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Groin Hernia Repair: Inguinal and Femoral

Groin Hernia Repair: Inguinal and Femoral

AMERICAN COLLEGE OF SURGEONS • DIVISION OF EDUCATION Repair and Femoral

Many patients become symptomatic after The Condition the fi rst 1 to 2 years and crossover to Patient Education A hernia occurs when tissue bulges out due to increased on exertion, chronic 3 This educational information is to through an opening in the muscles. or urinary symptoms. help you be better informed about Any part of the can your operation and empower you weaken and develop a hernia, but with the skills and knowledge the most common sites are the groin Benefits and Risks needed to actively participate in (inguinal), the (umbilical) and of Your Operation your care. a previous surgical incision site. B e n e fi t s — An operation is the only way Keeping You Common Symptoms to repair a hernia. You can return to ● Visible bulge in the or groin your normal activities and in most cases Informed area, especially with coughing will not have further discomfort. or straining Information that will help you Possible risks include—Return of the further understand the operation ● Pain or pressure at the hernia site hernia; infection; injury to the bladder, and your role in your recovery. blood vessels, intestines or nerves, Groin Hernia Location diffi culty passing urine, continued pain, Education is provided on: and swelling of the testes or groin area. Overview ...... 1 Risks of not having an operation—Your Condition, Symptoms, Tests ...... 2 hernia may cause pain and increase in size. Treatment Options…...... 3 If your intestine becomes trapped in the hernia pouch you will have sudden pain, Risks and , and need an immediate operation. Possible Complications ...... 4 Preparation and Expectations ...... 5 Femoral Your Recovery Expectations and Discharge ...... 6 Before your operation—Evaluation Inguinal Pain Control...... 7 may include blood work and urinalysis. Glossary/References ...... 8 Your surgeon and anesthesia provider will discuss your health history, home Treatment Options medications, and pain control options. Surgical Procedure The day of your operation—You will Open hernia repair—An incision is not eat or drink for 6 hours before the made near the site and the hernia is operation. Most often you will take your repaired with mesh or by suturing normal medication with a sip of water. You (sewing) the muscle closed. will need someone to drive you home. Laparoscopic hernia repair—The hernia Your recovery—If you do not have is repaired by mesh or sutures inserted complications you usually will go home through instruments placed into small the same day. incisions in the . Call your surgeon—If you have severe pain, cramping, chills, or a high Nonsurgical Procedure (over 101°F or 38.3°C), odor or Watchful waiting is a safe and acceptable increased drainage from your incision, option for adults with inguinal or no bowel movements for 3 days. that are not uncomfortable.1-2

This first page is an overview. For more detailed information, review the entire document.

AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation Groin Hernia Repair The Condition, Symptoms, Inguinal and Femoral and Diagnostic Tests SAMPLE

Keeping You Informed Fat Groin Hernia Who Gets Hernias? Muscle There may be no cause for a hernia. Some risk factors are: • Older age—muscles Hernia with intestine become weaker • —increased weight places pressure on abdominal muscle • Sudden twist, pulls, or strains • Chronic straining Femoral • Family history Symptoms Inguinal • Connective tissue The most common symptoms are: disorders ●●Bulge in the groin, scrotum, or • —1 in abdominal area that often increases 2,000 women in size with coughing or straining. develop a hernia The Condition ●●Mild pain or pressure at the hernia site.2 during pregnancy.2 The Hernia ●●Numbness or irritation due to pressure on the nerves around the hernia.2 Other medical A groin hernia occurs when the intestine disorders bulges through the opening in the muscle ●●Sharp and vomiting in the groin area. A reducible hernia can be can mean that the intestine has slipped that have symptoms pushed back into the opening. When intestine through the hernia sac and is strangulated. similar to hernias include or abdominal tissue fills the hernia sac and This is a and enlarged lymph nodes, cannot be pushed back, it is called irreducible immediate treatment is needed. cysts, and testicular or incarcerated. A hernia is strangulated if problems such as the intestine is trapped in the hernia pouch scrotal .2-4 and the blood supply to the intestine is Common Tests decreased. This is a surgical emergency.2 History and Physical exam2 There are two types of groin hernias: The site is checked for a bulge. An appears as a bulge in the groin or scrotum. Inguinal hernias account for Other tests may include (see glossary): 2 75% of all hernias and are most common in men. ●●Digital exam A appears as a bulge in the groin, ●●Blood tests upper thigh, or labia (skin folds surrounding ●●Urinalysis the vaginal opening). Femoral hernias are ten ●Electrocardiogram (ECG)—for patients times more common in women.2 They are always ● over 45 or if high risk of heart problems repaired because of a high risk of strangulation.1-3 ●● Herniorraphy is the surgical repair of a hernia. ●Computerized tomography (CT) scan Hernioplasty is the surgical repair of a hernia ● with mesh.

