Overview of treatment for inguinal and femoral hernia in adults

Overview of treatment for inguinal and femoral hernia in adults 12/26/17, 9)18 AM Official reprint from UpToDateđ www.uptodate.com â2017 UpToDate, Inc and/or its affiliates All Rights Reserved The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc Overview of treatment for inguinal and femoral hernia in adults Author David C Brooks, MD Section Editor Michael Rosen, MD Deputy Editor Wenliang Chen, MD, PhD All topics are updated as new evidence becomes available and our peer review process is complete Literature review current through: Nov 2017 | This topic last updated: Mar 27, 2017 INTRODUCTION — The definitive treatment of all hernias, regardless of origin or type, is surgical repair [1] Groin hernia repair is one of the most commonly performed operations Over 20 million inguinal or femoral hernias are repaired every year worldwide [2], including over 700,000 in the United States [3] An inguinal or femoral hernia repair is performed urgently in patients who develop complications such as acute incarceration or strangulation For patients without a complication, the optimal timing of repair (watchful waiting versus early repair) and the optimal surgical technique (open versus laparoscopic) are controversial and are the focus of this topic The clinical features and diagnosis of an inguinal or femoral hernia, the technical details of performing an inguinal or femoral hernia repair, the complications of hernia repair, and the treatment of recurrent hernias are discussed separately in other topics (See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults" and "Open surgical repair of inguinal and femoral hernia in adults" and "Laparoscopic inguinal and femoral hernia repair in adults" and "Overview of complications of inguinal and femoral hernia repair" and "Recurrent inguinal and femoral hernia".) INDICATIONS FOR SURGICAL REPAIR — There was a time when the mere presence of a groin hernia was a sufficient indication for surgical repair Contemporary practice, however, triages patients to surgery versus watchful waiting according to the severity of symptoms and the type of hernia (inguinal versus femoral) Complicated hernia — Patients who develop strangulation or bowel obstruction should undergo urgent surgical repair Surgery performed within four to six hours from the onset of symptoms may prevent bowel loss due to one of these complications Patients with an acutely incarcerated inguinal hernia but without signs of strangulation (eg, skin changes, peritonitis) should be offered urgent surgical repair However, hernia reduction can be attempted in patients who wish to delay surgery If hernia reduction is successful, the patient should follow up with their surgeon within one to two days to exclude recurrent incarceration and arrange for elective repair Those who fail hernia reduction should proceed urgently to surgery The clinical manifestations and diagnosis of incarcerated/strangulated inguinal or femoral hernias can be found elsewhere (See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults".) Uncomplicated hernias — In patients with uncomplicated inguinal or femoral hernias, surgical repair is intended to https://www.uptodate.com/contents/overview-of-treatment-for-inguin…w=full&source=search_result&selectedTitle=1%7E100&elapsedTimeMs=4 Page of 15 Overview of treatment for inguinal and femoral hernia in adults 12/26/17, 9)18 AM relieve symptoms and to prevent future complications The indications for surgical repair of uncomplicated hernias are less rigid than complicated hernias, and depend upon the type of hernias (inguinal versus femoral) involved, the severity of symptoms, and patient preference In select patients, watchful waiting is an alternative to surgery (See 'Asymptomatic hernia' below.) Femoral hernia — For all patients with a newly diagnosed femoral hernia, we suggest elective surgical repair, rather than watchful waiting, regardless of the patient’s sex and symptoms Femoral hernias are associated with a high risk of complications and therefore early elective surgical repair is indicated Femoral hernias are associated with a higher risk of developing complications than inguinal hernias In one study, the rates of strangulation were 22 and 45 percent at and 21 months, respectively, for femoral hernias, compared with 2.8 and 4.5 percent for inguinal hernias [4] Thus, early elective repair is advised for patients with a newly diagnosed femoral hernia to avoid complications