Reoperation as surrogate endpoint in hernia surgery. A three year follow-up of 1565 herniorrhaphies

Reoperation for Recurrence After Groin Hernia Repair in Adolescents: A Nationwide Register-Based Cohort Study

BACKGROUND

Although mesh-based repairs are used in adults to reduce the risk of recurrence, their necessity in adolescents remains debated. Nonmesh repairs are often preferred in younger patients to avoid potential long-term complications, but data on recurrence rates in this age group are limited. We aimed to assess the rate of reoperation for recurrence following primary groin hernia repair in adolescents aged 10-19 years.

METHODS

This was a register-based cohort study covering three decades (1992-2022), utilizing data from the Danish National Patient Register linked to data from the Danish Civil Registration System, ensuring comprehensive nationwide coverage and complete follow-up. The cumulative rate of reoperation for recurrence was estimated at 10 years of follow-up. Cox proportional hazards regression analysis was used to compare the risk of reoperation for recurrence between mesh and nonmesh repairs. Outcomes included reoperation for recurrence, readmission, and mortality.

RESULTS

Among the 2404 included groins, most were male (80%), and the median age was 16 (IQR, 12-19) years. Most (99%) groin hernias were inguinal, and few (1%) were femoral. Of the inguinal repairs, 35% were mesh, 64% were nonmesh, and 1% were unspecified repairs. The follow-up time was median 16 (IQR, 9-21) years. The cumulative rate of reoperation for recurrence across all inguinal repairs was 3.8% (95% CI, 3.0-4.9) after 10 years of follow-up. For older adolescents aged 15-19 years, the cumulative rate of reoperation for recurrence after mesh and nonmesh repair was 2.7% (95% CI, 1.6-4.6) and 4.1% (95% CI, 2.6-6.7), respectively. Nonmesh repair had a higher adjusted hazard ratio of reoperation for recurrence compared with mesh repair (adjusted hazard ratio, 2.11; 95% CI, 1.05-4.23). For femoral repairs, most (67% [18/27]) were open nonmesh repairs, and few were reoperated for recurrence.

CONCLUSION

The cumulative rate of reoperation for recurrence was low in adolescents. These findings suggest that nonmesh repair may be sufficient for primary groin hernia repair in adolescents, potentially avoiding the need for mesh implantation.

Surgical unit volume and reoperation for recurrence following total extraperitoneal groin hernia repairs: nationwide population-based register study

BACKGROUND

The quality of total extraperitoneal groin hernia repair and recurrence rates are influenced by various factors, potentially including the annual surgical unit volume of repairs. The precise nature of this relationship remains unclear. The aim of this study was to investigate the influence of surgical unit volume on reoperation rates for recurrence following total extraperitoneal groin hernia repair.

METHODS

This observational nationwide population-based study utilized prospectively collected data from the Swedish Hernia Register. Patients aged 15 years old or older who underwent a total extraperitoneal groin hernia repair from 1 January 2015 to 31 August 2019 were eligible. Follow-up time was until 31 August 2022. Surgical units were grouped into low-volume (fewer than 12 repairs per year), low-medium-volume (12-50 repairs per year), medium-high-volume (greater than 50-150 repairs per year), and high-volume (greater than 150 repairs per year) units. The primary outcome was reoperation for recurrence. The secondary outcome was postoperative complications.

RESULTS

A total of 20 656 elective total extraperitoneal groin hernia repairs were included across 75 surgical units. The reoperation rate for recurrence was higher in all three lower-volume groups (low-volume, 5.3%; low-medium-volume, 3.8%; and medium-high-volume, 3.5%) compared with the high-volume group (2.9%). Adjusted multivariable Cox regression analysis revealed a statistically significant increased HR for reoperation for recurrence in the low-volume group (1.87 (95% c.i. 1.31 to 2.67)) and the low-medium-volume group (1.32 (95% c.i. 1.07 to 1.62)) compared with the high-volume group. No difference was seen between the groups regarding the risk of postoperative complications.

CONCLUSION

The risk of reoperation for recurrence following total extraperitoneal groin hernia repair is significantly increased in surgical units that perform fewer than 51 repairs per year. The findings may influence guidelines on required annual surgical unit volume to improve patient outcomes following total extraperitoneal groin hernia repair.

