Inguinal, Umbilical and Femoral Hernias Summary Inguinal and umbilical hernias are relatively common; femoral hernias

however are less common. There is a risk of complications in hernias, such as strangulation and intestinal obstruction, particularly in the case of femoral hernias; surgery will help to prevent and/or treat complications. In the main, Wirral is performing in line with national figures regarding hernia procedures, the one exception being the number of day case surgical treatments for people aged over 69 years and/or with complications (Healthcare Resource Group (HRG) F73). Wirrals day case procedure rate during 2006/07 under this HRG code was 16.9% (19.1% 2005/06) compared to a national rate of 24% in 2005/06. Maximising the day-case surgery rate can improve the cost effectiveness of the procedure. There is a limited evidence base regarding umbilical and femoral hernias and the only guidance identified was the National Institute for Health and Clinical Excellence (NICE) clinical guideline published in 2004 for the less established procedure laparoscopic repair for an inguinal hernias. Evidence suggests that laparoscopic repair for an inguinal hernia is more costly than the traditional open methods but is associated with reduced pain and numbness; the cost-effectiveness of the procedure is influenced by the expertise of the surgeon. Open mesh methods for inguinal repair are more effective and cost effective than non mesh methods. Surgery should be the first treatment of choice in children with groin hernias (inguinal and femoral) and adults with femoral hernia due to the increased risk of complications. Background A hernia is the protrusion of an internal organ through the muscle or tissue wall that encloses the organ 1 . There are three options for the management of hernias; surgery, a truss (a padded belt that keeps the hernia in place) or no treatment. 2 The purpose of hernia surgery is to relieve symptoms and to prevent deformity and complications. The most serious complications associated with a hernia are strangulation (the blood supply to the protruding bowel is cut off) and intestinal obstruction (the contents of the intestine cannot pass through the hernia)2. The mortality rates for emergency procedures on groin hernias are higher than for elective treatment 3 . There are various different types of hernia; this evidence briefing will review three types; inguinal, umbilical and femoral. Inguinal This is the most common type of hernia found in the groin area. It is caused by the bowel pushing through a weakness in the inguinal canal (an opening between layers of abdominal muscle near the groin) 4 . There are two types of inguinal hernias; direct (the hernia enters through the wall of the canal) and indirect (the hernia enters through internal ring at the top of the inguinal canal)3. In England during 2005/06 there were over 70,000 surgical repairs for inguinal hernia 5 .
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They are most common in men and male babies when a small portion of the bowel enters the narrow canal down towards the scrotum. Risk factors include: - Premature birth - Male sex - Obesity - Constipation - Chronic cough - Heavy lifting - Family history 6 Inguinal hernia can be repaired using traditional open methods or using newer laparoscopic techniques. The most common technique currently in use in the UK is the open flat mesh method popularised by Irving Lichtenstein; a mesh is sutured deep to the external oblique muscle. Other open methods include the open preperitoneal mesh (e.g. Stoppa and Nyhus) and the plug and mesh (Rutkow and Robbins) 7 . Laparoscopic methods for hernia repair means the procedure is done without opening the abdominal wall. The operation is done by making small incisions and using mesh to cover the hernia, preventing the intestine from protruding again. There are two main types of laparoscopic approaches: - Transabdominal preperitoneal (TAPP) repair; mesh is placed inside the peritoneal cavity to cover the site of the hernia. The mesh will eventually be incorporated into the fibrous tissue. - Totally extraperitoneal (TEP) repair; the peritoneal cavity is not entered and the hernia is sealed with the mesh from outside the peritoneum.

Femoral These groin hernias are much less common than inguinal hernias, accounting for just 7% of all groin hernias and 1% of groin hernias in children 8 . A femoral hernia occurs when part of the intestine passes through the femoral canal in the groin (the main artery to the thigh) which causes swelling on the upper and inner part of the thigh. In England during 2005/06 there were just over 4000 operations for the repair of femoral hernias. Risk factors include - Female sex - Increasing age - Obesity - Chronic cough - Heavy lifting 9 There is a high incidence of complications in femoral hernias. There are three main methods used to repair femoral hernias, the low approach (called Lockwood), the transinguinal approach (called Lotheissen) and the high approach (called McEvedy). All three approaches dissect the hernia sac, remove its contents and then ligate the sac8. Laparoscopic and mesh methods may also be used2.

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Umbilical This is a relatively common type of abdominal hernia caused when a portion of the intestine presses through the abdominal wall near the navel. In 2005/06 there were almost 20,000 operations in England for umbilical hernias An acquired umbilical hernia occurs predominantly in adults, particularly in middle age 10 . Risk factors include: - Multiple pregnancies - Ascites (excess fluid in peritoneal cavity) - Obesity - Cirrhosis The main methods for repair are open methods (suture or mesh) A congenital umbilical hernia occurs in infants, through a weak umbilical scar. Most do not need treatment and close of their own accord by 3-5 years. They are one of the most common paediatric conditions and are twice as common in boys as girls, and are more common in black newborn babies.

