C o n t ro v e r s i e s i n I n g u i n a l

Her n ia
a a,b,
Veeshal H. Patel, MD, MBA , Andrew S. Wright, MD *

KEYWORDS
 Hernia  Inguinal hernia  Mesh  Hernia repair  Robotic surgery  Sports hernia

KEY POINTS
 Watchful waiting of minimally symptomatic hernias is safe, but most patients will have pro-
gressive symptoms and will eventually need hernia repair.
 Laparoscopic and open inguinal hernia repair have equivalent recurrence rates, but lapa-
roscopic approach has less acute pain, faster return to work, and lower risk of chronic
pain.
 Robotic hernia repair offers no advantage over laparoscopic repair but may help
encourage the transition from open to minimally invasive surgery and is a bridge to
more complex robotic abdominal wall reconstruction.
 Athletic-related groin pain (“sports hernia”) is complex and needs multidisciplinary evalu-
ation by sports medicine, hernia surgery, orthopedic surgery, and physical therapy.
 Nonmesh options for inguinal hernia repair continue to play a role in modern hernia sur-
gery, and the Shouldice repair is the likely the best option.

INTRODUCTION

Inguinal hernias represent one of the most common pathologic conditions presenting
to the general surgeon, accounting for 500,000 cases per year in the United States and
more than $48 billion in health care expenditures.1 Inguinal hernia is regarded as one
of the oldest afflictions involving humanity, and observations and methods of repair
are delineated as early as ancient Egypt. Notably, Leonardo da Vinci’s famous drawing
“Vitruvian Man” is thought to show a man with an inguinal hernia. Inguinal hernias are
more common in men, with a 27% lifetime risk, when compared with women, with a
3% lifetime risk.2 Over time the approach to hernia management and repair have grad-
ually evolved from different techniques of open tissue repair to the introduction of
mesh and eventually the widespread adoption of minimally invasive techniques.

The authors have nothing to disclose.

a
Department of Surgery, University of Washington Medical School, 1959 Northeast Pacific
Street Box 356410, Seattle, WA 98195, USA; b Center for VideoEndoscopic Surgery Endowed
Professor, University of Washington
* Corresponding author.
E-mail address: Awright2@uw.edu
Twitter: @andrewswright (A.S.W.)

Surg Clin N Am 101 (2021) 1067–1079

https://doi.org/10.1016/j.suc.2021.06.005 surgical.theclinics.com
0039-6109/21/ª 2021 Elsevier Inc. All rights reserved.
1068 Patel & Wright

Indirect inguinal hernias are resultant of failure of obliteration of the processus vag-
inalis, whereby a resultant hernia sac containing peritoneum passes through the inter-
nal inguinal ring. Direct inguinal hernias result from a weakness or defect in the
transversalis fascia and are generally thought to be the result of developed weakness.
The annual risk of hernia incarceration is not well known, but estimates are approxi-
mately 2 of 1000 cases annually.
Given the complex evolution of hernia repair and variations in practice patterns and
individual surgeon technique, there remain several viable approaches and consider-
ations in the management of a patient with an inguinal hernia. In surgical practice,
several controversies persist: when to operate, the utility of a laparoscopic versus
open approach, the applicability of robotic surgery, the approach to bilateral hernias,
management of athletic-related groin pain (“sports hernia”), and the role of tissue-
based repairs in modern hernia surgery.