Temporal patterns for inguinal hernia recurrence operations after Shouldice Repair

PURPOSE

Shouldice Repair for inguinal hernias results in a low recurrence rate; however, little is known about the risk factors for these relapses. In the present study, we reviewed all patient's undergoing a reoperation for recurrence after a primary Shouldice Repair.

METHODS

Patients undergoing recurrent inguinal hernia repair from 2013 to 2017 were identified. The subgroup of patients with the first recurrence after a Shouldice Repair at this institution was selected and included. Data collection from the index and the reoperation surgery were performed, as well as statistical analysis.

RESULTS

A total of 125 patients were included in the analysis. The mean age was 50.8 ± 13.9 (body mass index: 24.6 ± 2.6 kg/m2), 97% were male. The most common interval for a recurrence reoperation was in the first 5 years following the initial surgery (37.6% of patients; mode: 1 year; median: 7 years; mean: 13.7 ± 13.8 years). A temporal median pattern for recurrence reoperation according to age interval was noted (patients < 41 years old: 20 years; patients aged 41-60 years old: 10 years and patients > 61 years: 2 years)).

CONCLUSION

Patients undergoing reoperations for recurrent inguinal hernias after a primary Shouldice Repair presented a pattern of temporal recurrence according to age. Older patients present with earlier recurrences than younger ones, an important consideration in the assessment of patients postoperatively.

Epidemiology and surgical management of 184 obturator hernias: a nationwide registry-based cohort study

PURPOSE

We aimed describe the patient characteristics, surgical details, postoperative outcomes, and prevalence and incidence of obturator hernias. Obturator hernias are rare with high mortality and no consensus on the best surgical approach. Given their rarity, substantial data is lacking, especially related to postoperative outcomes.

METHODS

The study was based on data from the nationwide Danish Hernia Database. All adults who underwent obturator hernia surgery in Denmark during 1998-2023 were included. The primary outcomes were demographic characteristics, surgical details, postoperative outcomes, and the prevalence and incidence of obturator hernias.

RESULTS

We included 184 obturator hernias in 167 patients (88% females) with a median age of 77 years. Emergency surgeries constituted 42% of repairs, and 72% were laparoscopic. Mesh was used in 77% of the repairs, with sutures exclusively used in emergency repairs. Concurrent groin hernias were found in 57% of cases. Emergency surgeries had a 30-day mortality of 14%, readmission rate of 21%, and median length of stay of 6 days. Elective surgeries had a 30-day mortality of 0%, readmission rate of 10%, and median length of stay of 0 days. The prevalence of obturator hernias in hernia surgery was 0.084% (95% CI: 0.071%-0.098%), with an incidence of one per 400,000 inhabitants annually.

CONCLUSIONS

This was the largest cohort study to date on obturator hernias. They were rare, affected primarily elderly women. The method of repair depends on whether the presentation is acute, and emergency repair is associated with higher mortality.

Low incidence of recurrence and chronic pain after groin hernia repair in adolescents: a systematic review and meta-analysis

PURPOSE

The best operative management of groin hernia in adolescents is uncertain. The aim of this systematic review was to assess recurrence and chronic pain after mesh versus non-mesh repair for groin hernia in adolescents.

METHODS

A systematic search was done in PubMed, EMBASE, and Cochrane CENTRAL in May 2022 for studies reporting postoperative chronic pain (≥6 months) or recurrence after groin hernia repair in adolescents aged 10-17 years. We included randomized controlled trials and observational studies on primary unilateral or bilateral groin hernia repair. Risk of bias was assessed with the Cochrane risk-of-bias tool and Newcastle-Ottawa Scale. Meta-analysis of the incidence of recurrence was conducted. This review is reported according to PRISMA guideline.

