Update of the international HerniaSurge guidelines for groin hernia management

Update of the international HerniaSurge guidelines for groin hernia management Cesare Stabilini 1, * , Nadine van Veenendaal 2 , Eske Aasvang 3,4 , Ferdinando Agresta 5 , Theo Aufenacker 6 , Frederik Berrevoet 7 , Ine Burgmans 8 , David Chen 9 , Andrew de Beaux 10 , Barbora East 11 , Jose Garcia-Alamino 12 , Nadia Henriksen 13 , Ferdinand Köckerling 14 , Jan Kukleta 15 , Maarten Loos 16,17 , Manuel Lopez-Cano 18 , Ralph Lorenz 19 , Marc Miserez 20 , Agneta Montgomery 21 , Salvador Morales-Conde 22 , Chris Oppong 23 , Maciej Pawlak 24 , Mauro Podda 25 , Wolfgang Reinpold 26 , David Sanders 24 , Alberto Sartori 27 , Hanh Minh Tran 28 , Mireia Verdaguer 18 , Reiko Wiessner 29 , Michael Yeboah 30 , Willem Zwaans 16,17 and Maarten Simons 31 1 Department of Surgery (DISC), University of Genoa, Genoa, Italy 2 Department of Anaesthesiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands 3 Department of Anaesthesiology, The Centre for Cancer and Organ Diseases, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark 4 Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark 5 Department of Surgery, Vittorio Veneto General Hospital, Vittorio Veneto, Italy 6 Department of Surgery, Rijnstate Hospital, Arnhem, The Netherlands 7 Department of Surgery, University Hospital Ghent, Ghent, Belgium 8 Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands 9 David Geffen School of Medicine at UCLA, Los Angeles, California, USA 10 Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK 11 Department of Surgery, Fakultní Nemocnice v Motole, Prague, Czech Republic 12 Department of Surgery, Universitat Ramon Llull, Barcelona, Spain 13 Department of Gastrointestinal and Hepatic Diseases, Copenhagen University Hospital–Herlev and Gentofte, Herlev, Denmark 14 Vivantes Hospital Berlin, Academic Teaching Hospital of Charité University Medicine, Berlin, Germany 15 Department of Surgery, Klinik Im Park, Zurich, Zurich, Switzerland 16 SolviMáx Centre of Excellence for Abdominal Wall and Groin Pain, Eindhoven, The Netherlands 17 Department of General Surgery, Máxima Medical Center, Veldhoven, The Netherlands 18 Department of Surgery, Hospital Universitari Vall d’Hebron, Barcelona, Spain 19 Department of Surgery, Hernia Center 3+CHIRURGEN, Berlin, Germany 20 Department of Surgery, KU Leuven–University Hospital Leuven, Leuven, Belgium 21 Department of Surgery, Skåne University Hospital, Malmö, Sweden 22 Department of Surgery, Universidad de Sevilla, Sevilla, Spain 23 Department of Surgery, Derriford Hospital Plymouth, Plymouth, UK 24 North Devon Comprehensive Hernia Centre, North Devon District Hospital, Royal Devon University Healthcare NHS Foundation Trust, Barnstaple, UK 25 Department of Surgery, Azienda Ospedaliero Universitaria di Cagliari, Cagliari, Italy 26 Department of Surgery, Gross-Sand Hospital Hamburg, Hamburg, Germany 27 Department of Surgery, Ospedale Civile di Montebelluna, Montebelluna, Italy 28 Westmead Clinical School, Sydney Medical School, University of Sydney, New Galles, Australia 29 Department of Surgery, Bodden-Kliniken Ribnitz-Damgarten GmbH, Ribnitz-Damgarten, Germany 30 Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, P.M.B., Kumasi, West Africa 31 Department of Surgery, Onze Lieve Vrouwe Gasthuis Hospital, Amsterdam, The Netherlands *Correspondence to: Cesare Stabilini, Policlinico San Martino IRCCS, Largo R. Benzi 10, 16132, Genoa, Italy (e-mail: [email protected]) Abstract Background: Groin hernia repair is one of the most common operations performed globally, with more than 20 million procedures per year. The last guidelines on groin hernia management were published in 2018 by the HerniaSurge Group. The aim of this project was to assess new evidence and update the guidelines. The guideline is intended for general and abdominal wall surgeons treating adult patients with groin hernias. Method: A working group of 30 international groin hernia experts and all involved stakeholders was formed and examined all new literature on groin hernia management, available until April 2022. Articles were screened for eligibility and assessed according to GRADE methodologies. New evidence was included, and chapters were rewritten. Statements and recommendations were updated or newly formulated as necessary. Results: Ten chapters of the original HerniaSurge inguinal hernia guidelines were updated. In total, 39 new statements and 32 recommendations were formulated (16 strong recommendations). A modified Delphi method was used to reach consensus on all statements and recommendations among the groin hernia experts and at the European Hernia Society meeting in Manchester on October 21, 2022. Conclusion: The HerniaSurge Collaboration has updated the international guidelines for groin hernia management. The updated guidelines provide an overview of the best available evidence on groin hernia management and include evidence-based statements and recommendations for daily practice. Future guideline development will change according to emerging guideline methodology. Received: February 13, 2023. Revised: July 05, 2023. Accepted: July 16, 2023 © The Author(s) 2023. Published by Oxford University Press on behalf of BJS Foundation Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. BJS Open, 2023, zrad080 https://doi.org/10.1093/bjsopen/zrad080 Guideline Downloaded from https://academic.oup.com/bjsopen/article/7/5/zrad080/7325871 by guest on 14 July 2025 Introduction The European Hernia Society (EHS) has published eight clinical guidelines on all hernia types except diaphragmatic hernias since 2009. The largest project was the (HerniaSurge) International Guidelines for Groin Hernia Management 1 . Fifty expert hernia surgeons, representing all six international hernia societies and the European Association for Endoscopic Surgeons (EAES), published these evidence-based guidelines, including 128 statements and 88 recommendations. Consensus voting sessions were held at international meetings of the EHS, EAES, American Hernia Society and Asia Pacific Hernia Society 2 . The HerniaSurge guidelines were published in 2018, with the literature deadline being January 2015. Despite a high number of citations that have made HerniaSurge one of the most cited papers in hernia literature, adoption in everyday practice has been limited. Surveys published on the uptake of the recommendations have shown wide variability in the choice of treatment, despite clear guidance in favour of one intervention over another. A recently published paper reported a rate of adoption of laparoscopy below 42 per cent to treat patients with an appropriate indication 3 . Ehlers et al. 4 published how female sex is a risk factor for not receiving a treatment consistent with guidelines and being unhappy with results when undergoing surgery for inguinal hernia. The same group 5 tried to explore possible determinants of deviations from recommendations through semi-structured qualitative interviews and realized that factors such as personal beliefs and autonomy of the surgeon and access to resources (availability of devices) are the most relevant influencing factors in the choice of treatment. These observations have highlighted the issues surrounding the publication of evidence-based guidelines that may not be able to be implemented due to barriers and local factors. The guideline expiry date was June 2018. In June 2020, the HerniaSurge committee members decided to update key chapters where recent publications could alter the statements and/or recommendations published in the ‘expired’ guidelines. The aim of the present document is to provide updated statements and recommendations pertaining to specific key questions (KQs) from the previous version of HerniaSurge where new evidence is available. Secondary aims include improving patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. Methodology In 2020 the steering committee of the HerniaSurge collaboration formed a working group (WG) of hernia experts to update the groin hernia guidelines. At the start of the update process, formal tools to help prioritizing key questions were not available 6 . The project was developed from EHS executive board meetings, proposals from the advisory board of quality and on the basis of transparent criteria. These criteria included the time elapsed from the last search in the first publication, availability of new evidence and relevance of the topics. Usually, guidelines are updated in a period ranging from two to five years from their last search 7 ; at the time of decision, it was five years since publication, making a new update a priority. The secretary of quality monitors the literature, keeping track of all the new published papers. A working group of senior authors of HerniaSurge was formed and, after consensus, the most relevant topics were chosen and the related KQs prioritized on the basis of presence of new RCTs or systematic reviews and meta-analyses. Ten of the 28 chapters were selected for the update. Chapter development group composition and stakeholders’ involvement Teams of 4–6 members were created to perform the task of updating individual chapters (Table 1). At least two prior authors of the expired guidelines were invited for each chapter. Young surgeon researchers were added to join these teams where possible. A total of 18 HerniaSurge experts and 12 new members were appointed. The same group voted on recommendations after discussion. It is acknowledged that a certified guideline methodologist would have been preferred to help inform these guidelines; however, due to the coronavirus disease 2019 (COVID-19) pandemic this was not practical. Cochrane experts were consulted for the literature search and provided training on Grade methodology. Subsequently we have relied on the group experience in guideline methodology. Conflicts of interest were expressed prior to updating the guideline and the numbers of experts meant that a wide breadth of experience was available for recommendations. In each chapter, a balance was sought among members with strong opinions and neutral members. The former were deemed crucial to select and appraise the evidence, the latter were involved in the draft of the chapter to avoid influence and bias coming from strong opinions. In all cases recommendations and statements were presented to the whole panel and subsequently voted through online anonymous surveys. The composition of the group was planned also according to the multidisciplinary aspect of some of the key questions. Two anaesthetists (N.V.V., E.A.), both experts in abdominal wall and pain management, were involved from the beginning in the update process and were responsible for the chapter on anaesthesia and chronic postoperative pain. Two representatives of low-income countries (M.Y., C.O.) were also included in the group that analysed literature on alternative meshes in low-resource settings. Patient representatives were involved thanks to a spontaneous group formed on Facebook called ‘Hernia Patients Support Group’ that EHS helps facilitate. This group comprises 3000 members that have had hernia surgery or are on a waiting list for abdominal wall defect and officially engages with EHS. A formal call was launched, and five patients joined the working group for consultation. They were asked to rate the most relevant outcomes according to their values and preferences as well as the thresholds for the decision on these outcomes. They received written materials in plain English, explaining methodology, KQs, basics of treatment options, main findings of the literature review as well as the recommendations. The document containing the manuscript was also provided for evaluation. Finally, the recommendations were discussed with them in an online meeting with the steering committee to explore level of agreement, suggestions, patients’ perspectives and values pertaining to the final statements and recommendations. It was not possible to include patient representatives from low-income countries. These guidelines are an update from the level 1 publications that informed the original guidelines. It was decided that the same methodology would be used from the HerniaSurge 2018 guidelines. The current standards for guideline production are 2 | BJS Open, 2023, Vol. 7, No. 5 Downloaded from https://academic.oup.com/bjsopen/article/7/5/zrad080/7325871 by guest on 14 July 2025 changing and new tools for evidence appraisal are available with better external validity and reliability (AMSTAR 2, RoB2, ROBINS-I). The steering committee decided to adopt the same tools already used in the older version of HerniaSurge. In order to be consistent with the past document, the Scottish Intercollegiate Guidelines Network (SIGN) checklists were adopted in the preparation of this update. A literature search was performed for all level 1 evidence and large registry studies using the search term ‘inguinal hernia’ and recorded in Endnote reference manager. The search was performed in PubMed, PubMed Central, MEDLINE, The Cochrane central registry of controlled trials, Google Scholar and Embase. The last literature search was performed on 1 April 2022. Additionally, all teams conducted literature searches. Each team analysed the search results, made a final selection of articles (according to the PRISMA flowcharts), analysed the included articles and created evidence tables. This process started in June 2020 and ended August 2022. The principles of guideline development were followed according to SIGN, Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. Where possible, Patients, Intervention, Comparator, Outcome (PICOs) were developed for comparison of the techniques individually or clustered. The search terms, PICOs, PRISMA charts and tables with articles are published in supplementary material. Due to the COVID-19 pandemic, there were some delays in the process and face-to-face meetings were not possible. During a second online meeting, an expert consensus meeting was organized. The results of each chapter were presented and discussed by all members. A modified Delphi method was used to vote on all statements and recommendations. Refraining from voting was not allowed. Consensus was defined as at least 70 per cent agreement among experts. All statements and recommendations that did not reach consensus were re-evaluated by the responsible teams. The content was