INGUINAL HERNIAS: WHEN TO OPERATE OR OBSERVE

The role of inguinal hernia repair is to pre-empt incarceration while also improving
quality of life. Previously, many authorities recommended routine repair of all inguinal
hernias at diagnosis to prevent future risk of incarceration, strangulation, and need for
emergent repair. Analysis of retrospective reviews of hernia complications shows a
low estimated lifetime risk of strangulation at 0.27% (1 in 368 patients) for an 18-
year-old man and 0.03% (1 in 2941 patients) for a 72-year-old man.3 Although most
surgeons agree that symptomatic hernias should be repaired, given the apparently
low risk of life-threatening complications, the role of watchful waiting in asymptomatic
or minimally symptomatic hernias has been extensively debated.4
The VA Watchful Waiting trial by Fitzgibbons and colleagues5 compared watchful
waiting with hernia repair in minimally symptomatic patients. In this seminal trial,
only 2 of the 364 patients in the watchful waiting group sustained incarceration and
required emergent surgery, accounting for a frequency of only 1.8 per 1000 patient
years. In addition, watchful waiting did not increase the complication rate of future her-
nia repair. As a result of this and similar studies, many surgeons began to recommend
watchful waiting in the minimally symptomatic population. This finding was ultimately
used by some payers, including multiple regional councils in England’s National Health
Service, to restrict access to elective hernia repair on the basis that surgery for mini-
mally symptomatic hernias was “unnecessary.”
A more recent publication followed the original VA Watchful Waiting trial participants
for an additional 7 years.6 In the initial study 32% of the patients crossed over to the
surgical repair group, whereas the cumulative crossover rate increased to 68% at
10 years. Crossover was considerably more common in men older than 65 years.
The most common reason to undergo hernia repair was pain (54%). A similar random-
ized trial in the United Kingdom showed low risk to watchful waiting but that patients in
the surgical repair group had improved quality of life when compared with the patients
in the watchful waiting arm.7 Crossover from the watchful waiting arm of the trial to
surgery was 72% at 7 years.
Several systematic reviews and international guidelines have now been published
looking at this question.4,8 It seems clear that patients can be counseled that watchful
waiting is a safe and reasonable option for minimally symptomatic hernias but that
symptoms can be expected to progress, and surgery will eventually be needed in
most people. As such, symptomatic inguinal hernias should be repaired given the
high likelihood of progression of symptoms and the need for repair in the future. Asymp-
tomatic or minimally symptomatic hernias should entail a discussion about the risks and
 Controversies in Inguinal Hernia 1069

benefits of repair versus watchful waiting, leading to a shared decision-making model in

which the patient is empowered to make an educated choice. This discussion should be
between the surgeon and patient, and not dictated by the insurer or payer.

TECHNICAL APPROACH: LAPAROSCOPIC VERSUS OPEN INGUINAL HERNIA REPAIR

Laparoscopic inguinal hernia repair was initially reported more than 30 years ago. Un-
like other laparoscopic innovations such as cholecystectomy, the adoption of laparo-
scopic inguinal hernia has lagged and in 2017 represented only approximately 25% of
inguinal hernia operations in the United States.9 Adoption is highly surgeon depen-
dent, and less than half of the surgeons who perform inguinal hernia repairs ever
use a laparoscopic approach.10 Adoption is also regionally variant, with the rate of uti-
lization in the United States ranging from 10% to 48% depending on location. This
variability in approach has led to significant disparities in the use of minimally invasive
surgery, with laparoscopy being used less commonly in black patients10 and women.9
There have been several reasons proposed for the lack of adoption of laparoscopic
inguinal hernia repair, including perceived lack of evidence for improved outcomes,
increased cost, technical difficulty, perceived ergonomic challenges, increased oper-
ative times, and the learning curve of the procedure.11 Economic concerns have also
hampered adoption, because reimbursement is uniformly lower for laparoscopic
inguinal hernia repairs than for their open equivalents.12
Laparoscopic totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP)
repairs are the 2 most common approaches for laparoscopic inguinal hernia repair.13
Both approaches are characterized by the use of a bridging mesh in the preperitoneal
space, covering the entire myopectineal orifice consisting of the internal ring, inguinal
floor, and femoral space.14 The 2 approaches differ primarily in the initial entry and port
placement. In the TAP approach the abdomen is entered as in conventional laparos-
copy and the surgeon then opens the peritoneum, performs the dissection and places
mesh, and then closes the peritoneum with suture or tacks. The TEP approach avoids
the violation of the peritoneum but is associated with a longer learning curve for the
surgeon and reduced working space. Outcomes are essentially equivalent between
the 2 laparoscopic techniques.15
There have been several randomized controlled studies of laparoscopic and open
inguinal hernia repair. Perhaps most famously, the landmark VA Multicenter trial re-
ported in 2004 by Neumayer and colleagues16 found that recurrence was more than
twice as common in the laparoscopic group (10.1%) when compared with the open
repair group (4.9%). This study was done early in the experience with laparoscopic
inguinal hernia, and there are some notable issues that may make this study not gener-
alizable to more recent experience. The size of the mesh used in this study was quite
small by modern standards, and surgeons were only required to have experience with
25 prior laparoscopic hernia repairs to participate in the study.
More recent studies have shown equivalent or better results with laparoscopic
inguinal hernia repair when compared with open. For example, the LEVEL trial is a ran-
domized controlled trial (RCT) that compared the Lichtenstein and TEP approaches,17
demonstrating that laparoscopic repair results in less early postoperative pain, faster
recovery of activities of daily living, and less absence from work (1 week vs 1.4 weeks).
At a mean 49-month follow-up, recurrence rates were comparable (3.8% in TEP vs
3.0% with Lichtenstein repair). A large population-based series of more than 66,000
patients showed that the laparoscopic approach was more expensive ($15,030 vs
$13,303) but resulted in less use of narcotic pain medicine, reduced rate of wound
complications, fewer outpatient visits, and fewer missed work hours.18
1070 Patel & Wright