RESULTS

A total of 21 studies including 3,816 adolescents with groin hernias were included comprising two randomized controlled trials, six prospective, and 13 retrospective cohort studies. For non-mesh repairs, the weighted mean incidence proportion of recurrence was 1.6% (95% CI 0.6-2.5) after 2,167 open repairs and 1.9% (95% CI 1.1-2.8) after 1,033 laparoscopic repairs. For mesh repairs, it was 0.6% (95% CI 0.0-1.4) after 406 open repairs while there were no recurrences after 347 laparoscopic repairs (95% CI 0.0-0.6). Across all surgical techniques, the rate of chronic pain after 1,153 repairs ranged from 0 to 11%. Follow-up time varied and was reported in various ways.

CONCLUSION

The incidences of recurrence after groin hernia repair in adolescents were low for both open and laparoscopic mesh and non-mesh repairs. Rates of postoperative chronic pain were low.

TRIAL REGISTRATION

PROSPERO: CRD42022130554.

Postoperative outcomes that matter to patients undergoing inguinal hernia repair: A qualitative study

Background

The purpose was to explore which postoperative outcomes are important to patients operated for inguinal hernia to gain a better insight into the patient experience going through surgery.

Methods

A qualitative study was performed using semistructured individual interviews. Participants were all male and had undergone inguinal hernia repair. Data were analyzed with directed content analysis.

Results

Ten patients were interviewed. Identified domains were function, sensation, expectations, appearance, social aspects, and satisfaction with surgeon/staff. Preoperative functional limitations were the main motivation for seeking surgery, and postoperative functional improvement seemed to be the most important factor determining overall patient satisfaction.

Conclusion

Patients consider a wide range of factors when assessing the outcome of their inguinal hernia repair. Our results suggest that the current practice of outcome assessment of inguinal hernia repair with focus on recurrence may be too narrow and may not adequately reflect the patients' experience.

Summary

This qualitative study explored patients' perspectives on postoperative outcome after inguinal hernia repair, and the identified domains of importance were function, sensation, expectations, appearance, social aspects, and satisfaction with surgeon/staff. These results highlight that patients emphasize a wide range of elements when assessing the outcome of their inguinal hernia repair that are important to acknowledge, as current practice of outcome assessment of inguinal hernia repair may be too narrow.

Five year trends in surgical technique and outcomes of groin hernia repair in the United States

INTRODUCTION

Despite being one of the most commonly performed operations in the US, there is a paucity of data on practice patterns and resultant long-term outcomes of groin hernia repair. In this context, we performed a contemporary assessment of operative approach with 5 year follow-up to inform care for the 800000 persons undergoing groin hernia repair annually.

METHODS

This was a retrospective cohort study of adult patients undergoing elective groin hernia repair in a 20% representative Medicare sample from 2010-17. Surgical approach [minimally invasive (MIS) vs open] was defined using appropriate CPT codes. The primary outcome was operative recurrence at up to 5 years following surgery. We estimated the overall risk of operative recurrence using a multivariable Cox proportional hazards model.

RESULTS

Among 118119 patients, the majority (76.4%) underwent an open repair. Compared to patients who underwent MIS repair, patients in the open surgery cohort were older (mean age 72.7 vs 71.0, p < 0.001), more often female (14.4 vs 10.9%, p < 0.001), less often white (86.9 vs 87.7%, p < 0.001), and had a higher prevalence of nearly all measured comorbidities Patients in the open cohort had a lower incidence of operative recurrence at 1-year (1.0 vs 1.5%, p < 0.001), 3-years, (2.5 vs 3.5%, p < 0.001), and 5-years (3.7 vs 4.7%, p < 0.001). In the Cox proportional hazards model, we found that patients who underwent an open groin hernia repair were significantly less likely to experience operative recurrence (HR 0.86, 95% CI 0.79-0.93).

CONCLUSIONS

In this study, we found that open groin hernia repair was associated with a lower risk of operative recurrence over time. While this may be related to patient comorbidity and age at the index operation, future work should focus on the impact of surgeon volume on outcomes in the modern era.

Lichtenstein and Total Extraperitoneal Techniques in Inguinal Hernia Surgery: A Comparison of the Intraoperative and Early Postoperative Complications Between the Two Approaches

Background and objective

The Lichtenstein technique (LSt) and total extraperitoneal technique (TEPt) are the most frequently performed surgical procedures for inguinal hernia (IH). This study aimed to compare LSt and TEPt in terms of intraoperative and postoperative complications as well as recurrence rates.

