PDF(Pubmed)
Abstract：
Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.
An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group\'s first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as \"strong\" (recommendations) or \"weak\" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term \"should\" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with \"watchful waiting\" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon\'s expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation \"Hernia Center\". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.
The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.
An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group\'s first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as \"strong\" (recommendations) or \"weak\" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term \"should\" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with \"watchful waiting\" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon\'s expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation \"Hernia Center\". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.
The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.
摘要：
全球,每年有超过2000万患者接受腹股沟疝修补术。许多不同的方法，治疗适应症和一系列重要的腹股沟疝修补技术需要指导规范护理，尽量减少并发症，并改善结果。这些指南的主要目标是改善患者的预后，特别是为了降低复发率和减少慢性疼痛，腹股沟疝修补后最常见的问题。它们已经得到了所有五个大陆疝气协会的认可，国际Endo疝学会和欧洲内窥镜手术协会。
成立了一个由国际外科医生（HerniaSurge小组）和一名麻醉师疼痛专家组成的专家组。该小组由来自各大洲的成员组成，他们在疝气相关研究方面具有特殊经验。注意包括进行不同类型的修复并优选进行腹股沟疝手术研究的外科医生。在专家组第一次会议期间，进行了循证医学（EBM）培训，制定了166个关键问题（KQ）。到2015年1月1日和2015年7月1日，在完整的文献搜索（包括荷兰Cochrane数据库的完整搜索）中遵循EBM规则，以获取1级出版物。根据牛津大学的说法，这些文章是由两三个人组成的团队评分的，标志和等级方法。在五个为期两天的会议中，结果与工作组成员讨论,得出136份声明和88份建议.建议被评为“强”（建议）或“弱”（建议），并在某些情况下通过协商一致进行了升级。在下面的结果和摘要部分中，术语“应该”是指建议。AGREEII工具用于验证指南。三名国际专家进行了外部审查。他们推荐了高分的指南。腹股沟疝（IH）的危险因素包括：家族史，以前的对侧疝,男性,年龄,胶原蛋白代谢异常，前列腺切除术,和低体重指数。围手术期复发的危险因素包括手术技术差，低手术量，手术经验不足和局部麻醉。在治疗IH患者时应考虑这些因素。IH诊断仅通过体格检查就可以在绝大多数具有适当体征和症状的患者中得到证实。很少,超声检查是必要的。不太常见的是，可能需要动态MRI或CT扫描或疝造影。EHS分类系统建议对IH患者进行分层以进行量身定制的治疗，研究和审计。症状性腹股沟疝应手术治疗。无症状或症状轻微的男性IH患者可以接受“观察等待”治疗，因为他们患疝气相关紧急情况的风险很低。这些人中的大多数最终将需要手术；因此，应与患者讨论手术风险和观察等待策略.手术治疗应根据外科医生的专业知识量身定制，与患者和疝气相关的特征以及当地/国家资源。此外，与患者健康相关的,生活方式和社会因素都应影响导致疝气管理的共同决策过程。建议将网格修复作为首选，通过开放式手术或腹腔镜内窥镜修复技术。不存在用于所有腹股沟疝的一种标准修复技术。