reconsidered and/or reformulated. After revisions, a follow-up expert consensus meeting was held online (August 2022). Revised statements and recommendations were presented and voted on by all experts. Finally, consensus was reached on all statements and recommendations of the updated guideline on groin hernia management among the experts (Table 2). The consensus methodology used for the updated guideline was similar as in the previous guideline 2 . A total of 23 statements and recommendations were presented at the EHS meeting in Manchester on 21 October 2022 and voted on in order to get feedback and comments from delegates. According to EHS strategy, this is possibly the last update of guidelines as a set of several key questions. In the future, each new updated chapter will be published as a separate document to allow the easier update of a single KQ instead of the entire Guideline. Each chapter in the present update is structured as in a traditional guideline: • A summary is provided to help the reader in understanding the process and the challenges encountered in the preparation of the evidence and their appraisal. •A grid with the final recommendation, level of evidence and strength of recommendation (statements are included whenever needed as findings supporting the recommendation). • A general introduction. • Results of evidence search and detailed description of relevant data. • Discussion with evidence appraisal containing the criteria used to produce the updated recommendation. According to the GRADE method, scientific evidence is not the only guidance but other factors (patients’ values, desirable and undesirable effects, balance among them, cost effectiveness, acceptability, equity and feasibility) are incorporated in the process to inform decisions in a structured and transparent manner. Table 2 Level of consensus after each expert consensus meeting First expert consensus meeting Second expert consensus meeting Third expert consensus meeting Consensus: 71 items No consensus: 14 items Consensus: 33 items No consensus: 7 items Consensus: 39 items No consensus: 0 items Table 1 Team composition of the updated guideline on groin hernia management Chapter Team 6a. Tissue repair Lorenz (DE), Wiessner (DE), Chen (USA), Miserez (BE) 6d. Open preperitoneal repair Berrevoet (BE), Lopez-Cano (ES), Garcia-Alamino (ES), Lorenz (DE) 6f. Laparo-endoscopic repair Simons (NL), Köckerling (DE), Lopez-Cano (ES), Tran (AUS), Verdauguer (ES) 8. Occult DeBeaux (UK), Burgmans (NL), Reinpold (DE), East (CZE), Stabilini (IT) 10. Mesh Burgmans (NL), Köckerling (DE), Montgomery (SE), Kukleta (CH) 12. Antibiotic prophylaxis Kockerling (DE), Montgomery (SE), Henriksen (SE), Aufenacker (NL) 13. Anaesthesia Agresta (IT), van Veenendaal (NL), Sartori (IT), Simons (NL) 19. Chronic pain treatment Miserez (BE), Zwaans (NL), Loos (NL), Pawlak (UK), Aasvang (DK), van Veenendaal (NL), Chen (USA) 21. Emergency Pawlak (UK), de Beaux (UK), Agresta (IT), Podda (IT), East (CZE), Morales-Conde (ES) 28. Non-commercial mesh Sanders (UK), Berrevoet (BE), Oppong (UK), Yeboah (GH), Simons (NL) AUS = Australia; BE = Belgium; CZE = Czech Republic; DE = Germany; DK = Denmark; ESP = Spain; IT = Italy; NL = Netherlands; SE = Sweden; UK = United Kingdom; USA = United States of America; GH = Ghana; CH = Switzerland. Stabilini et al. | 3 Downloaded from https://academic.oup.com/bjsopen/article/7/5/zrad080/7325871 by guest on 14 July 2025 Chapter 6a–b. Mesh or non-mesh and best non-mesh repair Key Question 1: Which is the preferred repair method for inguinal hernias: mesh or non-mesh? Key Question 2: Which non-mesh technique is the preferred repair method for inguinal hernias? Introduction In the HerniaSurge guidelines, a mesh-based technique was recommended as first choice for all groin hernias 1 . It was stated that there was not enough evidence to support the use of a Shouldice in L1 and L2 inguinal hernias unless a shared decision with the patient was made. More research was advised to help clarify this issue. Subsequent to the publication of the International HerniaSurge Guidelines, there has been global interest and public concern regarding the possible deleterious effects of mesh 8 . Patients, healthcare providers and surgeons have shared their concerns over potential risks associated with mesh repair and possible consequences for patients. There are scientific, social, medicolegal, economic, societal and personal implications surrounding this issue. In this chapter, the evidence is updated with the same key questions as in the original HerniaSurge guidelines. In this introduction a summary of the evidence concerning factual and feared adverse effects of mesh use is offered. The potential risks of mesh are also extensively described in the HerniaSurge Guidelines chapter 10, which is not being updated this year 1 . It is important to reiterate that the literature demonstrates the benefit and safety of mesh prostheses. However, the following complications of mesh repair, whether due to prosthetic or surgical technique, have been observed and should be taken into consideration when advising patients’ treatment options. Mesh, especially small pore meshes and three-dimensional mesh gadgets, have been found to shrink, migrate, or erode into adjacent structures, serving as a common mechanism for chronic post-inguinal hernia repair pain 8–11 . Dysejaculation and pain associated with sexual activity have been reported as a complication of mesh inguinal hernia repair, although other studies have demonstrated an improvement in sexual function and fertility with hernia repair 10,12 . Mesh repair, especially with preperitoneal mesh placement, confers the potential for rare visceral complications because of the proximity to adjacent organs including the colon, small intestine and bladder 13,14 . Preperitoneal mesh repair can complicate the performance of future radical prostatectomy, especially in the non-minimally invasive era of open prostate surgery 15,16 . Finally, the potential for true mesh allergy seen in autoimmune/inflammatory syndrome induced by adjuvants (ASIA)/Schoenfeld syndrome must be considered, although such cases are extremely rare relative to the global volume of mesh-based inguinal hernia repair 17,18 . Recognizing that these potential complications are infrequent, they can cause concern to such an extent that patients and surgeons in a shared decision process decide a non-mesh repair would be preferable. Key Question 1: Which is the preferred repair method for inguinal hernias: mesh or non-mesh? Results The search yielded 22 relevant publications: 1 guideline 19 , 8 systematic reviews with meta-analysis 14,20–26 , 8 randomized controlled trials 27–34 , 3 database analyses 35–37 , 1 review and 1 cross-sectional study. The quality of the articles was scored using SIGN checklists by two authors individually and where there was discrepancy a consensus agreement was reached among all four authors regarding quality. Key questions were formulated and answered with available evidence. Statements and recommendations were made depending on the strength of the evidence and on consensus of the Guidelines group. Since publication of the International HerniaSurge Guidelines for groin hernia management there were two systematic reviews with meta-analysis 21,38 and one database analysis with high quality 36 . The other five systematic reviews with meta-analysis, nine randomized controlled trials, two database analyses, one review, and one cross-sectional study were of acceptable quality. Updated Statements and Recommendations Text Level of evidence Strength of recommendation KQ 1 Statement Mesh and non-mesh repairs are effective surgical approaches in treating groin hernias, each demonstrating benefits in different areas. ☒☒☒☐ Statement Mesh-based repair reduces the risk of recurrence without increasing the risk for chronic pain. ☒☒☒☐ Statement In selected groups of patients with primary unilateral inguinal hernia repair, the Shouldice technique achieves one-year outcomes comparable to that of Lichtenstein, TEP and TAPP operations providing expertise and competence are available. ☒☒☐☐ Recommendation A mesh-based repair technique is recommended for the majority of patients undergoing inguinal hernia repair. ☒☒☒☐ Strong Recommendation A non-mesh repair for inguinal hernia repair can be suggested after careful patient selection and shared decision-making if expertise is available. ☒☐☐☐ Weak KQ 2 Statement The Shouldice technique has lower recurrence rates than other suture repairs. ☒☒☒☐ Statement The Desarda technique has a shorter learning curve compared to the Shouldice technique with favourable preliminary outcomes. There is insufficient high-quality long-term data on recurrence and chronic pain to make recommendations on generalized adoption. ☒☒☐☐ Recommendation The Shouldice technique is recommended in non-mesh inguinal hernia repair. ☒☒☒☐ Strong 4 | BJS Open, 2023, Vol. 7, No. 5 Downloaded from https://academic.oup.com/bjsopen/article/7/5/zrad080/7325871 by guest on 14 July 2025 High-quality systematic reviews, meta-analysis and database studies A recently updated 2018 Cochrane meta-analysis of RCTs on the use of mesh versus no mesh in inguinal (and femoral) hernia repair (studies included up to 9 May 2018) concluded that mesh and non-mesh repairs are effective surgical approaches in treating hernias, each demonstrating benefits in different areas. Compared to non-mesh repair, mesh repairs reduce the rate of hernia recurrence and neurovascular injury. Non-mesh repair is favoured because of less seroma formation and in low-income countries due to significantly lower cost and lack of availability of meshes. Recurrence Current data show persistent high recurrence rates over 10 per cent with all operation techniques in more than 300 000 patients in registry data (Mayo Clinic, ACS-NSQIP, Premier Database) 39 . Mesh reduces the risk of recurrence (moderate quality of evidence) despite higher seroma formation. In absolute numbers, one hernia recurrence was prevented for every 46 mesh repairs compared with non-mesh repairs 19,20 . In a Database registry analysis of female patients, no significant differences in the recurrence rate were reported between Shouldice, transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) hernia repairs 35 . The long-term follow-up update from the RCT by Barbaro et al. 31 reported a 20-year recurrence rate of 9.7 per cent for the Shouldice operation 31 . This was quite favourable versus a recurrence rate of 25.7 per cent for the TEP procedure. However, while this study gives a unique longitudinal assessment of the well-established Shouldice technique, it likely misrepresents the efficacy of the standardized minimally invasive TEP repair found in modern practice. The authors stress that at the time of the initial study (1992–1994), laparoscopic (hernia) repair was still developing without a standardized technique, which contributes to the unfavourable and inconsistent results for TEP 31 . Chronic pain A meta-analysis and network analysis of all available RCTs in inguinal hernia repair showed no differences in the presence/ severity of chronic pain between Shouldice, Lichtenstein and laparoscopic repairs, with up to 5 years postoperative follow-up 25 . With respect to possible male infertility after surgery, mesh does not seem to have a negative effect 27 . The 2018 database study by Köckerling showed that after 1 year, there was lower pain at rest and on exertion (but not requiring additional treatment) in favour of the Shouldice versus the Lichtenstein technique. When the Shouldice technique was compared with TAPP or TEP, no differences for these outcome parameters could be found 36 . The second study analysing only women did not show any difference regarding pain at 1 year between the Shouldice technique, TAPP and TEP. By contrast, the Lichtenstein technique had disadvantages versus TAPP and TEP in terms of pain on exertion 35 . Key Question 2: Which non-mesh technique is the preferred repair method for inguinal hernias? Results The search yielded 21 relevant publications: 1 high-quality systematic review 40 , 1 high-quality database study 36 , 1 database study concerning female patients of acceptable quality 35 , 1 database study comparing Lichtenstein with annulorrhaphy of acceptable quality 37 , 11 RCTs in which Desarda and Lichtenstein were compared, 1 RCT in which Shouldice and TEP were compared with 20-year follow-up 31 , 1 study on femoral hernias 27 , and 4 cohort studies concerning herniotomy (low level) 41–44 . The latter articles were best evidence but low quality level. Shouldice repair All statements and recommendations regarding the primacy of the Shouldice repair among non-mesh-based tissue techniques remain unchanged from the previous Guidelines. The Shouldice technique remains the best evaluated and best standardized non-mesh-based tissue repair. A large database study reporting 1-year follow-up by questionnaire from Germany has shown no significant differences in selected inguinal hernia cases (mean age 40 years old, 30 per cent women, smaller defects < 3 cm, average BMI 24, and no risk factors) regarding the recurrence rate in Shouldice repair compared to TAPP, TEP and Lichtenstein 36 . Shouldice repair has lower recurrence rates than other suture repairs and favourable outcomes in primary inguinal hernia repair. Recent data with only short- to medium-term outcomes have supported that Shouldice tissue repair is an acceptable choice for primary hernia repair under certain circumstances. There was one long-term-follow-up study after Shouldice repair under local anaesthesia performed by trainees with a recurrence rate of 2.88 per cent after 18 years (80 per cent follow-up) and moderate or severe pain of 1.8 per cent after 3 years 45 . Two high-quality database studies have shown for selected groups of patients with specific hernia characteristics (that is, smaller indirect and direct hernias <3 cm, female sex after exclusion of any femoral hernia, younger patients under 40, and lower average BMI of 24) that the Shouldice technique can be used for primary unilateral inguinal hernia repair if expertise is present, achieving 1-year outcomes comparable to that of Lichtenstein, TEP and TAPP operations 35,36 . In addition to the updated Cochrane Review, a systematic review about the Shouldice technique was recently published along with a