Methods

This retrospective study involved patients hospitalized for IH repair. The study included a total of 262 patients (LSt group: n=125; TEPt group: n=137). 

Results

The follow-up period of the patients ranged between 16 and 30 months (mean: 22.3 months). While intraoperative complications were more commonly reported in the TEPt group, postoperative complications were more common in the LSt group (2.9% vs. 1.6%). Postoperative bleeding/hematoma developed in three (2.4%) patients in the LSt and three (2.2%) in the TEPt group. One of the patients in the LSt group was reoperated due to persistent bleeding. Two patients in the LSt and two in the TEPt group were reoperated for postoperative recurrence (1.6% vs. 2.4%). One patient was reoperated due to chronic persistent pain. Seroma was aspirated in three (2.4%) patients in the LSt and two (1.5%) in the TEPt group.

Conclusion

This study revealed no significant difference between TEPt and LSt groups regarding intraoperative and postoperative complications. We propose that both TEPt and LSt could be safely performed in cases of primary and complex IH by selecting the appropriate method based on the hernia type and patient and with sufficient surgical experience.

Inguinal hernia repairs performed for recurrence in Spain: population-based study of 16 years and 1,302,788 patients

PURPOSE

The objective of this study was to assess data on inguinal hernia repairs (IHR) performed for recurrence over a 16 year period (2004-2019) in Spain.

METHODS

A retrospective cohort study of 1,302,788 patients who underwent IHR from January 2004 to December 2019 was conducted. Data were extracted from the Spanish Minimum Basic Data Set (MBDS) of the Health Ministry database. The primary objective was to analyse the proportion of IHR performed by recurrence. As secondary objectives, we evaluated factors related to recurrent hernia (analysed by univariate analysis and multivariable logistic regression analysis) and trends in the recurrent case rate over the 16 year period.

RESULTS

We identified 95,025 patients (7.3% of all IHR) who underwent surgery for recurrent inguinal hernia. Patients undergoing recurrent IHR were more likely to be male (OR 1.687, 95% CI 1.645-1.730), elderly (age > 74 years), and more complicated when they arrived in the operating room (gangrene OR 3.951, 95% CI 3.734-4.180; occlusion OR 1.905, 95% CI 1.853-1.960), and thus had more surgical site occurrences and related mortality. The proportion of IHR performed for recurrence has been dropping over the years (8.7% in 2004 vs. 6.5% in 2019, p < 0.005).

CONCLUSION

The rate of recurrent IHR in Spain (2004-2019) is 7.3%. Recurrent IHR correlates to emergent and complicated surgery and thus to a worst outcome. The trend of this 16 year period is of decreasing operated recurrent inguinal hernia. This is good news even though the improvement is slight and certainly insufficient. Establishing and optimising the rate of hernia recurrence is important for patients and for the health-care system.

Impact of Trainee Participation on Inguinal Hernia Repair Outcome: A Study Based on the Swedish Hernia Register

OBJECTIVE

The aim of this study was to investigate whether differences in postoperative outcome exist between open inguinal hernia repairs performed by surgical trainees and those performed by specialist surgeons.

SUMMARY OF BACKGROUND DATA

Inguinal hernia repair is the prototype educational surgical procedure. The impact of trainee participation on postoperative outcome is still controversial and despite earlier studies no reliable hernia-specific data exist.

METHODS

The study cohort was based on the Swedish Hernia Register and consisted of 61,161 cases of male patients aged 18 years and older with open anterior mesh repair of a primary inguinal hernia between January 1, 2002, and December 31, 2014. The study cohort was selected to represent the typical trainee procedure in Sweden. Primary outcome measures were reoperation due to hernia recurrence and postoperative 30-day complications.

RESULTS

Procedures with longer operating times were at a higher risk for reoperation when performed by supervised trainees [57 to 72 minutes: hazard ratio (HR) 1.55, 99% confidence interval (99% CI) 1.05-2.27] or unsupervised trainees (57 to 72 minutes: HR 1.60, 99% CI 1.18-2.17; >72 minutes: HR 1.72, 99% CI 1.25-2.37). The same was true for specialist and trainee-assisted specialists with operating times <43 minutes (HR 1.63, 99% CI 1.25-2.13; HR 1.58, 99% CI 1.09-2.28). Postoperative 30-day complications were generally associated with longer operating times and occurred at all levels of experience.