2 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation Groin Hernia Repair Surgical and Inguinal and Femoral Nonsurgical Treatment

Open Repair Laparoscopic Repair

Muscle Inguinal ring Inguinal ring Mesh plug Spermatic cord Mesh Port Open Mesh Nerve and genital branch of nerve

Surgical Treatment Suture Only Muscle The type of operation depends on hernia size Inguinal ring and location, and if it is a repeat hernia. Your Port sites will vary health, age, anesthesia risk, and the surgeon’s Spermatic cord expertise are also important. An operation Sutured muscle is the only treatment for incarcerated/ Nerve and genital strangulated and femoral hernias. branch of nerve Mesh repair Your hernia can be repaired either as an open or laparoscopic approach. The repair can be done by using sutures Laparoscopic Hernia Repair only or adding a piece of mesh. The surgeon will make several small punctures Open Hernia Repair or incisions in the abdomen. Ports (hollow The surgeon makes an incision near tubes) are inserted into the openings. The the hernia site and the bulging tissue abdomen is inflated with carbon dioxide gas Keeping You is pushed back into the abdomen. to make it easier to see the internal organs. Most inguinal hernia repairs use mesh Surgical tools and a laparoscopic light are Informed 5 placed into the ports. The hernia is repaired with to close the muscle. An open repair Open vs. Laparoscopic can be done with local anesthesia. mesh and sutured or stapled in place. The repair is done as a TransAbdominal PrePeritoneal Incisional Repair ●●For an open mesh repair: The hernia sac (TAPP) procedure, which means the A laparoscopic repair of inguinal is removed. Mesh is placed over the hernia (the sac that contains all of the abdominal site. The mesh is attached using sutures hernia may result in less pain organs) is entered, or the repair is done as a and numbness, lower infection sewn into the stronger tissue surrounding Totally ExtraPeritoneal (TEP) procedure.2-4 the hernia site. Mesh plugs can also be rate, and faster return to normal placed into the inguinal or femoral hernia activity when compared with open 6 space. The mesh plug fills the open site surgery. Laparoscopic repair may and is sutured to the surrounding tissue. Nonsurgical Treatment lengthen the operative time and 5 An additional mesh patch is applied Watchful waiting is an option if you have may cost more. A recurrence from and may or may not be sutured.2 Mesh an inguinal hernia with no symptoms.1 a previous open hernia repair is is often used for large hernia repairs Hernia incarceration occurred in 1.8 per best repaired laparoscopically and may reduce the risk that the hernia 1,000 men who waited longer than 2 years because you avoid scar tissue from 7 will come back. The site is closed using to have a repair.2 Femoral hernias should previous incisions. Laparoscopic sutures, staples, or surgical glue. always be repaired because of the high risk repair of a bilateral (both sides ●●For a suture-only repair: The hernia (400 of 1,000) of incarceration and bowel of the groin) inguinal hernias sac is removed. Then the tissue along strangulation within 2 years of diagnosis.2 also resulted in earlier return to work than open repairs. 8 the muscle edge is sewn together. Trusses or belts can help manage the symptoms This procedure is often used for of a hernia by applying pressure at the site. A The risk of complications strangulated or infected hernias or truss requires correct fitting and increases for both the open and small defects (less than 3 cm). complications include testicular nerve laparoscopic procedure if the 9 damage and incarceration may result.4 hernia extends into the scrotum. 3 Groin Hernia Repair Risks of this Procedure Inguinal and Femoral SAMPLE