standardized protocol of the operation technique including clear key points under supervision of the Shouldice hospital 46 . This paper identified the following indications for the Shouldice technique, suggested mainly based on low evidence: • primary indirect and small direct inguinal hernias in young men (EHS-Classification LI, LII, MI) below 40 years • primary indirect and direct hernias in women after ruling out femoral hernias (EHS-Classification LI, LII, MI, MII) • recurrent indirect hernias following primary TAPP or TEP (EHS-Classification LI, LII–R1) 46 . Desarda repair In the HerniaSurge guidelines, the Desarda repair did not have enough scientific evidence of acceptable quality to make any specific statements or recommendations. Several studies including RCTs, systematic reviews and meta-analyses report currently the equivalence of the Desarda and Lichtenstein techniques regarding recurrence. Several RCTs of different methodological quality comparing Lichtenstein and Desarda techniques in elective primary inguinal hernia repair have been published. There are three meta-analyses comparing the Desarda and Lichtenstein techniques with acceptable quality 22,23 and one more recent meta-analysis with high quality 21 . Based on these data, the Desarda technique can achieve equivalent recurrence rates to Lichtenstein mesh repair. Stabilini et al. | 5 Downloaded from https://academic.oup.com/bjsopen/article/7/5/zrad080/7325871 by guest on 14 July 2025 There are no RCTs that directly compare the Desarda and Shouldice techniques. The meta-analysis by Bracale et al. indirectly compared the Desarda technique with the Shouldice technique by using studies that compared these techniques with the Lichtenstein repair 40 . However, the available data on Desarda repair have some limitations and potential for bias. Only five RCTs report recurrence rates with a follow-up of 2 years or longer 28,29,33,47,48 . The quality of these studies, duration of follow-up and level of evidence is heterogeneous. Further high-level studies are needed to support these findings. The role of the Desarda technique in patients with larger indirect hernias and especially direct hernias (with potential underlying collagen deficit) is unclear for the moment, not only with respect to the long-term outcome but also regarding technique. There is no clear standard protocol delineating limitations of the Desarda technique as well as operative technique and modifications for hernia subtypes (for example, opening of the transversalis fascia to exclude femoral hernias). In addition, all RCTs specifically excluded patients with a divided, thin or weak external oblique fascia, and although this is probably a minority, this is a rather subjective criterion that would confer a selection bias. Additionally, some studies excluded patients with chronic obstructive pulmonary disease (COPD), chronic cough and other co-morbidities. Finally, there does not seem to be a consensus on the suture technique and material used to fixate the strip of the released external oblique fascia cranially and caudally. The data on the occurrence and severity of chronic pain between Lichtenstein and Desarda are neither designed or powered in the included studies to reasonably answer this question. Due to the lack of a clear definition and timing of evaluation of chronic pain, they have not been included in the present meta-analyses. All comparative RCTs have been performed using a standard ‘normal pore’ polypropylene mesh in the Lichtenstein arm, whereas it has been suggested in previous guidelines and confirmed recently that the use of large pore meshes in the Lichtenstein technique is beneficial in decreasing the rate of moderate/severe chronic pain or foreign body sensation 16 . For other operative parameters and perioperative outcomes such as operation time and early convalescence, the Desarda technique demonstrates some benefit 32 , although this finding is not universal and is not reflected in the current meta-analysis. For now, the Desarda technique is an interesting option as a pure tissue repair because of its simplicity, based on a low number of small RCTs of mostly acceptable quality. As there is insufficient high-quality data on long-term recurrence rate, incidence of chronic pain and patient selection, it is too early to recommend this technique for everyday practice as an alternative to the well-established Shouldice repair. Other pure tissue repairs There is no current high-level evidence to provide specific statements or recommendations on other tissue-based techniques including Marcy, Moloney darn or Bassini as an alternative to the Shouldice repair. As they are still used in low-resource regions the evidence is described. Annulorrhaphy/Marcy repair High ligation of the inguinal hernia sac (Marcy repair) is a standard procedure for most paediatric hernias. There are a few mostly cohort studies that address annulorrhaphy with high ligation for 12–29-year–old male patients including long-term follow-up demonstrating low and acceptable recurrence rates and low cumulative reoperation rates 37,41–43 . Taking into consideration that the same group of young male patients has a higher risk of developing chronic pain after mesh repair, annulorrhaphy could be offered as an alternative for young men with small indirect inguinal hernias wishing to avoid a mesh-based repair, albeit with a known higher rate of recurrence (4.8 per cent on telephone follow-up) and reoperation rate of 8.1–14 per cent (median follow-up 15 years) 37 . Moloney darn A modified version of the older, but recently re-popularized, non-mesh Moloney darn technique demonstrates comparable outcomes to the Lichtenstein mesh technique, but the quality and validity of these studies do not support specific statements or recommendations. It remains problematic that there are several different ‘modified’ techniques, as described by the extensive systematic review by Finch et al. 24 . Analysis of the RCTs include two (low-quality) papers including 473 patients with a follow-up longer than 1 year demonstrating comparable outcomes with Lichtenstein for recurrence rate (between 0 and 1 per cent) 49,50 , but only the paper by Kucuk et al. reports on the incidence of chronic pain (0.6 per cent in the non-mesh technique), without sufficient details regarding methodology 50 . All other included studies are of insufficient quality. Discussion The analysis of tissue-based inguinal hernia repairs especially in comparison to mesh-based techniques includes many different specific operations with significant heterogeneity in methodology and technique. Aside from the Shouldice repair, there is no clear standardization of patient selection, operative technique and decision-making based upon hernia subtypes. The specific non-mesh repairs with available evidence include Shouldice, Desarda, Marcy and Moloney darn techniques. There are no comparative RCTs between the various non-mesh techniques, particularly the Desarda and Shouldice techniques, and no comparative studies between minimally invasive and pure tissue procedures. Proficiency in surgical technique and patient selection make rigorous comparison challenging in even the highest-quality studies. As with all techniques, surgeons’ expertise will influence the results of comparative studies of all operation techniques 44 . HerniaSurge guidelines have recommended a tailored approach to inguinal hernia management including being proficient in offering patients both an anterior and a posterior approach 1 . As tissue repair can be indicated in cases of infection and in a shared decision with a patient it is recommended that surgeons master the Shouldice technique or refer patients to a surgeon experienced in the technique. The Shouldice is the best non-mesh technique, but has an unknown but long learning curve. Patients’ values and preferences inherent to Chapter 6a–b During the meeting patients were asked their perspectives and level of agreement or disagreement on the document. They agreed with the strength and direction of recommendations. During discussion, the importance of the surgeon’s experience in performing tissue repair was highlighted, acknowledging the issue represented by the reduced number of surgeons trained in this type of procedure. Shared decision-making is crucial between surgeon and patient to select the optimal technique. 6 | BJS Open, 2023, Vol. 7, No. 5 Downloaded from https://academic.oup.com/bjsopen/article/7/5/zrad080/7325871 by guest on 14 July 2025 Summary The HerniaSurge recommendation to use mesh in all adult patients was altered to the use of mesh in the majority of patients (consensus 88 per cent). Although there is high evidence that mesh repair is superior to non-mesh, there are cases in which a non-mesh repair can be suggested. Due to concerns regarding the use of permanent mesh, related to adverse events in other surgical fields, some patients search for surgeons who are prepared to offer tissue or non-mesh repairs. There are some clinical scenarios where the use of permanent mesh is contraindicated, for example in some infected operative fields. There are parts of the world where mesh is not available or affordable. There is some discussion concerning the value of non-mesh hernia repairs in young male patients with an L1–2 hernia. The evidence for this is very low and does not allow for a recommendation. Shouldice is the best non-mesh repair, although the experts agreed that it has a learning curve that should not be underestimated. In countries where mesh material is available it is infrequently used, and further training is needed but is not always readily available. Chapter 6d Update. Which is the preferred open-mesh technique for inguinal hernias: Lichtenstein or any open preperitoneal technique? Key Question 1: Is there new evidence concerning open posterior (preperitoneal) versus open anterior repair (Lichtenstein) for inguinal hernias? Key Question 2: Is there new evidence concerning open posterior (preperitoneal) versus laparo-endoscopic repair (TAPP or TEP) for inguinal hernias? Introduction In the HerniaSurge guidelines, it was suggested that open preperitoneal mesh repairs may result in less short-term postoperative and chronic pain as well as a faster recovery compared to the Lichtenstein repair. However, the use of these often non-flat meshes leads to higher costs and some of these approaches use both anterior and posterior anatomical planes. In this chapter the role of the open preperitoneal technique versus the open anterior repair and open preperitoneal technique versus posterior laparo-endoscopic approach are updated. Key Question 1: Is there new evidence concerning open posterior (preperitoneal) versus open anterior repair (Lichtenstein) for inguinal hernias? Results The search yielded 11 relevant publications (2 meta analyses, 7 RCTs 51–55 and 2 registry analyses 56,57 ). The quality of the articles was scored using SIGN checklists by two authors (F.B., R.L.) individually, and where there was discrepancy a consensus agreement was reached among all four authors with regard to quality. Updated Statements and Recommendations Text Level of evidence Strength of recommendation KQ 1 Statement Currently available open preperitoneal mesh techniques can achieve comparable results in terms of recurrence rate compared to the Lichtenstein technique. There is not enough evidence to compare results between different open preperitoneal techniques. ☒☒☐☐ Statement Open preperitoneal mesh techniques can achieve favourable results in terms of operating time, acute and chronic postoperative pain and return to work compared to Lichtenstein repair. ☒☒☐☐ Statement There is no evidence regarding the best technique to treat recurrence after former open preperitoneal repair. Repair might be more complex as both the anterior and posterior anatomical planes may have been used in some of those techniques. ☒☒☐☐ Recommendation In open surgery a preperitoneal flat mesh technique seems to be an acceptable alternative, providing expertise and competence are available, with at least equal results as Lichtenstein repair. ☒☒☐☐ Weak KQ 2 Statement No recommendation to advocate laparo-endoscopic preperitoneal mesh placement over open preperitoneal repairs can be made due to insufficient and heterogeneous data. However, there are patients and hernia characteristics that warrant a Lichtenstein or an open preperitoneal mesh technique as first choice. ☒☐☐☐ Stabilini et al. | 7 Downloaded from https://academic.oup.com/bjsopen/article/7/5/zrad080/7325871 by guest on 14 July 2025 Since publication of the HerniaSurge guidelines for groin hernia management, two meta-analyses are available 58,59 . They both concluded that there is at least equivalence of the different open preperitoneal techniques compared to the Lichtenstein repair. The seven RCTs showed comparable results as well, but most favour the open preperitoneal techniques in terms of pain 34,51,54,55,60 and demonstrated quicker convalescence compared to an anterior mesh repair. These findings partly change the recommendations and conclusions published in the previous HerniaSurge guidelines. The concerns regarding the use of three-dimensional meshes such as in the Gilbert technique and the TIPP (transinguinal preperitoneal) technique are only theoretical and not evidence-based 56,57 . The group of open preperitoneal techniques comprises several techniques. The specific transinguinal preperitoneal techniques include TIPP (Pelissier, Kugel), MOPP (minimal open preperitoneal), TREPP (transrectus extraperitoneal), the Onstep and the Gilbert technique. The evidence of all subgroups is low. Conclusion update: • Although the available evidence is rather heterogeneous concerning surgical techniques used for an open preperitoneal mesh placement, they are all at least comparable or favour the open preperitoneal techniques compared to the Lichtenstein approach in terms of recurrence rate, short-term postoperative pain and recovery time. • Concerns regarding the use of three-dimensional or non-flat meshes (mesh plugs are not considered as a preperitoneal mesh technique) seem only theoretical and are not based on evidence. The dissection technique conducted in the plane used for eventual recurrent repair could be a complicating factor. Key Question 2: Is there new evidence concerning open posterior (preperitoneal) versus laparo-endoscopic repair (TAPP or