-up. Ann Surg 2009; 249:33.
- Matthews RD, Anthony T, Kim LT, et al. Factors associated with postoperative complications and hernia recurrence for patients undergoing inguinal hernia repair: a report from the VA Cooperative Hernia Study Group. Am J Surg 2007; 194:611.
- . SSAT patient care guidelines. Surgical repair of groin hernias. J Gastrointest Surg 2007; 11:1228.
- Brooks DC. Laparoscopic herniorrhaphy: where are we now? Surg Endosc 1999; 13:321.
- Zhao G, Gao P, Ma B, et al. Open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials. Ann Surg 2009; 250:35.
- Amato B, Moja L, Panico S, et al. Shouldice technique versus other open techniques for inguinal hernia repair. Cochrane Database Syst Rev 2009; :CD001543.
- Glassow F. The Shouldice Hospital technique. Int Surg 1986; 71:148.
- Rutkow IM, Robbins AW. "Tension-free" inguinal herniorrhaphy: a preliminary report on the "mesh plug" technique. Surgery 1993; 114:3.
- Kugel RD. Minimally invasive, nonlaparoscopic, preperitoneal, and sutureless, inguinal herniorrhaphy. Am J Surg 1999; 178:298.
- Koning GG, Wetterslev J, van Laarhoven CJ, Keus F. The totally extraperitoneal method versus Lichtenstein's technique for inguinal hernia repair: a systematic review with meta-analyses and trial sequential analyses of randomized clinical trials. PLoS One 2013; 8:e52599.
- Yang J, Tong da N, Yao J, Chen W. Laparoscopic or Lichtenstein repair for recurrent inguinal hernia: a meta-analysis of randomized controlled trials. ANZ J Surg 2013; 83:312.
- Dedemadi G, Sgourakis G, Radtke A, et al. Laparoscopic versus open mesh repair for recurrent inguinal hernia: a meta-analysis of outcomes. Am J Surg 2010; 200:291.
- Schmedt CG, Sauerland S, Bittner R. Comparison of endoscopic procedures vs Lichtenstein and other open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials. Surg Endosc 2005; 19:188.
- 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.
- Memon MA, Cooper NJ, Memon B, et al. Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair. Br J Surg 2003; 90:1479.
- Karthikesalingam A, Markar SR, Holt PJ, Praseedom RK. Meta-analysis of randomized controlled trials comparing laparoscopic with open mesh repair of recurrent inguinal hernia. Br J Surg 2010; 97:4.
- Voyles CR, Hamilton BJ, Johnson WD, Kano N. Meta-analysis of laparoscopic inguinal hernia trials favors open hernia repair with preperitoneal mesh prosthesis. Am J Surg 2002; 184:6.
- Grant AM, EU Hernia Trialists Collaboration. Laparoscopic versus open groin hernia repair: meta-analysis of randomised trials based on individual patient data. Hernia 2002; 6:2.
- EU Hernia Trialists Collaboration. Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000; 87:860.
- McCormack K, Scott NW, Go PM, et al. Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev 2003; :CD001785.
- Hernandez-Rosa J, Lo CC, Choi JJ, et al. Laparoscopic versus open inguinal hernia repair in octogenarians. Hernia 2011; 15:655.
- Sajid MS, Bokhari SA, Mallick AS, et al. Laparoscopic versus open repair of incisional/ventral hernia: a meta-analysis. Am J Surg 2009; 197:64.
- Laparoscopic versus open repair of groin hernia: a randomised comparison. The MRC Laparoscopic Groin Hernia Trial Group. Lancet 1999; 354:185.
- Neumayer L, Giobbie-Hurder A, Jonasson O, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 2004; 350:1819.
- Liem MS, van der Graaf Y, van Steensel CJ, et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair. N Engl J Med 1997; 336:1541.
- Jacobs DO. Mesh repair of inguinal hernias--redux. N Engl J Med 2004; 350:1895.
- Wauschkuhn CA, Schwarz J, Bittner R. Laparoscopic transperitoneal inguinal hernia repair (TAPP) after radical prostatectomy: is it safe? Results of prospectively collected data of more than 200 cases. Surg Endosc 2009; 23:973.
- Dulucq JL, Wintringer P, Mahajna A. Totally extraperitoneal (TEP) hernia repair after radical prostatectomy or previous lower abdominal surgery: is it safe? A prospective study. Surg Endosc 2006; 20:473.
- Deeba S, Purkayastha S, Paraskevas P, et al. Laparoscopic approach to incarcerated and strangulated inguinal hernias. JSLS 2009; 13:327.
- Kald A, Anderberg B, Carlsson P, et al. Surgical outcome and cost-minimisation-analyses of laparoscopic and open hernia repair: a randomised prospective trial with one year follow up. Eur J Surg 1997; 163:505.
- Sarli L, Iusco DR, Sansebastiano G, Costi R. Simultaneous repair of bilateral inguinal hernias: a prospective, randomized study of open, tension-free versus laparoscopic approach. Surg Laparosc Endosc Percutan Tech 2001; 11:262.
- Krähenbühl L, Schäfer M, Schilling M, et al. Simultaneous repair of bilateral groin hernias: open or laparoscopic approach? Surg Laparosc Endosc 1998; 8:313.
