Family Practice Vol. 17, No. 5, 442-447
© Oxford University Press 2000
Selections from Current Literature |
Evidence-based management of groin hernia in primary care—a systematic review
Section of Public Health, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA and
a Tees Health Authority, Poole House, Stokesley Road, Middlesborough TS7 0PN, UK.
McIntosh A, Hutchinson A, Roberts A and Withers H. Evidence-based management of groin hernia in primary care—a systematic review. Family Practice 2000; 17: 442–447.
Received 29 March 2000; Accepted 16 May 2000.
Abstract
Background. National clinical guidelines on the surgical management of groin hernia have been published by the Royal College of Surgeons of England. There is also a need for guidance on the management of pre- and post-hernia repair patients in primary care, in areas such as diagnosis, referral and advice on recuperation.
Objective. The purpose of the present study was to determine best practice in primary care aspects of managing groin hernia in adults, by examination of the evidence base.
Method. A systematic review of the available evidence was carried out , searching the major electronic databases: Medline, the Cochrane Library, Embase, Assia, Helmis, Cinahl and Psyclit. Key search terms were hern$, inguinal, femoral, groin, truss$, with searches limited to human adult subjects and the English language.
Results. Robust research on groin hernia is concerned almost exclusively with the in-patient surgical management of patients undergoing primary elective hernia repair. The areas with which this review was concerned, principally diagnosis, referral and advice about return to work, are areas in which it is more difficult to conduct robustly designed studies. Perhaps because of this, the evidence base on the non-surgical aspects of management is of poor methodological quality, being based primarily on expert opinion, reviews of clinical practice and experience, surveys, descriptive case studies and clinical audits.
Conclusions. As the research in this area is generally of poor quality, strong conclusions are precluded, but it is possible to define best practice in some areas of care. In relation to diagnosis, GPs should distinguish correctly between a femoral and inguinal hernia because of the increased risks of strangulation and incarceration associated with the former. Due to clinical inaccuracy, the identification of whether a hernia is direct or indirect is not a good basis on which to base decision making regarding referral for elective repair. The risks associated with surgical repair are those of the normal range found for any procedure. Decisions about the fitness of patients for surgery in this instance are not procedure specific, and therefore the decisions about elective repair especially in older patients should be considered in terms of quality of life and patient choice rather than increased risks with surgical repair. Further research is required to address the gap in the evidence for the management of groin hernia within the primary care sector.
Keywords. Hernia, inguinal, primary health care, physicians/family.
Introduction
The incidence of groin hernia in adults is ~12 times more common in males than females. In men, the rate is 70 per 10 000 aged 45–64 years, rising to 150 per 10 000 aged 75+ years.1 In 1993/4, ~80 000 patients underwent surgical repair of an inguinal hernia and there were 5600 repairs of a femoral hernia in the NHS in England.2 Currently, groin hernia repair is the tenth most frequently performed operative procedure in England.3
The Royal College of Surgeons in England have published clinical guidelines on the surgical management of groin hernia in adults,4 Simons5 conducted a systematic review and meta-analysis of the effectiveness of the Shouldice technique, and a systematic review of groin hernia surgery has been undertaken by Cheek.6 There remains, however, a paucity of information on the non-surgical aspects of care such as referral, effectiveness of trusses and advice on post-surgical management. This systematic review, of the best available evidence, was undertaken to support best practice recommendations in these areas.
Methods
A search of the literature was conducted using Medline, Embase, Helmis, Cinahl, Assia, Psyclit and the Cochrane Library. Key search terms were hern$, inguinal, femoral, groin and truss$, with searches limited to human adult subjects and the English language. The abstracts of the articles identified in the literature searches were examined. Articles that appeared to contain relevant subject matter were selected and obtained. Bibliographies of all articles located in this way were examined for further citations. On the basis of the abstract, articles were excluded because they had been superseded (the literature on hernia extends over more than a century) or because they dealt only with technical surgical considerations. The included studies are indicated in Table 1
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Results
Pre-operative management
Diagnosis..