that may necessitate urgent surgery Urgent surgery for complicated hernias is more likely to involve bowel resection, which is associated with a higher mortality rate In one study, for example, bowel resection was required in 23 percent of urgent, compared with 0.6 percent of elective femoral hernia repairs, and urgent femoral hernia repairs were associated with a 10-fold increase in mortality [5] For patients who have a long-standing (>3 months) femoral hernia that is asymptomatic, surgery is preferred but observation is a reasonable option Inguinal hernia — For patients with moderate to severe symptoms from an inguinal hernia, surgical repair is indicated Patients with minimal or no symptoms from an inguinal hernia may be managed with elective surgery or watchful waiting The only nonsurgical therapy for groin hernia in men is a truss A truss is a strap similar to an athletic supporter with a metal or hard plastic plug positioned to lie over the hernia defect When applied appropriately, the hard disc or plug exerts pressure to keep the hernia contents in the abdomen Although the use of a truss may be helpful in certain situations, we generally discourage their use because there is insufficient evidence to prove their efficacy [6,7] In addition, inappropriate use of a truss may harm abdominal contents in a hernia sac or complicate subsequent surgical repair [8] Symptomatic hernia — Patients with significant symptoms attributable to an inguinal hernia should undergo elective surgical repair [1] Such symptoms typically include: ● Groin pain with exertion (eg, lifting) ● Inability to perform daily activities due to pain or discomfort from the hernia ● Inability to manually reduce the hernia (ie, chronic incarceration) Asymptomatic hernia — For patients with minimal or no symptoms from an inguinal hernia, we suggest elective hernia repair However, those who wish to avoid surgery can be managed with watchful waiting provided that they know to seek immediate medical attention if the hernia becomes acutely incarcerated (See 'Complicated hernia' above.) Historically, groin hernias were repaired once detected, under the assumption that complications from unrepaired hernias were common and could increase operative morbidity Randomized trials comparing watchful waiting with surgical repair of inguinal hernias, however, demonstrated that delaying surgical repair in asymptomatic patients was safe, as acute complications rarely occurred However, for about half of patients, surgical repair was required eventually because symptoms gradually increased over time The largest trial (the WW trial) randomly assigned 720 men with an uncomplicated inguinal hernia to watchful waiting or https://www.uptodate.com/contents/overview-of-treatment-for-inguin…w=full&source=search_result&selectedTitle=1%7E100&elapsedTimeMs=4 Page of 15 Overview of treatment for inguinal and femoral hernia in adults 12/26/17, 9)18 AM open surgical repair [9,10] The patients, who were men mostly between the ages of 40 and 65, were asymptomatic or minimally symptomatic, and the hernias remained easily reducible within six weeks of the initial screening The following results were reported: ● At two years, similar numbers of patients in each group reported pain sufficient to limit activities (5.1 with watchful waiting versus 2.1 percent with surgery) Although 23 and 31 percent of patients in the watchful waiting group required surgery at two and four years, respectively, only two patients required urgent surgery due to acute complications, at a rate of 0.0018 events per patient-year [9] ● After an additional seven years of follow-up, a total of 68 percent of men in the watchful waiting group had surgery, most commonly for pain (54 percent) Men older than 65 years were more likely to require surgery than younger men (79 versus 62 percent) However, only one additional patient required urgent surgery [10] A subsequent trial of 160 men also found no differences in either the rate of hernia complications or pain scores between the surgery and watchful waiting groups [11] However, at six and twelve months, patients in the surgery group reported improvement in their general health, whereas patients in the watchful waiting group reported a decline At 15 months, 26 percent of men in the watchful waiting group required surgery, including three urgent operations We suggest that patients with inguinal hernias that are managed with watchful waiting be counseled that: ● Although the risks of hernia complications (eg, incarceration, strangulation, or bowel obstruction) are low (3 cm) with an open approach because of the technical difficulty associated with managing and reducing a large hernia sac laparoscopically [23] Patients with ascites — In patients with ascites, we prefer an open approach to laparoscopic approaches In particular, the laparoscopic TAPP approach (which is transperitoneal) should be avoided Prior to surgery, ascites should be minimized as much as possible with medical treatment At the time of surgery, the hernia sac should be left intact to avoid complications such as persistent leakage of ascitic fluid (See "Open surgical repair of inguinal and femoral hernia in adults" and "Laparoscopic inguinal and femoral hernia repair in adults".) Patients who cannot tolerate general anesthesia — Laparoscopic groin hernia repair is typically performed under general anesthesia Thus, patients who cannot tolerate general anesthesia for medical reasons should undergo open repair under local or regional anesthesia (See 'Choice of anesthesia' below.) Patients eligible for both open and laparoscopic repair — Patients who not have a history of prior preperitoneal surgery, ascites, or a complicated hernia are eligible for both open and laparoscopic repairs of a groin hernia The choice of the surgical procedure then depends upon whether the hernia is primary or recurrent, unilateral or bilateral, and femoral or inguinal Primary hernia — A primary, unilateral inguinal hernia can be repaired open or laparoscopically based upon surgeon and patient preference A primary, unilateral femoral hernia, and all bilateral hernias (both inguinal and femoral), should be repaired laparoscopically https://www.uptodate.com/contents/overview-of-treatment-for-inguin…w=full&source=search_result&selectedTitle=1%7E100&elapsedTimeMs=4 Page of 15 Overview of treatment for inguinal and femoral hernia in adults 12/26/17, 9)18 AM Unilateral hernia Inguinal hernia — There is no consensus as to whether the optimal approach to inguinal hernia repair is open or laparoscopic [24-26] Some surgeons prefer to repair a primary, unilateral inguinal hernia with an open technique, while others prefer a laparoscopic approach (See 'Open tension-free mesh repairs' below.) Open and laparoscopic approaches have been directly compared most often in inguinal hernia repairs In general, laparoscopic repair has been associated with less postoperative pain and quicker recovery, but longer operative time and higher recurrence rates [21,27-39] Laparoscopic repair could also result in serious complications (eg, massive pelvic bleeding) that would rarely occur during open repairs The largest trial randomly assigned 1983 men with inguinal hernias to receive open or laparoscopic mesh repair at of 14 United States Veterans Affairs Medical Centers [40] Patients treated laparoscopically had less pain on the day of surgery and at two weeks, and returned to work one day earlier However, they suffered more postoperative complications (39 versus 33.4 percent), life-threatening complications (1.1 versus 0.1 percent), and hernia recurrences (10.1 versus 4.9 percent at two years) In subgroup analysis, the difference in recurrence rate was significant for primary (10.1 versus percent), but not recurrent hernias (10 versus 14 percent) This trial has been criticized for higher than average rates of recurrences in both groups due to surgeon inexperience, as well as for a patient population that is older (average age 58) and less healthy (only 34 percent were American Society of Anesthesiologists class I) than the average patient who needs inguinal hernia repair A subsequent trial randomly assigned 389 patients with a primary unilateral inguinal hernia to receive either open Lichtenstein repair under local anesthesia or laparoscopic total extraperitoneal (TEP) repair under general anesthesia [41] Fewer patients in the laparoscopic group reported having persistent groin pain at one year (21 versus 33 percent) However, this difference may not be clinically relevant, as most patients reported mild pain (described as “can be easily ignored” on the questionnaire); only a few patients in each group (2 percent in the laparoscopic versus percent in open group) reported severe pain In addition, fewer patients in the laparoscopic group reported having groin pain that limited their ability to perform physical exercise (3 versus percent) The recurrence rates at one year were similarly low in both groups (1 percent laparoscopic versus percent open) Femoral