TEP) for inguinal hernias? The search yielded four relevant publications (three RCTs 61–63 and one observational comparative analysis 64 ). The quality of the articles was scored using SIGN checklists by two authors (M.L.C., C.S.) individually, and where there was discrepancy a consensus agreement was reached among all four authors with regard to quality. Since the publication of the HerniaSurge guidelines for groin hernia management only three studies comparing the TEP technique versus the open preperitoneal technique have been published. The three RCTs are of acceptable but low quality with a lack of information regarding bias control. They all showed comparable results between the laparo-endoscopic TEP and the open preperitoneal technique. However, the analysed outcomes have been heterogeneous: activity parameters of the lower extremity muscles, quality of life or postoperative complications in the different studies. The comparator ‘open preperitoneal’ has also been heterogeneous, because in some studies an open approach has been used with maximum exposure of the preperitoneal space and in others only minimal exposure was required. Therefore, the results are impossible to interpret given the scarcity of data and patients analysed and no statement or recommendation can be made regarding the question whether in male patients with a unilateral primary inguinal hernia the preferred repair is a laparo-endoscopic or open preperitoneal technique. Conclusion update: • The available evidence remains heterogeneous and outcomes, although variable, seem to show equivalence between the open versus laparo-endoscopic preperitoneal repair techniques. • These findings strengthen the statements published in the previous HerniaSurge guidelines. Patients’ values and preferences inherent to Chapter 6d Patients’ preferences are substantially concordant with panel recommendation direction and strength. Their choice for intervention is connected to the minimization of adverse effects, improved recovery time and early discharge from hospital. A unanimous concern is expressed over those techniques that, violating both preperitoneal space and inguinal canal, can be difficult to manage if recurrence occurs. Summary In the HerniaSurge guidelines, it was suggested that the open preperitoneal mesh repairs may result in less short-term postoperative and chronic pain as well as a faster recovery compared to the Lichtenstein repair. However, the use of these often non-flat meshes leads to higher costs and some of these approaches use both anterior and posterior anatomical planes. In this update it is concluded that there is no scientific evidence that open preperitoneal techniques (of different types) are inferior to Lichtenstein hernioplasty. Indeed, some studies report slightly less postoperative pain. There is no evidence that a recurrence after a preperitoneal mesh repair is more challenging or has a higher risk of complications. Statements that open preperitoneal mesh techniques might show favourable results in terms of operation time, short-term postoperative pain and convalescence compared to Lichtenstein repair and that there is no evidence that the use of non-flat or pre-shaped meshes leads to more postoperative complications received consensus (72 per cent). The recommendation that preperitoneal techniques can be suggested as a good option compared to Lichtenstein repair received a consensus of 72 per cent and after discussion the experts in these techniques (diverse and with follow-up of 3 years) advised that they can be suggested as an alternative to a Lichtenstein repair. However, HerniaSurge and the current WG have a majority albeit only expert opinion that the open preperitoneal technique could have a major downside in comparison to Lichtenstein, as dissection often goes through the groin anteriorly, has a longer learning curve than Lichtenstein repair and uses more frequently specifically engineered meshes, which makes the technique more expensive. No recommendation can be made comparing open preperitoneal techniques to TEP or TAPP, although one RCT was published after our deadline 65 . 8 | BJS Open, 2023, Vol. 7, No. 5 Downloaded from https://academic.oup.com/bjsopen/article/7/5/zrad080/7325871 by guest on 14 July 2025 Chapter 6f. Open (Lichtenstein) versus laparo-endoscopic repair in unilateral uncomplicated inguinal hernia repair Key Question: When considering recurrence, pain, learning curve, postoperative recovery and costs, which is the preferred technique for primary unilateral inguinal hernias: best open mesh (Lichtenstein) or a laparo-endoscopic (TEP and TAPP) technique? Introduction The EHS guidelines advocate for open Lichtenstein and laparoendoscopic inguinal hernia techniques (TEP and TAPP) as the best evidence-based options for repair of primary unilateral inguinal hernias, provided the surgeon is sufficiently experienced and resources needed are available for the specific procedure 1,66,67 . TEP and TAPP are superior regarding recovery, postoperative pain and chronic pain. Furthermore, laparo-endoscopic techniques seem to be safe and cost-effective in high-volume centres and expert hands. Nonetheless, according to previous guidelines 1 there is a well-documented difference in learning curve and initial costs favouring Lichtenstein. However, the studies available in this area have some limitations. They include the lack of clear definitions or end points in pain evaluation, quality of the surgeon’s technique and caseload per surgeon. With the aim to update the key question, all meta-analyses and RCTs that compared laparo-endoscopic techniques with open techniques other than Lichtenstein must be excluded as well as those that enrolled patients other than primary unilateral inguinal hernias. Results The search yielded 12 relevant publications: 4 randomized clinical trials 68–71 , 3 systematic reviews 72–74 , 2 meta-analyses 75,76 and 3 registry analyses 77–79 . The quality of the articles was scored using SIGN checklists by two authors individually (M.L., M.V.) and where there was discrepancy a consensus agreement was reached among all four authors regarding quality. Since publication of the HerniaSurge guidelines for groin hernia management, four randomized clinical trials have been published: two of acceptable quality 70,71 and two of high quality 68,69 . Three of the RCTs concluded in favour of laparo-endoscopic techniques 68,70,71 and one concluded that they are comparable in terms of recurrence and length of hospital stay as secondary outcomes 69 . Five systematic reviews and meta-analyses were found: three of high quality 72,75,76 with advantages for laparo-endoscopic techniques compared to Lichtenstein repair. There were three registry analyses found with acceptable quality. Systematic reviews and meta-analyses Meta-analyses before 2015 80–83 compared laparo-endoscopic techniques with all open procedures, except for a subgroup analysis from 2005 84 that identified advantages with the Lichtenstein operation in terms of operating time, seroma formation and recurrences, although it was strongly influenced by a trial 85 using a smaller mesh size than recommended 1,86,87 . A recent systematic review and meta-analysis 72,75 compared TAPP and TEP with Lichtenstein for primary unilateral inguinal hernias in both sexes and found better outcomes for laparo-endoscopic techniques in terms of pain (OR 0.41, 95 per cent c.i. 0.3–0.56, P ≤ 0.00001 72 ), postoperative recovery and shorter hospital stay, with the same rates of recurrence (OR 1.14, c.i. 0.51–2.55, P = 0.76 72 ). Aiolfi et al. 73 concluded both techniques were comparable in terms of chronic pain, recurrence and length of hospital stay, although including a minor percentage of rTAPP in their systematic review. Better outcomes for TAPP and TEP were also found in a late network meta-analysis 76 with regard to early postoperative pain and chronic pain (TAPP/Lichtenstein RR = 0.36, 95 per cent c.i. 0.15–0.81; TEP/Lichtenstein RR = 0.36, 95 per cent c.i. 0.21–0.54), return to work, haematoma and wound infection, with a similar recurrence rate and hospital length of stay. However, results must be carefully considered because the study includes retrospectively analysed data from a prospective registry 77 with the largest number of patients included, which could strongly influence the outcome. Updated statements and recommendations Text Level of evidence Strength of recommendation Statement When the surgeon has sufficient experience in the technique, laparo-endoscopic techniques do not take longer than Lichtenstein operations ☒☒☒☐ Statement When the surgeon has sufficient experience, no significant differences are observed in the perioperative complications needing reoperation between the laparo-endoscopic and Lichtenstein techniques. ☒☒☒☐ Statement Laparo-endoscopic techniques have less chronic pain and faster recovery than the Lichtenstein repair. ☒☒☒☐ Statement The direct operative costs for laparo-endoscopic inguinal hernia repair are higher. The difference decreases when the total community costs are considered and the surgeon has sufficient experience. ☒☒☒☐ Statement The learning curve for laparo-endoscopic techniques (especially TEP) is longer than for Lichtenstein. There are rare but severe complications mainly described early in the learning curve. It is imperative that laparo-endoscopic techniques be learned in a properly supervised manner in order to minimize complications. ☒☒☒☐ Recommendation For patients (all sexes) with primary unilateral inguinal hernia, a laparo-endoscopic technique is recommended because of a lower postoperative pain incidence and a reduction in chronic pain incidence, provided that a surgeon with specific expertise and sufficient resources is available. However, there are patient and hernia characteristics that warrant Lichtenstein as first choice (chapter 7 on individualization). ☒☒☒☐ Strong (upgraded) Stabilini et al. | 9 Downloaded from https://academic.oup.com/bjsopen/article/7/5/zrad080/7325871 by guest on 14 July 2025 Introduction After the publication of the HerniaSurge guidelines 1 , the use of a mesh continues to be an argument in favour of antibiotic prophylaxis in hernia surgery. Two recent surveys have revealed that surgeons still administer antibiotic prophylaxis in inguinal hernia surgery 134,135 even though the International Guidelines do not recommend this. That is also true for laparo-endoscopic inguinal hernia surgery 135 . Both surveys were conducted in a low-risk environment for surgical-site infections (SSIs) 134,135 . The surgeons in both surveys stated that their decision to administer antibiotic prophylaxis was in line with the scientific evidence. The findings of these surveys demonstrate just how important it is to collate and evaluate all available data on the use of antibiotic prophylaxis in inguinal hernia surgery. Accordingly, this chapter now evaluates and reports on the new studies published between January 2015 and November 2021 on antibiotic prophylaxis and SSIs in inguinal hernia surgery for their relevance to the update of the HerniaSurge guidelines 1 . The HerniaSurge guidelines stated that antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. The update aimed to answer the following key question on the basis of the new studies. Results In addition to the surveys cited above 134,135 , the search yielded 12 relevant publications (Fig. 1): 1 guideline 1 , 4 meta-analyses 72,136–138 , 3 systematic reviews 139–141 and 4 large database studies 142–145 . Comparison of outcome in open groin hernia repair with and without antibiotic prophylaxis Meta-analyses Since January 2015 three new meta-analyses have been published on antibiotic prophylaxis (AP) in open inguinal hernia surgery 136–138 . The maximum number of included RCTs is 27 with a total of 8308 patients (Table 1). The Cochrane analysis distinguished between open suture and mesh technique as well as between high infection and low infection risk environments 136 . Studies with an SSI rate of ≥5 per cent are assigned to a high infection risk environment and those with an SSI rate of <5 per cent to a low infection risk environment. For the five studies on suture repair with 1865 patients no significant difference was identified in the SSI rate for either the high infection risk environment (8.8 per cent with AP versus 8.9 per cent without AP; P = 0.97) or the low infection risk environment (1.6 per cent with AP versus 3.2 per cent without AP; P = 0.26). Matters were different for the open mesh techniques with a total of 22 studies and 6443 patients. Nine studies reported on a low infection risk environment and 13 studies on a high infection risk environment. The nine studies conducted in a low infection risk environment reported an SSI rate of 2.6 per cent following open inguinal hernia mesh repair without antibiotic prophylaxis versus 1.8 per cent (P = 0.16) with antibiotic prophylaxis. The use of antibiotic prophylaxis for the open mesh technique in a low infection risk environment did not have a significant effect on the SSI rate 136 . However, the 13 studies conducted in a high infection risk environment identified a significant influence of antibiotic prophylaxis on the SSI rate following the open mesh technique in that it was reduced from 8.5 per cent to 4.3 per cent (P = 0.0002). As such, antibiotic prophylaxis should be administered for the open inguinal hernia mesh repair technique in a high infection risk environment. The evidence suggesting that antibiotic prophylaxis has no effect on the SSI rate in the open mesh technique in a low infection risk environment is classified by the Cochrane Collaboration as being of moderate quality. Another meta-analysis 137 investigated the influence of antibiotic prophylaxis on open mesh repair of groin hernias and included 16 RCTs with 5519 patients. Considering all RCTs, Investigations No Manual reduction Successful Observation until meets local discharge criteria. Urgent hernia repair during same admission or in timely manner depending on local system capabilities. Not successful Emergency surgery Yes Signs of strangulation? Skin changes, fever and pain Time since the onset of symptoms (>24 h) Peritonism NLR >6.5 D-Dimer >300 mg/ml Serum phosphokinase >140 lU/I Patient presenting with acutely irreducible groin hernia? Fig. 1 The proposed algorithm for the treatment of acute hernias 16 | BJS Open, 2023, Vol. 7, No. 5 Downloaded