CONCLUSION

Trainee participation in open inguinal repair in combination with longer operating time is a risk factor associated with higher reoperation rates. This calls for a more structured supervision of trainees in an assumedly basic procedure.

Mesh repair for lateral inguinal hernias: a non-evidence-based practice

INTRODUCTION

The EHS clinical guidelines recommend the use of mesh to repair symptomatic primary inguinal hernias (PIH) in adult males but, in spite of this, it begs the question as to why there is still place for tissue techniques. Lack of stratification of patients according to risk of recurrence in RCTs might be a cause of results disparity, since medial and mixed are hernias with higher risk of recurrence (HRRH), whereas lateral hernias present a lower risk (LRRH).

OBJECTIVE

To determine whether the lack of stratification may lead to questionable conclusions regarding the protective effect of mesh techniques and to identify other methodological flaws.

METHODS

In the RCTs included in the clinical guidelines that addressed recurrences of PIH after mesh and non-mesh techniques, we assessed the type of hernias classification used, the number needed to treat in LRRH and HRRH and the statistical power.

RESULTS

Most of trials were underpowered; five studies classified the hernia types; in the three studies that compared the recurrence rates of LRRH and HRRH the effect of mesh techniques was small; only two trials record data needed to calculate the NNT in LRRH (46 y 84 patients, respectively).

CONCLUSION

The idea that mesh techniques reduce the recurrence rate in all PIHs is not supported by high level of evidence. The NNT for pure lateral hernias was very high and should be interpreted taking into account chronic pain rates and costs.

Lower reoperation rates after open and laparoscopic groin hernia repair when performed by high-volume surgeons: a nationwide register-based study

PURPOSE

Previous studies have shown a correlation between surgeons with high annual volume and better outcomes after various surgical procedures. However, the preexisting literature regarding groin hernia repair and annual surgeon volume is limited. The aim was to investigate how annual surgeon volume affected the reoperation rates for recurrence after primary groin hernia repair.

METHODS

This nationwide cohort study was based on data from the Danish Hernia Database and the Danish Patient Safety Authority's Online Register. Patients ≥ 18 years undergoing laparoscopic or Lichtenstein primary groin hernia repair between November 2011 and January 2020 were included. Annual surgeon volume was divided into five categories: ≤ 10, 11-25, 26-50, 51-100, and > 100 cases/year.

RESULTS

We included 25,262 groin hernia repairs performed in 23,088 patients. The risk of reoperation for recurrence after Lichtenstein repair was significantly higher for the volume categories of ≤ 10 (HR 4.02), 11-25 (HR 3.64), 26-50 (HR 3.93), or 51-100 (HR 4.30), compared with the > 100 category. The risk of reoperation for recurrence after laparoscopic repair was significantly increased for the volume categories of ≤ 10 (HR 1.89), 11-25 (HR 2.08), 26-50 (HR 1.80), and 51-100 (HR 1.58) compared with the > 100 category.

CONCLUSION

The risk of reoperation for recurrence was significantly higher after Lichtenstein and laparoscopic repairs performed by surgeons with < 100 cases/year compared with > 100 cases/year. This indicates that higher surgeon volume minimizes the risk of reoperation for recurrence after groin hernia repair.

Lower recurrence rate after groin and primary ventral hernia repair performed by high-volume surgeons: a systematic review

PURPOSE

Hernia repair is a common procedure; however, an overview is lacking regarding the impact of annual surgeon volume and total surgical experience on the outcome of hernia repair. We aimed to explore the impact of annual surgeon volume and total surgical experience on outcomes of groin and primary ventral hernia repair.

METHODS

This systematic review followed the Prefered Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. A protocol was registered at PROSPERO (CRD42020176140). PubMed, EMBASE, and Cochrane CENTRAL were searched. We investigated recurrence rates after groin and primary ventral hernia repair reported according to annual surgeon volume or total surgical experience with at least 6 months follow-up. Surgeons were pooled in three overlapping categories: high-volume (> 50 cases/year), medium-volume (11-50 cases/year) and low-volume (≤ 25 cases/year).