Risks Based on the ACS Risk Calculator Open and Laparoscopic Inguinal and Femoral Hernia Surgery from the ACS Risk Calculator—July 17, 2018

Percent for Risks Keeping You Informed Average Patient

Wound Infection: Infection at the Open 0.3% Antibiotics and drainage of the wound may be needed. area of the incision or near the Laparoscopic 0.2% can increase the risk of infection. where the surgery was performed

Complications: Including surgical Open 1.5% Complications related to general anesthesia and surgery may be higher infections, breathing difficulties, Laparoscopic 1.2% in smokers, elderly and/or obese patients, and those with high blood blood clots, renal (kidney) pressure and breathing problems. Wound healing may also be decreased complications, cardiac complications, in smokers and those with diabetes and immune system disorders. and return to the operating room

Pneumonia: Infection in the lungs Open 0.1% Movement, deep breathing, and stopping smoking Laparoscopic 0.1% can help prevent respiratory infections.

Urinary tract infection: Infection Open 0.1% Drinking fluids and catheter care decrease the risk of bladder infection. of the bladder or kidneys Laparoscopic 0.1%

Venous thrombosis: A blood clot in Open 0.1% Longer surgery and bed rest increase the risk. Getting up, walking 5 the legs that can travel to the lungs Laparoscopic 0.1% to 6 times per day, and wearing support stockings reduce the risk.

Death Less than 1% Your surgical team is prepared for all emergency situations.

Risks from Outcomes Reported Percent for Keeping You Informed in the Last 10 years of Literature Average Patient

Chronic (long-term) pain 10% to 12% may have Factors contributing to chronic pain include emergency hernia repair, pain one year after scrotal hernia, or recurrent hernia repair.1 Pain may be less with laparoscopic surgery; possibly less procedures than open procedures.2 Pain caused by compression or tension with lapraoscopic10-12 may gradually decrease with time as a result of tissue rearrangement.13

Recurrence: A hernia can All patients 1% to 17% 14 Recurrence occurs half as often when mesh is used versus non- recur after the repair Open 4.9% mesh repair.2 Laparoscopic repair is recommended for recurrent Laparoscopic 10.1% hernias because the surgeon avoids previous scar tissue. There is a higher rate of recurrence in older men with laparoscopic repair.

Neuralgia: Nerve pain causing Open 10.7% Pressure, staples, stitches, or a trapped nerve in the surgical area tingling or numbness Laparoscopic 7.4% can cause nerve pain. Tell your doctor if you feel severe, sharp, or tingling pain in the groin and leg immediately after your procedure; an operation may be required if the nerve is trapped.2

Seroma: A collection of Mesh repairs 8% Seromas can form around the former hernia site. Removal clear/yellow fluid Nonmesh repairs 3.1% of fluid with a sterile needle may be required.2-4

Hematoma: a collection of blood Mesh repairs 2.2% Hematomas are treated with anti-inflammatory medications, in the wound site or scrotum Nonmesh repairs 7% elevation, and rest. Rarely blood replacement or further testing for a blood vessel injury is needed.4

The data have been averaged per 1,000 cases

The ACS Surgical Risk Calculator estimates the risk of an unfavorable outcome. Data is from a large number of patients who had a surgical procedure similar to this one. If you are healthy with no health problems, your risks may be below average. If you smoke, are obese, or have other health conditions, then your risk may be higher. This information is not intended to replace the advice of a doctor or health care provider. To check your risks, go to the ACS Risk Calculator at http://riskcalculator.facs.org.