hernia — We prefer to repair a femoral hernia laparoscopically because of its ease of access Anterior femoral hernia repairs require a breach of the inguinal canal to gain access to the femoral hernia posteriorly; posterior repairs have direct access to the femoral hernia without going through the inguinal canal In one study, posterior repair of femoral hernias was associated with a lower recurrence rate than anterior repair [5] Posterior repairs are mostly done laparoscopically, as the only open posterior repair (Kugel) is rarely performed In addition, laparoscopic femoral hernia repair is also better at identifying occult hernias [42] In one study of 250 men undergoing laparoscopic repair of presumed inguinal hernias, femoral hernias were detected in additional to (29) or in lieu of (4) inguinal hernias in 33 patients (13.2 percent) [43] Of the 33 patients with a femoral hernia, 61 percent had undergone a previous open inguinal hernia repair, reflecting either the failure to recognize a concomitant femoral hernia during their initial open surgery, or the interval development of a femoral hernia Bilateral hernias — We prefer to repair bilateral groin hernias laparoscopically because: ● Both hernias can be repaired through the same incisions, which improves cosmesis ● A single large piece of mesh can be used with a laparoscopic TEP repair, reducing costs and potentially the risk of direct hernia recurrence medially [44] ● A laparoscopic approach permits exploration of the contralateral groin in patients with symptoms suggestive but not diagnostic of a contralateral hernia [45] https://www.uptodate.com/contents/overview-of-treatment-for-inguin…w=full&source=search_result&selectedTitle=1%7E100&elapsedTimeMs=4 Page of 15 Overview of treatment for inguinal and femoral hernia in adults 12/26/17, 9)18 AM Three randomized trials have independently concluded that laparoscopic compared with open repair of bilateral inguinal hernias caused less postoperative pain, faster recovery, and similar rates of recurrence [46-48] The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom advocates laparoscopic repair for patients with bilateral hernias [49] When laparoscopic repair is not available, the alternative for patients with bilateral hernias is bilateral open tension-free mesh repair, which can be performed as a single operation, rather than two separate procedures [50] Recurrent hernia — We prefer to repair a recurrent groin hernia with a laparoscopic approach if the initial repair was open, but with an open approach if the initial repair was laparoscopic The rationale is that recurrent hernia repair is optimal if performed in a previously undissected tissue plane Patients with prior open repair — Many surgeons feel that recurrent hernias, particularly those that recur after an anterior mesh repair, are best addressed via a laparoscopic technique [29,33] As with primary repairs, a laparoscopic repair of recurrent hernias was also associated with faster recovery, less postoperative pain, and fewer complications [33,48,51-53] The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom also advocates laparoscopic repair for recurrent hernias [49] Patients with prior laparoscopic repair — An open repair is required for patients with a recurrent hernia if they have had a previous laparoscopic hernia repair (usually with mesh placement) or other surgeries involving the preperitoneal space (eg, prostatectomy, hysterectomy, cesarean section, or laparotomy via lower midline incision) In such patients, the preperitoneal space may be difficult to access (See 'Patients with prior surgery involving the preperitoneal space' above.) Special considerations Cost-effectiveness — Studies have generally found an overall cost benefit for open, as opposed to laparoscopic, hernia repair [54-58] Factors considered in such studies included the cost of operating room time and equipment (especially single-use items), length of hospital stay, and the cost of treating potential complications Variations in one or more of these factors (eg, by using reusable equipment) could make laparoscopic surgery more cost-effective [54] Female patients — Groin hernias are uncommon in females; less than percent of hernia repairs are performed in women [5,59-61] Compared with men, women are more likely to have femoral hernias, complicated hernias (incarceration or strangulation), or recurrent hernias [59] (See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults", section on 'Epidemiology' and "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults", section on 'Femoral hernia'.) For women who have had a prior surgery involving the preperitoneal space (eg, cesarean section or hysterectomy), an open anterior mesh repair is the best option In others, a laparoscopic approach is preferred because it allows identification and repair of occult hernias (especially femoral hernias) SURGICAL TECHNIQUES — Specific techniques of inguinal or femoral hernia repair are briefly discussed below Detailed information can be found in other topics (See "Open surgical repair of inguinal and femoral hernia in adults" and "Laparoscopic inguinal and femoral hernia repair in adults".) Open techniques — Open techniques approach the hernia defect anteriorly, and include tension-free mesh repairs as well as primary tissue approximation nonmesh repairs For patients in whom mesh placement is not contraindicated, we recommend using a mesh repair technique to achieve a tension-free repair rather than a nonmesh repair technique Nonmesh repair techniques may be required for patients with active groin infection or contamination (eg, as a result of bowel perforation from a strangulated hernia) Open tension-free mesh repairs — Successful hernia repair depends upon a tension-free closure, which is https://www.uptodate.com/contents/overview-of-treatment-for-inguin…w=full&source=search_result&selectedTitle=1%7E100&elapsedTimeMs=4 Page of 15 Overview of treatment for inguinal and femoral hernia in adults 12/26/17, 9)18 AM typically achieved with placement of a mesh Multiple studies have demonstrated that tension-free mesh repair of inguinal hernias reduces postoperative groin pain, expedites recovery, and reduces recurrence rate [1,2,23,62-65] Thus, the tension-free mesh techniques are most widely used and endorsed by various hernia societies [1,24,25] Tension-free repairs that use mesh include Lichtenstein, plug and patch, and Kugel (preperitoneal repair) (See "Open surgical repair of inguinal and femoral hernia in adults", section on 'Mesh versus non-mesh repair' and "Open surgical repair of inguinal and femoral hernia in adults", section on 'Hernia repair techniques'.) Open primary tissue approximation nonmesh repairs — Shouldice, Bassini, and McVay repairs are open techniques that achieve primary tissue approximation without the use of mesh [64,66-70] Although the Shouldice repair does not incorporate mesh, some regard it as a tension-free technique Nonmesh repair techniques are primarily used when mesh placement is contraindicated, such as when there is active infection or contamination of the groin, or when the use of a mesh is cost-prohibitive (eg, in resource-limited settings) (See "Open surgical repair of inguinal and femoral hernia in adults", section on 'Hernia repair techniques'.) Laparoscopic techniques — Laparoscopic repairs approach the hernia defect posteriorly The two main techniques are totally extraperitoneal (TEP) repair and transabdominal preperitoneal patch (TAPP) repair, both of which require the use of mesh and are considered tension-free repairs [71] The mesh employed for these repairs must be of sufficient size to cover the entire preperitoneal groin space in order to prevent recurrences (See "Laparoscopic inguinal and femoral hernia repair in adults", section on 'Laparoscopic repair approaches'.) PREOPERATIVE PREPARATION — Inguinal and femoral hernias can usually be repaired with minimal morbidity and mortality We use the following preoperative routine to optimize patient outcomes and experience Confirm presence and location of hernia — The diagnosis of an inguinal or femoral hernia is clinical for most patients Immediately prior to surgery, the patient should be reexamined to confirm the presence of a hernia and mark its laterality (See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults".) Obtain informed consent — The risks and benefits of hernia repair versus watchful waiting, including potential complications of each approach, should be reviewed with the patient In particular, the surgeon should inform the patient of a potential risk of chronic groin pain or discomfort after groin hernia repair If surgical repair is elected, the risks and benefits of an open versus laparoscopic approach should also be discussed with the patient (See 'Choosing a surgical approach' above.) Medical risk assessment — Much of the preoperative medical evaluation is directed toward ensuring that the patient can tolerate anesthesia, especially if general anesthesia is