Inguinal Hernia Slides

Surgical Management of Inguinal Hernia
Prepared for:
Agency for Healthcare Research and Quality (AHRQ)
www.ahrq.gov
Outline of Material
Agency for Healthcare Research and Quality Comparative
Effectiveness Review (CER) Process
Background
Clinical Questions Addressed in the CER
Clinical Bottom Line: Summary of CER Results
Conclusions
Gaps in Knowledge
Resources for Shared Decisionmaking
Agency for Healthcare Research and Quality (AHRQ)

Comparative Effectiveness Review (CER) Development
Topics are nominated through a public process, which includes
submissions from health care professionals, professional organizations,
the private sector, policymakers, the public, and others.
A systematic review of all relevant clinical studies is conducted by
independent researchers, funded by AHRQ, to synthesize the evidence in
a report summarizing what is known and not known about the select
clinical issue. The research questions and the results of the report are
subject to expert input, peer review, and public comment.
The results of these reviews are summarized into a Clinician Research
Summary and a Consumer Research Summary for use in decisionmaking
and in discussions with patients. The Research Summaries and the full
report are available at www.effectivehealthcare.ahrq.gov/inguinalhernia.cfm.
Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at
www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.
Strength of Evidence Ratings

The strength of evidence ratings are classified into four broad ratings:
AHRQ Methods Guide for Effectiveness and Comparative Effectiveness Reviews. Available at www.effectivehealthcare.ahrq.gov/methodsguide.cfm.
Owens DK, Lohr KN, Atkins D, et al. J Clin Epidemiol. 2010 May;63(5):513-23. PMID: 19595577.
Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm .
Background: Inguinal Hernias in Adults

An inguinal hernia is a protrusion of abdominal contents into the inguinal
canal through an abdominal wall defect.
Approximately 4.5 million people in the United States have an inguinal
hernia.
Around 500,000 new inguinal hernias are diagnosed annually.
The lifetime risk of inguinal hernia is about 25 percent in males and 2
percent in females.
Inguinal hernia can affect all ages, but the risk for one increases with
age.
Approximately 20 percent of hernia cases are bilateral.
Abramson JH, et al. J Epidemiol Community Health. 1978;32:59-67. Available at http://www.ncbi.nlm.nih.gov/pubmed/95577.
Everhart, JE, ed. Digestive diseases in the United States: epidemiology and impact. Washington, DC: US Government Printing
Office, 1994; NIH publication no. 94-1447.
Goroll AH, et al. Primary care medicine: office evaluation and management of the adult patient, 5th ed. Philadelphia, Lippincott
Williams & Wilkins; 2005:431-434.
Nicks BA. Hernias. Medscape Reference: Drugs, Diseases, and Procedures. Last Updated June 6, 2012. Available at
http://emedicine.medscape.com/article/775630-overview. Accessed April 30, 2013.
Rutkow IM. Surg Clin North Am. 1998;78:941-951. Available at http://www.ncbi.nlm.nih.gov/pubmed/9927978.
Background: Inguinal Hernias in Children

The incidence of inguinal hernia in children ranges from
0.8 to 4.4 percent.
It is 10 times as common in boys as in girls.
It is more common in infants born before 32 weeks
gestation (13% prevalence) and in infants weighing less
than 1,000 grams at birth (30% prevalence).
Brandt ML. Pediatric hernias. Surg Clin North Am. 2008 Feb;88(1):27-43, vii-viii. PMID: 18267160.
Direct and Indirect Inguinal Hernias

A direct inguinal hernia protrudes through the inguinal
floordefined by Hesselbach's triangle, the pubic
tubercle, the lateral border of the rectus, and the
inguinal ligamentand accounts for one-third of all
inguinal hernias.
An indirect inguinal hernia protrudes through the internal
inguinal ring and may descend through the inguinal canal
and accounts for about two-thirds of all inguinal hernias.
Direct hernias typically develop only in adulthood and are
more likely to recur than indirect hernias.
Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al. JAMA. 2006 Jan 18;295(3):285-92. PMID: 16418463.
Simons MP, Aufenacker T, Bay-Nielson M, et al. Hernia. 2009 Aug;13(4):343-403. PMID: 19636493.
Symptoms of Inguinal Hernias