from https://academic.oup.com/bjsopen/article/7/5/zrad080/7325871 by guest on 14 July 2025 antibiotic prophylaxis significantly reduced the overall SSI incidence from 4.8 per cent to 3.2 per cent (OR 0.68, 95 per cent c.i. 0.51–0.91). However, after removal of two outlier studies, which were identified by evaluating the standard residual, the results of the meta-analysis became non-significant (OR 0.76, 95 per cent c.i. 0.56–1.02). Another meta-analysis explored the efficacy of various antibiotics for prophylaxis of SSI following open inguinal hernia surgery 138 . Fifteen RCTs with 5159 patients were included. Ten of the 15 RCTs were from a high infection risk environment 137 . The meta-analysis showed that β-lactam/β-lactamase inhibitors and first-generation cephalosporins were significantly superior to placebo, with a pooled risk ratio of 0.44 (95 per cent c.i. 0.25– 0.75) and 0.62 (95 per cent c.i. 0.42–0.92), respectively. If using antibiotics these are the family of antibiotics that are recommended 138 . Current data on the SSI rates following open and laparo-endoscopic repair of groin hernias with no information on antibiotic prophylaxis The Cochrane Collaboration meta-analysis reports an SSI rate of <5 per cent as constituting a low infection risk environment. As some of the studies included in the meta-analysis are older, this present publication aimed to collate more recent data on the SSI rates expected. No information was given in any of the studies on the use of antibiotic prophylaxis. One meta-analysis with 12 RCTs and 1926 Lichtenstein and 2040 laparo-endoscopic inguinal hernia repairs compared the SSI rates for these two techniques 139 , identifying a significantly higher SSI rate following open Lichtenstein repair (1.7 per cent versus 0.95 per cent; P = 0.09). An analysis of data from the Health Core Integrated Research database with 77 666 groin hernia repairs reported an SSI rate of 0.48 per cent for the open and 0.34 per cent for the laparo-endoscopic technique (P = 0.020) 139 . Another analysis of data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) identified SSI rates of 0.51 per cent for 45 582 open and of 0.33 per cent for 17 919 laparo-endoscopic groin hernia repairs (P = 0.002) 140 . A systematic review of the perioperative complications in inguinal hernia repair identified an overall complication rate of 2.9 per cent for 571 445 patients and an SSI rate of 0.48 per cent for 345 746 patients 141 . Another systematic review of SSIs after inguinal hernia repair performed in low and middle human development index countries identified for open groin hernia repair a rate of 4.1 per cent for open and of 0.4 per cent for laparo-endoscopic repair 143 . Antibiotic prophylaxis in laparo-endoscopic groin hernia repair For laparo-endoscopic inguinal hernia repair, HerniaSurge guidelines recommend no antibiotics in all patients and in any risk environment 1 . The search did not yield any RCT studies. The best evidence was derived from a registry-based study. The SSI rates presented demonstrate the beneficial effect of the laparo-endoscopic technique for the prevention of postoperative complications. All studies show lower SSI rates for the laparo-endoscopic technique compared with the open operation. SSI rates following the laparo-endoscopic technique have been consistently below 1 per cent, so it is not surprising that antibiotic prophylaxis did not confer any additional benefit. That was also confirmed by a multivariable analysis of data from the Herniamed registry for 48 201 patients 143 . No other potential influencing factors were identified 144 . Laparo-endoscopic groin hernia repair can be conducted independently of potential risk factors and in any risk environment without antibiotic prophylaxis. Risk factors for SSIs in open inguinal hernia repair Previous studies show a significantly higher SSI rate following open compared with laparo-endoscopic groin hernia repair. If one takes the threshold value of 5 per cent as per the guidelines of the Cochrane Collaboration, all studies are below the threshold including the open technique. The quality of groin hernia repair has improved worldwide as it is only being performed in a low infection risk environment. This suggests that based on the analysis by the Cochrane Collaboration, antibiotic prophylaxis is not required for groin hernia repair. Another analysis of data from the ACS NSQIP with 57 951 patients with primary open inguinal hernia repair identified an SSI rate of 0.4 per cent 145 . A significantly higher SSI rate was reported for diabetes mellitus, BMI ≥ 35 kg/m 2 and current smoking 145 . The multivariable analysis of data from the Herniamed registry identified additional risk factors for SSI following open inguinal hernia repair: high ASA score (ASA IV versus I: OR 5.106, 95 per cent c.i. 1.836–14.200; P < 0.001), operation for recurrence (primary versus recurrent: OR = 0.512, 95 per cent c.i. 0.339– 0.774; P = 0.001) and female sex (male versus female: OR = 0.532, 95 per cent c.i. 0.350–0.807; P = 0.003) 143 . Therefore, in low infection risk environments, antibiotic prophylaxis should be considered for open inguinal hernia in these patient groups. Patients’ values and preferences inherent to Chapter 12 Patients’ preferences are substantially concordant with panel recommendation direction and strength. No relevant comments were added to the discussion. Summary In agreement with the HerniaSurge guidelines, in an environment with low risk for infection, antibiotic prophylaxis is not recommended in open or in laparo-endoscopic inguinal hernia surgery. The expert panel are aware that these recommendations are often not followed possibly for medico-legal and cultural factors. The recommendation that antibiotic prophylaxis is not recommended in elective laparo-endoscopic inguinal hernia repair in any patient and in any risk environment was downgraded to a suggestion (weak) with consensus of 80 per cent after only achieving a 64 per cent agreement when defined as strong. The argument was that antibiotics may still be appropriate in a small group of patients with certain risk factor profiles. Stabilini et al. | 17 Downloaded from https://academic.oup.com/bjsopen/article/7/5/zrad080/7325871 by guest on 14 July 2025 Chapter 13. Anaesthesia in open inguinal hernia repair Key Question 1: What is the preferred form of anaesthesia in open inguinal hernia repair in adults with primary unilateral hernias? General, spinal or local. Key Question 2: What is the best anaesthesia in elderly and frail patients? Local, spinal or general. Key Question 3: What is the best anaesthesia in the teaching/university hospitals? Key Question 4: Is there evidence that short-acting lignocaine is safer than long-acting lignocaine in spinal (regional) anaesthesia? Key Question 1. What is the preferred form of anaesthesia in open inguinal hernia repair in adults with primary unilateral hernias? General, spinal or local. Introduction Open inguinal hernia repair can be performed under either local (LA), regional or general anaesthesia. Regional anaesthesia includes spinal, epidural and paravertebral routes. The ideal anaesthesia technique should provide good peri-/postoperative analgesia, have a low complication rate and be cost-effective. The HerniaSurge guidelines on groin hernia management recommended that local anaesthesia is preferred for open repair in reducible inguinal hernias, provided surgeons/teams are experienced in the technique. Paravertebral and epidural anaesthesia are not included in this chapter, due to limited studies on these anaesthetic techniques in inguinal hernia repair. The HerniaSurge guidelines on groin hernia management demonstrated that local anaesthesia has several advantages over general or regional anaesthesia in elective reducible inguinal hernia repairs. When compared with general anaesthesia, local anaesthesia is more cost-effective when hospital and total healthcare costs are considered and provides earlier patient mobilization and earlier hospital discharge. A review article demonstrated lower urinary retention in local anaesthesia compared to spinal anaesthesia 146 . However, hernia registry data showed that local anaesthesia is associated with an increased risk of reoperation for recurrence in open inguinal hernia repair. Results The literature review identified 75 articles (July 2015 to August 2020). After exclusion of RCTs already covered in the HerniaSurge guidelines, three RCTs 147–149 , two systematic reviews with meta-analysis 150,151 and one network metaanalysis 152 comparing different techniques in open anterior inguinal hernia repairs in adults were included in the analysis. The 2021–22 search for level 1 studies revealed one RCT of moderate quality that describes spinal versus general anaesthetic in TAPP inguinal hernia repair 153 . The RCTs were scored according to SIGN as high quality. One RCT compared LA with spinal anaesthesia 149 , one RCT compared LA with general anaesthesia 147 and one RCT analysed all three anaesthetic techniques 148 . The two RCTs comparing LA with spinal anaesthesia demonstrated that LA is effective, has good postoperative analgesia and fewer postoperative complications. The RCT by Rafiq et al. 147 showed a shorter hospital stay in LA compared with general anaesthesia. When comparing all three anaesthetic techniques, patients receiving LA could be discharged faster 148 . These results confirm the findings of HerniaSurge and do not influence the statements and/or recommendations. The systematic review by Prakash et al. 150 evaluated LA compared to spinal anaesthesia in unilateral primary inguinal hernias. The new RCT from 2016 149 was included in this systematic review in comparison to the publications used in HerniaSurge. Prakash et al. included 10 RCTs, with a total of 1379 patients. There was no significant difference in operative time between the two groups (P = 0.79). However, patients in the LA group reported significantly less pain (P < 0.01), lower rates of urinary retention (P < 0.01) and significantly increased satisfaction (P < 0.01). The conclusions confirm the findings of HerniaSurge and do not influence the statements and or recommendations. The systematic review of Argo et al. 151 evaluated all three anaesthetic techniques and included 18 RCTs. It was scored as high quality. The RCT by Zamani et al. 149 was not included in this review. The overall complication rate and surgical time were similar in LA compared to the other anaesthetic techniques (P = 0.06 resp. P = 0.86). Urinary retention and operating room time were significantly decreased in LA Updated statements and recommendations Text Level of evidence Strength of recommendation KQ 1–4 Recommendation Local anaesthesia is recommended for open repair of reducible inguinal hernias by surgeons/teams experienced with this technique. ☒☒☒☒ Strong Recommendation If performed correctly, local anaesthesia is a good alternative to general or regional anaesthesia in frail or co-morbid patients. ☒☒☐☐ Weak Statement Regional compared to general anaesthesia in patients aged 65 and older might be associated with a higher incidence of medical complications including myocardial infarction, pneumonia and venous thromboembolism. ☒☒☒☐ Recommendation General or local anaesthesia is suggested instead of regional in patients aged 65 and older. ☒☒☐☐ Weak Statement Open inguinal hernia repair under local anaesthesia can be safely performed by trainees under supervision of surgeons experienced in the administration of local anaesthesia. ☒☒☐☐ 18 | BJS Open, 2023, Vol. 7, No. 5 Downloaded from https://academic.oup.com/bjsopen/article/7/5/zrad080/7325871 by guest on 14 July 2025 (P = 0.0002 resp. P < 0.0001). Despite these advantages in favour of LA, patients under LA reported the same degree of satisfaction as the other anaesthetic techniques (P = 0.03). The literature review of the included studies showed a significantly decreased length of hospital stay and lower cost in the LA group. The conclusions confirm the findings of HerniaSurge and do not influence the statements and or recommendations. A network meta-analysis by Olsen et al. 152 included 53 studies (12 RCTs and 41 cohort studies), including 11 683 patients and rated as high quality. The aim of this study was to investigate possible differences in urinary retention and mortality after Lichtenstein repair under different types of anaesthesia. Urinary retention was seen in 0.1 per cent for LA, 8.6 per cent for regional anaesthesia and 1.4 per cent for general anaesthesia. The risk of urinary retention for regional anaesthesia had an odds ratio of 15.73 (P < 0.001) and for general anaesthesia an odds ratio of 4.07 (P = 0.04) compared with local anaesthesia. The mortality rate was zero in all three anaesthetic groups. These results strengthen the conclusions found in HerniaSurge and do not influence the statements and/or recommendations. Discussion The RCTs, two systematic reviews and the network analysis were all scored as high quality with a low risk of bias. The results are very consistent, stating that local anaesthesia has advantages over general and regional anaesthesia. A consistent lower length of stay and lower cost is seen comparing LA versus either general or regional anaesthesia as well as a very significant lower risk of urinary retention in favour of LA. In some studies, LA offers less postoperative pain and higher patient satisfaction. Few studies had pain as the primary outcome. This last conclusion is biased by a lack of information on technique specifics, additional analgesia and/or sedatives during the operation and the exact definitions of pain. Complication rates are comparable between all techniques although two registry studies 154,155 showed a possible higher risk of recurrence after LA. When considering the advantages, it is recommended to perform open reducible primary inguinal hernia repair under local anaesthesia as first choice. There was expert consensus within HerniaSurge that operating under LA requires expertise (there is a learning curve to overcome) and experience. It is generally accepted that LA is particularly suitable for frailer or co-morbid patients. Key Question 2. What is the best anaesthesia in the elderly and frail patients? Local, spinal or general. Introduction The world’s elderly population is increasing; it has been estimated that by 2050 the number of elderly people