Abstract
Introduction
The main risk factors for inguinal hernia are male sex and increasing age. Complications of inguinal hernia include strangulation, intestinal obstruction, and infarction. Recurrence can occur after surgery.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of elective treatments for primary unilateral, primary bilateral, and recurrent inguinal hernia in adults? We searched: Medline, Embase, The Cochrane Library, and other important databases up to September 2007 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations, such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 24 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: expectant management, open mesh repair, open suture repair, totally extraperitoneal (TEP) laparoscopic repair, and transabdominal preperitoneal (TAPP) laparoscopic repair.
Key Points
The main risk factors for inguinal hernia are male sex and increasing age.
Complications of inguinal hernia include strangulation, intestinal obstruction, and infarction. Recurrence can occur after surgery.
The consensus is that surgery is the treatment of choice for inguinal hernia, although few good-quality studies have compared surgery with expectant management.
Open suture repair is a well-established surgical treatment for people with unilateral inguinal hernia, but seems less effective at preventing recurrence, and prolongs recovery, compared with other techniques.
Open mesh repair reduces the risk of recurrence compared with open suture repair, without increasing the rate of surgical complications.
Totally extraperitoneal (TEP) laparoscopic repair may lead to less pain, faster recovery, and similar recurrence rates compared with open mesh repair, but studies have given inconclusive results.
Transabdominal preperitoneal (TAPP) laparoscopic repair reduces pain and speeds up recovery compared with open mesh repair, but both procedures have similar recurrence rates.
Open suture repair may be associated with longer recovery times compared with open mesh repair or TAPP laparoscopic repair in people with bilateral inguinal hernia.
Open mesh repair seems as effective as TEP laparoscopic repair, but may prolong recovery and increase complication rates compared with TAPP laparoscopic repair.
Open suture repair may be associated with an increased recovery time compared with open mesh repair in people with recurrent inguinal hernia.
About this condition
Definition
Inguinal hernia is an out-pouching of the peritoneum, with or without its contents, which occurs through the muscles of the anterior abdominal wall at the level of the inguinal canal in the groin. It almost always occurs in men because of the inherent weakness of the abdominal wall where the spermatic cord passes through the inguinal canal. A portion of bowel may become caught in the peritoneal pouch and present as a lump in the groin. The hernia may extend into the scrotum and can cause discomfort or ache. Primary hernias relate to the first presentation of a hernia, and are distinct from recurrent hernias. A hernia is described as reducible if it occurs intermittently (e.g., on straining or standing) and can be pushed back into the abdominal cavity, or irreducible if it remains permanently outside the abdominal cavity. Inguinal hernia is usually a long-standing condition and the diagnosis is made clinically, on the basis of these typical symptoms and signs. The condition may occur in one groin (unilateral hernia) or both groins simultaneously (bilateral hernia), and may recur after treatment (recurrent hernia). Inguinal hernias are frequently classified as direct or indirect, depending on whether the hernia sac bulges directly through the posterior wall of the inguinal canal (direct hernia), or whether it passes through the internal inguinal ring alongside the spermatic cord and follows the course of the inguinal canal (indirect hernia). Occasionally, hernia may present acutely because of complications (see prognosis). Clinical experience and consensus suggest that surgical intervention is an effective treatment for inguinal hernia. However, surgery is associated with complications (see outcomes). Therefore, much of this review examines the relative effectiveness and safety of different surgical techniques. None of the studies that we identified distinguished between direct and indirect types of inguinal hernia. Identified studies gave little detail about the severity of hernia among included participants. In general, studies explicitly excluded people with irreducible or complicated hernia, large hernia (extending into the scrotum), or serious comorbidity, and those at high surgical risk (e.g., because of coagulation disorders). In this review, we deal only with non-acute uncomplicated inguinal hernias in adults.
Incidence/ Prevalence
Inguinal hernia is usually repaired surgically in resource-rich countries. Therefore, surgical audit data provide reasonable estimates of incidence. We found one nationally mandated guideline, which reported that in 2001–2002 there were about 70,000 inguinal hernia surgeries performed in England, involving 0.14% of the population, and requiring over 100,000 NHS hospital-bed days. Of these procedures, 62,969 were for the repair of primary hernias and 4939 were for the repair of recurrent hernias. A similar number of inguinal hernia repairs were undertaken in public healthcare settings in England in 2002–2003. In the USA, estimates based on cross-sectional data suggest that about 700,000 inguinal hernia repairs were undertaken in 1993. A national survey of general practices, covering about 1% of the population of England and Wales in 1991–1992, found that about 95% of people presenting to primary-care settings with inguinal hernia were male. It found that the incidence rose from about 11/10,000 person-years in men aged 16 to 24 years to about 200/10,000 person-years in men aged 75 years and over.