If the hernia is severe enough to restrict blood supply to
the intestine, it is termed a strangulated hernia;
immediate corrective surgery of this type of hernia is
necessary.
Most inguinal hernias, however, are less dangerous, and
elective surgery is often performed to correct the defect.
Symptoms include abdominal pain and a lump in the groin
area, which is most easily palpated during a cough.
Some inguinal hernias, however, are asymptomatic and
are only detected by palpation during a cough.
Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al. JAMA. 2006 Jan 18;295(3):285-92. PMID: 16418463.
Surgical Repair of Inguinal Hernias

Surgical repair of inguinal hernias is the most commonly
performed general surgical procedure in the United States.
About 770,000 surgical repairs were performed in 2003.
Most repairs (87%) are performed on an outpatient basis.
The primary goals of surgery are to:
Repair the hernia
Minimize the chance of recurrence
Return the patient to normal activities quickly
Improve quality of life
Minimize postsurgical discomfort and the adverse effects of
surgery
Rutkow IM. Surg Clin North Am. 2003 Oct;83(5):1045-51, v-vi. PMID: 14533902.
Zhao G, Gao P, Ma B, et al. Ann Surg. 2009 Jul;250(1):35-42. PMID: 19561484.
Types of Surgical Repair for Inguinal Hernias

Surgical repairs of inguinal hernia generally fall into three
categories:
Open repair without a mesh implant (i.e., sutured)
Open repair with a mesh
Laparoscopic repair with a mesh
Several procedures have been employed within each of these

categories.
The nearly universal adoption of mesh (except in pediatric
cases) means that the most relevant questions about hernia
repair involve various mesh procedures.
Brandt ML. Surg Clin North Am. 2008 Feb;88(1):27-43, vii-viii. PMID: 18267160.
Rutkow IM. Surg Clin North Am. 2003 Oct;83(5):1045-51, v-vi. PMID: 14533902.
Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.
Example:
Open Mesh-Based Repair of an Inguinal Hernia
Before
After
Mesh
Example: Laparoscopic Mesh-Based Repair

of an Inguinal Hernia
Laparoscope
Small cuts are

made to insert
the tools
Open Mesh-Based Repair of Inguinal Hernias

(1 of 2)
Kugel patch repair: An oval-shaped mesh is held open by
a memory recoil ring and inserted behind the hernia
defect and held in place with a single suture.
Lichtenstein technique: A tension-free open repair
wherein mesh is sutured in front of the hernia defect
(anteriorly).
Mesh plug technique: A preshaped mesh plug is
introduced into the hernia weakness during surgery and a
piece of flat mesh is put on top of the hernia.
Open preperitoneal mesh technique: A tension-free repair
wherein mesh is sutured posteriorly.
Open Mesh-Based Repair of Inguinal Hernias

(2 of 2)
PROLENE Hernia System: A one-piece mesh device
constructed of an onlay patch connected to a circular
underlay patch by a mesh cylinder.
Read-Rives repair: A tension-free repair wherein mesh is
placed just over the peritoneum.
Stoppa technique: A large polyester mesh is interposed in
the preperitoneal connective tissue between the
peritoneum and the transversalis fascia to prevent visceral
sac extension through the myopectineal orifice.
Trabucco technique: A hernia repair procedure that involves
placing a single preshaped mesh without using sutures.
Laparoscopic Mesh-Based Repair Procedures for

Inguinal Hernias
Intraperitoneal onlay mesh technique: A mesh is placed
under the hernia defect intra-abdominally to circumvent
a groin dissection.
Totally extraperitoneal technique: The peritoneal cavity
is not entered, and a mesh is used to cover the hernia
from outside the preperitoneal space.
Transabdominal preperitoneal technique: A laparoscopic
repair procedure wherein the surgeon enters the
peritoneal cavity, incises the peritoneum, enters the
preperitoneal space, and places the mesh over the
hernia; the peritoneum is then sutured and tacked
closed.
Surgical Mesh Products for Hernia Repair