A recent meta-analysis of open versus laparoscopic repair of unilateral nonrecurrent

inguinal hernias reviewed 12 RCTs with almost 4000 patients.19 There were no signif-
icant differences in recurrence between laparoscopic and open repair. Laparoscopic
repair had less acute pain. Importantly, laparoscopic repair also had a lower incidence
of chronic pain, with an odds ratio (OR) of 0.41 (confidence interval [CI], 0.30–0.56,
P.00001).
A recent international guideline from multiple European hernia societies carefully
reviewed the literature surrounding inguinal hernia.8 It was found that direct operative
costs were higher for laparoscopic approach than for open, but that this difference
disappears once community costs are factored in. Furthermore, operative times
were found to be equivalent between open repair with mesh and laparoscopic repair.
Learning curves vary in different studies, but the general consensus seems to be a
learning curve of between 50 and 100 cases.8
Despite initial data suggesting increased recurrence rates in the laparoscopic
inguinal hernia repair, with changes in practice patterns and increased surgical expe-
rience, both approaches now have demonstrably similar recurrence rates. There are
minimal perioperative complications with the laparoscopic approach, and there is
significantly decreased acute pain with faster return to normal activities. Given the
increased recognition of the serious morbidity of chronic pain following inguinal hernia
repair, the evidence of decreased rates of chronic pain after laparoscopic repair
should ideally drive further adoption.

NEW CONSIDERATIONS: ROLE OF ROBOTIC INGUINAL HERNIA REPAIR

One of the key reasons behind slow adoption of the laparoscopic hernia repair despite
similar outcomes and decreased postoperative pain is the learning curve associated
with laparoscopic repair. The initial learning curve of laparoscopic repair is estimated
to be between 50 and 100 cases,8 with additional improvements in complication rates
and operative time continuing to occur in a linear fashion until approximately 450
cases.20 Robotic surgery has been proposed as a novel way to increase adoption
of minimally invasive inguinal hernia repair. Although there has been minimal evidence
to date in support of this, proponents of robotic hernia repair point to 3D visualization,
improved ergonomics, and wristed instrumentation as potential advantages of the ro-
botic platform. In addition, the laparoscopic inguinal hernia repair is considered by
many surgeons to be ergonomically challenging owing to port positioning and small
working space. The potential ergonomic advantages of robotic surgery have also
been proposed as an enabling technology for the adoption of minimally invasive
inguinal hernia repair.
Driven primarily by marketing and social media, the adoption of robotic inguinal her-
nia repair has been rapid, increasing from 0.7% in 2012 to 28.8% of cases in 2018.21
During this same period there was also a smaller increase in laparoscopic repair but a
decrease in open repair, indicating that some but not all robotic adoption was driven
by a movement from open to minimally invasive surgery.
There have been several case series of robotic inguinal hernia repairs. For example,
the University of Pittsburgh has reported their first 300 cases22 with acceptable short-
term results. The investigators estimated that the learning curve for robotic inguinal
hernia repair was 11 to 12 cases, although this was derived from a surgeon with exten-
sive previous laparoscopic experience. In a review of 510 patients at the University of
Virginia who underwent unilateral inguinal hernia repair (14% robotic, 48% laparo-
scopic, and 38% open), robotic hernia repair was associated with a longer operative
time (105 minutes robotic, 81 minutes laparoscopic, 71 minutes open).23
 Controversies in Inguinal Hernia 1071