4 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation Groin Hernia Repair Expectations: Preparation Inguinal and Femoral for Your Operation

What to Bring Questions Preparing for Your ●● Insurance card and identification to Ask Operation ●●Advance directives (see glossary) About my operation Home Medication ●●List of medicines • What are the risks Bring a list of all of the medications and vitamins ●●Loose-fitting, comfortable clothes and side effects of that you are taking. Your medication may have general anesthesia? to be adjusted before your operation. Some ●●Slip-on shoes that don’t require that medications can affect your recovery and you bend over • What technique will response to the anesthesia. Most often you will be used to repair the ●●Leave jewelry and valuables at home take your morning medication with a sip of water. hernia—laparoscopic What You Can Expect or open; mesh or Anesthesia with sutures? An identification (ID) bracelet and allergy bracelet Let your anesthesia provider know if you have with your name and hospital/clinic number will allergies, neurologic disease (epilepsy, stroke), • Ask your surgeon be placed on your wrist. These should be checked heart disease, stomach problems, lung disease how frequently they by all health team members before they perform (asthma, emphysema), endocrine disease perform laparoscopic any procedures or give you medication. Your (diabetes, thyroid conditions), or loose teeth; hernia repairs? surgeon will mark and initial the operation site. if you smoke, drink alcohol, use drugs, or take • What are the risks any herbs or vitamins; or if you have a history Fluids and Anesthesia of this procedure? of and vomiting with anesthesia. An intravenous line (IV) will be started to • Will you be If you smoke, you should let your surgical team give your fluids and medication. For general performing the entire know and you should plan to quit. Quitting anesthesia, you will be asleep and pain-free. A procedure yourself? before your surgery can decrease your rate tube will be placed down your throat to help of respiratory and wound complications and you breathe during the operation. For spinal • What level of pain increase your chances of staying smoke- anesthesia, a small needle with medication should I expect free for life. Resources to help you quit may will be placed in your back near your spinal and how will it be found at www.facs.org/patienteducation column. You will be awake and pain-free. be managed? or www.lungusa.org/stop-smoking. After Your Operation Length of Stay • How long will it be You will be moved to a recovery room where your before I can return to If you have local anesthesia, you will usually go heart rate, breathing rate, oxygen saturation, my normal activities— home the same day. You may stay overnight if blood pressure, and urine output will be closely work, driving, lifting? you had a repair of a large or incarcerated hernia, watched. Be sure that all visitors wash their hands. laparoscopic repair with a longer anesthesia time, postanesthesia issues such as severe nausea Preventing Pneumonia and Blood Clots and vomiting, or you are unable to pass urine. Movement and deep breathing after your operation can help prevent postoperative complications such as blood clots, fluid in your lungs, and The Day of Your Operation pneumonia. Every hour take 5 to 10 deep breaths ●● Do not eat or drink for at least 6 hours before and hold each breath for 3 to 5 seconds. your operation. When you have an operation, you are at risk of ●●Shower and clean your abdomen and groin getting blood clots because of not moving during area with a mild antibacterial soap. anesthesia. The longer and more complicated your surgery, the greater the risk. This risk is decreased ●●Brush your teeth and rinse your mouth out by getting up and walking 5 to 6 times per day, with mouthwash. wearing special support stockings or compression ●●Do not shave the surgical site; your surgical boots on your legs, and, for high risk patients, team will clip the hair nearest the incision site. taking a medication that thins your blood.

