ガイドライン委員会日本ヘルニア学会. 鼠経部ヘルニア診療ガイドライン. 金原出版; 2015.
日本化学療法学会日本外科感染症学会．. 術後感染予防抗菌薬適正使用のための実践ガイドライン. 日本外科感染症学会雑誌. 2016;13(2):79–158.
日本外科感染症学会. 消化器外科SSI予防のための周術期ガイドライン2018 [Internet]. 2018. Available from: http://www.gekakansen.jp/pdf/guideline2018.pdf（2021年5月閲覧）
日本ヘルニア学会. 2021年版 鼠径部ヘルニア分類（新JHS分類） [Internet]. Available from: http://jhs.mas-sys.com/pdf/New_JHS_hernia_classification.pdf （2021年5月閲覧）
Robert J Fitzgibbons, Bala Ramanan, Shipra Arya, Scott A Turner, Xue Li, James O Gibbs, Domenic J Reda, Investigators of the Original Trial
Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias.
Ann Surg. 2013 Sep;258(3):508-15. doi: 10.1097/SLA.0b013e3182a19725.
Abstract/Text
OBJECTIVE: To assess the long-term crossover (CO) rate in men undergoing watchful waiting (WW) as a primary treatment strategy for their asymptomatic or minimally symptomatic inguinal hernias.
BACKGROUND: With an average follow-up of 3.2 years, a randomized controlled trial comparing WW with routine repair for male patients with minimally symptomatic inguinal hernias led investigators to conclude that WW was an acceptable option [JAMA. 2006;295(3):285-292]. We now analyze patients in the WW group after an additional 7 years of follow-up.
METHODS: At the conclusion of the original study, 254 men who had been assigned to WW consented to longer-term follow-up. These patients were contacted yearly by mail questionnaire. Nonresponders were contacted by phone or e-mail for additional data collection.
RESULTS: Eighty-one of the 254 men (31.9%) crossed over to surgical repair before the end of the original study, December 31, 2004, with a median follow-up of 3.2 (range: 2-4.5) years. The patients have now been followed for an additional 7 years with a maximum follow-up of 11.5 years. The estimated cumulative CO rates using Kaplan-Meier analysis was 68%. Men older than 65 years crossed over at a considerably higher rate than younger men (79% vs 62%). The most common reason for CO was pain (54.1%). A total of 3 patients have required an emergency operation, but there has been no mortality.
CONCLUSIONS: Men who present to their physicians because of an inguinal hernia even when minimally symptomatic should be counseled that although WW is a reasonable and safe strategy, symptoms will likely progress and an operation will be needed eventually.
Robert J Fitzgibbons, Anita Giobbie-Hurder, James O Gibbs, Dorothy D Dunlop, Domenic J Reda, Martin McCarthy, Leigh A Neumayer, Jeffrey S T Barkun, James L Hoehn, Joseph T Murphy, George A Sarosi, William C Syme, Jon S Thompson, Jia Wang, Olga Jonasson
Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial.
JAMA. 2006 Jan 18;295(3):285-92. doi: 10.1001/jama.295.3.285.
Abstract/Text
CONTEXT: Many men with inguinal hernia have minimal symptoms. Whether deferring surgical repair is a safe and acceptable option has not been assessed.
OBJECTIVE: To compare pain and the physical component score (PCS) of the Short Form-36 Version 2 survey at 2 years in men with minimally symptomatic inguinal hernias treated with watchful waiting or surgical repair.
DESIGN, SETTING, AND PARTICIPANTS: Randomized trial conducted January 1, 1999, through December 31, 2004, at 5 North American centers and enrolling 720 men (364 watchful waiting, 356 surgical repair) followed up for 2 to 4.5 years.
INTERVENTIONS: Watchful-waiting patients were followed up at 6 months and annually and watched for hernia symptoms; repair patients received standard open tension-free repair and were followed up at 3 and 6 months and annually.