Guidelines NICE In 2004, NICE published technology appraisal guidance for the repair of inguinal hernia by laparoscopic surgery 11 . This guidance is detailed in table 1 below. Table 1: NICE guidance on laparoscopic surgery for inguinal hernia repair. 1.1 Laparoscopic surgery is recommended as one of the treatment options for the repair of inguinal hernia 1.2 To enable patients to choose between open and laparoscopic surgery (either by the TAPP or the TEP procedure), they should be fully informed of all the risks (e.g. immediate serious complications, postoperative pain/numbness and longterm recurrence rates) and benefits associated with each of the three procedures. In particular, the following points should be considered in discussion between the patient and the surgeon: The individuals suitability for general anaesthesia The nature of the presenting hernia (that is, primary repair, recurrent hernia or bilateral hernia) The suitability of the particular hernia for a laparoscopic or an open approach The experience of the surgeon in the three techniques 1.3 Laparoscopic surgery for inguinal hernia repair by TAPP or TEP should only be performed by appropriately trained surgeons who regularly carry out the procedure

Wirral guidelines

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There are no local guidelines for the treatment of inguinal, umbilical and femoral hernias. Situation in Wirral Procedures In Wirral there were 537 patients admitted for procedures on inguinal hernias during 2006/07. This is considerably greater than the number of patients admitted for treatment on femoral and umbilical hernias during this period, which was 20 and 110 respectively. These figures however are all in line with national figures; the standardised admissions ratio (SAR) for procedures on inguinal and femoral hernias is 101.6 and for umbilical hernia the SAR is slightly but not significantly lower at 93.4. The numbers of non-elective procedures (i.e. emergency procedures) for these types of hernias are not significantly higher or lower than national figures. The number of procedures performed as day cases, under HRG code F73 (Inguinal, Umbilical or Femoral Hernia Repairs >69yrs with complications) during 2005/06 was 19.1% and in 2006/07 was slightly lower at 16.5%. This is below the national day case for this HRG code which in 2005/06 was 24%. The number of procedures performed as day cases, under HRG code F74 (Inguinal, Umbilical or Femoral Hernia Repairs <70yrs without complications) during 2005/06 was 61%. This compares well against the national average, which had a day case rate of 60% over the same time period. Financial In Wirral the total cost of procedures related to the above procedures was 803,000 for 2006/07. As would be expected the greatest cost was for inguinal hernias at a cost of 624,000. The cost for femoral and umbilical hernias was 35,000 and 144,000 respectively. Per operation, the cost is greatest for femoral hernias at a cost on average of 1,750. In comparison, individual treatment costs for inguinal and umbilical hernias are approximately 1,162 and 1,309 respectively. Evidence base for hernia procedures The vast majority of the evidence base is on inguinal hernias. There were no Cochrane reviews or Centre for Reviews and Dissemination (CRD) reviewed studies on umbilical hernias. A Health Technology Assessment7 that reviewed the effectiveness and costeffectiveness of laparoscopic surgery for inguinal hernia repair against the open mesh method reported that: - Laparoscopic repair was associated with reduced pain and numbness and quicker return to routine activities. - The operation took longer to perform and there appears to be a higher occurrence of serious visceral complications, notably of the bladder. - Superficial infection rates between the laparoscopic and open mesh methods are similar and there is little difference between recurrence rates, although one large trial on 2,164 participants did find that recurrence is significantly more likely following TEP repairs. - Laparoscopic repair is more costly at an additional estimated cost of 300-350 per procedure. After five years this cost is estimated to reduce to approximately 100-200 per patient. - The cost-effectiveness of laparoscopic surgery is influenced by the experience and skills of the surgeon.
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Whilst open flat mesh method is the least costly method it provides less quality adjusted life years (QALYs) than TEP or TAPP. TEP appears to be more effective and less costly than TAPP but this is deduced from a relatively small evidence base; decisions about which method to use would be therefore be better based on clinical decisions. - Laparoscopic repair may be more cost effective for the treatment of bilateral hernias, as the operation time may be reduced and the recovery time quicker than the open mesh method. A Cochrane Review that explored the effectiveness of open mesh and nonmesh groin hernia repair concluded that open mesh repair has a much lower recurrence rate, by between 50% and 75%. This procedure was also reported to be associated with a quicker return to normal activities and to have lower rates of persisting pain 12 . This is similarly supported by a later study reviewed by the CRD that reported that the open flat mesh method for inguinal hernia repair was more effective and cost-effective than the non-mesh repair 13 . A Cochrane Review that compared the clinical effectiveness of TAPP and TEP methods for inguinal hernia repair reported that there was not enough evidence to draw firm conclusions regarding which should be the favoured approach. The number of vascular injuries for both procedures was rare and there were very few deep and/or mesh infections 14 . A Cochrane Review that explored the evidence base to identify the effectiveness of antibiotic prophylaxis in infection rates following open inguinal hernia surgery concluded that there is not enough evidence to actively support its use but stated that neither can it be recommended against when high rates of wound infection are observed 15 . According to a Health Care Needs Assessment (HCNA) review of groin hernias, surgery is the treatment of choice for children and for people with femoral hernias as the risk of complications in these two groups is higher2. The HCNA review also reports that cost-effectiveness of groin surgery can be maximised by reducing recurrence rates and increasing day-case surgery; day cases are more likely when local rather than general anaesthetic is used (laparoscopic surgery cannot be performed under local anaesthetic). No Cochrane Review, systematic review or CRD reviewed study has been identified that demonstrates which is the most effective and cost effective surgical treatment for femoral and umbilical hernias. No Cochrane Review, systematic review or CRD reviewed study has been identified that determines the effectiveness of conservative treatment (i.e. trusses) against surgery for hernias (inguinal, umbilical and femoral). However the HCNA review of groin hernias report that there is no clinical justification for the use of trusses2. A systematic review that explored the evidence base for the management of groin hernias in primary care highlighted the importance of General Practitioners distinguishing correctly between femoral and inguinal hernias due to the increased risk of complications in the former. Suspected femoral hernias should be referred for an early surgical opinion. Herniography (radiographic examination of suspected hernia) has been identified as a valuable diagnostic tool in secondary care that can save unnecessary surgical exploration.