In adults, there are two main types of groin hernia, inguinal and femoral hernia. Inguinal hernias are described further as being direct, where the hernia enters through the wall of the canal, or indirect, where the hernia enters the inguinal canal via the internal ring at the top. Femoral hernias account for <10% of all groin hernias, but 40% of these present as emergencies with incarceration or strangulation.7 The mortality rates for emergency repair are higher than for elective repair. Femoral hernias are more common in older patients and in those who have previously undergone an inguinal hernia repair. There is also a higher incidence amongst females, the male to female ratio being ~1:4.8,9 Gallegos10 and Rai9 found that the risk of strangulation was higher not only in femoral hernias but also in hernias of short duration, both femoral and inguinal. Studies by Ralphs,11 Cameron12 and Kark13 show that the accuracy with which direct and indirect inguinal hernias can be distinguished clinically before surgery is doubtful. It is possible, therefore, that some indirect hernias (incorrectly diagnosed as direct) are going untreated.12
Diagnostic investigations.. Where clinical diagnosis of a groin hernia is inconclusive and particularly where a patient has a painful hernia repair but no detectable recurrence, herniography has been shown to be a valuable diagnostic tool which can save unnecessary surgical exploration.14,15
Van den Berg16 undertook a small study to determine the feasibility of dynamic magnetic resonance imaging (MRI) in the diagnosis of groin hernia. It was concluded that the anatomical structures crucial for the assessment and differentiation of inguino-femoral herniations could be identified properly prospectively with MRI. Further prospective clinical trials and economic analyses are required before definitive conclusions can be drawn.
Referral to secondary care.. A study of 25 patients aged over 65 admitted for emergency groin hernia repair found that of these, 20 knew of their hernia before admission, 18 had informed their GPs, but in 13 cases the GP had chosen not to refer them for elective surgery.17 However, no firm conclusions can be drawn from this study because of the small numbers involved. In their retrospective clinical series of 54 patients with strangulated hernia, Askew et al.18 found that 20 (37%) had previously consulted their GPs about the hernia, but only seven had been referred for surgery. The difficulty lies in distinguishing hernias that are likely to strangulate from those that are unlikely to do so. They concluded that a strangulated hernia was often misdiagnosed and that all patients who present with a hernia must be referred to a surgeon and warned about strangulation. Referral for surgery of older people with a groin hernia may not occur because of concern about the surgical risk. Neuhauser19 considered that the decision not to refer patients over the age of 65, because of concern about the risks of surgery, was not justified by the available mortality data. He compared the mortality rates for elective and emergency repairs of inguinal hernias in patients in the USA who were 65 years and over. By calculating the risk of incarceration and strangulation for an untreated hernia, it was demonstrated that, because of the improvements in mortality rates for emergency repairs, the overall risks of elective and emergency surgery were similar in the long run. However, the use of trusses or elective surgery were important in quality of life issues and could be justified on those grounds rather than on overall risk grounds.
Trusses.. Estimates suggest that 20 000 spring trusses are manufactured each year and 40 000 trusses of all types are sold in the UK annually.20 It has been suggested that only a quarter are distributed through the National Health Service and the rest are sold through retail outlets.21
The advice on whether or not trusses are recommended appears to be based upon clinical experience rather than clinical trials. Complications associated with prolonged use of a truss include atrophy of the spermatic cord or fusion to the hernial sac, and atrophy or deterioration of the fascial margins, rendering surgical repair more difficult.22
There are insufficient good studies to determine how effective trusses are at controlling symptoms and on whether trusses are as effective as operative treatment in controlling symptoms.
Surgical management issues with implications for primary care
Anaesthesia..
In a small study of 41 patients, Prado23 investigated tolerance to inguinal hernia repair under local anaesthesia, concluding that there was good tolerance and a low complication rate. Comparing bupivacaine against inguinal field block, Spittal24 concluded that bupivacaine instillation was simple, safe and effective, and particularly appropriate for day case surgery. Tingwald25 found that local anaesthesia had lower complication rates in older people than either spinal or general anaesthesia.
A systematic review6 found no evidence to suggest wound complications were more common with local anaesthesia, and that there was some evidence that the opposite may be true. Time to return to work was similar regardless of type of anaesthesia.
Bilateral hernia repairs.. In a small (n = 111) prospective study, Serpell26 found no detectable increase in rates of wound complications, post-operative respiratory complications or other adverse effects in comparison with unilateral repairs. The operating time and duration of convalescence are also shorter for simultaneous repair, compared with sequential bilateral repair.