MAIN OUTCOME MEASURES: Pain and discomfort interfering with usual activities at 2 years and change in PCS from baseline to 2 years. Secondary outcomes were complications, patient-reported pain, functional status, activity levels, and satisfaction with care.
RESULTS: Primary intention-to-treat outcomes were similar at 2 years for watchful waiting vs surgical repair: pain limiting activities (5.1% vs 2.2%, respectively; P = .06 [corrected]); PCS (improvement over baseline, 0.29 points vs 0.13 points; P = .79). Twenty-three percent of patients assigned to watchful waiting crossed over to receive surgical repair (increase in hernia-related pain was the most common reason offered); 17% assigned to receive repair crossed over to watchful waiting. Self-reported pain in watchful-waiting patients crossing over improved after repair. Occurrence of postoperative hernia-related complications was similar in patients who received repair as assigned and in watchful-waiting patients who crossed over. One watchful-waiting patient (0.3%) experienced acute hernia incarceration without strangulation within 2 years; a second had acute incarceration with bowel obstruction at 4 years, with a frequency of 1.8/1000 patient-years inclusive of patients followed up for as long as 4.5 years.
CONCLUSIONS: Watchful waiting is an acceptable option for men with minimally symptomatic inguinal hernias. Delaying surgical repair until symptoms increase is safe because acute hernia incarcerations occur rarely.Clinical Trials Registration ClinicalTrials.gov Identifier: NCT00263250.
Patrick J O'Dwyer, Lucia Chung
Watchful waiting was as safe as surgical repair for minimally symptomatic inguinal hernias.
Evid Based Med. 2006 Jun;11(3):73. doi: 10.1136/ebm.11.3.73.
Abstract/Text
Gang Zhao, Peng Gao, Bin Ma, Jinhui Tian, Kehu Yang
Open mesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials.
Ann Surg. 2009 Jul;250(1):35-42. doi: 10.1097/SLA.0b013e3181ad63cc.
Abstract/Text
OBJECTIVE: The aim of this report is to evaluate the efficacy of the 3 most common open mesh techniques used in practice.
BACKGROUND: The open mesh technique of choice, inguinal hernia repair, remains controversial. Some randomized controlled trials (RCTs) have been published assessing its effectiveness; however, available data regarding the outcomes were noncoincident. Therefore, it is necessary to carry out a meta-analysis of the evidence on outcomes for the open mesh technique.
METHODS: : A fully recursive literature search was conducted in the Cochrane Controlled Trials Register Databases, Medline, Embase, ISI databases, and Chinese Biomedical Literature Database in any language. RCTs between 1989 and 2008 of open mesh techniques were considered for inclusion. Statistical analyses were carried out using RevMan software.
RESULTS: Ten RCTs with 2708 patients were included. There was no significant difference in recurrence when comparing Lichtenstein's operation to mesh plug repair or prolene hernia system (PHS) repair (risk ratio: 0.71; 95% confidence intervals: 0.32-1.56), (risk ratio: 2.19; 95% confidence intervals: 0.63-7.62), respectively. There was insufficient evidence to determine the greater effectiveness between mesh plug repair and PHS repair.
CONCLUSIONS: Lichtenstein's operation was similar to mesh plug or PHS repair in terms of time to return to work, complications, chronic pain, and hernia recurrence in the short- to mid-term, although mesh plug and PHS repair was associated with shorter surgical time.
Wouter Willaert, Dirk De Bacquer, Xavier Rogiers, Roberto Troisi, Frederik Berrevoet
Open Preperitoneal Techniques versus Lichtenstein Repair for elective Inguinal Hernias.
Cochrane Database Syst Rev. 2012 Jul 11;(7):CD008034. doi: 10.1002/14651858.CD008034.pub2. Epub 2012 Jul 11.