planned (See "Preoperative medical evaluation of the adult healthy patient" and "Evaluation of cardiac risk prior to noncardiac surgery" and "Evaluation of preoperative pulmonary risk" and "Perioperative management of blood glucose in adults with diabetes mellitus".) Treat hernia complications if present — Patients with complicated hernias should receive complication-specific treatment prior to hernia repair As examples, patients with bowel obstruction require fluid resuscitation and nasogastric decompression; patients with bowel ischemia or perforation require antimicrobial coverage (See "Overview of management of mechanical small bowel obstruction in adults" and "Overview of gastrointestinal tract perforation", section on 'Initial management'.) Preoperative prophylaxis — Most inguinal and femoral hernia repairs are elective procedures performed in an outpatient setting Thromboprophylaxis and/or prophylactic antibiotics may be required in selected patients to prevent complications such as venous thromboembolism (VTE) or surgical site infection (SSI) Thromboprophylaxis — Thromboprophylaxis is administered according to the patient’s risks of developing VTE perioperatively (table 1) Patients who are young (3 months), surgery is preferred but observation is a reasonable option (See 'Femoral hernia' above.) • For patients with moderate or severe symptoms attributable to an inguinal hernia, we recommend elective repair rather than watchful waiting (Grade 1B) (See 'Symptomatic hernia' above.) • Patients who have an inguinal hernia but minimal or no symptoms, who wish to avoid surgery, can be managed with watchful waiting provided that they are appropriately counseled to seek prompt medical attention should the hernia become acutely incarcerated Trusses are associated with negative consequences and should not be used to manage symptoms related to inguinal hernias (See 'Asymptomatic hernia' above.) ● The surgical approach to groin hernia repair should be the one that the surgeon is most comfortable with and most experienced in performing For surgeons who are equally facile with both open and laparoscopic repairs, the choice of a surgical approach depends upon hernia and patient characteristics as follows (algorithm 1): • We prefer an open approach for patients with prior surgery involving the preperitoneal space (including laparoscopic groin hernia repair, prostatectomy, hysterectomy, cesarean section, and laparotomy via lower midline incision), complicated inguinal hernias (infected, incarcerated, strangulated, large scrotal), ascites, or intolerance of general anesthesia Laparoscopic repair is relatively contraindicated in these patients (See 'Patients precluded from laparoscopic repair' above.) • A primary, unilateral inguinal hernia can be repaired open or laparoscopically based upon surgeon and patient preferences (See 'Inguinal hernia' above.) • We prefer to repair a femoral hernia laparoscopically (See 'Femoral hernia' above.) • We prefer to repair bilateral inguinal or femoral hernias laparoscopically (See 'Bilateral hernias' above.) • We prefer to repair a recurrent groin hernia with a laparoscopic approach if the initial repair was open, but with an open approach if the initial repair was laparoscopic (See 'Recurrent hernia' above.) ● For patients with uncomplicated inguinal and femoral hernias, we recommend performing a tension-free repair, which typically requires the use of mesh, rather than a repair that produces tension (ie, most nonmesh primary tissue approximation repairs except Shouldice) (Grade 1B) Nonmesh repair techniques may be required for patients with active groin infection or contamination (eg, as a result of bowel perforation from a strangulated hernia), or when the use of a mesh is cost-prohibitive (See 'Surgical techniques' above.) https://www.uptodate.com/contents/overview-of-treatment-for-ingui…w=full&source=search_result&selectedTitle=1%7E100&elapsedTimeMs=4 Page 10 of 15 Overview of treatment for inguinal and femoral hernia in adults 12/26/17, 9)18 AM ● For patients undergoing elective inguinal or femoral hernia repair requiring mesh placement, we suggest using preoperative prophylactic antibiotics (Grade 2B) (See 'Antibiotics' above.) ● We prefer to perform open groin hernia repair under local anesthesia, especially in patients with comorbidities (eg, advanced liver disease) Most laparoscopic repairs require general anesthesia (See 'Choice of anesthesia' above.) 