Postoperative complications were similar (2.9% robotic, 3.3% laparoscopic, 5.2%

open), and cost was significantly increased in the robotic group ($7162 robotic,
$4527 laparoscopic, and $4264 open).
Using a large single-source electronic health record across 32 hospitals, Abdel-
moaty and colleagues24 looked at 734 robotic inguinal hernia repairs when compared
with 1671 laparoscopic repairs. The investigators found that the robotic approach had
both increased operative time (87 vs 56 minutes) and cost ($5517 vs $3269). The
increased cost was primarily driven by the amortized fixed cost of the robot itself,
as the variable costs (disposable equipment, mesh, etc.) were higher for laparoscopic
surgery. This observation highlights the importance of different cost accounting and
economic modeling approaches to analysis of robotic surgery.
To date there has been one RCT of robotic and laparoscopic inguinal hernia repair.
The RIVAL trial demonstrated no differences between laparoscopic and robotic TAPP
approaches in 102 patients with regard to wound complications, readmission, or
pain.25 Robotic repair was associated with a longer operative time (75.5 minutes)
and cost ($3258) when compared with laparoscopic repair (40.5 minutes and
$1421). There was no difference in patient quality of life or return to activity. Although
many proponents of robotic surgery tout purported ergonomic advantages, in the
RIVAL trial there were no overall differences in surgeon ergonomics between laparo-
scopic and robotic surgery as measured by the Rapid Upper Limb Assessment (RULA)
tool. There was also increased surgeon frustration in the robotic cases as measured
by the NASA Task Load Index Scale.
Despite the lack of evidence that robotic surgery offers any measurable advantage
over laparoscopic inguinal hernia repair, it is clear from the adoption numbers that sur-
geons are finding value in the robotic platform. The primary advantage of the robot
may be not in a comparison of laparoscopy and robotics, but in transitioning surgeons
from open to MIS. Robotic inguinal hernia repair may also be a necessary stepping
stone to more complex robotic abdominal wall surgery such as reoperative surgery
or complex MIS abdominal wall reconstruction. The increased costs of robotic repair
are concerning from a systems-level perspective but will hopefully improve with
competition as new companies release robotic platforms over the coming few years.

BILATERAL VERSUS UNILATERAL HERNIA REPAIR

The presence of a unilateral inguinal hernia is a clear risk factor for development of a
later contralateral hernia. Several trials have reported the rate of contralateral hernias
at various follow-up intervals after index unilateral open repair. The rate of contralateral
inguinal hernia formation is approximately 10%26 at 5 years and 21% to 25% at
11 years.27 In many cases, the contralateral hernia was likely present at the index
operation, but clinically occult.
With the wider adoption of minimally invasive approaches for inguinal hernia repair,
surgeons are more clearly able to evaluate for an occult contralateral hernia at the time
of index surgery. In particular, occult contralateral hernias that are asymptomatic and
not identified on preoperative examination are frequently encountered in the operating
room during minimally invasive TAPP repair. A recent study noted that 15.8% of pa-
tients undergoing a robotic inguinal hernia repair were found to have an incidental
contralateral inguinal hernia.28
On the one hand, repair of a contralateral hernia seems to be low risk. Repair of
bilateral hernias during a TAPP repair is notable for a slightly longer operative time
(25 minutes on average), but there are no significant differences in complications,
time to recovery, reoperation, and recurrence rate.13,29 On the other, the primary
1072 Patel & Wright

disadvantage to routine repair of an occult contralateral hernia is the possibility of

development of chronic groin pain from the repair at a previously asymptomatic
site. Weighing the relative risks and advantages, the recent HerniaSurg international
guidelines suggest that it is safe and preferable to repair an occult contralateral
inguinal hernia if identified intraoperatively, although they give this recommendation
their weakest level of support. Given the high prevalence of an occult contralateral her-
nia, it is our practice to routinely discuss the possibility of bilateral repair with patients
before TAPP inguinal hernia repair and to repair the contralateral side if a hernia is seen
at exploration. During open or TEP inguinal hernia we do not routinely open or explore
the asymptomatic contralateral side.

