Pitfalls in interpretation of large registry data on hernia repair

Major complications and mortality after ventral hernia repair: an eleven-year Swedish nationwide cohort study

BACKGROUND AND AIMS

Ventral hernia repair is one of the most common surgical procedures performed worldwide. Despite the large volume, consensus is lacking regarding indications for repair or choice of surgical method used for reconstruction. The aim of this study was to explore the risk for major complications and mortality in ventral hernia repair using data from a nationwide patient register.

METHOD

Patient data of individuals over 18 years of age who had a ventral hernia procedure between 2004 and 2014 were retrieved from the Patient Register kept by the Swedish National Board of Health and Welfare. After exclusion of patients with concomitant bowel surgery, 45 676 primary surgical admissions were included. Procedures were dichotomised into laparoscopic and open surgery, and stratified for primary and incisional hernias.

RESULTS

A total of 45 676 admissions were analysed. The material comprised 36% (16 670) incisional hernias and 64% (29 006) primary hernias. Women had a higher risk for reoperation during index admission after primary hernia repair (OR 1.84 (1.29-2.62)). Forty-three patients died of complications within 30 days of index surgery. Patients aged 80 years and older had a 2.5 times higher risk for a complication leading to reoperation, and a 12-fold higher mortality risk than patients aged 70-79 years.

CONCLUSION

Age is the dominant mortality risk factor in ventral hernia repair. Laparoscopic surgery was associated with a lower risk for reoperation during index admission. Reoperation seems to be a valid outcome variable, while registration of complications is generally poor in this type of cohort.

Association of Mesh and Fixation Options with Reoperation Risk after Laparoscopic Groin Hernia Surgery: A Swedish Hernia Registry Study of 25,190 Totally Extraperitoneal and Transabdominal Preperitoneal Repairs

BACKGROUND

International guidelines concerning mesh and mesh fixation options in laparoscopic totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) groin hernia repair are based on studies focusing on either mesh or fixation. We hypothesized that the value of such recommendations is limited by lacking knowledge on how mesh and fixation interact. The current registry-based nationwide cohort study compared different mesh/fixation combinations for relative risks for reoperation after TEP and TAPP groin hernia repair.

STUDY DESIGN

All TEP and TAPP registered in the Swedish Hernia Registry 2005 to 2017 with standard polypropylene (StdPPM) or lightweight (LWM) flat mesh, having tack, fibrin glue, or no fixation, were included. The endpoint was reoperation due to recurrence as of December 31, 2018. Multivariable Cox regression rendered relative risk differences between the exposures, expressed as hazard ratios (HR) with 95% CIs.

RESULTS

Of 25,190 repairs, 924 (3.7%) were later reoperated for recurrence. The lowest, mutually equivalent, reoperation risks were associated with StdPPM without fixation (HR 1), StdPPM with metal tacks (HR 0.8, CI 0.4 to 1.4), StdPPM with fibrin glue (HR 1.1, CI 0.7 to 1.6), and LWM with fibrin glue (HR 1.2, CI 0.97 to 1.6). Except for with fibrin glue, LWM correlated with increased risk, whether affixed with metal (HR 1.7, CI 1.1 to 2.7), or absorbable tacks (HR 2.4, CI 1.8 to 3.1), or deployed without fixation (HR 2.0, CI 1.6 to 2.6).

CONCLUSIONS

With StdPPM, neither mechanical nor glue fixation seemed to improve outcomes. Thus, for this mesh category, we recommend nonfixation. With LWM, we recommend fibrin glue fixation, which was the only LWM alternative on par with nonaffixed StdPPM.

Early outcomes of component separation techniques: an analysis of the Spanish registry of incisional Hernia (EVEREG)

AIM

To analyze the outcomes of component separation techniques (CST) to treat incisional hernias (IH) in a large multicenter cohort of patients.

METHODS

All IH repair using CST, registered in EVEREG from July 2012 to December 2019, were included. Data on the pre-operative patient characteristics and comorbidities, IH characteristics, surgical technique, complications, and recurrence were collected. Outcomes between anterior (ACS) and posterior component separation (PCS) techniques were compared. Risk factors for complications and recurrences were analyzed.