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:CD001543 68 Glassow F The Shouldice Hospital technique Int Surg 1986; 71:148 69 Rutkow IM, Robbins AW "Tension-free" inguinal herniorrhaphy: a preliminary report on the "mesh plug" technique Surgery 1993; 114:3 70 Kugel RD Minimally invasive, nonlaparoscopic, preperitoneal, and sutureless, inguinal herniorrhaphy Am J Surg 1999; 178:298 71 Bittner R, Arregui ME, Bisgaard T, et al Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)] Surg Endosc 2011; 25:2773 72 Mazaki T, Mado K, Masuda H, Shiono M Antibiotic prophylaxis for the prevention of surgical site infection after tension-free hernia repair: a Bayesian and frequentist meta-analysis J Am Coll Surg 2013; 217:788 73 Sanabria A, Domínguez LC, Valdivieso E, Gómez G Prophylactic antibiotics for mesh inguinal hernioplasty: A meta-analysis Ann Surg 2007; 245:392 74 Li JF, Lai DD, Zhang XD, et al Meta-analysis of the effectiveness of prophylactic antibiotics in the prevention of postoperative complications after tension-free hernioplasty Can J Surg 2012; 55:27 75 Aufenacker TJ, Koelemay MJ, Gouma DJ, Simons MP Systematic review and meta-analysis of the effectiveness of antibiotic prophylaxis in prevention of wound infection after mesh repair of abdominal wall hernia Br J Surg 2006; 93:5 76 Moon V, Chaudry GA, Choy C, Ferzli GS Mesh infection in the era of laparoscopy J Laparoendosc Adv Surg Tech A 2004; 14:349 77 Yin Y, Song T, Liao B, et al Antibiotic prophylaxis in patients undergoing open mesh repair of inguinal hernia: a meta-analysis Am Surg 2012; 78:359 78 Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL Antibiotic prophylaxis for hernia repair Cochrane Database Syst Rev 2012; :CD003769 79 Sanchez VM, Abi-Haidar YE, Itani KM Mesh infection in ventral incisional hernia repair: incidence, contributing factors, and treatment Surg Infect (Larchmt) 2011; 12:205 80 Fry DE Surgical site infections and the surgical care improvement project (SCIP): evolution of national quality measures Surg Infect (Larchmt) 2008; 9:579 81 Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, et al Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project Clin Infect Dis 2004; 38:1706 82 Nordin P, Zetterström H, Gunnarsson U, Nilsson E Local, regional, or general anaesthesia in groin hernia repair: multicentre randomised trial Lancet 2003; 362:853 83 Young DV Comparison of local, spinal, and general anesthesia for inguinal herniorrhaphy Am J Surg 1987; 153:560 84 van Veen RN, Mahabier C, Dawson I, et al Spinal or local anesthesia in lichtenstein hernia repair: a randomized controlled trial Ann Surg 2008; 247:428 85 Abi-Haidar Y, Sanchez V, Itani KM Risk factors and outcomes of acute versus elective groin hernia surgery J Am Coll Surg 2011; 213:363 86 Arenal JJ, Rodríguez-Vielba P, Gallo E, Tinoco C Hernias of the abdominal wall in patients over the age of 70 years Eur J Surg 2002; 168:460 87 Nilsson H, Stylianidis G, Haapamäki M, et al Mortality after groin hernia surgery Ann Surg 2007; 245:656 Topic 3687 Version 21.0 Contributor Disclosures https://www.uptodate.com/contents/overview-of-treatment-for-ingui…w=full&source=search_result&selectedTitle=1%7E100&elapsedTimeMs=4 Page 14 of 15 Overview of treatment for inguinal and femoral hernia in adults 12/26/17, 9)18 AM David C Brooks, MD Nothing to disclose Michael Rosen, MD Grant/Research/Clinical Trial Support: WL Gore; Miromatrix [Mesh (Mesh)] Speaker's Bureau: WL Gore; Bard [Mesh (Mesh)] Consultant/Advisory Boards: Artiste Medical [Mesh (Mesh)] Employment: Medical Director of AHSQC (Americas Hernia Society Quality Collaborative) Wenliang Chen, MD, PhD Nothing to disclose Contributor disclosures are reviewed for conflicts of interest by the editorial group When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence Conflict of interest policy https://www.uptodate.com/contents/overview-of-treatment-for-ingui…w=full&source=search_result&selectedTitle=1%7E100&elapsedTimeMs=4 Page 15 of 15 ... repair of inguinal and femoral hernia in adults" and "Laparoscopic inguinal and femoral hernia repair in adults" .) Patients who cannot tolerate general anesthesia — Laparoscopic groin hernia. .. "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults" .) Obtain informed consent — The risks and benefits of hernia repair versus watchful waiting, including potential... https://www.uptodate.com/contents /overview- of- treatment- for- inguin…w=full&source=search_result&selectedTitle=1%7E100&elapsedTimeMs=4 Page of 15 Overview of treatment for inguinal and femoral hernia in adults 12/26/17,