MANAGEMENT OF ATHLETIC-RELATED GROIN PAIN (“SPORTS HERNIA”)

Athletic-related groin pain is a complex clinical scenario arising from musculoskeletal

disruptions of core abdominal structures rather than a true hernia.30 The diagnosis and
management and in fact even the existence of athletic-related groin pain is controver-
sial, and the debates over this topic could fill entire textbooks. This debate extends
even to nomenclature, with little disagreement about what to call this clinical entity.
The pain has been variably called athletica pubalgia, sportsman’s groin, Gilmore groin,
incipient hernia, inguinal disruption, core muscle injury, and numerous other terms.
Most commonly this has been referred to as a “sports hernia,” which adds to the
confusion as by definition in this entity there is no fascial defect or true hernia. A recent
review found that 33 different diagnostic terms were used across 72 studies in this
area.31
Two recent consensus groups have attempted to standardize nomenclature. The
British Hernia Society determined that this should be called “inguinal disruption,32”
whereas the Doha group has suggested that this should be called “groin pain in ath-
letes” with 3 major subheadings that attempt to distinguish the suggested cause of the
pain33:
 Defined clinical entities for groin pain: Adductor-related, iliopsoas-related,
inguinal-related, and pubic-related groin pain.
 Hip-related groin pain.
 Other causes of groin pain in athletes.
Much of the confusion stems from the fact there they may be several different
discrete injuries that can cause groin pain in athletes. The pelvic girdle and pubic
bone represent the key structures that dynamically move with exercise, permitting
the lower extremities to move with the torso. Specifically with athletic injuries, often
due to hyperextension or hyperabduction, one of the core muscles can partially tear
or become injured, leading to instability, particularly at the fibrocartilaginous attach-
ments to the pubic bone. This injury may be in the rectus insertion, obliques, transverse
abdominus, and/or the adductors. In addition, there may be injury of the pubic bone or
pubic symphysis. The “inguinal disruption” diagnosis suggested by the British Hernia
Society is likely a subtype of this injury, related to disruption of the transversalis, obli-
ques, or rectus and relating to pain in the inguinal region. There may be significant over-
lap with related orthopedic injuries including osteitis pubis, femoral acetabular
impingement, and snapping hip syndrome. This injury itself is a site of pain, but addi-
tional compensation from remaining core muscles can lead to additional pain and
injury in other locations through the pelvic girdle. There is also a school of thought
that athletic groin pain may in part be neuropathic due to compression of the inguinal
sensory nerves, sometimes as a sequela of musculoskeletal injury.34
 Controversies in Inguinal Hernia 1073

The diagnosis and management of athletic-related groin pain can be difficult. These
can be career-ending injuries for the elite college or professional athlete. Increasingly
these injuries are also being recognized in high-performing recreational athletes and
frequently impair return to sport. The specific type of injury affects the presentation
and should also influence the choice of treatment. Patients should be evaluated by
an experienced multidisciplinary team of sports medicine physicians, hernia surgeons,
physical therapists, and orthopedic surgeons. Zuckerbraun and colleagues30 have
published a recent review of the many potential injuries that can cause groin pain in
athletes, as well as an excellent algorithm for working through the evaluation and man-
agement of this complex process.
History and physical examination are key, along with testing of individual muscles to
attempt to identify the cause. Physical examination includes evaluation for hernias, hip
examination (active and passive range of motion and FADIR and FABER tests), adduc-
tion, and resisted sit-ups or abdominal crunch. Multiple injuries may be common, and
in particular hip injuries may cause secondary compensatory injuries in the pelvic
ring.35
Per the British Hernia Society consensus paper, the diagnosis of inguinal disruption
(by Doha nomenclature: athletic groin pain, inguinal related) can be made if 3 of the
following 5 clinical signs are present: (1) pinpoint tenderness over the pubic tubercle
at the point of insertion of the conjoint tendon, (2) palpable tenderness over the
deep inguinal ring, (3) pain and/or dilation of the external ring with no obvious hernia
evident, (4) pain at the origin of the adductor longus tendon, and (5) dull, diffused
pain in the groin, often radiating to the perineum and inner thigh or across the
midline.32
Imaging additionally plays a role but may be difficult to interpret in the clinical
context and is neither 100% sensitive nor 100% specific. Ultrasonography can help
identify occult inguinal hernias that may be a cause of pain. Dedicated musculoskel-
etal ultrasonography can also evaluate for muscle or tendon injury, although this is
highly operator dependent. MRI, specifically protocoled for groin pain, can also help
elucidate the mechanism of injury. It remains important to evaluate for the various
causes of pubic pain, including the hip joint, back, core muscles, and other intra-
abdominal visceral pathologic conditions. Diagnostic injections may additionally
play a role.
In most cases, initial treatment should be nonoperative and involve ice, anti-
inflammatories, and rest. If pain continues beyond a few weeks, high-quality physical
therapy is the next line. Physical therapy helps strengthen the supporting muscles to
offload the pubic joint and index injury. There is good evidence that the quality of phys-
ical therapy is important and that therapy should focus on core stability and retraining
of surrounding core muscles.36 Active physical therapy with a focus on core strength
and balancing exercises has a significantly higher success rate than conventional
physical therapy with rest, massage, and mobilization.37
Percutaneous interventions such as corticosteroid injections or ilioinguinal nerve
hydrodissection can serve as temporizing measures to facilitate return to activities.
Although patients are often anxious to have surgery to return to sport more quickly,
there is evidence that return to sport is faster with physical therapy than with surgical
intervention.38
In selected patients who do not respond to physical therapy, surgery may be
considered. Although there are no hard guidelines on how long to wait before surgery,
there are suggestions that pain lasting more than 2 months may not resolve without
intervention.32 We therefore typically recommend at least 8 to 10 weeks of high-
quality physical therapy before considering surgery.
1074 Patel & Wright