Abstract/Text
BACKGROUND: Current techniques for inguinal hernia repair show similar recurrence rates. Therefore, recurrence is no longer the main issue discussed when considering improving the current standards for groin hernia repair. Post surgical chronic pain represents a major, largely unrecognised clinical problem. Consequently, there is a need to not only decrease an extensive dissection in the inguinal canal with less manipulation of the inguinal nerves, but also to minimize the interaction between the mesh and major surrounding structures. As a result, placing the mesh in the preperitoneal space is a valuable option.
OBJECTIVES: To compare elective open preperitoneal mesh techniques with Lichtenstein mesh repair in terms of pain.
SEARCH METHODS: We searched The Cochrane Central Register of Controlled Trials (The Cochrane library 2011, Issue 4), MEDLINE (January 1966 to April 2011), EMBASE (1947 to October 2009), and ISI WEB OF KNOWLEDGE (1900 to April 2011) for randomized controlled trials. The reference list of identified trials, the World Journal of Hernia and Abdominal Wall Surgery, and relevant book chapters were handsearched for useful trials. If we found relevant ongoing trials using national and international trials registers, we contacted the main investigators for further information. The language of the trials was not an exclusion criterion.
SELECTION CRITERIA: Randomized controlled studies comparing elective open preperitoneal mesh techniques with Lichtenstein mesh repair.
DATA COLLECTION AND ANALYSIS: Three authors independently extracted the pre-specified data and assessed the methodological quality using domain-based evaluation. Missing information was obtained by contacting the original investigators using open-ended questions.
MAIN RESULTS: Three eligible trials involving 569 patients were identified. Due to methodological limitations in the included studies, there was considerable variation in the results of acute (risk range 38.67% to 96.51%) and chronic pain (risk range 7.83% to 40.47%) across the control groups. Therefore, meta-analysis was not performed but the results of the outcomes in the individual trials were compared. Two trials involving 322 patients reported less chronic pain after preperitoneal repair (relative risk (RR) 0.18, number needed to treat (NNT) 8; RR 0.51, NNT 5), whereas one trial, including 247 patients, described more chronic pain after this repair (RR 1.17, NNT 77). The same trials favoured the preperitoneal technique concerning acute pain (RR 0.17, NNT 3; RR 0.78, NNT 7), whereas in the third trial it was almost omnipresent and thus comparable in both intervention arms (RR 0.997, NNT 333). Early and late hernia recurrence rates were similar across the studies, whereas contrasting results were reported for other early outcomes as infection and hematoma. No late mesh infection occurred in the included trials.
AUTHORS' CONCLUSIONS: Both techniques are valid as they result in similar low recurrence rates. Evaluation of pain results in the individual trials shows some evidence that preperitoneal repair causes less or comparable acute and chronic pain compared to the Lichtenstein procedure. We emphasize the need for homogeneous high quality randomized trials comparing elective preperitoneal inguinal hernia techniques and Lichtenstein repair in terms of chronic pain.
J Dalenbäck, C Andersson, B Anesten, S Björck, S Eklund, O Magnusson, G Rimbäck, B Stenquist, N Wedel
Prolene Hernia System, Lichtenstein mesh and plug-and-patch for primary inguinal hernia repair: 3-year outcome of a prospective randomised controlled trial. The BOOP study: bi-layer and connector, on-lay, and on-lay with plug for inguinal hernia repair.
Hernia. 2009 Apr;13(2):121-9; discussion 231. doi: 10.1007/s10029-008-0443-4. Epub 2008 Nov 13.
Abstract/Text
BACKGROUND: Dissection requirements differ between various methods for inguinal hernia repair, which may affect operation times, pain response and possibly recovery time. The objectives of this study were to establish if any differences concerning these aspects could be detected following three principally different techniques for primary inguinal hernia repair.
METHODS: A total of 472 men between 30 and 75 years of age with primary inguinal hernias were included in a prospective controlled study and randomised to Lichtenstein mesh (L), PerFix Plug (P) or the Prolene Hernia System (PHS) procedure. All patients were seen and data were collected after 2 weeks, 3 months, 1 year and 3 years.
