Groin hernia repair is one of the most common surgeries performed globally on around 20 million people annually [1, 2]. There are two main types of groin hernias: femoral hernias and inguinal hernias [3]. The majority of inguinal hernias are symptomatic, and surgery is the only curative treatment. Even amongst the minority of patients who are asymptomatic and managed with a watch-and-wait approach, surgery will be required within 5 years in approximately 70% of cases.

Hernia repair may be undertaken as open (“classical”) or laparoscopic [4] surgery. In addition, the specific surgical technique chosen for a repair is influenced by several factors: the need to use a synthetic mesh for reinforcement of the repaired posterior wall, individual patient factors (such as obesity), primary or recurrent hernia, patient preference, and surgeon experience.

Both open and laparoscopic techniques are associated with low rates of recurrence, but laparoscopic surgery is generally associated with lower rates of chronic pain (when compared to some open techniques). Chronic pain after inguinal hernia surgery can occur in up to 10%–12% of cases [5].

While surgery is successful in most cases, recurrence of hernia affects over 10% of cases, with 57% occurring within 10 years of surgery [6].

Open preperitoneal mesh techniques are a long-standing and globally accepted option for the treatment of inguinal hernias. Since the fifties of the 20th century, numerous surgical techniques have been developed. Since the 2023 Update of the Herniasurge Guidelines, an open preperitoneal mesh technique has been an acceptable alternative, providing available expertise and competence with at least equal results as Lichtenstein repair [7]. Regarding the use of mesh, international HerniaSurge guidelines recommend the use of a mesh in the majority of cases, noting that “Although there is strong evidence that mesh repair is superior to non-mesh, there are cases in which a non-mesh repair can be suggested” [7].

Both open and laparoscopic techniques are associated with low rates of recurrence, but laparoscopic surgery is generally associated with lower rates of chronic pain. However, laparoscopic surgery requires access to endoscopic equipment with suitably trained surgeons and is therefore associated with greater costs and a steeper learning curve [8, 9].

Open tension-free mesh repair (Lichtenstein) is a popular technique due to its easy reproducibility by non-specialist surgeons [9]. Whilst this technique is associated with low recurrence and complication rates, there are concerns over reported chronic post-surgical pain [10]. Over time, alternative open repair techniques (e.g., open new simplified totally extraperitoneal, “ONSTEP”; TransREctus sheath Preperitoneal, “TREPP”; TransInguinal Preperitoneal repair, “TIPP” and Minimal Open PrePeritoneal repair, “MOPP”) have strived to offer the simplicity of the Lichtenstein method while reducing the risk of chronic post-surgical pain. Open approaches have been used safely and effectively for a number of years, but their evidence is limited, and the choice of approach may be based on surgeon experience [5]. Due to difficulties in conducting an RCT in surgery, there is often a lack of comparative data to determine the optimal approach. An alternative, albeit with weaker evidence, is to capture the expert opinion of European surgeons regarding aspects of inguinal hernia repair [11].

The aim of this project is to understand the views of surgeons regarding approach to inguinal hernia repair, and determine best practice principles for optimal surgical outcomes.

Following an independent facilitator (Triducive Partners Ltd.)’s review of available literature, a steering group of European surgeons experienced in inguinal hernia repair (see Author list) convened in December 2022 to discuss surgical methods employed in inguinal hernia repair. The steering group was selected based on published research and experience in inguinal hernia surgery.

This project was funded by BD Medical Ltd. by supporting the costs of the methodological process, which was performed by Triducive Partners Ltd. Ian Walker and Tim Warren are employees of Triducive Partners Ltd. and acted as facilitators during the expert group discussions to identify key topics and to generate the consensus statements. The survey distribution was supported by the European Hernia Society (EHS), and Triducive Partners Ltd. performed an independent analysis of the results. ¹

Using a modified Delphi methodology (see Figure 1) guided by the independent facilitator, the steering group identified six main domains of focus:

1. Indication and diagnosis

These domains were each discussed by the steering group and 42 statements were initially agreed. The steering group members reviewed the statements independently to remove, add or change any statements. Suggestions were upheld if either they provided more clarity to a statement or were agreed by a simple majority of the group. The resulting 41 statements were then used to develop the final agreed statement set for wider testing. This constituted the first round of the process.