There have been several proposed approaches to surgical treatment, and the
choice of repair should be tailored to the athlete and the injury. Generally speaking,
the quality of data in this area is poor31 and there are no data that definitively suggest
that any one surgical approach is superior. One major school of thought, led primarily
by the Meyers group in Philadelphia, has argued for open groin reconstruction. Meyers
and colleagues39 have reported their personal experience in more than 5000 opera-
tions and identify at least 19 different syndromes, 26 procedures, and 121 different
combinations of procedures. The investigators report that 95% of their patients under-
going operative repair return to full athletic pursuits within 3 months of surgery,
although they do not report the specifics of the operative interventions or follow-up.
It is difficult to know the exact components of their group’s operative approach, but
it seems to include suture repair of the rectus abdominus to the pubis and inguinal lig-
ament, possible division of inguinal sensory nerves, and sometimes adductor longus
tenotomies or using the adductor longus tendon to buttress the rectus repair.
Other groups prefer more limited open approaches to reinforce the inguinal floor
with a “minimal” suture repair,40 modified Bassini repair,41 or Lichtenstein tension-
free repair with mesh.32 Some groups also feel that nerve impingement is a key feature
and advocate for neurolysis, neurectomy, hydrodissection, or ablation of the ilioingui-
nal, iliohypogastric, and/or genitofemoral nerves, sometimes but not always combined
with inguinal floor reinforcement. Still other groups advocate for a laparoscopic
approach with mesh reinforcement of the area, with or without release of the inguinal
ligament.42,43 As many patients have adductor-related pain as a sole or additional
injury, adductor tendon release may be performed either as a separate procedure
or in conjunction with any of the aforementioned approaches.44
The 2 highest quality trials in surgical management of athletic-related groin pain
have both shown good results with laparoscopic mesh reinforcement. Paajanen and
colleagues42 randomized 60 patients to either TEP mesh reinforcement or active phys-
ical therapy and found that 90% of patients in the surgical group returned to sport
within 3 months, compared with only 27% in the nonoperative group. Pain was
improved in the operative group at both 3- and 12-month follow-up. Sheen and col-
leagues45 randomized patients to either laparoscopic repair or open suture repair
and found that both approaches were equivalent with respect to return to sport with
less initial pain in the laparoscopic group. Based on the results of these trials, we pre-
fer a laparoscopic mesh reinforcement as the initial surgical approach in most patients
who need surgery but will occasionally perform open groin reconstruction, neurolysis/
neurectomy, and/or adductor tenotomy based on the location and mechanism of
injury and symptoms.

THE ROLE OF TISSUE REPAIR IN MODERN HERNIA SURGERY

The vast majority of inguinal hernia repairs performed in the United States are per-
formed with mesh, either via open or minimally invasive technique. In some ways, tis-
sue repairs without mesh have become a lost art because surgical trainees no longer
learn these operations and surgeons in practice have lost their comfort level with the
art of a primary inguinal hernia repair. In a recent review of the Americas Hernia Society
Quality Collaborative database, less than 4% of inguinal hernias were repaired without
mesh.46 Owing to high-profile mesh recalls, several lawsuits against companies that
make mesh (and related legal advertisements on late night television and in sponsored
Internet search results), and social media amplification of patients who have felt that
they have been harmed by mesh, many patients now come into surgical consultation
wary of any mesh-based hernia repair and asking specifically for a “no mesh” repair.
 Controversies in Inguinal Hernia 1075