5 Groin Hernia Repair Inguinal and Femoral Your Recovery and Discharge SAMPLE

Your Recovery Keeping You and Discharge Informed Thinking Clearly High-Fiber Foods If general anesthesia is given, or if you are Foods high in fi ber include beans, taking narcotic pain medication, it may Handwashing Steri-Strips® bran cereals and whole-grain cause you to feel diff erent for 2 or 3 days, breads, peas, dried fruit (fi gs, have diffi culty with memory, and feel more Wound Care apricots, and dates), raspberries, fatigued. You should not drive, drink alcohol, ● Always wash your hands before and blackberries, strawberries, or make any big decisions for at least 2 days. after touching near your incision site. sweet corn, broccoli, baked Nutrition potatoes with skin, plums, pears, ● Do not soak in a bathtub until your stitches, apples, greens, and nuts. ● When you wake up from the anesthesia, Steri-Strips®, or staples are removed. you will be able to drink small amounts You may take a shower after the second of liquid. If you do not feel sick, you postoperative day unless you are told not to. can begin eating regular foods. ● Follow your surgeon’s instructions on ● Continue to drink about 8 to 10 when to change your bandages. glasses of water per day. ● A small amount of drainage from the ● Eat a high-fi ber diet so you don’t strain incision is normal. If the dressing is while having a bowel movement. soaked with blood, call your surgeon. Activity ● If you have Steri-Strips in place, they will fall off in 7 to 10 days. ● Slowly increase your activity. Be sure If you have a glue-like covering to get up and walk every hour or so ● over the incision, just allow the to prevent blood clot formation. glue to fl ake off on its own. ● Patients usually take 2 to 3 weeks to Avoid wearing tight or rough clothing. return comfortably to normal activity.7 ● It may rub your incisions and make ● You may go home the same day after a it harder for them to heal. simple repair. If you have other health Protect the new skin, especially from the sun. conditions or complications such as ● The sun can burn and cause darker scarring. nausea, vomiting, , or diffi culty passing urine, you may stay longer. ● Your scar will heal in about 4 to 6 weeks and will become softer and ● Persons sexually active before the continue to fade over the next year. operation reported being able to return to sexual activity in 14 days (average). Bowel Movements Work and Return to School Avoid straining with bowel movements by increasing the fi ber in your diet with high- ● You may return to work after 1 to 2 weeks fi ber foods or over-the-counter medicines (like after laparoscopic or open repair, as Metamucil® and FiberCon®). Be sure you are Do not lift anything long as you don’t do any heavy lifting. drinking 8 to 10 glasses of water each day. over 10 pounds. Discuss the timing with your surgeon. A gallon of milk ● Do not lift items heavier than 10 pounds Pain weighs 9 pounds. or participate in strenuous activity for at The amount of pain is diff erent for each least 4 to 6 weeks. person. The new medicine you will need ● Lifting limitation may last for 6 months after your operation is for pain control, and after complex or recurrent hernia repairs. your doctor will advise how much you should take. You can use throat lozenges if you have sore throat pain from the tube placed in your throat during your anesthesia.

6 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation Groin Hernia Repair Inguinal and Femoral

