What are the guideline sources, guidelines and references for Inguinal hernia ?
Guideline sources The following summarized guidelines for the evaluation and management of inguinal hernia are prepared by our editorial team based on guidelines from the American College of Radiology (ACR 2022), the International Endohernia Society (IEHS 2018; 2015), and the World Society of Emergency Surgery (WSES 2017). 1 2 3 4 Guidelines 1. Diagnostic investigations Initial evaluation: As per ACR 2022 guidelines, obtain pelvic ultrasound, MRI, or abdominopelvic CT (with or without IV contrast) as the initial imaging in patients with suspected inguinal hernia. B As per IEHS 2018 guidelines, perform clinical examination and obtain ultrasound for diagnosis in patients with vague groin swelling or possible occult groin hernias. Consider obtaining https://web.pathway.md/diseases/recIRH05Cufdr2zDU 1/6 6/24/23, 2:34 PM Inguinal hernia Pathway dynamic MRI or CT for further evaluation if the ultrasound is negative or nondiagnostic. A Evaluation for bowel strangulation: assess for systemic inflammatory response syndrome, obtain contrast-enhanced CT, serum lactate, creatinine phosphokinase, and D-dimer to assess for bowel strangulation. B Evaluation of the contralateral groin: inspect the contralateral groin at the time of transabdominal preperitoneal repair. Perform repair if a contralateral inguinal hernia is found at the time of surgery and prior informed consent was obtained. A Show 2 more 2. Diagnostic procedures Diagnostic laparoscopy: consider performing diagnostic laparoscopy to assess bowel viability after spontaneous reduction of strangulated groin hernias. C 3. Medical management Management of modifiable risk factors: take into consideration acquired, surgical, and perioperative risk factors since they are potentially modifiable and can influence the type of repair performed. A 4. Perioperative care Antibiotic prophylaxis: As per IEHS 2018 guidelines, do not administer antibiotic prophylaxis for open mesh repair in average-risk patients in a low-risk environment. D Show 3 more As per WSES 2017 guidelines, administer short-term antimicrobial prophylaxis in patients with intestinal incarceration with no evidence of ischemia and no bowel resection (CDC wound class I). B Show 2 more Choice of anesthesia: As per IEHS 2018 guidelines, administer local anesthesia for open repair of reducible inguinal hernias provided surgeons/teams are experienced in local anesthesia use and administering the local anesthetic. A Show 2 more As per WSES 2017 guidelines, consider administering local anesthesia to provide effective anesthesia with fewer postoperative complications for emergency inguinal hernia repair in the absence of bowel gangrene. B Prevention of postoperative pain: offer pre- or perioperative field block of the inguinal nerves and/or subfascial/subcutaneous infiltration of local anesthetics in all open groin hernia repairs. A https://web.pathway.md/diseases/recIRH05Cufdr2zDU 2/6 6/24/23, 2:34 PM Inguinal hernia Pathway Show 2 more 5. Surgical interventions Indications for emergency repair (wound class I): perform emergency hernia repair immediately when intestinal strangulation is suspected. B Indications for emergency repair (wound class II): consider performing emergent prosthetic repair with a synthetic mesh in patients with complicated hernia with intestinal strangulation and/or concomitant need of bowel resection without gross enteric spillage (clean-contaminated surgical field, CDC wound class II), regardless of the size of the hernia defect. B Indications for emergency repair (wound class III-IV): perform primary hernia repair when the size of the defect is small (< 3 cm) in stable patients with strangulated hernia with bowel necrosis and/or gross enteric spillage during intestinal resection (contaminated, CDC wound class III) or peritonitis from bowel perforation (dirty surgical field, CDC wound class IV). Consider using a biological mesh for repair when a direct suture is not feasible. B Choice of surgical approach: As per IEHS 2018 guidelines, perform laparoendoscopic repair in patients with primary bilateral inguinal hernias provided a surgeon with specific and sufficient resources is available. A Show 6 more As per WSES 2017 guidelines, consider using a laparoscopic approach to repair incarcerated inguinal hernias. Prefer an open preperitoneal approach in case of strangulation and suspicion of the need for bowel resection. C As per IEHS 2015 guidelines, recognize that both transabdominal preperitoneal and totally extraperitoneal endoscopic techniques are acceptable and effective laparoscopic methods for inguinal hernia repair. A Show 4 more Technical considerations for surgery (transabdominal preperitoneal approach): Consider using the direct trocar insertion technique to establish pneumoperitoneum as a safe alternative to the Veress needle technique, Hasson approach, or optical trocar, taking into account the patient's risk factors and provided that the surgeon is appropriately trained. C Close fascial defects of 10 mm. Achieve a thorough closure of peritoneal incision or bigger peritoneal tears. B Technical considerations for surgery (totally extraperitoneal endoscopic approach): consider closing large direct inguinal hernia defects with a pre-tied suture