Aetiology/ Risk factors
Age and male sex are risk factors. Chronic cough and manual labour involving heavy lifting are conventionally regarded as risk factors because they lead to high intra-abdominal pressure. Obesity has also been suggested as a risk factor.
Prognosis
Strangulation, intestinal obstruction, and infarction are the most important acute complications of untreated hernia, and are potentially life-threatening. National statistics from England found that 5% of primary inguinal hernia repairs were undertaken as emergencies (presumably because of acute complications) in 1998–1999. Older age, longer duration of hernia, and longer duration of irreducibility are thought to be risk factors for acute complications.
Aims of intervention
To prevent recurrence; to alleviate symptoms; to allow return to normal activities; to improve quality of life; to prevent acute hernia complications; to minimise adverse effects of treatment.
Outcomes
Pain (persistent or continuing hernia pain); hernia complications; hospitalisation (hospital stay, operation duration); return to normal activities/work; recurrence; quality of life; adverse effects (seroma; haematoma; numbness; infection; postoperative pain, vascular injury; visceral injury; wound hernia or dehiscence; surgical mortality; and other complications of intervention).
Methods
Clinical Evidence search and appraisal September 2007. The following databases were used to identify studies for this systematic review: Medline 1966 to September 2007, Embase 1980 to September 2007, and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials 2007, Issue 3. Additional searches were carried out using these websites: NHS Centre for Reviews and Dissemination (CRD) — for Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA) — and NICE. We also searched for retractions of studies included in the review. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the contributor for additional assessment, using predetermined criteria to identify relevant studies. Study design criteria for inclusion in this review were: published systematic reviews and RCTs in any language; "open", "open-label", or non-blinded studies were included where blinding was impossible; and containing more than 20 individuals of whom more than 80% were followed up. There was no minimum length of follow-up required to include studies. We also did a search for cohort and cross-sectional studies relating to "expectant management". In addition, we use a regular surveillance protocol to capture harms alerts from organisations such as the FDA and the MHRA, which are added to the reviews as required. To aid readability of the numerical data in our reviews, we round many percentages to the nearest whole number. Readers should be aware of this when relating percentages to summary statistics such as RRs and ORs. We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table). The categorisation of the quality of the evidence (high, moderate, low, or very low) reflects the quality of evidence available for our chosen outcomes in our defined populations of interest. These categorisations are not necessarily a reflection of the overall methodological quality of any individual study, because the Clinical Evidence population and outcome of choice may represent only a small subset of the total outcomes reported, and population included, in any individual trial. For further details of how we perform the GRADE evaluation and the scoring system we use, please see our website (www.clinicalevidence.com).
Table.
GRADE Evaluation of interventions for Inguinal hernia.
| Important outcomes | Adverse effects, Hernia complications, Hospitalisation, Pain, Quality of life, Recurrence, Return to normal activities/work | ||||||||
| Studies (Participants) | Outcome | Comparison | Type of evidence | Quality | Consistency | Directness | Effect size | GRADE | Comment |
| What are the effects of elective treatments for primary unilateral inguinal hernia in adults? | |||||||||
| 2 (880) | Pain | Open mesh repair versus expectant management (in people with minimally symptomatic hernia) | 4 | –1 | 0 | –2 | 0 | Very low | Quality point deducted for subsequent crossover between groups. Directness points deducted for restricted population and inclusion of people with recurrent hernia |
| 1 (720) | Hernia complications | Open mesh repair versus expectant management (in people with minimally symptomatic hernia) | 4 | –1 | 0 | –2 | 0 | Very low | Quality point deducted for subsequent crossover between groups. Directness points deducted for restricted population and inclusion of people with recurrent hernia |
| 2 (880) | Quality of life | Open mesh repair versus expectant management (in people with minimally symptomatic hernia) | 4 | –1 | –1 | –2 | 0 | Very low | Quality point deducted for subsequent crossover between groups. Consistency point deducted for conflicting results. Directness points deducted for restricted population and inclusion of people with recurrent hernia |
| 9 (2393) | Pain | Open mesh repair versus open suture repair | 4 | 0 | –1 | –1 | 0 | Low | Consistency point deducted for heterogeneity between RCTs. Directness point deducted for inclusion of people other than with primary unilateral hernia |
| 19 (4035) | Hospitalisation | Open mesh repair versus open suture repair | 4 | 0 | –1 | –2 | 0 | Very low | Consistency point deducted for heterogeneity between studies. Directness points deducted for uncertainty about clinical relevance of improvement and for inclusion of people other than with primary unilateral hernia |
| 11 (1681) | Return to normal activities/work | Open mesh repair versus open suture repair | 4 | 0 | –1 | –2 | 0 | Very low | Consistency point deducted for heterogeneity between studies. Directness points deducted for uncertainty about clinical relevance of improvement and for inclusion of people other than with primary unilateral hernia |
| 22 (5120) | Recurrence | Open mesh repair versus open suture repair | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results. Directness point deducted for inclusion of people other than with primary unilateral hernia |
