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.