Surgical mesh products are typically made from
polypropylene or polyester.
Other available materials include:
Polytetrafluoroethylene
Polyglactin
Polyglycolic acid
Polyamide
Mohamed H, Ion D, Serban MB, et al. J Med Life. 2009 Jul-Sep;2(3):249-53. PMID: 20112467.
Robinson TN, Clarke JH, Schoen J, et al. Surg Endosc. 2005 Dec;19(12):1556-60. PMID: 16211441.
Properties of Mesh Products for Hernia Repair

Seven important properties of mesh are:
1. Withstands physiologic stresses over time
2. Conforms to the abdominal wall
3. Mimics normal tissue healing
4. Resists the formation of bowel adhesions and erosions into
visceral structures
5. Does not induce allergic reaction or foreign body reactions
6. Resists infection
7. Is noncarcinogenic
Mohamed H, Ion D, Serban MB, et al. J Med Life. 2009 Jul-Sep;2(3):249-53. PMID: 20112467.
Clinical Questions Addressed in the

Comparative Effectiveness Review
What is the comparative effectiveness of:
Laparoscopic versus open repair in adults with painful
hernia (primary, bilateral, and recurrent hernia)?
Different types of repair for the pediatric population?
Surgery versus watchful waiting in adults with a pain-free
or minimally symptomatic inguinal hernia?
Different types of open surgery?
Different types of laparoscopic surgery?
Different mesh materials?
Different mesh-fixation approaches?
Is there an association between surgical experience and

hernia recurrence?
Outcomes of Interest
Outcomes
Hernia recurrence
Hospital-related information
(length of hospital stay and
hospital/office visits)
Return to daily activities
Return to work
Quality of life
Patient satisfaction
Short-term pain (1 month
after surgery)
Intermediate-term pain (>1
and <6 months after surgery)
Long-term pain (6 months
after surgery)
Adverse effects
Infection
Perception of a foreign body
Small-bowel
perforation/obstruction
Hematoma
Epigastric vessel injury
Urinary retention
Spermatic cord injury
Results: Overview of the Patient Population

Patient Population
The typical adult in the studies included in this review was:
A man in his mid 50s
Who was of average weight (median body mass index of 25.3
kg/m2; interquartile rage of 25.026.7)
Who had an elective repair of a primary unilateral inguinal
hernia
About a quarter of the men worked in physically strenuous

jobs; for these men, a durable repair is important to
prevent a recurrence.
Results: Overview of Studies Included in the

Comparative Effectiveness Review
Total included studies: N = 151
Open versus laparoscopic repair in adults:
Primary hernias; n = 38
Bilateral hernias; n = 6
Recurrent hernias; n = 8
Open versus laparoscopic high ligation for pediatric hernias;

n=2
Repair versus watchful waiting in adults with pain-free
hernias; n = 2
Open mesh-based procedures; n = 21
Laparoscopic procedures; n = 11
Mesh materials; n = 32
Fixation methods; n = 23
Surgical experience and hernia recurrence; n = 32
Clinical Bottom Line: Laparoscopic Versus Open Repair

of Painful Primary Hernias in AdultsIncluded Studies
Thirty-eight studies met the inclusion criteria.
The most commonly compared procedures include:
TAPP repair versus Lichtenstein (n = 14)
TEP repair versus Lichtenstein (n = 14)
TAPP repair versus mesh plug (n = 3)
TEP repair versus mesh plug (n = 3)
TAPP repair/TEP repair versus Lichtenstein (n = 4)
Abbreviations: TAPP = transabdominal preperitoneal; TEP = totally
extraperitoneal
Clinical Bottom Line: Laparoscopic Versus Open

Repair of Painful Primary Hernias in Adults (1 of 2)
Outcome
Surgery
Favored
Calculated Differences
(95% CI)
Hernia recurrence
Open surgery
Low
Length of hospital
stay
Approximate
equivalence
RR = 1.43 (1.15 to 1.79); 2.49%

recurrence after open versus 4.46%
recurrence after laparoscopy
Summary difference in means =
-0.33 days (-0.52 to -0.14)
Return to normal
daily activities
Laparoscopic
SWMD in days = -3.9 (-5.6 to -2.2)
High
Return to work
Laparoscopic
SWMD in days = -4.6 (-6.1 to -3.1)
High
SOE
Low
Abbreviations: 95% CI = 95-percent confidence interval; RR = relative risk; SOE =