建议外科医生/外科服务提供前后入路选择。最好评估Lichtenstein和腹腔镜内窥镜修复。许多其他技术需要进一步评估。只要有资源和专门知识，腹腔镜技术有更快的恢复时间，降低慢性疼痛的风险和成本效益。讨论了潜在的双侧疝（隐匿性疝问题）的腹腔镜内镜治疗。患者同意后,在TAPP期间，应检查对侧。在单侧TEP维修期间不建议这样做。在与患者进行有关结果的适当讨论后，可以提供组织修复（首选是Shouldice技术）。建议对大多数腹股沟疝修补术进行日间手术，前提是组织好事后护理。外科医生应该意识到他们使用的网格的内在特征。使用所谓的低重量网片可能会有轻微的短期益处，如减少术后疼痛和缩短恢复期，但与更好的长期结局如复发和慢性疼痛无关.不建议仅根据重量选择网格。与扁平网相比，塞子的侵蚀发生率似乎更高。建议不要使用插头修复技术。目前不建议使用其他植入物代替Lichtenstein技术中的标准平网。在几乎所有情况下,TEP中的网片固定是不必要的。在TEP和TAPP中，建议将网状物固定在M3疝（大内侧）中以降低复发风险。在低风险环境中，不建议在开放手术中对平均风险患者进行抗生素预防。在腹腔镜内窥镜修复中，从不推荐。局部麻醉在开腹修补术中具有许多优点,如果外科医生有这种技术的经验，建议使用它。全身麻醉建议在65岁及以上的患者中进行局部麻醉，因为它可能与较少的并发症相关，如心肌梗塞，肺炎和血栓栓塞。在所有开放修复的情况下，建议围手术期进行野阻滞和/或筋膜下/皮下浸润。建议患者在感觉舒适后立即不受限制地恢复正常活动。只要有专业知识，建议患有腹股沟疝的女性接受腹腔镜内镜修复术，以降低慢性疼痛的风险并避免错过股疝。孕妇建议谨慎等待，因为腹股沟肿胀通常由自限的圆形韧带静脉曲张组成。建议在有专业知识的情况下，通过腹腔镜内窥镜方法对股骨疝进行及时的网状修复。腹股沟疝管理的所有并发症都在有关该主题的广泛章节中进行了讨论。总的来说,临床上显着的慢性疼痛的发生率在10-12％范围内，随着时间的推移而减少。影响正常日常活动或工作的衰弱性慢性疼痛的范围为0.5％至6％。慢性术后腹股沟疼痛(CPIP)被定义为影响术后至少3个月的日常活动并随时间减少的令人烦恼的中度疼痛。CPIP风险因素包括：年龄小，女性性别,术前高度疼痛，术后早期高疼痛，复发性疝和开放修复。对于CPIP，重点应该放在开放手术中的神经识别上，在选定的情况下，预防性实用神经切除（不建议计划切除）。建议由多学科团队进行CPIP管理。还建议通过药理和干预措施相结合来管理CPIP，如果不成功,其次是,在选定的情况下（三联）神经切除术和（在选定的情况下）网状物去除。对于前路修补后的复发性疝，建议进行后路修复。如果在后路修复后复发，建议前路修复。前后入路失败后，建议由专业的疝气外科医生进行管理。疝嵌顿/绞窄的危险因素包括：女性，股疝和腹股沟疝相关住院史。建议根据患者和疝气相关因素量身定制紧急情况的治疗方法，当地的专业知识和资源。学习曲线因不同技术而异。可能需要大约100个有监督的腹腔镜内窥镜修复才能达到与Lichtenstein等开放式网状手术相同的结果。建议每个外科医生的病例负荷比中心体积更重要。建议制定最低要求，以证明个人是专业的疝气外科医生。名称“疝中心”也是如此。从成本效益的角度来看，建议在日间进行腹腔镜IH修复，并尽量减少一次性使用。在每个国家（或地区，在小国家人口的情况下)。它们应包括患者随访数据，并说明当地的医疗保健结构。全球(HerniaSurge)将制定准则的传播和实施计划，通过互联网网站采取区域(国际社会)和地方(国家分会)举措，社交媒体和智能手机应用程序。需要一项总体计划，以改善在低资源环境（LRS）中获得安全的IH手术的机会。建议该计划包含简单的指导方针和可持续发展战略，独立于国际援助。建议在LRS中，重点是在使用低成本网状物的局部麻醉下进行高容量Lichtenstein修复。三章讨论了未来的研究，全科医生指南和患者指南。
HerniaSurge集团为成人腹股沟疝患者的治疗制定了这些广泛且包容性的指南。希望它们将为腹股沟疝患者带来更好的结果，无论他们居住在哪里。更多知识,更好的培训,腹股沟疝管理的国家审计和专业化将规范对这些患者的护理，导致更有效和高效的医疗保健，并为未来的研究提供方向。
成立了一个由国际外科医生（HerniaSurge小组）和一名麻醉师疼痛专家组成的专家组。该小组由来自各大洲的成员组成，他们在疝气相关研究方面具有特殊经验。注意包括进行不同类型的修复并优选进行腹股沟疝手术研究的外科医生。在专家组第一次会议期间，进行了循证医学（EBM）培训，制定了166个关键问题（KQ）。到2015年1月1日和2015年7月1日，在完整的文献搜索（包括荷兰Cochrane数据库的完整搜索）中遵循EBM规则，以获取1级出版物。根据牛津大学的说法，这些文章是由两三个人组成的团队评分的，标志和等级方法。在五个为期两天的会议中，结果与工作组成员讨论,得出136份声明和88份建议.建议被评为“强”（建议）或“弱”（建议），并在某些情况下通过协商一致进行了升级。在下面的结果和摘要部分中，术语“应该”是指建议。AGREEII工具用于验证指南。三名国际专家进行了外部审查。他们推荐了高分的指南。