- Mahon D, Decadt B, Rhodes M. Prospective randomized trial of laparoscopic (transabdominal preperitoneal) vs open (mesh) repair for bilateral and recurrent inguinal hernia. Surg Endosc 2003; 17:1386.
- National Institute for Health and Clinical Excellence (NICE). Laparoscopic surgery for inguinal hernia repair. NICE; 2004. Available online at www.nice.org.uk/TA083guidance (Accessed on April 22, 2010).
- Ohana G, Powsner E, Melki Y, et al. Simultaneous repair of bilateral inguinal hernias: a prospective, randomized study of single versus double mesh laparoscopic totally extraperitoneal repair. Surg Laparosc Endosc Percutan Tech 2006; 16:12.
- O'Rourke A, Zell JA, Varkey-Zell TT, et al. Laparoscopic diagnosis and repair of asymptomatic bilateral inguinal hernias. Am J Surg 2002; 183:15.
- Amid PK, Shulman AG, Lichtenstein IL. Simultaneous repair of bilateral inguinal hernias under local anesthesia. Ann Surg 1996; 223:249.
- 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.
- Eklund A, Rudberg C, Leijonmarck CE, et al. Recurrent inguinal hernia: randomized multicenter trial comparing laparoscopic and Lichtenstein repair. Surg Endosc 2007; 21:634.
- Kouhia ST, Huttunen R, Silvasti SO, et al. Lichtenstein hernioplasty versus totally extraperitoneal laparoscopic hernioplasty in treatment of recurrent inguinal hernia--a prospective randomized trial. Ann Surg 2009; 249:384.
- Bisgaard T, Bay-Nielsen M, Kehlet H. Re-recurrence after operation for recurrent inguinal hernia. A nationwide 8-year follow-up study on the role of type of repair. Ann Surg 2008; 247:707.
- Grant AM, Scott NW, O'Dwyer PJ, MRC Laparoscopic Groin Hernia Trial Group. Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia. Br J Surg 2004; 91:1570.
- Heikkinen T, Bringman S, Ohtonen P, et al. Five-year outcome of laparoscopic and Lichtenstein hernioplasties. Surg Endosc 2004; 18:518.
- Kumar S, Wilson RG, Nixon SJ, Macintyre IM. Chronic pain after laparoscopic and open mesh repair of groin hernia. Br J Surg 2002; 89:1476.
- Myers E, Browne KM, Kavanagh DO, Hurley M. Laparoscopic (TEP) versus Lichtenstein inguinal hernia repair: a comparison of quality-of-life outcomes. World J Surg 2010; 34:3059.
- Hindmarsh AC, Cheong E, Lewis MP, Rhodes M. Attendance at a pain clinic with severe chronic pain after open and laparoscopic inguinal hernia repairs. Br J Surg 2003; 90:1152.
- Beldi G, Haupt N, Ipaktchi R, et al. Postoperative hypoesthesia and pain: qualitative assessment after open and laparoscopic inguinal hernia repair. Surg Endosc 2008; 22:129.
- O'Reilly EA, Burke JP, O'Connell PR. A meta-analysis of surgical morbidity and recurrence after laparoscopic and open repair of primary unilateral inguinal hernia. Ann Surg 2012; 255:846.
- Medical Research Council Laparoscopic Groin Hernia Trial Group.. Cost-utility analysis of open versus laparoscopic groin hernia repair: results from a multicentre randomized clinical trial. Br J Surg 2001; 88:653.
- Payne JH Jr, Grininger LM, Izawa MT, et al. Laparoscopic or open inguinal herniorrhaphy? A randomized prospective trial. Arch Surg 1994; 129:973.
- Hynes DM, Stroupe KT, Luo P, et al. Cost effectiveness of laparoscopic versus open mesh hernia operation: results of a Department of Veterans Affairs randomized clinical trial. J Am Coll Surg 2006; 203:447.
- Anadol ZA, Ersoy E, Taneri F, Tekin E. Outcome and cost comparison of laparoscopic transabdominal preperitoneal hernia repair versus Open Lichtenstein technique. J Laparoendosc Adv Surg Tech A 2004; 14:159.
- Stylopoulos N, Gazelle GS, Rattner DW. A cost--utility analysis of treatment options for inguinal hernia in 1,513,008 adult patients. Surg Endosc 2003; 17:180.
- Koch A, Edwards A, Haapaniemi S, et al. Prospective evaluation of 6895 groin hernia repairs in women. Br J Surg 2005; 92:1553.
- Nilsson E, Kald A, Anderberg B, et al. Hernia surgery in a defined population: a prospective three year audit. Eur J Surg 1997; 163:823.
- Bay-Nielsen M, Kehlet H. Inguinal herniorrhaphy in women. Hernia 2006; 10:30.
- Arenal JJ, Rodríguez-Vielba P, Gallo E, Tinoco C. Hernias of the abdominal wall in patients over the age of 70 years. Eur J Surg 2002; 168:460.
- Nilsson H, Stylianidis G, Haapamäki M, et al. Mortality after groin hernia surgery. Ann Surg 2007; 245:656.