There have been numerous studies comparing various nonmesh and mesh inguinal
hernia repair approaches, and there is no evidence that mesh leads to higher risk of
chronic pain.8 In one example, the Danish and Swedish Hernia Database collaboration
looked at 1250 patients following Lichtenstein hernia repair compared with 630 pa-
tients with Shouldice repair and 732 with a Macy repair and found no difference in
the rate of chronic pain.47 A randomized trial of Shouldice, Lichtenstein, and TAPP
inguinal hernia repairs showed that chronic pain was equivalent between the 2 open
approaches and that chronic pain was least following laparoscopic repair with
mesh.48 A Cochrane review of 25 studies with 6293 participants showed that mesh re-
duces the risk of recurrence (relative risk 0.46; 95% CI, 0.26–0.80).49 A separate
Cochrane review showed no difference in chronic pain between the Shouldice repair
and open mesh repair.50
Although there is no evidence that mesh increases the risk of chronic pain after
inguinal hernia repair, it is still important that patients have the option of a nonmesh
repair if they still desire one after a careful and informed discussion. A
Cochrane review of 16 studies (2566 hernias) suggests that the Shouldice repair has
a lower recurrence rate than other open techniques (OR 0.62, 95% CI 0.45–0.85).50
The results appear to hold over time, because the recurrence risk at 18 years after
Shouldice repair is as low as 2.9%.51 The Shouldice repair is therefore likely the
preferred option for nonmesh repairs at this time.52 The Shouldice repair, however,
is technically challenging with a steep learning curve, and the best results have
been reported by single-center groups with high-volume experience in this technique.
In addition, the Shouldice clinic itself, which has produced the best evidence for this
repair, is highly restrictive in who they will operate on, and therefore it is unclear how
generalizable this approach is.
The Shouldice repair is the most commonly performed nonmesh repair in the United
States (77%), followed by Bassini (16%) and McVay (3.5%) repairs.46 Other nonmesh
approaches have been proposed as alternatives. The Moloney “darning” repair has
been studied in 6 RCTs, and in a meta-analysis it had equivalent recurrence to
mesh repair; however, there was insufficient evidence to determine the risk of chronic
pain.53 The Desarda repair is a relatively newly described alternative, in which a strip of
external oblique fascia is mobilized and used as a reinforcement of the inguinal floor.
Data on this approach are limited; however, one RCT has shown that recurrence after
Desarda is equivalent to Lichtenstein repair at 3 years.54 The Desarda repair may be
more replicable than the Shouldice repair, but further studies are needed before this
technique is adopted widely. Huynh and colleagues55 have recently reported an
intriguing case series of a minimally invasive nonmesh repair for low-risk patients
with small hernias, the robotic iliopubic tract repair. This repair is based on the open
iliopubic tract repair described by Nyhus, and in their phase 1 trial of 24 patients
they have seen no recurrences with median 25-month follow-up.

SUMMARY

Despite the fact that the “lowly” inguinal hernia repair is one of the most common gen-
eral surgical problems, or perhaps because it is so common, there remain numerous
controversies about the “best” approach. This controversy has driven numerous sci-
entific studies and international guidelines, as well as an explosion of surgeon interest
and discussion on social media forums like Twitter, Facebook, and YouTube.
Currently the International Hernia Collaboration on Facebook has more than 11,000
members, with frequent and active discussion on numerous hernia-related topics.56
Although these forums can be a great tool for self-education and discussion, it is
1076 Patel & Wright

important for the surgeon to look at posts with caution. Posts and opinions may be
educational and helpful but are often anecdotal and rarely evidence driven.57 A recent
review of YouTube videos of laparoscopic inguinal hernia repair videos found that only
16% had an adequate repair, whereas 46% of videos had technically unsafe maneu-
vers such as threatened critical structures, rough tissue handling, or dangerous fixa-
tion near the iliac vessels.58
Ideally, surgeons should approach each patient individually and tailor their
approach based on patient factors and preferences. The informed consent process
is critical, especially given increasing recognition of the risk of long-term chronic
pain following hernia repair. It is therefore important that hernia surgeons have facility
with multiple approaches including multiple open and minimally invasive techniques,
as well as the ability to offer nonmesh repairs, or have the ability and willingness to
refer patients when appropriate.

REFERENCES

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