RESULTS: The follow-up rates were 100, 99.8, 98.7 and 95.3%, respectively. The mean operation time was shorter for P (35.5 min, P < 0.001) and PHS (37.4 min, P < 0.02) versus L (40.4 min). More than 85% of the procedures were performed under local anaesthesia. There were no statistically significant differences between the groups concerning early or late complications, return to full functional ability, early pain response, analgesic consumption or the studied late-outcome parameters after 3 years of observation. Seven (1.5%) evenly distributed recurrences were registered.
CONCLUSION: All of the techniques are suitable for operation under local anaesthesia. The PHS and P techniques can be performed with shorter operation times than the L method. Early and late outcomes are, however, comparable, with no significant differences concerning complication rates, return to full functional status and/or pain response.
A M Grant, EU Hernia Trialists Collaboration
Laparoscopic versus open groin hernia repair: meta-analysis of randomised trials based on individual patient data.
Hernia. 2002 Mar;6(1):2-10.
Abstract/Text
The EU Hernia Trialists Collaboration was established to provide reliable evaluation of newer methods of groin hernia repair. It involved 70 investigators in 20 countries. The aim was to perform systematic reviews and enhance the value of individual studies by reanalysis of data from randomised controlled trials in meta-analyses. Forty-one eligible trials of laparoscopic versus open groin hernia repair were identified involving 7161 participants (with individual patient data available for 4165). Meta-analysis was performed, using individual patient data where possible. Operation times for laparoscopic repair were longer and there was a higher risk of rare serious complications. Return to usual activities was faster, and there was less persisting pain and numbness. Hernia recurrence was less common than after open non-mesh repair but not different to open mesh methods. The review showed that laparoscopic repair takes longer and has more serious complications, but recovery is quicker with less persisting pain. Reduced hernia recurrence was related to the use of mesh rather than the method of mesh placement.
Jaime Haidenberg, Michael L Kendrick, Tobias Meile, David R Farley
Totally extraperitoneal (TEP) approach for inguinal hernia: the favorable learning curve for trainees.
Curr Surg. 2003 Jan-Feb;60(1):65-8. doi: 10.1016/S0149-7944(02)00657-8.
Abstract/Text
PURPOSE: Endoscopic inguinal herniorrhaphy has become an established approach to groin hernia. The use of a totally extraperitoneal (TEP) approach allows a tension-free, preperitoneal approach with potentially less discomfort and morbidity than do classic repairs. Concerns have been raised regarding excessive cost, need for general anesthesia, and an extensive learning curve for surgeon and resident trainee alike.
METHODS: A retrospective analysis of 264 consecutive patients undergoing TEP for inguinal hernia repair from September 1995 to April 2000 was performed. All repairs were performed by surgical trainees under the supervision of a single staff surgeon.
RESULTS: Mean age of 256 men and 8 women undergoing 386 inguinal hernia repairs was 54 years (range, 15-86). Inguinal hernias were unilateral (n = 142) or bilateral (n = 122); indirect (52%), direct (33%), or pantaloon (15%); 37 defects (10%) were recurrent. Surgical residents (n = 74) participated in all 264 operations and were considered the "junior surgeon" in 211 cases: 19 chief residents did 35 operations, 9 PG-4s performed 27, 8 PG-3s did 17, 10 PG-2s completed 41, and 28 interns did 91 procedures. Mean operative time was 96 minutes (range, 30-261) with no statistical difference among PG-1s, 2s, 3s, 4s, or chief residents learning the procedure. Early postoperative complications included urinary retention (n = 25), seroma (n = 3), ileus (n = 3), and subcutaneous wound infection (n = 1). Fully 24% of patients desired or required overnight admission. All patients (100%) operated on for recurrence (n = 37) or a previous contralateral repair (n = 19) favored the current TEP approach over their prior repair. Hernia recurrence has developed in 8 patients, with 6 (75%) occurring within the first 40 study patients. Mean follow-up was 3.5 years (range, 1.2-5.9 years).