Cheek6 found insufficient evidence to determine whether simultaneous repair of bilateral hernias is as safe and effective as delayed repair.
Complications.. Approximately 7% of all operations are for recurrent hernia,2 although in large surveys rates range from 10 to 15%, varying according to surgical technique. Recurrence rates for the Shouldice technique range between 0 and 10% and, in specialist centres, from 0.6 to 1.4%.5 A number of studies have investigated the causes of recurrence or complications in hernia repair. Ingimarsson27 claimed that recurrence was dependent more on the surgeon than on the type of operation. Kingsnorth28 examined recurrence rates for a series of 183 inguinal hernias repaired under local anaesthesia and noted that the rate for beginners (surgeons who had repaired <6 repairs under local anaesthesia) was 9.4% (projected to 28% at 25 years post-operation). Once six hernias had been repaired under local anaesthetic, the chance of recurrence fell to 2.5% (projected to 7.5% at 25 years).
Morris29 reports a series of 471 inguinal hernia repairs performed on a day case basis under local anaesthesia, all performed by surgeons in training. The recurrence rate at an average of 34 months after surgery was 4.2% (2.2% for indirect and 8.2% for direct hernias).
Simons5 undertook a systematic review and meta-analysis to evaluate the Shouldice technique versus alternative methods in terms of recurrence. The results suggest that the Shouldice method is the best current conventional technique for inguinal hernia repair. However, in view of potential sources of bias caused by variables such as modifications in operative technique, suture material, level of surgeon, follow-up methods and outcome measurement, it is not clear whether the technique is superior to alternative methods, such as mesh repair, in preventing recurrence.
Patient weight, which does affect the ease with which a hernia can be repaired, may not increase the chance of recurrence. Thomas30 found that in a series of 686 patients, those patients with recurrence tended to be near or below ideal body weight, although in an uncontrolled study such as this no firm conclusions can be drawn.
Postlethwait31 examined the evidence from 584 operations for recurrent inguinal hernia repair to look for anatomical indications of the cause of the recurrence. The causes of recurrence in indirect hernias appeared to be: unrecognized hernia, incomplete dissection or ligation of the sac, failure to narrow the cord or inadequate reconstruction of the internal ring. No cause for the diffuse direct hernia recurrence was apparent, although those found in Hasselbach's triangle were considered to be caused by the cutting action of a suture under tension.
Post-operative groin hernia wound management in primary care
Bailey32 reported the results of a 3 year audit undertaken to assess post-operative wound complication rates following inguinal hernia repair. A total of 510 patients were assessed both at discharge and at 10–14 days in the community, revealing a wound complication rate of 28% compared with only 7% detected by hospital case notes.
Taylor33 reported a well conducted randomized multicentre, double-blind trial of antibiotic prophylaxis versus placebo in 619 patients undergoing open groin hernia repair. Wound infection rates were the same in both groups (at 8.8 and 8.9% of patients in treatment and control arms), suggesting that antibiotic prophylaxis does not confer a benefit to patients.
Pain relief.. A number of studies examine the effectiveness of analgesia in hernia repair. Two studies, those by Ben-David34 and Morris,35 were trials, but neither randomly allocated patients to the comparison groups. No generalized conclusions can therefore be drawn from these studies. Nehra et al.36 compared bupivacaine ilioinguinal field block (administered intra-operatively) and oral papaveretum–aspirin, with placebos (the trial required four arms to allow placebo substitution of each of the pair). At 6 and 24 hours, the combination of bupivacaine field block and oral analgesia provided the best relief from post-operative pain, and the authors concluded that it is a suitable analgesia technique for day case surgery. Ding et al.37 compared the use of an ilioinguinal– hypogastric nerve block with either bupivacaine or saline. They concluded that for adult out-patients undergoing inguinal hernia repair (with local anaesthetic infiltration), the use of an ilioinguinal–hypogastric nerve block with bupivacaine contributed to a decrease in post-operative pain. McEvoy38 compared two post-operative oral analgesic protocols after day case inguinal hernia repair. Diclofenac was found to provide effective analgesia and had a more acceptable side effect profile than morphine sulfate 48 hours post surgery, concluding that it was the treatment of choice after ambulatory hernia surgery.