will make up about 20 per cent of the world’s population. The World Health Organization defines an elderly person as a patient over 65 years of age; however, this age limit is not universally recognized. Another limitation of the research has been the concept of frailty, because in the literature many of the studies regarding surgery in elderly and frail patients involve stratification of this population to assess operative risks. The HerniaSurge guidelines on groin hernia management report one registry study that found a higher incidence of medical complications in patients aged 65 years and older after regional anaesthesia (1.17 per cent) compared with general anaesthesia (0.59 per cent) 156 . The medical complications include myocardial infarction, pneumonia and venous thromboembolism. The recommendation is made that general or local anaesthesia is suggested over regional in patients aged 65 and older. Results Covering the period from 2015 to July 2020, using the search terms above, only one article related to this key question has been identified. Faisal et al. performed a prospective study of 100 patients on the acceptability and outcome of operating on inguinal hernias among a population over 65 years of age who are at high risk for general or regional anaesthesia. Local anaesthesia was tolerated well in 95 per cent of the patients. Pain during the procedure was seen in 3 per cent of the patients and 1 per cent reported inguinodynia. No mortality was reported. The authors conclude that local anaesthesia is well tolerated and has favourable outcomes in elderly patients who are at high risk for general or regional anaesthesia. Discussion High-quality medical evidence on the best anaesthetic technique in elderly and frail patients is lacking. Faisal’s study considered a single cohort of patients without stratification 157 . General anaesthesia seems to be associated with an increase in cognitive dysfunction in the elderly patient as well as an increased risk of developing Alzheimer’s disease 158 . Regional anaesthesia is less suitable due to a higher incidence of medical complications, and urinary retention in elderly patients. There is no evidence on health economics. Although the evidence is weak, general or local anaesthesia is suggested over regional anaesthesia in elderly and frail patients. Key Question 3. What is the best anaesthesia in the teaching hospital? Introduction Although the previous guidelines recommended the presence of an experienced supervisor for inguinal hernia surgeries performed under local anaesthesia by surgeons new to the technique, the HerniaSurge guidelines provide low evidence and make no statements or recommendations on the best anaesthetic technique for open inguinal hernia repair in the teaching hospital. Results Covering the period from 2015, no articles were identified relating to the key question using the search terms. Discussion As limited data are available on this topic, it is not possible to answer this key question. As a consequence, what has been outlined in the previous guidelines can still be considered valid. However, research is warranted to provide data on this topic. Therefore, we believe that the previous statement is still valid. Key Question 4. Is there evidence that short-acting is safer than long-acting lignocaine in spinal (regional) anaesthesia? Introduction The HerniaSurge guidelines on groin hernia management provided no evidence and made no statements or recommendations regarding the type of anaesthetic used during loco-regional anaesthesia. It was decided to review the literature regarding the use of short- or long-acting lignocaine in spinal anaesthesia for open inguinal hernia repair. Stabilini et al. | 19 Downloaded from https://academic.oup.com/bjsopen/article/7/5/zrad080/7325871 by guest on 14 July 2025 Results Covering the period from 2015, using the search terms, no articles relating to the key question were identified. Discussion As limited data are available on this topic, it is not possible to answer this key question. More research is warranted to provide data on this topic. No recommendations were formulated. Patients’ values and preferences inherent to Chapter 13 Patients’ preferences are substantially concordant with panel recommendation direction and strength. Similarly to the choice of surgical technique, it is acknowledged that there are multiple options for anaesthesia, and these should be adapted to the hernia type and patient characteristics. Patients would choose the anaesthetic option that offers the best outcomes. Summary There is high-quality evidence with low risk of bias showing that local anaesthesia (LA) has advantages over general anaesthesia and especially over regional anaesthesia. A lower length of stay and lower costs are seen comparing LA with either general or regional anaesthesia. A significant lower risk of urinary retention is seen in favour of LA. In some studies, LA resulted in less postoperative pain and higher patient satisfaction. Few studies had pain as the primary outcome, so this conclusion is less strong. The experts agreed that performing inguinal hernia repair under local anaesthesia has a learning curve. The statement that when compared with general anaesthesia, regional anaesthesia in patients aged 65 and older is associated with a higher incidence of medical complications like myocardial infarction, pneumonia and venous thromboembolism received a low consensus of 68 per cent. With increasing patient frailty and co-morbidities, the experts agreed that there are benefits to using open repair under local anaesthesia and avoiding regional anaesthesia. However, the evidence is weak. The choice for local, regional or general anaesthesia in all patients should be tailored to minimize harm. Chapter 19. Chronic postoperative inguinal pain treatment Key Question 1: What are the diagnostic modalities (including dermatome mapping, ultrasound (US), MRI (magnetic resonance imaging), CT (computed tomography) scan, infiltrations, nerve blocks) in the evaluation of postoperative chronic inguinal/scrotal/groin pain? Key Question 2: What are the possible surgical therapeutic options (including neurectomy and (partial) mesh removal) in the treatment of postoperative chronic inguinal/scrotal/groin pain? Key Question 3: What evidence is available on non-surgical therapeutic options (including role of centralization and multidisciplinary team approach) in the treatment of postoperative chronic inguinal/scrotal/groin pain? Updated statements and recommendations Text Level of evidence Strength of recommendation KQ Statement In clinical practice, trigger point infiltrations and peripheral nerve blocks can be useful in the diagnostic management of chronic pain after inguinal hernia repair. ☒☒☐☐ Statement In patients with CPIP after laparoscopic preperitoneal inguinal hernia repair, MRI of the groin can be useful, mainly to exclude other pathologies. ☒☐☐☐ Statement For chronic neuropathic pain after open hernia repair, both open neurectomy and endoscopic retroperitoneal neurectomy provide acceptable outcomes. ☒☐☐☐ Statement Painful conditions interfering with sexual function after open hernia repair can also be improved by neurectomy, release of the spermatic cord and mesh removal. ☒☒☐☐ Statement In general, there is a risk of around 30 per cent that CPIP surgery will not be effective, with even a small risk for more pain. ☒☒☐☐ Recommendation It is recommended to inform patients clearly that evidence on the effectiveness of CPIP surgery is low and comes with a risk of pain intensification and other complications. ☒☒☐☐ Strong (upgraded) Recommendation A tailored approach to CPIP surgery (neurectomy, open mesh removal or combination) is suggested depending on the original repair method, experience of the surgeon, distribution and symptoms of pain, physical findings and potential radiographic images. ☒☒☐☐ Weak Recommendation It is suggested that microsurgical spermatic cord denervation is only performed in research settings. ☒☒☐☐ Weak Statement In clinical practice, peripheral nerve blocks can be useful in the therapeutic management of chronic pain after open inguinal hernia repair. ☒☒☐☐ Statement There is low evidence of the therapeutic value of repetitive trigger point infiltrations in CPIP after Lichtenstein repair. ☒☒☐☐ Statement No benefit has been shown for lidocaine and capsaicin patch for treatment of CPIP. ☒☒☐☐ Statement Pulsed radio frequency ablation may be an effective treatment for CPIP. ☒☐☐☐ Statement Early findings suggest that neuromodulation of the dorsal root ganglia (DRG) may be an effective treatment for chronic neuropathic pain conditions in the groin region. ☒☐☐☐ Recommendation The treatment of CPIP is complex. It is recommended to centralize CPIP evaluation and treatment in specialist centres with an experienced multidisciplinary team, depending on local settings. ☒☒☐☐ Strong (upgraded) Recommendation Pharmacologic and interventional measures—including therapeutic injection therapy— are suggested to continue for a minimum of 3 months (minimum of 6 months after hernia surgery). ☒☒☐☐ Weak 20 | BJS Open, 2023, Vol. 7, No. 5 Downloaded from https://academic.oup.com/bjsopen/article/7/5/zrad080/7325871 by guest on 14 July 2025 Introduction Chronic pain is a significant complication after inguinal hernia surgery leading to disability, dissatisfaction, and impaired productivity and quality of life. The international HerniaSurge guidelines for groin hernia management were published in 2018. They included a literature review until 1 January 2015 1 . Despite various interpretations of chronic pain, the HerniaSurge guidelines stated that chronic postoperative inguinal pain (CPIP) can be defined as ‘postoperative inguinal pain including a level of discomfort rated by the patient as at least “moderate” and impacting daily activities and lasting longer than a three-month time period’. While certain predisposing neuroanatomic and technical factors can be avoided, CPIP remains a complex challenge with several psychological, social, genetic and behavioural influences. In addition, it is important to determine whether the CPIP is indeed new postoperative pain (intensity, type, location) compared to preoperative pain status. The previous HerniaSurge guidelines concluded that there is a paucity of evidence-based data on the management of CPIP. Therefore, the statements and recommendations were, respectively, (very) low evidence and weakly supported. As the guidelines needed an update, in June 2020 the HerniaSurge committee decided to review key chapters where recent publications could have an effect on the statements and/or recommendations. One of the topics distinguished by the committee was Chapter 19 on CPIP. The aim of this update is to review the most recent literature regarding CPIP and examine if previously included recommendations and statements are still valid. Additionally, the aim was to examine if there are new statements and recommendations that should be proposed in the light of new evidence in the literature. Publications from January 2015 until April 2021 were included. The original key questions were modified to three more logical new key questions. Key Question 1: What are the diagnostic modalities (including dermatome mapping, ultrasound (US), MRI (magnetic resonance imaging), CT (computed tomography) scan, infiltrations, nerve blocks) in the evaluation of postoperative chronic inguinal/scrotal/groin pain? Introduction When evaluating CPIP, it is important to perform an extensive history and physical examination. The use of an inguinal pain assessment form can be helpful to register these aspects in a standardized way. Traditionally, a distinction has been made between neuropathic and nociceptive pain due to, respectively, nerve damage or mesh interference as a cause of pain. However, it is unclear if and to what extent both pain patterns overlap and/or interfere. Therefore, it remains a question whether discrimination between both is clinically possible and useful. Still, dermatome mapping can be helpful to describe more objectively the superficial pain distribution and allows a comparison of both groins. It can also be used to document the evolution of skin sensitivity disturbances in the groin and potential peripheral and central pain sensitization 159 . After open repair, the ilioinguinal and iliohypogastric nerves are most at risk, whereas after laparoscopic repair, the genital branch of the genitofemoral nerve (and the lateral cutaneous nerve of the thigh) are more endangered. When patients present with so-called scrotal or testicular pain, it is important to differentiate between scrotal skin pain (which is often related to the genital branch of the genitofemoral nerve) versus scrotal content or true parenchymal testicular pain (orchialgia). The latter can be due to inherent testicular problems or due to involvement of the paravasal nerves in the spermatic cord 160 . In those circumstances, a formal urological evaluation is also warranted. Furthermore, it is key to obtain the original operation report(s) of the groin hernia operation(s) performed and of the different diagnostic and therapeutic actions that were already taken before. Information on interference of pain in sexual activity or work status and presence of other chronic pain problems (migraine, gynaecological, intestinal, back pain, hip, etc.) should also be documented clearly. Results One randomized study has been performed to date. Due to the lack of high-level evidence, published cohort studies will be discussed here as well. An additional two articles were selected for the present update. The study by Wijayasinghe et al. is a methodologically high-quality crossover study on US-guided local fascial plane trigger point infiltration (10 ml bupivacaine 0.25 per cent versus placebo) in 14 patients after open inguinal hernia repair (8 patients of the 22 randomized were excluded) 161 . Infiltrations were done around the spermatic cord and the authors also use the term ‘nerve block’. The median pain intensity decrease (primary endpoint) with bupivacaine was 63 per cent compared to 36 per cent with placebo (P = 0.003). However, there was no difference in movement-related pain, summed pain intensity scores, or sleep quality scores between the two groups; 10 of 14 patients had at least 50 per cent reduction in pain after local anaesthetic (LA) injection compared