CONCLUSIONS: The totally extraperitoneal approach is a safe and effective method of inguinal hernia repair. Following a learning curve of 40 patients for the staff surgeon, the recurrence rate has been less than 1%, with surgical trainees safely performing TEP repairs under supervision.
P K Amid, A G Shulman, I L Lichtenstein
Local anesthesia for inguinal hernia repair step-by-step procedure.
Ann Surg. 1994 Dec;220(6):735-7.
Abstract/Text
OBJECTIVE: The authors introduce a simple six-step infiltration technique that results in satisfactory local anesthesia and prolonged postoperative analgesia, requiring a maximum of 30 to 40 mL of local anesthetic solution.
SUMMARY BACKGROUND DATA: For the last 20 years, more than 12,000 groin hernia repairs have been performed under local anesthesia at the Lichtenstein Hernia Institute. Initially, field block was the mean of achieving local anesthesia. During the last 5 years, a simple infiltration technique has been used because the field block was more time consuming and required larger volume of the local anesthetic solution. Furthermore, because of the blind nature of the procedure, it did not always result in satisfactory anesthesia and, at times, accidental needle puncture of the ilioinguinal nerve resulted in prolonged postoperative pain, burning, or electric shock sensation within the field of the ilioinguinal nerve innervation.
METHODS: More than 12,000 patients underwent operations in a private practice setting in general hospitals.
RESULTS: For 2 decades, more than 12,000 adult patients with reducible groin hernias satisfactorily underwent operations under local anesthesia without complications.
CONCLUSIONS: The preferred choice of anesthesia for all reducible adult inguinal hernia repair is local. It is safe, simple, effective, and economical, without postanesthesia side effects. Furthermore, local anesthesia administered before the incision produces longer postoperative analgesia because local infiltration, theoretically, inhibits build-up of local nociceptive molecules and, therefore, there is better pain control in the postoperative period.
Pär Nordin, Henrik Zetterström, Ulf Gunnarsson, Erik Nilsson
Local, regional, or general anaesthesia in groin hernia repair: multicentre randomised trial.
Lancet. 2003 Sep 13;362(9387):853-8. doi: 10.1016/S0140-6736(03)14339-5.
Abstract/Text
BACKGROUND: In specialised centres, local anaesthesia is almost always used in groin hernia surgery; whereas in routine surgical practice, regional or general anaesthesia are the methods of choice. In this three-arm multicentre randomised trial, we aimed to compare the three methods of anaesthesia and to determine the extent to which general surgeons can reproduce the excellent results obtained with local anaesthesia in specialised hernia centres.
METHODS: Between January, 1999, and December, 2001, 616 patients at ten hospitals, were randomly assigned to have either local, regional, or general anaesthesia. Primary endpoints were early and late postoperative complications. Secondary endpoints were duration of surgery and anaesthesia, length of postoperative hospital stay, and time to normal activity. Analysis was by intention to treat.
FINDINGS: Intraoperative tolerance for local anaesthesia was high. In the early postoperative period, local anaesthesia was superior to the other two types with respect to almost all endpoints. At 8 days' and 30 days' follow-up, there were no significant differences between the three groups. Although the mean duration of surgery was longer, the total anaesthesia time-ie, time from the start of anaesthesia until the patient left the operating room-was significantly shorter than it was for regional or general anaesthesia.
INTERPRETATION: Local anaesthesia has substantial advantages compared with regional or general anaesthesia, such as shorter duration of admission, less postoperative pain, and fewer micturition difficulties. The favourable results obtained with local anaesthesia in specialised hernia centres can, to a great extent, be reproduced by general surgeons in routine surgical practice.
Claudia C Orelio, Coen van Hessen, Francisco Javier Sanchez-Manuel, Theodorus J Aufenacker, Rob Jpm Scholten
Antibiotic prophylaxis for prevention of postoperative wound infection in adults undergoing open elective inguinal or femoral hernia repair.
Cochrane Database Syst Rev. 2020 Apr 21;4:CD003769. doi: 10.1002/14651858.CD003769.pub5. Epub 2020 Apr 21.