| at least 20 (at least 4198) | Adverse effects | Open mesh repair versus open suture repair | 4 | –1 | 0 | –1 | 0 | Low | Quality point deducted for incomplete reporting of results. Directness point deducted for inclusion of people other than with primary unilateral hernia |
| 3 (759) | Pain | TEP laparoscopic repair versus open suture repair | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for incomplete reporting of results. Consistency point deducted for different results at different endpoints |
| 5 (1582) | Hospitalisation | TEP laparoscopic repair versus open suture repair | 4 | 0 | 0 | –2 | 0 | Low | Directness points deducted for uncertainty about clinical relevance of result and for inclusion of people with recurrent and bilateral inguinal hernia and femoral hernia |
| 1 (94) | Return to normal activities/work | TEP laparoscopic repair versus open suture repair | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 6 (1763) | Recurrence | TEP laparoscopic repair versus open suture repair | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| at least 4 (at least 1598) | Adverse effects | TEP laparoscopic repair versus open suture repair | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 5 (2362) | Pain | TEP laparoscopic repair versus open mesh repair | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 11 (less than 2787) | Hospitalisation | TEP laparoscopic repair versus open mesh repair | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for methodological weakness in meta-analysis. Consistency point deducted for different results for different outcome measures |
| 10 (less than 2413) | Return to normal activities/work | TEP laparoscopic repair versus open mesh repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for methodological weaknesses in meta-analysis and no direct statistical comparison between groups |
| 16 (less than 3586) | Recurrence | TEP laparoscopic repair versus open mesh repair | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| at least 12 (at least 3243) | Adverse effects | TEP laparoscopic repair versus open mesh repair | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 2 (less than 118) | Hospitalisation | TEP laparoscopic repair versus TAPP laparoscopic repair | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, no statistical analysis between groups, and incomplete reporting of results |
| 1 (less than 66) | Return to normal activities/work | TEP laparoscopic repair versus TAPP laparoscopic repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (52) | Recurrence | TEP laparoscopic repair versus TAPP laparoscopic repair | 4 | –2 | 0 | 0 | 0 | Low | Quality point deducted for sparse data and incomplete reporting of results |
| 8 (1233) | Pain | TAPP laparoscopic repair versus open suture repair | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 13 (at least 1586) | Hospitalisation | TAPP laparoscopic repair versus open suture repair | 4 | –2 | –1 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results and uncertainty about clinical relevance of improvement. Consistency point deducted for heterogeneity between RCTs |
| 8 (1770) | Return to normal activities/work | TAPP laparoscopic repair versus open suture repair | 4 | –2 | –1 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results and uncertainty about clinical relevance of improvement. Consistency point deducted for heterogeneity between RCTs |
| 19 (less than 3757) | Recurrence | TAPP laparoscopic repair versus open suture repair | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for incomplete reporting. Consistency point deducted for conflicting results |
| 8 (1550) | Pain | TAPP laparoscopic repair versus open mesh repair | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 2 (less than 116) | Hospitalisation | TAPP laparoscopic repair versus open mesh repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting |
| 9 (less than 1091) | Return to normal activities/work | TAPP laparoscopic repair versus open mesh repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for incomplete reporting and statistical uncertainty of result on sensitivity analysis |
| 17 (less than 2444) | Recurrence | TAPP laparoscopic repair versus open mesh repair | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting |
| at least 15 (at least 1902) | Adverse effects | TAPP laparoscopic repair versus open mesh repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for incomplete reporting and statistical uncertainty of result on sensitivity analysis |
| What are the effects of elective treatments for primary bilateral inguinal hernia in adults? | |||||||||
| 2 (46) | Hospitalisation | Open mesh repair versus open suture repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 2 (46) | Recurrence | Open mesh repair versus open suture repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 2 (74) | Pain | TEP laparoscopic repair versus open mesh repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 3 (73) | Return to normal activities/work | TEP laparoscopic repair versus open mesh repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 3 (110) | Recurrence | TEP laparoscopic repair versus open mesh repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 3 (86) | Pain | TAPP laparoscopic repair versus open mesh repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 6 (107) | Hospitalisation | TAPP laparoscopic repair versus open mesh repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 6 (87) | Return to normal activities/work | TAPP laparoscopic repair versus open mesh repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 7 (152) | Recurrence | TAPP laparoscopic repair versus open mesh repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 6 (140) | Adverse effects | TAPP laparoscopic repair versus open mesh repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 2 (63) | Pain | TAPP laparoscopic repair versus open suture repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 4 (97) | Hospitalisation | TAPP laparoscopic repair versus open suture repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 3 (59) | Return to normal activities/work | TAPP laparoscopic repair versus open suture repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| at least 4 (at least 97) | Adverse effects | TAPP laparoscopic repair versus open suture repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| What are the effects of elective treatments for recurrent inguinal hernia in adults? | |||||||||