腹股沟疝（IH）的危险因素包括：家族史，以前的对侧疝,男性,年龄,胶原蛋白代谢异常，前列腺切除术,和低体重指数。围手术期复发的危险因素包括手术技术差，低手术量，手术经验不足和局部麻醉。在治疗IH患者时应考虑这些因素。IH诊断仅通过体格检查就可以在绝大多数具有适当体征和症状的患者中得到证实。很少,超声检查是必要的。不太常见的是，可能需要动态MRI或CT扫描或疝造影。EHS分类系统建议对IH患者进行分层以进行量身定制的治疗，研究和审计。症状性腹股沟疝应手术治疗。无症状或症状轻微的男性IH患者可以接受“观察等待”治疗，因为他们患疝气相关紧急情况的风险很低。这些人中的大多数最终将需要手术；因此，应与患者讨论手术风险和观察等待策略.手术治疗应根据外科医生的专业知识量身定制，与患者和疝气相关的特征以及当地/国家资源。此外，与患者健康相关的,生活方式和社会因素都应影响导致疝气管理的共同决策过程。建议将网格修复作为首选，通过开放式手术或腹腔镜内窥镜修复技术。不存在用于所有腹股沟疝的一种标准修复技术。建议外科医生/外科服务提供前后入路选择。最好评估Lichtenstein和腹腔镜内窥镜修复。许多其他技术需要进一步评估。只要有资源和专门知识，腹腔镜技术有更快的恢复时间，降低慢性疼痛的风险和成本效益。讨论了潜在的双侧疝（隐匿性疝问题）的腹腔镜内镜治疗。患者同意后,在TAPP期间，应检查对侧。在单侧TEP维修期间不建议这样做。在与患者进行有关结果的适当讨论后，可以提供组织修复（首选是Shouldice技术）。建议对大多数腹股沟疝修补术进行日间手术，前提是组织好事后护理。外科医生应该意识到他们使用的网格的内在特征。使用所谓的低重量网片可能会有轻微的短期益处，如减少术后疼痛和缩短恢复期，但与更好的长期结局如复发和慢性疼痛无关.不建议仅根据重量选择网格。与扁平网相比，塞子的侵蚀发生率似乎更高。建议不要使用插头修复技术。目前不建议使用其他植入物代替Lichtenstein技术中的标准平网。在几乎所有情况下,TEP中的网片固定是不必要的。在TEP和TAPP中，建议将网状物固定在M3疝（大内侧）中以降低复发风险。在低风险环境中，不建议在开放手术中对平均风险患者进行抗生素预防。在腹腔镜内窥镜修复中，从不推荐。局部麻醉在开腹修补术中具有许多优点,如果外科医生有这种技术的经验，建议使用它。全身麻醉建议在65岁及以上的患者中进行局部麻醉，因为它可能与较少的并发症相关，如心肌梗塞，肺炎和血栓栓塞。在所有开放修复的情况下，建议围手术期进行野阻滞和/或筋膜下/皮下浸润。建议患者在感觉舒适后立即不受限制地恢复正常活动。只要有专业知识，建议患有腹股沟疝的女性接受腹腔镜内镜修复术，以降低慢性疼痛的风险并避免错过股疝。孕妇建议谨慎等待，因为腹股沟肿胀通常由自限的圆形韧带静脉曲张组成。建议在有专业知识的情况下，通过腹腔镜内窥镜方法对股骨疝进行及时的网状修复。腹股沟疝管理的所有并发症都在有关该主题的广泛章节中进行了讨论。总的来说,临床上显着的慢性疼痛的发生率在10-12％范围内，随着时间的推移而减少。影响正常日常活动或工作的衰弱性慢性疼痛的范围为0.5％至6％。慢性术后腹股沟疼痛(CPIP)被定义为影响术后至少3个月的日常活动并随时间减少的令人烦恼的中度疼痛。CPIP风险因素包括：年龄小，女性性别,术前高度疼痛，术后早期高疼痛，复发性疝和开放修复。对于CPIP，重点应该放在开放手术中的神经识别上，在选定的情况下，预防性实用神经切除（不建议计划切除）。建议由多学科团队进行CPIP管理。还建议通过药理和干预措施相结合来管理CPIP，如果不成功,其次是,在选定的情况下（三联）神经切除术和（在选定的情况下）网状物去除。对于前路修补后的复发性疝，建议进行后路修复。如果在后路修复后复发，建议前路修复。前后入路失败后，建议由专业的疝气外科医生进行管理。疝嵌顿/绞窄的危险因素包括：女性，股疝和腹股沟疝相关住院史。建议根据患者和疝气相关因素量身定制紧急情况的治疗方法，当地的专业知识和资源。学习曲线因不同技术而异。可能需要大约100个有监督的腹腔镜内窥镜修复才能达到与Lichtenstein等开放式网状手术相同的结果。建议每个外科医生的病例负荷比中心体积更重要。建议制定最低要求，以证明个人是专业的疝气外科医生。名称“疝中心”也是如此。从成本效益的角度来看，建议在日间进行腹腔镜IH修复，并尽量减少一次性使用。在每个国家（或地区，在小国家人口的情况下)。它们应包括患者随访数据，并说明当地的医疗保健结构。全球(HerniaSurge)将制定准则的传播和实施计划，通过互联网网站采取区域(国际社会)和地方(国家分会)举措，社交媒体和智能手机应用程序。需要一项总体计划，以改善在低资源环境（LRS）中获得安全的IH手术的机会。建议该计划包含简单的指导方针和可持续发展战略，独立于国际援助。建议在LRS中，重点是在使用低成本网状物的局部麻醉下进行高容量Lichtenstein修复。三章讨论了未来的研究，全科医生指南和患者指南。
HerniaSurge集团为成人腹股沟疝患者的治疗制定了这些广泛且包容性的指南。希望它们将为腹股沟疝患者带来更好的结果，无论他们居住在哪里。更多知识,更好的培训,腹股沟疝管理的国家审计和专业化将规范对这些患者的护理，导致更有效和高效的医疗保健，并为未来的研究提供方向。