Abstract/Text
BACKGROUND: Inguinal or femoral hernia is a tissue protrusion in the groin region and has a cumulative incidence of 27% in adult men and of 3% in adult women. As most hernias become symptomatic over time, groin hernia repair is one of the most frequently performed surgical procedures worldwide. This type of surgery is considered 'clean' surgery with wound infection rates expected to be lower than 5%. For clean surgical procedures, antibiotic prophylaxis is not generally recommended. However after the introduction of mesh-based hernia repair and the publication of studies that have high wound infection rates the debate as to whether antibiotic prophylaxis is required to prevent postoperative wound infections started again.
OBJECTIVES: To determine the effectiveness of antibiotic prophylaxis in reducing postoperative (superficial and deep) wound infections in elective open inguinal and femoral hernia repair.
SEARCH METHODS: We searched several electronic databases: Cochrane Registry of Studies Online, MEDLINE Ovid, Embase Ovid, Scopus and Science Citation Index (search performed on 12 November 2019). We also searched two trial registers and the reference list of included studies.
SELECTION CRITERIA: We included randomised controlled trials comparing any type of antibiotic prophylaxis versus placebo or no treatment for preventing postoperative wound infections in adults undergoing inguinal or femoral open hernia repair surgery (tissue repair and mesh repair).
DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies, extracted data and assessed risk of bias. We separately analysed results for two different surgical methods (herniorrhaphy and hernioplasty). Several studies revealed infection rates that were higher than the expected 5% for clean surgery and we therefore divided studies into two subgroups: high infection risk environments (≥ 5% infection rate); and low infection risk environments (< 5% infection rate). We performed meta-analyses with random-effects models. We analysed three outcomes: superficial surgical site infections (SSSI); deep surgical site infections (DSSI); and all postoperative wound infections (SSSI + DSSI).
MAIN RESULTS: In this review update we identified and included 10 new studies. In total, we included 27 studies with 8308 participants in this review. It is uncertain whether antibiotic prophylaxis as compared to placebo (or no treatment) prevents all types of postoperative wound infections after herniorrhaphy surgery (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.56 to 1.33; 5 studies, 1865 participants; very low quality evidence). Subgroup analysis did not change these results. We could not perform meta-analyses for SSSI or DSSI as these outcomes were not reported separately. Twenty-two studies related to hernioplasty surgery (total of 6443 participants) and we analysed three outcomes: SSSI; DSSI; SSSI + DSSI. Within the low infection risk environment subgroup, antibiotic prophylaxis as compared to placebo probably makes little or no difference for the outcomes 'prevention of all wound infections' (RR 0.71, 95% CI 0.44 to 1.14; moderate-quality evidence) and 'prevention of SSSI' (RR 0.71, 95% CI 0.44 to 1.17, moderate-quality evidence). Within the high infection risk environment subgroup it is uncertain whether antibiotic prophylaxis reduces all types of wound infections (RR 0.58, 95% CI 0.43 to 0.77, very low quality evidence) or SSSI (RR 0.56, 95% CI 0.41 to 0.77, very low quality evidence). When combining participants from both subgroups, antibiotic prophylaxis as compared to placebo probably reduces the risk of all types of wound infections (RR 0.61, 95% CI 0.48 to 0.78) and SSSI (RR 0.60, 95% CI 0.46 to 0.78; moderate-quality evidence). Antibiotic prophylaxis as compared to placebo probably makes little or no difference in reducing the risk of postoperative DSSI (RR 0.65, 95% CI 0.26 to 1.65; moderate-quality evidence), both in a low infection risk environment (RR 0.67, 95% CI 0.11 to 4.13; moderate-quality evidence) and in the high infection risk environment (RR 0.64, 95% CI 0.22 to 1.89; low-quality evidence).
