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The objective of this study was to comprehensively review the evidence to inform key decisions in the management of inguinal hernia in adults and pediatric patients. These questions include whether to repair a pain-free hernia or "wait and see," and whether to repair a painful hernia using an open or laparoscopic approach. They also include which procedure to use if an open approach is used; which procedure to use if a laparoscopic approach is used; which type of mesh to use; which mesh fixation method (if any) to use; how experience with laparoscopic repair may be related to the risk of hernia recurrence; for pediatric hernia, whether to surgically explore a possible contralateral hernia or "wait and see"; and for pediatric hernia, whether to repair using an open or laparoscopic approach.
MEDLINE®, PreMEDLINE, Embase, Cochrane Library, and reference lists. The last search date was November 17, 2011.
We refined the topic with Key Informants and finalized the protocol with Technical Expert Panel members. We determined the study inclusion criteria as well as the risk-of-bias items a priori. Study information was extracted into tables regarding general information, patient enrollment criteria, baseline characteristics, risk-of-bias items, and data. We performed meta-analysis where appropriate and rated the strength of evidence for major comparisons and outcomes. We discussed applicability by focusing on the population, interventions, and settings of the included studies separately for each clinical question.
We included 223 publications describing 151 unique studies: 123 were randomized controlled trials (RCTs), 2 were registries, and 26 had other designs (included only for the laparoscopic surgical experience question). The evidence came from international sources; only 10 percent of the studies were conducted exclusively in the United States. The risk of bias was moderate for most outcomes in the RCTs but high in the registries. For painless hernia, evidence was mostly insufficient to permit conclusions, but quality of life at 1 year was better after surgery than watchful waiting. For painful primary hernias in adults, the risk of recurrence was lower after open surgery than after laparoscopy, whereas for recurrent hernia, this risk was lower after laparoscopic repair. Other outcomes, including short-term recovery and long-term pain, favored laparoscopic repair over open repair. Different open repair procedures generally yielded similar results, and transabdominal preperitoneal repair had the same or better outcomes compared with other laparoscopic procedures. Different meshes and fixation approaches often showed similar results. Many studies reported that surgical experience lowers the risk of recurrence after laparoscopic repair, but the data were reported unevenly and do not permit any estimate of the length of the learning curve. For pediatric hernia, no studies have compared surgical exploration for a contralateral hernia with watchful waiting, but comparing laparoscopy versus open high ligation, outcomes generally favored laparoscopy.
Patients, families, and providers can use this evidence review to improve decisionmaking about inguinal hernia. The applicability of our findings is limited to the types of populations, procedures, and settings in the included studies. The typical patient was a middle-aged man of average weight with primary unilateral inguinal hernia.