RESULTS

During the study period, 1536 patients underwent CST (45.5% females) with a median age of 64.0 years and median body mass index (BMI) of 29.7 kg/m². ACS was the most common technique (77.7%). Overall complications were frequent in both ACS and PCS techniques (36.5%), with a higher frequency of wound infection (10.6% vs. 7.0%; P = 0.05) and skin necrosis (4.4% vs. 0.1%; P < 0.0001) with the ACS technique. Main factors leading to major complications were mesh explant (OR 1.72; P = 0.001), previous repair (OR 0.75; P = 0.038), morbid obesity (OR 0.67; P = 0.015), ASA grade (OR 0.62; P < 0.0001), COPD (OR 0.52; P < 0.0001), and longitudinal diameter larger than 10 cm (OR 0.58; P = 0.001). After a minimum follow-up of 6 months (median 15 months; N = 590), 59 (10.0%) recurrences were diagnosed. Operations performed in a non-specialized unit were significantly associated with recurrences (HR 4.903, CI 1.64-14.65; P = 0.004).

CONCLUSION

CST is a complex procedure with a high rate of complications. Both ACS and PCS techniques have similar complication and recurrence rates. Operations performed in a specialized unit have better outcomes.

Building a national hernia registry in South Africa: initial ventral hernia repair results from a diverse healthcare sector

PURPOSE

The purpose of this paper was to introduce a new registry in a developing country by describing the demographics, management and 30-day outcomes of patients undergoing ventral hernia repair in the public and private healthcare sectors of South Africa.

METHODS

This study was a retrospective review of a prospectively maintained hernia registry from the 1st of February 2019 to 29th of February 2020.

RESULTS

353 ventral hernia repair cases were recorded of which 47% were incisional hernias and the remainder were primary hernias. The median age was 54 years with even distribution of males and females. Half of the patients were obese with a median BMI of 31 kg/m². The private sector performed 190 cases (54%) and the public sector 163 cases (46%). The public sector had more current smokers undergoing elective repairs, 28% vs 15%, p = 0.01 and performed more emergency repair cases, 21% vs 8%, p < 0.01. The majority (89%) of hernias were repaired with mesh and one-third were repaired laparoscopically. 30 day follow up was obtained in 30% of cases, the private sector had better follow up rates (42% vs 14%).

CONCLUSION

Participation in the HIG (SA) registry was low with poor follow up over the first year. Ongoing prospective data capture on the HIG (SA) hernia registry will continue to provide further insights into hernia repair practices in South Africa.

Mesh erosion into urinary bladder, rare condition but important to know

BACKGROUND

Although rare, mesh migration or erosion into viscera has been reported as case report, and most of the cases involved with the urinary bladder. With the increasing use of prosthetic mesh in hernia repair, this severe complication would increase in the future; thus, we feel that it is necessary to analyze the clinical patterns of mesh erosion into the urinary bladder, and to discuss the prevention and treatment of this severe complication.

METHOD

In the present study, we made a thorough identification of all published reports on mesh migration or erosion into the urinary bladder, and the data were summarized, analysed, and discussed.

RESULTS

A total of 23 cases of mesh erosion into urinary bladder were reported since 1994. Among them, two cases were from incisional hernia repairs, and 21 cases were following inguinal hernia repairs. The most frequently reported procedures were TAPP, followed by TEP. The duration from initial hernia repair to the onset of mesh erosion into bladder varied greatly (3 months-20 years), and most of cases occurred in 1-5 years after the initial hernia repair (10/23, 43.5%), while a certain number of cases occurred 10 years after hernia repair (6/23, 26.1%). Most of these cases were treated with mesh removal via a open procedure (12/22, 54.5%), and in 7 cases (7/22, 31.8%), the partial cystectomy was performed as well as mesh removal. Laparoscopic or robotic treatment procedures were performed in three cases.

CONCLUSION

Mesh erosion into the urinary bladder can occur after both open and laparoscopic inguinal hernia repairs in a wide range of duration. This complication most frequently happened following laparoscopic inguinal hernia repair. It was usually treated with partial or complete mesh removal, with or without partial cystectomy. A registry system is necessary for monitoring this complication.