AUTHORS' CONCLUSIONS: Evidence of very low quality shows that it is uncertain whether antibiotic prophylaxis reduces the risk of postoperative wound infections after herniorrhaphy surgery. Evidence of moderate quality shows that antibiotic prophylaxis probably makes little or no difference in preventing wound infections (i.e. all wound infections, SSSI or DSSI) after hernioplasty surgery in a low infection risk environment. Evidence of low quality shows that antibiotic prophylaxis in a high-risk environment may reduce the risk of all wound infections and SSSI, while evidence of very low quality shows that it is uncertain whether antibiotic prophylaxis reduces DSSI after hernioplasty surgery.
Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Francisco Javier Sanchez-Manuel, Javier Lozano-García, Juan Luis Seco-Gil
Antibiotic prophylaxis for hernia repair.
Cochrane Database Syst Rev. 2012 Feb 15;2:CD003769. doi: 10.1002/14651858.CD003769.pub4. Epub 2012 Feb 15.
Abstract/Text
BACKGROUND: The use of antibiotic prophylaxis for hernia repair is currently a controversial issue given the disparity among study results in this area.
OBJECTIVES: The objective of this systematic review was to clarify the effectiveness of antibiotic prophylaxis in reducing postoperative wound infection rates in elective open inguinal hernia repair.
SEARCH METHODS: We searched the Cochrane Colorectal Cancer Group specialized register, by crossing the terms herni* and inguinal or groin and the terms antimicr* or antibiot* , as free text and MeSH terms. A similar search were performed in Medline using the following terms: #1 antibiotic* OR antimicrob* OR anti infecti* OR antiinfecti*; #2 prophyla* OR prevent*; #3 #1 AND #2; #4 clean AND (surgery OR tech* OR proced*); #5 herni*; #6 (wound infection) AND #4; #7 #3 AND (#4 or #5 or #6). National Research Register, ISI-Web, DARE, Scirus, TRIPDATABASE, NHS EED, reference list of the included studies and web of clinical trials register (www.controlled-trials.com and clinicaltrials.gov) were checked to identify further studies.
SELECTION CRITERIA: Only randomised clinical trials were included.
DATA COLLECTION AND ANALYSIS: In the present review, we searched for eligible trials in October 2011. This revealed four new included trials, so seventeen trials are included in the meta-analysis. Eleven of them used prosthetic material for hernia repair (hernioplasty) whereas the remaining studies did not (herniorrhaphy). Pooled and subgroup analysis were conducted depending on whether prosthetic material was or not used. A fixed effects model was used in the analysis.
MAIN RESULTS: The total number of patients included was 7843 (prophylaxis group: 4703, control group: 3140). Overall infection rates were 3.1% and 4.5% in the prophylaxis and control groups, respectively (OR 0.64, 95% CI 0.50 - 0.82). The subgroup of patients with herniorrhaphy had infection rates of 3.5% and 4.9% in the prophylaxis and control groups, respectively (OR 0.71, 95% CI 0.51 - 1.00). The subgroup of patients with hernioplasty had infection rates of 2.4% and 4.2% in the prophylaxis and control groups, respectively (OR 0.56, 95% CI 0.38 - 0.81).
AUTHORS' CONCLUSIONS: Based on the results of this systematic review the administration of antibiotic prophylaxis for elective inguinal hernia repair cannot be universally recommended. Neither can the administration be recommended against when high rates of wound infection are observed.
R Platt, D F Zaleznik, C C Hopkins, E P Dellinger, A W Karchmer, C S Bryan, J F Burke, M A Wikler, S K Marino, K F Holbrook
Perioperative antibiotic prophylaxis for herniorrhaphy and breast surgery.
N Engl J Med. 1990 Jan 18;322(3):153-60. doi: 10.1056/NEJM199001183220303.