Narcotic (Opioid) Pain Medication When to Contact Narcotics or opioids are used for severe Keeping You Your Surgeon pain. Possible side effects of narcotics are Informed Contact your surgeon if you have: sleepiness, lowered blood pressure, heart rate, and breathing rate; skin rash and Pain after Inguinal ●●Pain that will not go away itching; constipation; nausea; and difficulty Hernia Repair ●●Pain that gets worse urinating. Some examples of narcotics include morphine, oxycodone (Percocet®/Percodan®), Pain that continues one year after ●●A fever of more than 101°F or 38.3°C and hydromorphone (Dilaudid®). Medications inguinal hernia repair is more ●●Continuous vomiting can be given to control many of the side common in women, patients effects of narcotics. younger than 40 years, and those ●●Swelling, redness, bleeding, or who have had previous groin bad-smelling drainage from your Pain Control without Medication surgery. Pain may be higher wound site Distraction helps you focus on other activities when heavy versus light-weight ●●Strong or continuous abdominal instead of your pain. Listening to music, mesh is used.13 Other causes of pain or swelling of your abdomen playing games, or other engaging activities pain should be ruled out, such can help you cope with mild pain and anxiety. as lower back, spine, or hip pain. ●●No bowel movement by 2 to 3 days Treatment options may include Guided imagery helps you direct and after the operation non-steroidal anti-inflammatory control your emotions. Close your eyes drugs (NSAIDs), acetaminophen, and gently inhale and exhale. Picture oral medications or injections yourself in the center of somewhere Pain Control (gabapentin or pregabalin) for beautiful. Feel the beauty surrounding nerve pain, or procedures to Everyone reacts to pain in a different you and your emotions coming back to remove the nerves. way. A scale from 0 to 10 is used to your control. You should feel calmer. measure pain. At a “0,” you do not feel any pain. A “10” is the worst pain you have ever felt. Following a laparoscopic procedure, pain is sometimes felt in the shoulder. This is due to the gas inserted OTHER INSTRUCTIONS: into your abdomen during the procedure. Moving and walking helps to decrease the gas and the right shoulder pain.2-3 Extreme pain puts extra stress on your body at a time when your body needs to focus on healing. Do not wait until your pain has reached a level “10” or is unbearable before FOLLOW-UP APPOINTMENTS telling you doctor or nurse. It is much easier Distraction WHO: to control pain before it becomes severe. Non-Narcotic Pain Medication Most non-opioid analgesics are classified DATE: as non-steroidal anti-inflammatory drugs (NSAIDs). They are used to treat mild pain and or combined with narcotics PHONE: to treat severe pain. Possible side effects of NSAIDs are stomach upset, bleeding in the digestive tract, and fluid retention. These side effects usually are not seen with short- term use. Let your doctor know if you have heart, kidney, or liver problems. Examples of NSAIDs include ibuprofen, Motrin®, Aleve®, and Toradol® (given as a shot). Guided imagery

7 Groin Hernia Repair Inguinal and Femoral More Information SAMPLE

For more information, please go to the American College of Surgeons Patient Education website at facs.org/patienteducation. For a complete review of hernia repair, consult Selected Readings in , “Hernia” 2015 Vol. 41 No. 7 at facs.org/SRGS.

