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Oyola et al. Mini-invasive Surg 2023;7:26 https://dx.doi.org/10.20517/2574-1225.2023.26 Page 3 of 7

Figure 1. A visual schematic modified from Hernia Group 2018 depicting the process by which the newest inguinal hernia guidelines
were established.

(TAPP) laparoscopic hernia repair, flat mesh vs. plug and patch in open hernia repair, type of anesthesia,
type of mesh selection, operative approach for femoral hernias, and nerve recognition vs. prophylactic
neurectomy. Within the above publication, the questions were answered with recommendations that were
assigned a strength based on the quality of evidence encountered during the literature search [Figure 1]
Compliance with a given guideline was defined as following the recommendation in 70% of cases.

RESULTS
The majority of the subjects include males between the ages of 31 and 65 with primary unilateral hernias
[Table 1]. Based on our analysis, 19 of the recommendations were able to be evaluated from the available
ACHQC data. Of these, 12 questions met recommendations, and seven did not [Tables 2 and 3]. The eight
recommendations met with strong evidence were (1) use of mesh for large direct hernias during
laparoscopic repair to decrease recurrence (100%); (2) deferring choice of TEP or TAPP laparoscopic repair
to surgeon preference and experience due to comparable outcomes (99%); (3) nerve awareness and
recognition to avoid chronic pain (96%); (4) same day elective surgery if appropriate follow-up can be
arranged (92%); (5) mesh-based repair in both open and laparoscopic approaches (89%); (6) laparoscopic
approach for bilateral hernia repair (89%); (7) laparoscopic approach for femoral hernia repair (78%); and
(8) flat mesh over plug and patch/3D bilayer when used for open repair (70%).

The four recommendations with weak evidence that were met included (1) optional round ligament
division during TEP/TAPP (96%); (2) limiting pre-peritoneal mesh as opposed to Lichtenstein repair to
research settings (87%); (3) using general or local over regional anesthesia in patients over the age of 65 due
to higher associated incidence of medical complications, such as myocardial infarction, pneumonia, and
venous thromboembolism (84%); and (4) using mesh in emergent hernia repair (82%).

Four recommendations with strong evidence not met were that (1) women with groin hernias undergo
laparoscopic repair with mesh (57%); (2) the Shouldice technique be used in non-mesh inguinal hernia
repair (52%); (3) local anesthesia be used for open repair of reducible inguinal hernias; and (4) prophylactic
antibiotics be avoided in laparoscopic hernia repair (5%).

Three recommendations with weak evidence not met were the laparoscopic approach for unilateral inguinal
hernia repair in male patients due to lower incidence of post-operative and chronic pain (59%), avoiding
prophylactic partial or complete neurectomy in an attempt to prevent chronic pain (50%), and using
lightweight over the heavyweight mesh.