Abstract/Text
We assessed the efficacy of perioperative antibiotic prophylaxis for surgery in a randomized, double-blind trial of 1218 patients undergoing herniorrhaphy or surgery involving the breast, including excision of a breast mass, mastectomy, reduction mammoplasty, and axillary-node dissection. The prophylactic regimen was a single dose of cefonicid (1 g intravenously) administered approximately half an hour before surgery. The patients were followed up for four to six weeks after surgery. Blinding was maintained until the last patient completed the follow-up and all diagnoses of infection had been made. The patients who received prophylaxis had 48 percent fewer probable or definite infections than those who did not (Mantel-Haenszel risk ratio, 0.52; 95 percent confidence interval, 0.32 to 0.84; P = 0.01). For patients undergoing a procedure involving the breast, infection occurred in 6.6 percent of the cefonicid recipients (20 of 303) and 12.2 percent of the placebo recipients (37 of 303); for those undergoing herniorrhaphy, infection occurred in 2.3 percent of the cefonicid recipients (7 of 301) and 4.2 percent of the placebo recipients (13 of 311). There were comparable reductions in the numbers of definite wound infections (Mantel-Haenszel risk ratio, 0.49), wounds that drained pus (risk ratio, 0.43), Staphylococcus aureus wound isolates (risk ratio, 0.49), and urinary tract infections (risk ratio, 0.40). There were also comparable reductions in the need for postoperative antibiotic therapy, non-routine visits to a physician for problems involving wound healing, incision and drainage procedures, and readmission because of problems with wound healing. We conclude that perioperative antibiotic prophylaxis with cefonicid is useful for herniorrhaphy and certain types of breast surgery.
Stefan Sauerland, Maren Walgenbach, Brigitte Habermalz, Christoph M Seiler, Marc Miserez
Laparoscopic versus open surgical techniques for ventral or incisional hernia repair.
Cochrane Database Syst Rev. 2011 Mar 16;(3):CD007781. doi: 10.1002/14651858.CD007781.pub2. Epub 2011 Mar 16.
Abstract/Text
BACKGROUND: There are many different techniques currently in use for ventral and incisional hernia repair. Laparoscopic techniques have become more common in recent years, although the evidence is sparse.
OBJECTIVES: We compared laparoscopic with open repair in patients with (primary) ventral or incisional hernia.
SEARCH STRATEGY: We searched the following electronic databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, metaRegister of Controlled Trials. The last searches were conducted in July 2010. In addition, congress abstracts were searched by hand.
SELECTION CRITERIA: We selected randomised controlled studies (RCTs), which compared the two techniques in patients with ventral or incisional hernia. Studies were included irrespective of language, publication status, or sample size. We did not include quasi-randomised trials.
DATA COLLECTION AND ANALYSIS: Two authors assessed trial quality and extracted data independently. Meta-analytic results are expressed as relative risks (RR) or weighted mean difference (WMD).
MAIN RESULTS: We included 10 RCTs with a total number of 880 patients suffering primarily from primary ventral or incisional hernia. No trials were identified on umbilical or parastomal hernia. The recurrence rate was not different between laparoscopic and open surgery (RR 1.22; 95% CI 0.62 to 2.38; I(2) = 0%), but patients were followed up for less than two years in half of the trials. Results on operative time were too heterogeneous to be pooled. The risk of intraoperative enterotomy was slightly higher in laparoscopic hernia repair (Peto OR 2.33; 95% CI 0.53 to 10.35), but this result stems from only 7 cases with bowel lesion (5 vs. 2). The most clear and consistent result was that laparoscopic surgery reduced the risk of wound infection (RR = 0.26; 95% CI 0.15 to 0.46; I(2)= 0%). Laparoscopic surgery shortened hospital stay significantly in 6 out of 9 trials, but again data were heterogeneous. Based on a small number of trials, it was not possible to detect any difference in pain intensity, both in the short- and long-term evaluation. Laparoscopic repair apparently led to much higher in-hospital costs.
AUTHORS' CONCLUSIONS: The short-term results of laparoscopic repair in ventral hernia are promising. In spite of the risks of adhesiolysis, the technique is safe. Nevertheless, long-term follow-up is needed in order to elucidate whether laparoscopic repair of ventral/incisional hernia is efficacious.