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Conclusions/recommendations Inguinal hernia repair is one of the most common hernia procedures performed in Wirral; there were 537 patients admitted for procedures on inguinal hernias during 2006/07. Femoral and umbilical hernias are less common with only 20 and 110 procedures performed in Wirral during the same time period. In the main, Wirral is performing in line with national figures regarding hernia repair for inguinal, umbilical and femoral hernias, including the number of emergency procedures performed. In the case of patients older than 68 years and/or with complications (HRG F73) the number of surgical day cases is lower than the national average. Maximising the day-case surgery rate can improve the cost effectiveness of the procedure. There is a very limited evidence base regarding umbilical hernias, no Cochrane reviews or systematic reviews were identified. There is also limited evidence regarding femoral hernias. Laparoscopic repair for inguinal hernia is more costly but is associated with reduced pain and numbness and quicker return to normal activities. The costeffectiveness of the procedure is influenced by the expertise of the surgeon. Laparoscopic repair for inguinal hernia is endorsed by NICE; NICE guidelines should be adhered to. Open mesh methods for inguinal hernia repair is a more effective and costeffective treatment than the non-mesh method of repair. For children with groin hernias and adults with femoral hernias, surgery should be the treatment of choice due to the increased risk of complications in these groups.
Digestive Disorders Foundation (2005). Hernias. CORE factsheet 16. Digestive Disorders Foundation. Phillips, W. and Goldman, M. (2004). Groin Hernia. In Stevens, A. et al. (Eds.) Health Care Needs Assessment. The epidemiologically based needs assessment reviews. Volume 1. 2nd ed. Radcliffe Publishing Ltd. 3 McIntosh, A. et al. (2000). Evidence-based management of groin hernia in primary care a systematic review. Family practice, 17, p.442-447. 4 NHS Direct (2007). Hernia. Patient Information Leaflet. 5 Hospital Episode Statistics 2005/06. www.hesonline.nhs.uk 6 Mayo Clinic (n.d.) Inguinal hernia. Retrieved 5 September 2007 from http://www.mayoclinic.com/health/inguinal-hernia/DS00364/DSECTION=4 7 McCormack, K. et al. (2005). Laparoscopic surgery for inguinal hernia repair: systematic review of effectiveness and economic evaluation. Health Technology Assessment, 9 (14). 8 Patient UK (n.d). Femoral Hernias. Retrieved 22 August 2007 from http://www.patient.co.uk/showdoc/40002779/ 9 NHS Choices (n.d.) Hernia, femoral repair. Retrieved 5 September 2007 from http://www.nhs.uk/Conditions 10 GP Notebook (n.d). Umbilical hernia. Retrieved 6 September 2007 from http://www.gpnotebook.co.uk/simplepage.cfm?ID=-241565682&linkID=146&cook=yes 11 NICE (2004). Laparoscopic surgery for inguinal hernia repair. Technology Appraisal 83. NICE. 12 Scott, N. et al. (2001). Open Mesh versus non-Mesh for groin hernia repair (Review). Cochrane Database of Systematic Reviews. Issue 3. 13 CRD (2005). Cost-effectiveness of alternative methods of surgical repair of inguinal hernia. NHS Economic Evaluation Database (NHS EED)
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Wake, B. L. et al. (2005). Transabdominal pre-peritoneal (TAPP) vs totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair (Review). Cochrane Database of Systematic Reviews. Issue 1. 15 Sanchez-Manual, F. J. et al. (2007). Antibiotic prophylaxis for hernia repair (Review). Cochrane Database of Systematic Reviews, Issue 3.

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