with 3 of 14 patients after placebo. There were no major complications. Follow-up was only 7–14 days. Because of the low number of patients this study provides only very low evidence for tender point blocks with bupivacaine. A small retrospective study compared landmark-based (n = 20) versus US-guided (n = 16) ilioinguinal/iliohypogastric nerve blocks in patients with CPIP 162 . The number of patients that experienced at least 50 per cent pain reduction was comparable in both groups (70 and 79 per cent, respectively). There were no complications in both groups. No information was given on the duration of the effect. Burgmann et al. performed a retrospective study in 53 patients on the comparison of MRI findings in patients with pain post-TEP (n = 55) versus pain-free post-TEP (n = 12) and unoperated (n = 39) 163 . Two experienced radiologists assessed the MRI examinations independently, according to a protocol. They concluded that for patients with post-TEP hernia groin pain, MRI is useful to confirm a correct flat mesh position and to identify possible (not operation-related) causes of groin pain. MRI revealed treatable findings explanatory for persisting groin pain in 15 per cent of the patients. However, MRI is of little help to identify a specific cause of groin repair related pain, as none of the predefined disorders on MRI (hernia, bulging, fibrosis, etc.) was observed significantly more in painful versus pain-free operated groins. Altogether, this study provides very low evidence for performing systematically an MRI in persistent pain after TEP. Discussion This update of the HerniaSurge guidelines provides some new evidence on the diagnostic value of trigger point infiltrations. Because injections are minimally invasive and generally a safe procedure to perform, this might be an appropriate first diagnostic modality for CPIP after open inguinal hernia repair. Stabilini et al. | 21 Downloaded from https://academic.oup.com/bjsopen/article/7/5/zrad080/7325871 by guest on 14 July 2025 Multiple authorities consider that peripheral nerve blocks serve an important diagnostic function and can be effective in the workup of CPIP. However, no evidence-based recommendations for the preferred technique of these blocks (US-guided, neuro-stimulator directed, anatomic landmark) could be made. The literature does not always differentiate clearly between a peripheral nerve block or a trigger point infiltration. The fact that the latter also seems to be effective, at least temporarily, in a number of patients suggests that CPIP might be (partially) related to neuroma formation or chronic peripheral nerve inflammation. On the other hand, many trigger points are probably only inflammation/foreign body reaction/fibrosis with or without adjacent nerve or mesh, or even only referred pain points without actual anatomical abnormality. Future studies involving trigger point infiltration should be clearly differentiated from a peripheral nerve block, where the purpose is to block a specific (group of) nerve(s) proximal of the suggested nerve lesion. Also, a clear distinction should be made between US-guided versus landmark-based blocks, especially for peripheral ilioinguinal/iliohypogastric and spermatic cord blocks. Despite the fact none of the techniques for peripheral nerve blocks is superior, it is recommended that US-guided blocks are used in order to obtain optimal visualization of the injection site. An infiltration at a trigger point or a nerve block may be beneficial for a certain time. To our knowledge, no objective criteria exist to determine whether an infiltration can be considered as effective. Moreover, different variables that might play a role in the size of the effect are the location and the amount and composition of the injection. In addition, some unmeasurable personal psychological and genetic factors are possibly involved. This also means that a certain placebo effect is likely, as demonstrated by Wijayasinghe et al. 161 , and ideally sham injection versus infiltrations with or without active substance injected should be compared in studies. Concerning radiological investigations, it is logical to start with a dynamic US. No new qualitative data are available in this respect. The study by Burgmann et al. offers very low evidence to perform a systematic MRI after laparoscopic preperitoneal mesh placement 163 . Whether US would be an equally useful tool at much lower cost remains unclear. Anyhow, an expert radiologist and sufficient clinical input are needed for evaluating this difficult pathology. Key Question 2. What are the possible surgical therapeutic options (including neurectomy and (partial) mesh removal) in the treatment of postoperative chronic inguinal/scrotal/groin pain? Introduction Very low evidence suggested that both open and endoscopic retroperitoneal neurectomy provide acceptable outcomes for patients with CPIP. A tailored approach to such a neurectomy (with or without mesh removal) was suggested depending on the original repair method and presentation of complaints. It is logical from a pathophysiological point of view that neurectomy (as is also the case for nerve blocks) should be done proximal to the expected nerve lesion. The decision about neurectomy type—selective or triple—is debatable and at the moment left to the surgeon’s discretion. There was insufficient evidence to support mesh removal alone without neurectomy. Also, painful conditions interfering with sexual function after open hernia repair can be improved by the same surgical interventions, including release of the spermatic cord (funiculolysis). The decision whether to opt for surgery (and the type of surgery) should be taken after multidisciplinary team evaluation including pain specialists. This was also highlighted in the previous HerniaSurge guidelines 1 . Results From 2015 on, only one randomized study was published 164 . Verhagen et al. describe a non-blinded, single-centre study in which 54 patients with CPIP after primary Lichtenstein repair and at least 50 per cent pain reduction after a diagnostic trigger point infiltration were randomized to undergo an open (tailored) neurectomy of one or more inguinal nerves or trigger point infiltrations using LA. After 6 months, trigger point infiltration was successful in 22 per cent, but a neurectomy was successful in 71 per cent. Nineteen patients (76 per cent) crossed over from the infiltration to neurectomy group. Overall, the success rate of neurectomy was 65 per cent (n = 11/19). No major complications were observed, although pain worsened in one patient in the neurectomy group. The overall risk of bias was considered low, except the small numbers of patients and lack of blinding may have influenced outcomes of the study. Other randomized studies have not been performed to date and thus firm conclusions regarding the effectivity of neurectomy or mesh removal cannot be drawn based on a high level of evidence. Due to the lack of high-level evidence, the published cohort studies will be discussed here as well. An additional 15 articles were selected for the present update. Valvekens et al. reported on 15 patients operated for chronic postoperative groin pain. In three patients the original operation was not an inguinal hernia repair 165 . With a follow-up of one and a half years, only one in three patients benefitted from surgical intervention (with open neurectomy and/or mesh removal in half of the patients). The authors contemplate that most initial hernia repairs were laparo-endoscopic repairs in which the genitofemoral nerve can be injured, which was not adequately addressed at the reoperation. Magnusson et al. published their experience on surgical treatment of CPIP in 2015 166 . Between 1999 and 2006, 111 patients who had undergone (more than one) surgery for persistent pain after previous groin hernia surgery were analysed. Open neurectomy was usually done in a selective manner after preoperative nerve blocks. Mostly the ilioinguinal nerve was treated. In 45 procedures the mesh was (partially) removed. In 14 cases a suture at the pubic tubercle was removed. Sixty-two per cent reported a decrease in pain, with a median follow-up of 3.6 years. In 2016 Sun et al. concluded that most of their 44 patients did not experience immediate relief with reoperation for groin pain 167 . However, the majority (64 per cent patients) was (almost) pain-free at long-term follow-up (median 7 years). Mostly selective neurectomies were carried out (in 45 per cent) and the mesh was removed in 30 per cent. A recurrent hernia was repaired in more than half of the patients simultaneously. Irrespective of the type of neurectomy (selected or triple) for CPIP, a laparo-endoscopic or open approach can be performed. Laparo-endoscopic surgery approaches the nerves in the retroperitoneal plane and thus dissects the nerve more proximal to its origin. Most of the triple neurectomy data are derived from a single institute. Moore et al. described a prospective study of 62 patients undergoing laparo-endoscopic (totally extraperitoneal) retroperitoneal triple neurectomy (histopathologically confirmed) 22 | BJS Open, 2023, Vol. 7, No. 5 Downloaded from https://academic.oup.com/bjsopen/article/7/5/zrad080/7325871 by guest on 14 July 2025 for (primary) neuropathic pain after laparoscopic (n = 26) or open (n = 36) repair 168 . Their results demonstrated complete pain relief in 21 per cent and a reduction of pain of Numerical Rating Scale (NRS) < 4 (scale from 0 to 10) in 81 per cent of the patients, average follow-up time of 1.9 years. Furthermore, the measured quality of life improved in 94 per cent. Thirty-two per cent of patients developed deafferentation hypersensitivity and in 31 per cent lateral abdominal wall laxity was found. In a subset of 10 patients that also underwent additional quantitative sensory testing, two interesting observations were made: duration of chronic pain showed a negative relationship to clinical outcome and two patients with complete pain relief had received multiple nerve blocks before surgery without meaningful effect 169 . Moreno-Egea et al. described the results of 16 patients that underwent selective, double or triple transabdominal preperitoneal laparoscopic neurectomy for treatment of refractory inguinodynia (following a variety of groin repair techniques in 13/16 patients) 170 . About 69 per cent of patients were pain-free after surgery, with an average follow-up of 2 years. Karampinis et al. evaluated a laparoscopic transabdominal retroperitoneal approach for double or triple neurectomy in nine patients, of which eight for CPIP after inguinal hernia repair 171 . Four patients were pain-free after neurectomy, three described an improved pain status, whereas two did not observe any pain reduction at 14 months of follow-up. In a prospective, non-controlled explorative study by Pedersen et al., 66 of 240 referred patients received an open triple neurectomy with mesh removal in case of CPIP after Lichtenstein repair, or a laparoscopic triple neurectomy after previous endoscopic hernia repair 172 . Inclusion was based solely on clinical criteria. Patients were excluded for surgery if the index hernia repair was less than 6 months before, if a multimodal analgesic treatment had not been attempted for longer than 3 months, if a preoperative chronic pain syndrome unrelated to the inguinal intervention was present, or in case of non-compliance. Approximately 70 per cent experienced at least a 25 per cent improvement of pain-related functional impairment, with a median follow-up of 3 months. Gangopadhyay et al. described 12 patients undergoing selective (n = 3) or triple (n = 9) open retroperitoneal neurectomy with intraoperative electrical nerve stimulation and proximal crush injury of the nerve (after open inguinal hernia repair in eight patients) 173 . Before surgery, there was a favourable response to diagnostic nerve blocks in all patients. Sixty-seven per cent of patients had partial/complete pain relief, but no information on duration of follow-up is available. Initially, a simultaneous peripheral nerve stimulator was placed simultaneously in three triple neurectomy patients, which has since been discontinued. Three papers evaluated more specifically the role of mesh removal. Ramshaw et al. describe 94 consecutive operations (mesh removal with/without selective neurectomy) for CPIP after elective inguinal hernia repair in 93 patients 174 . Twenty-six laparoscopic (after previous laparoscopic repair) and 68 open and laparoscopic (after previous open repair) procedures were done. Other details were not mentioned. Forty-eight per cent of patients reported significant improvement, 41 per cent moderate, 11 per cent little or no improvement. There were 11 per cent of patients who developed recurrent hernias. Unfortunately, information on duration of follow-up was lacking. Zwaans et al. performed a retrospective, non-comparative study of 74 consecutive patients undergoing open (partial or total) mesh removal with selective neurectomy (in 74 per cent) after Lichtenstein hernioplasty (median interval 35 months) 175 . A ‘meshoma’ was described in 31 per cent of patients. Sixty-four per cent had a successful outcome at a median follow-up of 18 months (success rate similar in both groups). Testicular atrophy was described in 2.7 per cent, and 7 per cent of patients developed a hernia recurrence. The paper by Slooter et al. is also a retrospective, non-comparative study from the same group 176 . They report on 14 patients undergoing laparoscopic mesh removal after TEP/ TAPP with large pore mesh (intentional partial resection (n = 2) and planned genitofemoral neurectomy (n = 2)). Exploration revealed no meshomas and only slight mesh folding in seven patients. There were no conversions or major intraoperative/ early postoperative complications except from a small bladder laceration (n = 1). With a median follow up of 8 months, at least 50 per cent pain reduction was found in 64 per cent of patients. Patient satisfaction was excellent/good in 71 per cent of cases, although 14 per cent developed a recurrent hernia. A multivariable analysis on the outcome of a retrospective cohort of 136 patients undergoing open surgery for CPIP after Lichtenstein repair suggests better outcome of surgery after spinal anaesthesia and worse outcome in female patients and patients using opioids 177 . Regarding testicular pain, two