strength of evidence; SWMD = summary weighted mean difference

Repair of Painful Primary Hernias in Adults (2 of 2)
Outcome
Surgery
Favored
Calculated Differences
(95% CI)
SOE
Long-term pain
Laparoscopic
OR = 0.61 (0.48 to 0.78)
Moderate
Epigastric vessel
injury
Open
OR = 2.1 (1.1 to 3.9)
Low
Hematoma
Laparoscopic
OR = 0.70 (0.55 to 0.88)
Low
Wound infection
Laparoscopic
OR = 0.49 (0.33 to 0.71)
Moderate
Abbreviations: 95% CI = 95-percent confidence interval; OR = odds ration; SOE =

strength of evidence
Clinical Bottom Line:

Surgical Repair of Bilateral Hernias
Patients with bilateral hernias return to work about 2
weeks sooner after laparoscopic (TAPP or TEP) repair
versus open (Lichtenstein or Stoppa) repair.
Strength of Evidence = Low
Evidence was inconclusive for all other outcomes and
adverse effects for laparoscopic versus open repair of
bilateral hernias.
Abbreviations: TAPP = transabdominal preperitoneal; TEP = totally
extraperitoneal

Repair of Recurrent Hernias
Outcome
Surgery
Favored
Results (95% CI)
SOE
Return to daily
activities
Laparoscopic
SWMD = -7.4 days (-11.4 to

-3.4)
High
Long-term pain
Laparoscopic
OR = 0.24 (0.08 to 0.74)
Moderate
Re-recurrence
rates
Laparoscopic
(TAPP or TEP)
RR = 0.82 (0.70 to 0.96); 7.5%

for laparoscopic vs. 12.3%
for open repair
Low
Abbreviations: 95% CI = 95-percent confidence interval; OR = odds ratio; RR = relative risk;

SOE = strength of evidence; SWMD = summary weighted mean difference; TAPP =
transabdominal preperitoneal; TEP = totally extraperitoneal
Open Versus Laparoscopic High Ligation for

Pediatric Hernias (Ages 3 Months to 15 Years)
Laparoscopic repair is favored for three outcomes, although
some of the differences may not be clinically relevant:
Long-term overall patient/parent satisfaction
(difference in satisfaction points = 1.00; 95% CI, 0.47 to 1.53)
Strength of Evidence: Low
Length of hospital stay
(summary difference = 1 hour; 95% CI, 0.5 to 1.8)
Strength of Evidence: Moderate
Long-term cosmesis
(difference in satisfaction points = 0.25; 95% CI, 0.12 to 0.38)
The time to return to daily activities was equivalent.

Chan KL, Hui WC, Tam PK. Surg Endosc. 2005 Jul;19(7):927-32. PMID: 15920685. Koivusalo AI, Korpela R, Wirtavuori
K, et al. Pediatrics. 2009 Jan;123(1):332-7. PMID: 19117900. Treadwell J, Tipton K, Oyesanmi O, et al. AHRQ
Comparative Effectiveness Review No. 70. Available at www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm.
Clinical Bottom Line: Pain-Free Primary Hernias

Repair Versus Watchful Waiting in Adults
Mesh repair may improve a patients overall health status
at 12 months more than watchful waiting (difference in
mean SF-36 scores = 7.3; 95% CI, 0.4 to 14.3).
Low strength of evidence
There is not enough information to know if there are
differences in adverse effects.
Comparative Effectiveness of Open Mesh-Based

Repair Procedures
Twenty-one studies were included.
The most commonly compared procedures were:
Lichtenstein versus mesh plug (n = 7)
Lichtenstein versus the PROLENE Hernia System (PHS;
n = 5)
Lichtenstein versus the open preperitoneal mesh technique
(n = 3)
Mesh plug versus the PHS (n = 2)
Lichtenstein versus the Kugel Mesh Patch (n = 2)
Studies were typically conducted between 2000 and

2010.
Comparative Effectiveness of Open Mesh-Based Repair

ProceduresLichtenstein Versus Mesh Plug
Rates of recurrence were approximately equivalent.
Patients who have the Lichtenstein repair may return to
work about 4 days earlier (95% CI, 1 to 7).
Lichtenstein repair is associated with lower rates of
seroma than mesh plug repair (OR = 0.39; 95% CI 0.16 to
0.94).
Comparative Effectiveness of Other Open

