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PURPOSE Cord lipomas can clinically resemble groin hernias and missed cord lipomas can potentially result in persistent symptoms. However, no international guideline exists concerning the management of cord lipomas found during inguinal hernia surgery. This study aimed to gain insight into how surgeons typically manage cord lipomas found during inguinal hernia surgery. METHODS A questionnaire was sent to all general surgeons in Denmark performing unsupervised laparoscopic inguinal hernia repair and Lichtenstein repair. The survey contained questions about demographic details and questions about how surgeons would handle cord lipomas. The questionnaire was created by the research team and face-validated on general surgeons. RESULTS A total of 58 surgeons (60%) responded to the questionnaire. The majority agreed that cord lipomas should not be left untouched. During laparoscopic repairs, 53% of the surgeons recommended that cord lipomas should be resected and removed if the anatomical circumstances allowed it. During Lichtenstein repair, the surgeons recommended that cord lipomas should always be resected and removed (49%) or that resection should depend on the size of the lipoma (44%). CONCLUSION When asking surgeons about their preferred handling of cord lipomas, they answered that the management of cord lipomas found during inguinal hernia surgery depends on anatomical circumstances such as the pedicle appearance, the lipoma mobility, and its size. If the cord lipoma is left untouched, the patients' hernia resembling symptoms could persist, why the surgeons predominantly preferred to resect and remove cord lipomas.

Performing two anterior or two posterior inguinal hernia repairs in the same groin contradict guidelines. Nevertheless, there can be indications for using the same approach at reoperation, and information on complications other than the risk of a third repair and chronic pain is lacking in the literature. The aim was to assess intraoperative events and postoperative complications after two Lichtenstein repairs or laparoscopic inguinal hernia repairs in the same groin. This nationwide cohort study included patients that had received two Lichtenstein repairs (Lichtenstein–Lichtenstein) or two laparoscopic (Laparoscopy–Laparoscopy) inguinal hernia repairs in the same groin. Patients were identified in the Danish Hernia Database and outcomes were identified in medical records during a period of 6 years. Outcomes were intraoperative events that deviated from a standard repair and 1-year postoperative complications classified according to the Clavien–Dindo classification. Outcomes were reported separately for the two cohorts. Among the included 102 Lichtenstein reoperations, 27% of the repairs had intraoperative events, with drain placement being most common (10%). Half of the reoperations resulted in complications where infection (15%) and hematoma (12%) were most frequent. Among the 58 laparoscopic reoperations, 16% had an intraoperative event where bleeding requiring clips was most common (10%). Half of the reoperations resulted in a complication with surgery in general anesthesia in the same groin area being the most frequent complication (9%). Intraoperative events and 1-year postoperative complications were high for both Lichtenstein–Lichtenstein and Laparoscopy–Laparoscopy, and the results therefore support guidelines that recommend another approach at reoperation.

The best repair of a recurrent inguinal hernia after primary laparoendoscopic repair is debatable. The aim was to assess chronic pain after two laparoendoscopic repairs in the same groin compared with Lichtenstein reoperation preceded by a laparoendoscopic repair. This cohort study included adult patients who had received two laparoendoscopic repairs (Lap–Lap) or a laparoendoscopic repair followed by the Lichtenstein repair (Lap–Lich). Eligible patients were identified in the Danish and the Swedish hernia databases. Lap–Lap was matched 1:3 with Lap–Lich, and patients were sent validated questionnaires. The primary outcome was the proportion with chronic pain-related functional impairment, compared between the two groups. Secondary outcomes included chronic pain during various activities. In total, 74% (546 patients) responded to the questionnaires with a median follow-up since the second repair of 4.9 years (0.9–21.9 years). Regarding the primary outcome, 21% in Lap–Lap and Lap–Lich had chronic pain-related functional impairment of daily activities (p = 0.94). More patients in Lap–Lap compared with Lap–Lich reported pain ≥ 20 mm measured by the visual analog scale, 11% versus 5%, p = 0.04. However, there was no difference in the median VAS score or in the vast majority of the remaining secondary outcomes. There was no overall difference in chronic pain between patients who had received Lap–Lap compared with Lap–Lich. Choice of operative strategy for the second repair should, therefore, not be based on risk of chronic pain.

Regarding groin hernia repair in children, guidelines do not favor open or laparoscopic repair. Even so, most surgeons prefer an open technique. The aim of this systematic review was to compare short- and long-term outcomes after laparoscopic and open groin hernia repair in children. Systematic searches were conducted in three databases, and all randomized controlled trials comparing laparoscopic and open groin hernia repair in children under 18 years were included. Outcomes were postoperative complications, intraoperative complications, operative time, length of hospital stay, time to recovery, and wound appearance. The outcomes were compared between open and laparoscopic repairs in meta-analyses. We included ten studies with 1270 patients involving 1392 hernias. We found no differences in recurrence rate, testicular atrophy, hydrocele, hematoma, seroma, infection, pain, length of hospital stay, or time to full recovery. Laparoscopic repair was superior regarding wound appearance. Laparoscopic repair had shorter operative time than open repair for bilateral groin hernias. For unilateral groin hernias, extraperitoneal laparoscopic repair was faster than open repair, but open repair was faster than intraperitoneal laparoscopic repair. Our results indicate similar outcome after laparoscopic and open techniques for groin hernia repair in children. The surgeon’s preference as well as the wishes of the patient and parents should therefore determine the surgical approach.