The survey was distributed using a snowball method by the steering group members to inguinal hernia surgeons and professional societies, including the European Hernia Society (EHS), for distribution to their membership. A further review by EHS for accuracy and balance resulted in a finalised set of 43 statements. A consequence of using this approach is that it is not known how many individuals the survey was sent to, and so a response rate cannot be calculated. In October and November 2023, this anonymised survey with these statements was sent out to EHS members. Each online questionnaire response entered an MS-Excel-based program. The results were evaluated as part of a Delphi Consensus (>90% agreement = strong consensus, >75–90% consensus, <75% no consensus).

The survey presented each statement along with a 4-point Likert scale (“strongly disagree,” “tend to disagree,” “tend to agree,” and “strongly agree”) to allow respondents to indicate their corresponding level of agreement. The survey also captured some demographic data for further analysis. Demographic data captured included surgical speciality, country, time in a professional role, and general experience with open pre-peritoneal inguinal hernia repair (and specifically familiarity with open new, simplified, totally extraperitoneal (ONSTEP) technique). All responses collected from respondents based in Europe were included in the final analysis.

Stopping criteria were established as the minimum target of 150 responses in Round 2, with 90% of statements passing the threshold for consensus and a threshold for consensus set at 75% (a widely accepted threshold [12]). Consensus was then further defined as “strong” at ≥75% and “very strong” at ≥90%. If these criteria were not met, the steering group had the opportunity to modify those statements that fell below the threshold for consensus and reissue them for subsequent rounds of the survey.

A statement of consent was included at the start of the survey and consent was implied by completion and submission of the survey. As this study only collected the anonymous opinions of surgeons and no patient specific data was captured, ethical approval was not sought.

Completed surveys were collated and analysed by the independent facilitator to produce an arithmetic agreement score for each statement. This information was then reviewed by the members of the steering group to determine what recommendations and conclusions could be developed based on the responses received.

During the first round of consensus testing with the members of the steering group, the initial set of 42 statements was critically reviewed to determine the final set of statements for broader testing. From this first round, one statement was removed, 18 statements were modified and agreed upon, no new statements were included, and 23 statements were agreed upon for inclusion without modification, producing a final set of 41 statements for testing with a broader panel of experts. Distribution by EHS was pursuant to an additional review for balance and accuracy. This review resulted in the addition of two statements and further modification of 10 existing statements, which the steering group agreed upon, resulting in a final set of 43 statements.

221 (180 + 41) surgeons responded after the first, second and third rounds of the survey.

Surgeons from 37 countries worldwide took part in this survey.

The second round of testing comprised the broader body of European inguinal hernia surgeons.

Of this second round, 180 responses were collected, of which 18 were from non-European respondents, which were not included in the final results set. Of the 162 responses included in the analysis, 105 were from general surgeons, 26 gastrointestinal surgeons, 15 abdominal wall surgeons, 14 hernia surgeons and 2 colorectal surgeons. Responses were received from 27 European countries, the largest responder groups being Portugal (n = 44), Germany (n = 27), Italy (n = 19), France (n = 17), and Spain (n = 14); all other country responses were ≤5.

Results from Round 2 showed very strong agreement (≥90%) in 13/43 (30%) statements, strong agreement (<90% and ≥75%) in 16/43 (37%) statements and failure to achieve consensus agreement threshold in 14/43 (33%) statements. Of those that failed to achieve consensus, five statements were removed, seven were reworded, and it was agreed that the remaining two would be reported but not revised. Seven statements were retested with the more comprehensive panel in Round 3.

The final results from Rounds 2 and 3 show consensus agreement for 31 of the 38 remaining statements (of which 13 achieved ≥90% agreement), consensus agreement was not achieved for 7/38 statements (n = 202), results are shown in Table 1 and Figure 2.

Based on the results obtained during the survey phase of this study and the following discussion held by the steering group, the authors offer the following set of recommendations:

1. A Tailored Approach to groin hernia surgery should include endoscopic and open techniques with and without mesh. The decision as to which technique is optimal for the patient should always be made individually, depending on the hernia and the patient’s characteristics.

The acceptance of open preperitoneal procedures depends primarily on surgical expertise.

The advantages of open preperitoneal techniques lie primarily in the concept of intraoperative tailoring and in the selection of anaesthesia procedures up to and including implementation under local anaesthesia. In expert hands, there could also be advantages in terms of operating time, return to everyday activities and the occurrence of chronic pain.

Training plays a decisive role in this.