publications describe the effect of microsurgical spermatic cord denervation (MSCD) if conservative therapies have failed. Marconi et al. report a prospective series of 50 patients (10 per cent CPIP) who were operated after a positive response to a spermatic cord block test and no response to a placebo injection 178 . With a follow-up of 6 months, 80 per cent of patients were pain-free. There were no intra- or postoperative testicular complications. Calixte et al. report a retrospective cohort of 772 patients (15 per cent CPIP), operated with a more targeted approach and robotic assistance, after temporary resolution of pain with a spermatic cord block 179 . Two testicular artery injuries were repaired during the same surgery without further consequences. Testicular ischaemia in another patient led to orchidectomy. In the CPIP group, pain had decreased by 25 per cent after 1 year. Discussion A high level of expertise and experience are required for positive outcomes after surgery for CPIP. It is very difficult to evaluate data on the effect of mesh removal or neurectomy separately because the majority of studies combined mesh removal with a neurectomy or vice versa. Neurectomy leads to improvement or even complete resolution of pain in the majority of patients. Selective neurectomy avoids unnecessary dissection of nerves and thus potentially diminishes the risk of deafferentation hypersensitivity, sensory disturbances (numbness), and potential motor deficits. On the other hand, as nerve anatomy is complex, varies vastly and the inguinal nerves can have interconnections, the risk of ongoing CPIP due to a wrong pre- or intraoperative estimation of the affected nerve is minimized by a triple neurectomy. After preperitoneal inguinal hernia repair, a retroperitoneal neurectomy is a more logical choice. The advantage of retroperitoneal neurectomy is that surgery is performed outside the field of scarring. However, this approach increases the risk of abdominal wall bulging (in particular after iliohypogastric and ilioinguinal motor denervation) and postoperative pseudohernias may occur. Previous studies have demonstrated a lateral abdominal wall laxity in up to 31 per cent 168 . In addition, the larger distribution of numbness may be Stabilini et al. | 23 Downloaded from https://academic.oup.com/bjsopen/article/7/5/zrad080/7325871 by guest on 14 July 2025 bothersome for patients, especially in patients who did not experience pain in a particular numb area before neurectomy. Obvious disadvantages of open anterior neurectomy are that surgery is performed in a previously scarred surgical field, the highly variable inguinal neuroanatomy, and the inability to access nerves proximal to the site of damage after prior preperitoneal repair. Anyhow, the type (selective/triple) and approach (open/laparoscopic) of the neurectomy is probably a secondary consideration relative to the selection of appropriate patients that are likely to benefit from nerve resection. With respect to MSCD, there is low evidence to suggest this as a last resort step for chronic orchialgia. The authors stress the importance of temporary pain resolution before surgery with a spermatic cord block. The latter seems a logical prerequisite, but the fact that a spermatic cord block also targets (largely) the genital branch of the genitofemoral nerve is an important confounding factor of concern. Partial or total open mesh removal (with or without neurectomy) can be considered in CPIP due to mesh complications after Lichtenstein repair. Compression of adjacent structures like the spermatic cord and surrounding inflammation is thought to be the mechanism of this pain. Often the mesh is wrinkled and fibrotic, causing pain in certain positions like sitting. Laparoscopic mesh removal is a much more complex procedure with potential life-threatening complications. There is currently insufficient data to consider (partial) laparoscopic mesh removal. Numerous important variables such as patient selection, previous treatments, surgeons’ experience, surgical technique, side effects, duration and type of follow-up (pain scores, questionnaires, neurologic examination techniques, etc.) are inconsistent in the literature and mostly unclear. Of note, outcomes are highly dependent on the definition of success. Therefore, heterogeneity in patient data, the small numbers of included patients in the individual reports and the retrospective character of most studies prohibits firm conclusions due to a high risk of bias. In the absence of a control group, it is very difficult to compare these data to the natural course of CPIP. Sham surgery would be ideal from a methodological perspective but raises ethical considerations. The importance of a better description of neuropathic pain by means of self-reported questionnaires like DN4 180 and PainDETECT 181 , which report on pain sensitivity and neuropathic-like pain, remains unclear, as is the impact and optimal technique of preoperative peripheral nerve blocks. Key Question 3. What evidence is available on non-surgical therapeutic options (including role of centralization and multidisciplinary team approach) in the treatment of postoperative chronic inguinal/scrotal/groin pain? Introduction The HerniaSurge guidelines suggested with a weak recommendation to include a multidisciplinary team to manage chronic pain patients 1 . However, further specification on the definition and role of the different partners involved was not given. It is crucial that the team has experience with this pathology and that the important medical and paramedical disciplines are part of this team. Also, when a patient first presents to the pain specialist, we believe it is strongly advisable that he or she is seen at an early stage by an experienced surgeon in order to evaluate potentially important surgical aspects with relevance for the further work-up. A stepwise approach starting with minimally invasive measures like analgesics and nerve blocks was advocated. The HerniaSurge guidelines suggest that these should continue for a minimum of 3 months (minimum of 6 months after hernia surgery). Diagnostic/therapeutic nerve blocks or infiltration of trigger points can be done (blindly or US-guided) before a first multidisciplinary discussion. Although the HerniaSurge guidelines state that no benefit has been shown for lidocaine and capsaicin patch treatment of CPIP, it is not contraindicated to also try pharmacological therapy. More invasive management should ideally be done after evaluation by and discussion with the whole team. The HerniaSurge guidelines mentioned in this respect that pulsed radio frequency (RF) ablation may be an effective treatment and early findings suggested also that neuromodulation of the dorsal root ganglia (DRG) may be an effective treatment for chronic neuropathic pain conditions in the groin region 1 . Different algorithms have been suggested and published, but none of these is clearly based on high-level evidence. Results Since 2015 there has been one randomized study 164 . This paper was discussed under the heading of KQ 2 because it compared open (tailored) neurectomy of one or more inguinal nerves with trigger point infiltrations using LA. One retrospective cross-sectional study included 106 subjects with MR neurography-diagnosed groin pain (n = 41 after inguinal hernia repair), of which 58 subjects received CT-guided perineural injections based on abnormal inguinal nerve findings on MR (for example, hyperintensity or thickening of the respective nerves) 182 . Improvement was seen in 84 per cent of the cases. Although the results are promising, the retrospective, non-controlled, non-randomized study design and unclear duration of effect makes the study of too low quality to make a recommendation. Future research on this topic is warranted. Another retrospective study included 10 patients (9 with CPIP) who underwent US-guided microwave ablation of inguinal nerves (mainly ilioinguinal nerve) after a positive response to diagnostic US-guided nerve block 183 . The results showed immediate pain reduction in 92 per cent of the patients. The average duration of clinically significant pain reduction was 10.5 months. A study by Shaw et al. evaluated six patients undergoing peripheral nerve (field) stimulation after an externalized trial for the first week 184 . There were no major complications. Eighty-five per cent of patients were completely satisfied with an average follow-up of 22 months. Again, no recommendations can be based on these two studies due to their retrospective, non-controlled, non-randomized study design with very small numbers of patients. US-guided targeted cryoablation (UTC) of the peri-spermatic cord (branches of genitofemoral, ilioinguinal and inferior hypogastric nerves) has been described as a minimally invasive method for relieving scrotal content pain. During this procedure the targeted nerves are frozen with the intention to desensitize the nerves. Calixte et al. report on a retrospective series of 221 patients (15 per cent CPIP) as salvage treatment for patients who failed targeted MSCD. Although ‘minimally invasive’, the authors do not prefer to perform UTC first, because they believe that more scarring after ‘more aggressive’ UTC will make MSCD too challenging technically 185 . After a median follow-up of 3 years, success rates of 64 per cent with significant pain 24 | BJS Open, 2023, Vol. 7, No. 5 Downloaded from https://academic.oup.com/bjsopen/article/7/5/zrad080/7325871 by guest on 14 July 2025 reduction (Pain Index Questionnaire-6) have been described for the whole cohort. No major complications were reported. Injections with Botulinum-A toxin adjacent to the spermatic cord have been suggested for scrotal pain previously. In a study by Calixte et al. significant pain relief was obtained in 62.5 per cent of 44 patients at 7 months’ follow-up 186 . The problem of CPIP remains challenging due to its multidimensional aetiology. Multimodal treatment for CPIP has been suggested, such as with cognitive behavioural therapy (CBT) 187 . Although the CBT approach before CPIP surgery has been proven effective for selective patients, the study is methodologically heterogenic, resulting in difficulties identifying phenotypes with high success rate. On the other hand, the technique seems to have a minimal risk of adverse effect apart from time used. Discussion LA injection therapy is minimally invasive and generally a safe procedure to perform. Repetitive trigger point infiltration is an early modality in a stepwise approach in the treatment of CPIP after Lichtenstein repair. Trigger point infiltration might prevent a number of patients from needing surgery, at least for 6 months. No data are available on the ideal interval of repetitive infiltrations to obtain a longer and/or more pronounced effect. However, if the outcome of repetitive trigger point infiltrations or repetitive blocks of a specific (group of) nerve(s) is comparable (or better), a causal factor at this site becomes highly likely. Therefore, therapeutic infiltrations serve as an important diagnostic tool. Cryoablation and RF ablation have been the subject of a few case reports involving few patients and limited follow-up. Initial positive results should be viewed accordingly. All available studies on neuromodulation for CPIP cite sustained pain relief, quality-of-life improvement and/or analgesic use reduction or cessation. However, these studies have significant limitations, such as a retrospective design, case reports or series, lack of control groups, short follow-up times, and no report of adverse events or complications. The importance of the subject and the paucity of evidence on this topic highlights the need for future high-quality research. Until more high-quality data emerge, it seems logical to propose a pragmatic treatment algorithm. In treating CPIP the repetitive effect of more proximal nerve blocks needs to be explored (transversus abdominis plane block, quadratus lumborum block, thoracolumbar block), if ‘standard’ peripheral nerve blocks or infiltration of trigger points are ineffective. Once the ideal level of optimal pain relief has been determined, more invasive techniques (cryoablation, RF, other neuromodulation) can be pursued if repetitive injections have insufficient long-term effect. Accumulating evidence suggests that central sensitization is also driven by neuroinflammation in the peripheral and central nervous system (CNS). Due to the complexity of the pathology, treatment options, difficulties integrating a specific standardized stepwise therapeutic plan and need for an individualized approach, it is recommended that patients with CPIP should be managed in specialist centres. Patients’ values and preferences inherent to Chapter 19 Patients’ preferences are substantially concordant with panel recommendation direction and strength. Patients’ representatives agree that there is a need for specialized centres for the management of CPIP to manage this difficult condition that can severely impact patients’ quality of life. Summary In an extensive chapter developed by a larger team including two anaesthetists with an interest in chronic pain, 10 statements and 5 recommendations were formulated. There is only very low or low level evidence for the various modalities in the treatment of chronic postoperative inguinal pain (CPIP), in particular surgical interventions. This has led to the recommendation to inform patients clearly on the limited data on the effectiveness of CPIP surgery, with a potential risk of pain intensification and other complications with such interventions. A tailored approach to CPIP surgery (neurectomy, open mesh removal or combination) is suggested depending on the original repair method, experience of the surgeon, distribution and symptoms of pain, physical findings and potential radiographic images. The treatment of CPIP is complex and it is recommended to centralize the evaluation and treatment of CPIP in specialist centres with an experienced multidisciplinary team where possible. Chapter 21. Emergency groin hernia Key Question 1: What is an acute groin hernia? Key Question 2: What are the best management algorithm and the factors influencing the decision-making in the treatment of acute groin hernias? Key Question 3: Which is the best surgical approach for acute groin hernias? 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