The most effective treatment for longstanding groin pain with no hernia present has not been designated. The aim of this systematic review was to assess whether surgical or conservative treatment are the most effective in reducing pain and thereby returning patients to habitual activity. PubMed, Embase, and Cochrane were searched. We included adults diagnosed with longstanding groin pain with no hernia. Treatment included inguinal hernia repair, tenotomy, and nonsurgical management. Outcomes included return to habitual activity, pain, patient satisfaction, re-operations for the operated patients, and shift to surgery for the non-operated patients. We included randomized controlled trials and observational studies with more than 10 participants. In total, 72 studies with 3629 patients were included. Only five studies used a comparison group. After inguinal hernia repair, 94% returned to habitual activity after median 10 weeks, 92% became pain free, and 92% were satisfied with their treatment. After adductor tenotomy, 90% returned to habitual activity after median 12 weeks, 90% became pain free, and 84% were satisfied. After combined inguinal hernia repair and adductor tenotomy, 97% returned to habitual activity after median 10 weeks, 92% became pain free, and 91% were satisfied with their treatment. After nonsurgical management, 80% returned to habitual activity after median 12 weeks, 67% became pain free, 56% were satisfied, and 21% shifted to surgery. We found that surgery seems to be more efficient in return the patients to habitual activity, reduce their pain, and satisfy them than conservative treatment.

Surgical repair is recommended for all children with inguinal hernia due to fear of incarceration. The aim of this study was to assess the risk of incarceration and strangulation of inguinal hernias in children treated with delayed surgery or no surgery. Systematic searches were conducted in three databases. We included studies reporting on children with inguinal hernia, with the majority ≤ 10 years old. The interventions were non-acute inguinal hernia surgery or no surgery. The main outcomes were incarceration and strangulation. Secondary outcomes were postoperative complications. Randomized controlled trials, non-randomized controlled trials, and observational studies were included. We included 22 studies with 14,959 children. All studies reported on elective repairs. None of the studies specifically reported on watchful waiting. Of the studies reporting wait time as mean or median, the median wait time was 46 days (range 1–552). The crude incarceration rate across the included studies was 7% for all children and 11% for preterm children. The testicular atrophy rate was 1% and the recurrence rate was 1%. The risk of incarceration in children awaiting inguinal hernia surgery is substantial. In general, we cannot support delaying surgery unnecessarily. However, there may be benefits of delaying surgery in individual cases. In such cases, the surgeon should assess if the benefits may overrule the risk of incarceration.

Few studies have described recurrence rates after groin hernia repair in women. Our aim was to investigate if laparoscopic repair of primary groin hernias in women results in a lower reoperation rate for recurrence compared with open repairs. Furthermore, we wished to compare hernia subtypes at primary repair and reoperation. This nationwide cohort study was reported according to the RECORD statement. We used prospectively collected data from the Danish Hernia Database to generate a cohort of females operated for a primary groin hernia from 1998 to 2017. Our primary outcome was reoperation for recurrence. The secondary outcome was subtype of hernia at primary repair and reoperation. All females had at least 6-month follow-up. We included 13,945 primary groin hernia operations in women, of whom 649 had undergone a reoperation for recurrence. Median follow-up time was 8.8 years. The cumulative reoperation rates were lower after laparoscopic repair compared with the open techniques, for both inguinal hernias (1.8 vs. 6.3%, p

To investigate whether defect closure in laparoscopic ventral hernia repair reduces the re-operation rate for recurrence compared with no defect closure. Data were extracted from the Danish Ventral Hernia Database. Adults with an elective laparoscopic ventral hernia repair with tacks used as mesh fixation were included, if their first repair was between the 1st of January 2007 and the 1st of January 2017. Patients with defect closure were compared with no defect closure. Re-operation rates are presented as crude rates and cumulated adjusted re-operation rates. Sub-analyses assessed the effect of the suture material used during defect closure and also whether defect closure affected both primary and incisional hernias equally. Among patients with absorbable tacks as mesh fixation, 443 received defect closure and 532 did not. For patients with permanent tacks, 393 had defect closure and 442 did not. For patients with permanent tacks as mesh fixation, the crude re-operation rates were 3.6% with defect closure and 7.2% without defect closure (p = 0.02). The adjusted cumulated re-operation rate was significantly reduced with defect closure and permanent tacks (hazard ratio = 0.53, 95% confidence interval = 0.28–0.999, p = 0.05). The sub-analysis suggested that defect closure was only beneficial for incisional hernias, and not primary hernias. We did not find any benefits of defect closure for patients with absorbable tacks as mesh fixation. This nationwide cohort study showed a reduced risk of re-operation for recurrence if defect closure was performed in addition to permanent tacks as mesh fixation during laparoscopic incisional hernia repair.

Inguinal hernia repairs should have few complications and a short learning curve. A new operation called Onstep has promising results, but still some recurrences. The aim of the study was to find reasons for recurrence, by studying the re-operations.The study is a case series, where 565 patients operated with Onstep at six hospitals between December 2011 and April 2015 were identified. If a recurrence had occurred, the description of the re-operation was studied and compared to the primary Onstep operation.We found 26 inguinal hernia recurrences, giving a recurrence rate of 4.6 %. The reasons for recurrence were a cranial displacement of the mesh in five patients, a caudal displacement in three patients, a folded mesh in one patient, and broken sutures in the mesh laterally in six patients. We found indications of a learning curve, since 70 % of the recurrences had their primary operation among the first half of the total Onstep procedures. Another finding was that 30 patients had complaints from the ring in the mesh, and most of these patients were slender. Fifteen patients have had the ring removed, and for six patients with a follow-up, the complaints have been reduced or disappeared.The main reasons for recurrence may be broken sutures in the mesh laterally or a suboptimal size of the opening in fascia transversalis medially, enabling the mesh to displace. Furthermore, the results suggest a learning curve. These findings may guide further improvement in the Onstep method for inguinal hernia repair.