Mesh-Based Repair Procedures
Short-term pain outcomes were similar for these open repair
procedures:
Mesh plug versus the PROLENE Hernia System (PHS)
Lichtenstein versus the PHS
Lichtenstein versus open preperitoneal mesh
Lichtenstein versus the Kugel Mesh Patch
Intermediate-term pain was also similar for Lichtenstein

versus Kugel Mesh Patch repair.
Comparative Effectiveness of Laparoscopic

Repair ProceduresTAPP Versus TEP
Transabdominal preperitoneal (TAPP) repair may offer a
1.4-day earlier return to work; however, this may not be
clinically significant.
Short-term pain outcomes were similar.
Intermediate-term and long-term pain outcomes were
similar.
Research on comparative adverse effects between TAPP and
totally extraperitoneal repairs was inconclusive for
hematoma, urinary retention, and wound infection.
Comparative Effectiveness of Mesh Materials

Hernia recurrence occurred at similar rates with
polypropylene mesh versus combination materials.*
Long-term pain after surgery was similar for standard
polypropylene mesh when compared with biologic mesh
or light-weight polypropylene mesh.
Evidence on comparative adverse effects for the
different types of mesh materials was inconclusive.
*Descriptions of the combination-material mesh analyzed for this outcome can
be found in the full report.
Comparative Effectiveness of Fixation Methods

After laparoscopic surgery, hernia recurrence rates were
similar for tacks or staples versus no fixation. Strength of
Evidence: Moderate
Mesh fixed with sutures versus glue during open or
laparoscopic surgery had similar:
Recurrence rates
Long-term pain outcomes
Mesh fixed with fibrin glue during transabdominal

preperitoneal repair resulted in less long-term pain than when
the mesh was fixed with staples.
Data on adverse effects were either missing or inconclusive.
www.effectivehealthcare.ahrq.gov/inguinal-hernia.cfm
Association Between Laparoscopic Surgical

Experience and Hernia Recurrence
Thirty-two studies reported on this association.
The length of the learning curve for TEP or TAPP repair
could not be estimated due to problems associated with
not accounting for followup time, not accounting for the
evolution of procedures over time, and selective outcome
reporting.
Generally, the risk of recurrence decreases when a more
experienced surgeon performs a repair, but there were
not enough congruent studies to perform a meta-analysis.
Abbreviations: TAPP = transabdominal preperitoneal; TEP = totally extraperitoneal
Conclusions: Patient Population

The typical adult in the studies included in this review
was a man in his mid 50s, of average weight (median
body mass index, 25.3 kg/m2; interquartile range, 25.0
26.7), who had an elective repair of a primary unilateral
inguinal hernia.
It is unclear how these results apply to:
Women
Men of other age groups
About a quarter of the men with hernias worked in

physically strenuous jobs; for these men, a durable repair
is important to prevent a recurrence.
Conclusions: Laparoscopic Versus Open Repair of

Inguinal Hernias in Adults
Laparoscopic repair of an inguinal hernia is associated
with:
Faster recovery times
Less risk of long-term pain
A lower risk of another hernia recurrence after a previous
recurrence
Open hernia repair may be associated with:

Fewer internal injuries
Lower recurrence rates in the context of primary inguinal
hernia
Conclusions: Watchful Waiting Versus Repair for

Pain-Free Inguinal Hernias
Low-strength evidence suggests that choosing to repair a
pain-free hernia with a Lichtenstein or tension-free mesh
repair over watchful waiting may improve quality of life.
However, this finding may not be applicable to other
types of repair procedures (e.g., laparoscopic repair).
The evidence on adverse effects was inconclusive.
Conclusions: Mesh Material and Fixation Methods