| 2 (49) | Pain | Open mesh repair versus open suture repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 2 (59) | Hospitalisation | Open mesh repair versus open suture repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 2 (33) | Return to normal activities/work | Open mesh repair versus open suture repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 2 (59) | Recurrence | Open mesh repair versus open suture repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 2 (122) | Pain | TEP laparoscopic repair versus open mesh repair | 4 | –2 | –1 | 0 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Consistency point deducted for conflicting results |
| 3 (less than 170) | Hospitalisation | TEP laparoscopic repair versus open mesh repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 4 (less than 179) | Return to normal activities/work | TEP laparoscopic repair versus open mesh repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 3 (185) | Recurrence | TEP laparoscopic repair versus open mesh repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 3 (at least 175) | Adverse effects | TEP laparoscopic repair versus open mesh repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 5 (311) | Pain | TAPP laparoscopic repair versus open mesh repair | 4 | –1 | –1 | 0 | 0 | Low | Quality point deducted for incomplete reporting. Consistency point deducted for conflicting results |
| 7 (less than 280) | Hospitalisation | TAPP laparoscopic repair versus open mesh repair | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting |
| 8 (less than 350) | Return to normal activities/work | TAPP laparoscopic repair versus open mesh repair | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting |
| 8 (402) | Recurrence | TAPP laparoscopic repair versus open mesh repair | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 2 (53) | Pain | TAPP laparoscopic repair versus open suture repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 4 (92) | Hospitalisation | TAPP laparoscopic repair versus open suture repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 3 (57) | Return to normal activities/work | TAPP laparoscopic repair versus open suture repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 4 (93) | Recurrence | TAPP laparoscopic repair versus open suture repair | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
We initially allocate 4 points to evidence from RCTs, and 2 points to evidence from observational studies. To attain the final GRADE score for a given comparison, points are deducted or added from this initial score based on preset criteria relating to the categories of quality, directness, consistency, and effect size. Quality: based on issues affecting methodological rigour (e.g., incomplete reporting of results, quasi-randomisation, sparse data [<200 people in the analysis]). Consistency: based on similarity of results across studies. Directness: based on generalisability of population or outcomes. Effect size: based on magnitude of effect as measured by statistics such as relative risk, odds ratio, or hazard ratio.
Glossary
- Expectant management
A policy of no active intervention.
- Low-quality evidence
Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
- Moderate-quality evidence
Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
- Open mesh repair
An open operation in which a synthetic mesh is inserted across the posterior wall of the inguinal canal to repair the weakness in the muscles and fascia through which the hernia sac has protruded. Variants include the Lichtenstein and Stoppa procedures. The technique may be performed under local or regional anaesthetic.
- Open suture repair
An open operation using sutures to repair the weakness in the muscles and fascia through which the hernia sac has protruded. There are many variants of the technique (e.g., Bassini, McVay, Maloney, and Shouldice procedures). The technique is commonly performed under local or regional anaesthetic.
- Short Form 36 (SF-36)
A scale that assesses health-related quality of life across eight domains: limitations in physical activities (physical component); limitations in social activities; limitations in usual role activities due to physical problems; pain; psychological distress and wellbeing (mental health component); limitations in usual role activities because of emotional problems; energy and fatigue; and general health perceptions.
- Totally extraperitoneal (TEP) laparoscopic repair
An operation that uses mesh to repair the weakness in the muscles and fascia through which the hernia sac has protruded. This technique does not involve entering the peritoneum with the laparoscope (compare transabdominal preperitoneal [TAPP] laparoscopic repair). The technique is usually performed under general anaesthetic.
- Transabdominal preperitoneal (TAPP) laparoscopic repair
An operation that uses mesh to repair the weakness in the muscles and fascia through which the hernia sac has protruded. This technique involves entering the peritoneum with the laparoscope, although the repair itself (done with a mesh) is undertaken anterior to the peritoneum. The technique is usually performed under general anaesthetic.
- Very low-quality evidence
Any estimate of effect is very uncertain.
Disclaimer
The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients. To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.
Contributor Information
Mr Sanjay Purkayastha, Department of Biosurgery and Surgical Technology, Imperial College, St Mary's Hospital, London, UK.
Mr Andre Chow, Department of Biosurgery and Surgical Technology, Imperial College, St Mary's Hospital, London, UK.
Mr Thanos Athanasiou, Department of Biosurgery and Surgical Technology, Imperial College, St Mary's Hospital, London, UK.
Paris P Tekkis, Royal Marsden and Chelsea and Westminster Hospitals, Imperial College London, UK.
Ara Darzi, Department of Biosurgery and Surgical Technology, Imperial College, St Mary's Hospital, London, UK.
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