loop as an alternative to the fixation of the extended fascia transversalis to Copper's ligament. C Show 3 more Technical considerations for surgery (non-mesh repair): Consider performing a non-mesh inguinal hernia repair if the patient refuses a mesh and/or after shared decision-making. C Use the Shouldice technique for non-mesh inguinal hernia repair. A https://web.pathway.md/diseases/recIRH05Cufdr2zDU 3/6 6/24/23, 2:34 PM Inguinal hernia Pathway Technical considerations for surgery, mesh repair: As per IEHS 2018 guidelines, use a mesh-based repair technique in patients with inguinal hernias. A Show 8 more As per WSES 2017 guidelines, decide on the choice between a cross-linked and a non-cross- linked biological mesh depending on the defect size and degree of contamination. Consider using either polyglactin mesh or open wound management with delayed repair as a viable alternative if a biological mesh is not available. B Show 3 more As per IEHS 2015 guidelines, consider using a monofilament implant with a pore size of at least 1.0-1.5 mm (usually meaning low weight) consisting of a minimum tensile strength in all directions (including subsequent tearing force) of 16 N/cm. Consider using large pore polypropylene meshes for endoscopic hernia repair as it is harmless concerning azoospermia. C Show 3 more 6. Specific circumstances Female patients: As per IEHS 2018 guidelines, include femoral hernia in the differential diagnosis of groin swelling in female patients. A Show 3 more As per IEHS 2015 guidelines, put extra effort to reveal and treat occult synchronous femoral hernia when performing inguinal hernia repair in female patients. B Patients with sportsman's hernia: Consider performing endoscopic placement of retropubic mesh in patients with sportsman's hernia. B Consider performing radiofrequency denervation of both the ilioinguinal nerve and inguinal ligament, rather than administering anesthetic/corticosteroid injections, as a conservative treatment option (at least in the short term) in patients with refractory sportsman's hernia. B Resource-limited settings: focus on teaching inguinal hernia repair by a standardized technique (Lichtenstein) under local anesthesia using a low-cost mesh in low-resource settings. B Show 3 more 7. Patient education General counseling: discuss with patients about the timing of hernia repair involving attention to the social environment, occupation, and overall health. Weight the lower morbidity of elective surgery against the higher morbidity of emergency surgery. A https://web.pathway.md/diseases/recIRH05Cufdr2zDU 4/6 6/24/23, 2:34 PM Inguinal hernia Pathway 8. Follow-up and surveillance Management of postoperative pain: As per IEHS 2018 guidelines, define chronic pain as bothersome moderate pain impacting daily activities lasting 3 months postoperatively. A Show 4 more As per IEHS 2015 guidelines: Provide effective pain control for early return to work and activities of daily living. B Counsel patients regarding the availability and side effects of analgesics. Respect and facilitate the patient's individual wishes after counseling, such as by generous analgesics prescription. B Return to normal activities: As per IEHS 2018 guidelines, advise patients to resume normal activities without restrictions within 3-5 days or as soon as they feel comfortable. A As per IEHS 2015 guidelines: Assure patients that physical activity of any kind does not jeopardize the stability of groin hernia repair. Encourage patients to resume work and activities of daily living after 1 day. B Do not support extended periods of sick leave. D Management of recurrent hernia: Perform laparoendoscopic repair of a recurrent hernia after failed anterior tissue or Lichtenstein repair. Perform anterior repair after failed posterior repair. A Perform repair of a recurrent inguinal hernia after failed anterior and posterior repair by an expert hernia surgeon. Decide on the choice of technique depending on patient- and surgeon- specific factors. A 9. Quality improvement Hernia registries: Consider developing and implementing national or regional groin hernia registries with high coverage and long-term follow-up for quality control. C Develop hernia registries including patient follow-up data and accounting for local healthcare structures for research and audit purposes. B References 1. R Bittner, M A Montgomery, E Arregui et al. Update of guidelines on laparoscopic TAPP and endoscopic TEP treatment of inguinal hernia International Endohernia Society). Surg Endosc. 2015 Feb;29 2 289 321. Open 2. HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018 Feb;22 1 1 165. Open https://web.pathway.md/diseases/recIRH05Cufdr2zDU 5/6 6/24/23, 2:34 PM Inguinal hernia Pathway 3. Arianna Birindelli, Massimo Sartelli, Salomone Di Saverio et al. 2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias. World J Emerg Surg. 2017 Aug 7;12 37. Open 4. Evelyn M. Garcia, MD, Jason A. Pietryga et al. American College of Radiology ACR Appropriateness Criteria Hernia. ACR. 2022. Open 5. HerniaSurge Group. International guidelines for groin hernia management. Hernia. 2018 Feb;22 1 1 165. Open 6. Society of American Gastrointestinal and Endoscopic Surgeons. Choosing Wisely SAGES recommendations. Choosing Wisely. 2019. Open https://web.pathway.md/diseases/recIRH05Cufdr2zDU 6/6