Research found most of the meshes or fixation methods
to be equivalent in their effectiveness and risk of adverse
effects with only a few exceptions.
Gaps in Knowledge
How the surgeon's experience influences surgical outcomes
such as recurrence and pain
The comparative effectiveness and adverse effects of
laparoscopic repair versus watchful waiting for pain-free or
minimally symptomatic inguinal hernias in adults
The comparative effectiveness and adverse effects of
contralateral exploration/repair versus watchful waiting in the
pediatric population
More evidence on several outcomes related to the comparisons
of mesh products and fixation methods including recurrence
rates, perception of a foreign body, long-term pain, and
infection rates
Clarification in future studies of whether the population
includes emergent as well as elective surgeries and whether or
not the findings apply equally to both populations
Shared Decisionmaking:
What To Discuss With Your Patients
If repair or watchful waiting is the right decision for their
pain-free or minimally symptomatic inguinal hernia
How to choose between open or laparoscopic surgery if
the option is available
What to expect from open or laparoscopic repair as far as
outcomes and adverse effects, including the risk of longterm chronic pain
What to do if the hernia recurs
Resource for Patients

Surgery for an Inguinal Hernia,
A Review of the Research for
Adults is a free companion to
this continuing medical
education activity.
It can help patients talk with
their health care professionals
about the decisions involved
with the care and maintenance
of an inguinal hernia.
It provides information about:
Types of operative treatments
Current evidence of
effectiveness and harms
Questions for patients to ask
their doctor

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Surgical Management of Inguinal Hernia

Agency for Healthcare Research and Quality (AHRQ)

Strength of Evidence Ratings

Background: Inguinal Hernias in Adults

Background: Inguinal Hernias in Children

Direct and Indirect Inguinal Hernias

Symptoms of Inguinal Hernias

Surgical Repair of Inguinal Hernias

Types of Surgical Repair for Inguinal Hernias

Several procedures have been employed within each of these

Example: Laparoscopic Mesh-Based Repair

Small cuts are

Open Mesh-Based Repair of Inguinal Hernias

Open Mesh-Based Repair of Inguinal Hernias

Laparoscopic Mesh-Based Repair Procedures for

Surgical Mesh Products for Hernia Repair

Properties of Mesh Products for Hernia Repair

Clinical Questions Addressed in the

Is there an association between surgical experience and

Results: Overview of the Patient Population

About a quarter of the men worked in physically strenuous

Results: Overview of Studies Included in the

Open versus laparoscopic high ligation for pediatric hernias;

Clinical Bottom Line: Laparoscopic Versus Open Repair

Clinical Bottom Line: Laparoscopic Versus Open

RR = 1.43 (1.15 to 1.79); 2.49%

SWMD in days = -3.9 (-5.6 to -2.2)

SWMD in days = -4.6 (-6.1 to -3.1)

Abbreviations: 95% CI = 95-percent confidence interval; RR = relative risk; SOE =

Clinical Bottom Line: Laparoscopic Versus Open

OR = 0.61 (0.48 to 0.78)

OR = 2.1 (1.1 to 3.9)

OR = 0.70 (0.55 to 0.88)

OR = 0.49 (0.33 to 0.71)

Abbreviations: 95% CI = 95-percent confidence interval; OR = odds ration; SOE =

Clinical Bottom Line:

Clinical Bottom Line: Laparoscopic Versus Open

Results (95% CI)

SWMD = -7.4 days (-11.4 to

OR = 0.24 (0.08 to 0.74)

RR = 0.82 (0.70 to 0.96); 7.5%

Abbreviations: 95% CI = 95-percent confidence interval; OR = odds ratio; RR = relative risk;

Open Versus Laparoscopic High Ligation for

The time to return to daily activities was equivalent.

Clinical Bottom Line: Pain-Free Primary Hernias

Comparative Effectiveness of Open Mesh-Based

Studies were typically conducted between 2000 and

Comparative Effectiveness of Open Mesh-Based Repair

Comparative Effectiveness of Other Open

Intermediate-term pain was also similar for Lichtenstein

Comparative Effectiveness of Laparoscopic

Comparative Effectiveness of Mesh Materials

Comparative Effectiveness of Fixation Methods

Mesh fixed with fibrin glue during transabdominal

Association Between Laparoscopic Surgical

Conclusions: Patient Population

About a quarter of the men with hernias worked in

Conclusions: Laparoscopic Versus Open Repair of

Open hernia repair may be associated with:

Conclusions: Watchful Waiting Versus Repair for

Conclusions: Mesh Material and Fixation Methods

Resource for Patients

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