GLOSSARY REFERENCES Advance directives: Documents Incarceration: The protrusion or The information provided in this report is chosen from signed by a competent person constriction of an organ through recent articles based on relevant clinical research or trends. giving direction to health care the wall of the cavity that normally The research below does not represent all that is available providers about treatment choices. contains it. for your surgery. Ask your doctor if he or she recommends that you read any additional research. Computerized tomography (CT) Local anesthesia: The loss of scan: A diagnostic test X ray and sensation only in the area of the 1. Fitzgibbons RJ, Giobbie-Hurder A, Gibbs JO et al. Watchful waiting a computer to create a detailed, body where an anesthetic drug is vs. repair of inguinal hernia in minimally symptomatic men. JAMA. three-dimensional picture of your applied or injected. 2006:295(3):285-292. abdomen. A CT scan is commonly Nasogastric tube: A soft plastic 2. Malangoni MA, Rosen MJ. Hernias. In: CM Townsend, RD Beauchamp, et used to detect abnormalities or tube inserted in the nose and down al. Sabiston Textbook of Surgery, Philadelphia, PA: Elsevier, 2012:chap 46. disease inside the abdomen. It is to the stomach which is used to sometimes used to find a hernia not 3. Sarosi G, Yongliang W, Gibbs J, Reda D, McCarthy M, Fitzgibbons R, empty the stomach of contents and obvious during the physical exam. Barkun, J. A clinician’s guide to patient selection for watchful waiting gases to rest the bowel. management of inguinal hernia. Annals of Surgery. 2011;253(3):605-610. Digital exam: The examiner will Seroma: A collection of serous 4. Fitzgibbons RJ Jr., Filipi CJ, Quinn TH. Inguinal Hernias. In: FC Brunicardi, place their gloved index finger (clear/yellow) fluid. DK Andrson, et al. Principles of Surgery (8th edition). New York: McGraw gently into the scrotal sac and feel up to the inguinal ring in the groin. Strangulation: Part of the intestine Hill, 2005. Then the patient is asked to strain. or fat is squeezed in the hernia sac 5. Gould, J. Laparoscopic versus open inguinal hernia repair. Surgical Clinics and blood supply to the tissue is of North America. 2008;88(5):1073-1081 Electrocardiogram (ECG): Measures cut off. the rate and regularity of heartbeats 6. Abbas AE, Noaman N, Amin M, Patient-perspective quality of life after and any damage to the heart. Ultrasound: Sound waves are used laparoscopic and open hernia repair: A controlled randomized trial. to determine the location of deep Surgical . 2012;26:2465-2470. General anesthesia: A treatment structures in the body. A hand 7. Takata MC, Duh QY. Laparoscopic inguinal hernia repair. Surgical Clinics of with certain medicines that puts you roller is placed on top of clear gel North America. 2008;88(1):157-178 into a deep sleep so you do not feel and rolled across the abdomen. An pain during surgery. ultrasound may be used to find a 8. Mahon D, Decadt M, Rhodes M. Prospective randomized trial of hernia that is not obvious during the laparoscopic (transabdominal preperitoneal) vs. open (mesh) repair for Hematoma: A collection of blood physical exam. bilateral and recurrent inguinal hernia. Surgical Endoscopy. that has leaked into the tissues of 2003;17:1386-1390. Urinalysis: A visual and chemical the skin or in an organ, resulting 9. Schwab JR et al. After 10 years and 1.903 inguinal hernias, what is the examination of the urine, most from cutting in surgery or the outcome for the laparoscopic repair? Surgical Endoscopy. often used to screen for urinary blood’s inability to form a clot. 2002;16:12011206. tract infections and kidney disease. 10. Niebuhr H, Wegner F, Hukauf M, et al. What are the influencing factors for chronic pain following TAPP inguinal hernia repair: An analysis DISCLAIMER of 20,004 patients from the Herniamed Registry. Surgical Endoscopy. 2018 Apr;32(4):1971-1983. doi: 10.1007/s00464-017-5893-2. Epub 2017 Oct 26. The American College of Surgeons (ACS) is a scientific and educational association of surgeons that was founded in 1913 to improve the quality of 11. Öberg S, Andresen K , Tobias W, et al. Chronic pain after mesh versus care for the surgical patient by setting high standards for surgical education nonmesh repair of inguinal hernias: A systematic review and a network and practice. The ACS endeavors to provide procedure education for meta-analysis of randomized controlled trials. Surgery. 2018 prospective patients and those who educate them. It is not intended to take May;163(5):1151-1159. doi: 10.1016/j.surg.2017.12.017. Epub 2018 Mar 13. the place of a discussion with a qualified surgeon who is familiar with your 12. Matthews RD, Anthony T, Kim LT, et al. Factors associated with situation. The ACS makes every effort to provide information that is accurate postoperative complications and hernia recurrence for patients and timely, but makes no guarantee in this regard. undergoing inguinal hernia repair: A report from the VA Cooperative Hernia Study Group. American Journal of Surgery. 2007 Nov;194(5):611-617. Reviewed 2016 and 2018 by: 13. Inaba T, et al. Chronic pain and discomfort after inguinal hernia repair. David Feliciano, MD, FACS Surgery Today. 2012;42:825-829 Mary Hawn, MD, FACS 14. Itani K, Fitzgibbons R, Awad S et al. Management of recurrent inguinal Nancy Strand, MPH, RN hernias. Journal of the American College of Surgeons. 2009 Nov;209(5):653- 658. doi: 10.1016/j.jamcollsurg.2009.07.015. Epub 2009 Aug 20.

8 AMERICAN COLLEGE OF SURGEONS • SURGICAL PATIENT EDUCATION • www.facs.org/patienteducation

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