Wound pain has been researched in relation to the immediate post-operative period, but there is little work concerned with wound pain beyond this initial period. Briggs39 reports a randomized controlled trial of film dressings versus dry dressings in terms of their effect upon pain. The study did not show statistically significant differences between the two treatment groups for the first 2 days. A small difference was detected in favour of the film dressings on day 3 but this was probably due to the wound being undisturbed, as the dry dressings were changed on day 3 while the film dressings were not.
Recuperation and return to normal activities
The literature search found no robust studies in the areas of recuperation and return to work following groin hernia repair. There appears to be agreement in the material published, which is of variable type and quality, that recurrence of an inguinal hernia is independent of return to normal activities and of type of work done. However, descriptive studies show that the average time off work advised by surgeons and GPs is nearly always influenced by the type of work the patient does, although the length of time the patient is advised to take off would appear to be getting shorter on average. Bachoo40 found wide variations in the advice given by GPs to patients regarding return to work, with 97.5% of GPs stating that the patient's occupation had a direct bearing on the duration of convalescence. Baker et al. also reported on the differences in advice given between surgeons and GPs about return to work and the actual time taken by the patient.41 For example, for those in sedentary work, the mean time advised by surgeons was 2.8 weeks, the GP advised a mean of 5.1 weeks and the mean of patient practice was 3.4 weeks. Differences were also reported for those in light and heavy work.
Driving.. One small study was found regarding advice about driving post-operatively. Welsh42 examined reaction times in an emergency stop simulation which demonstrated that patients took 10 days to return to pre-operative performance levels. There was no difference pre-operatively between a group of men with right sided inguinal hernias and a control group of men, showing that the presence of the hernia itself did not affect foot reaction times.
Discussion
In England and Wales, groin hernia repair is one of the most common operative procedures. Whilst there is substantial good quality evidence on the surgical aspects of management, this review has highlighted that robust research on the primary and out-patient management of groin hernias is scarce. It is therefore difficult to provide many definitive, evidence-based, conclusions which might assist decision making within the primary care setting. Clearly, further robust research is required to address this conspicuous gap in the evidence.
Diagnosis can be made on clinical grounds in the majority of cases. Whilst femoral hernias are less prevalent, they are associated with increased risk of incarceration and/or strangulation. Suspected femoral hernias should be referred for an early surgical opinion, since there can be clinical inaccuracy in distinguishing direct and indirect hernias. Clinical examination, especially by a generalist, may not be a good basis on which to decide whether or not these hernias should be repaired surgically. There is some evidence to suggest that patients with a short history of herniation should be referred more urgently to hospital and given priority on the waiting list.
Further investigation at secondary care level may be necessary to identify some hernias. Herniography has been shown to be a valuable diagnostic tool; further prospective clinical trials and economic analyses are required before definitive conclusions can be made regarding MRI.
Some patients may benefit from the temporary use of a truss whilst waiting for surgery. Since surgical risks are low, few patients should be considered unfit for hernia repair. In patients over 65 years old, the effect of either a truss or elective surgery should be assessed in terms of the patient's quality of life.
Hernia repair can be carried out effectively using either general, regional or local anaesthetic. While most surgeons employ simultaneous repair in the case of bilateral hernias, there is insufficient evidence available as to whether it is as safe and effective as delayed repair.
It is generally agreed that the length of time needed to recover from hernia repair is much shorter than was previously thought. However, this is not fully reflected in the advice given by clinicians, with wide variations in practice and the average length of time off work advised by surgeons and GPs which is nearly always influenced by the type of work the patient does. There is little available evidence on the subject of driving post-operatively, although results from one small study suggest that 10 days is needed for reaction times to return to pre-operative levels.
Acknowledgments
The authors would like to thank the GPs and surgeons of the RCGP/RCS Clinical Guidelines for Primary and Outpatient Management of Groin Hernia in Adults development group: Dr Greg Rubin, Mr Simon Ambrose, Mr Peter Jones, Mr Simon Raimes, Dr Paul Sutton, Mr Robert Taylor and Dr Rodney Mitchell. Funding for the work was provided through the Central Clinical Audit Programme of the Department of Health and subsequently through the RCGP Effective Clinical Practice Programme. The opinions in this paper are those of the authors and do not necessarily represent those of the funding bodies.
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