RESULTS

Ten records for groin hernia and one for primary ventral hernia were included. The median (range) recurrence rates after laparoscopic groin hernia repair for high, medium, and low-volume surgeons were 2.6% (2.3-3.0), 2.4% (0.7-4.6), and 4.2% (1.0-6.8), respectively. The median (range) recurrence rate after open groin hernia repair for high, medium, and low-volume surgeons were 2.1% (2.0-2.2), 1.7% (1.6-2.3), and 2.4% (2.2-5.0). The groin hernia recurrence rate seemed to increase when annual surgeon volume decreased below 25 cases/year. For primary ventral hernia, increased annual surgeon volume was associated with decreased reoperation rate.

CONCLUSION

High-volume surgeons seemed to have lower rates of hernia recurrence after groin as well as primary ventral hernia repair and our data supports the need for centralization of groin hernia repair on individual surgeons.

Re-recurrence and pain 12 years after laparoscopic transabdominal preperitoneal (TAPP) or Lichtenstein's repair for a recurrent inguinal hernia: a multi-centre single-blinded randomised clinical trial

BACKGROUND

Long-term clinical outcome after a recurrent inguinal hernia repair may be associated with the type of repair, that is, laparoscopic or open. The results from previous randomised controlled trials are inconclusive regarding the long-term risk of re-recurrence chronic pain. Accordingly, this trial compared laparoscopic transabdominal preperitoneal repair (TAPP) with Lichtenstein's repair. The primary outcome was repair for a re-recurrence. The secondary outcome was chronic pain.

METHODS

Multi-centre single-blinded, randomised trial on TAPP vs Lichtenstein's repair in male patients operated for a recurrent inguinal hernia after a primary open inguinal hernia repair. Follow-up for repair for a re-recurrence was registered in the Danish Hernia Database. Prospective follow-up data were achieved by a structured questionnaire on pain-related functional impairment using the Activities Assessment Scale (AAS-pain).

RESULT

A total of 360 patients were randomised, 297 were mailed the follow-up questionnaire (63 excluded) after median 12 years (range 9-15). A total of 265 patients responded to the questionnaire (response rate 89%). The cumulative rate of repair for re-recurrence after 12 years was 10% (95% confidence interval (CI) 5.3-15.1%) vs 10% (5.6-14.7%) after TAPP or Lichtenstein, respectively (p = 0.764). Moderate/severe AAS-pain was reported by 4% (95% CI 1-8%) vs 7% (95% CI 3-11%) patients after TAPP or Lichtenstein, respectively (p = 0.698) CONCLUSION: Long-term re-recurrence rate and incidence of chronic pain was surprisingly high respectless of surgical approach and neither TAPP nor Lichtenstein's procedure was superior to improve surgical results.

Comparing large pore lightweight mesh versus small pore heavyweight mesh in open mesh plug repair of primary and recurrent unilateral inguinal hernia - A questionnaire study for a retrospective analysis of a cohort of elective groin hernia patients using propensity score matching

PURPOSE

For surgical treatment of inguinal hernia, large-pore, lightweight mesh has been shown to offer advantages over small-pore, heavyweight options in terms of chronic post-operative inguinal pain, but without the disadvantage of having to deal with an increased recurrence rate. Limited data are available for the mesh plug repair technique. Therefore, the primary aim of this study is to compare large-pore, lightweight mesh versus small-pore, heavyweight mesh for mesh plug repair with regard to chronic pain and recurrences in elective primary unilateral hernias. In addition, we report our experience in repairing recurrent hernias.

METHODS

Using a modified version of the questionnaire from the Danish Hernia Registry, two groups were surveyed: elective primary unilateral hernias and recurrent unilateral hernias. In both groups small-pore, heavyweight mesh (HWM) and lightweight, large-pore mesh (LWM) were compared with respect to chronic pain and recurrences. Propensity score matching (PS) was carried out on a pool of 1,782 patients. Effect sizes were assessed by using Cohen's d and Cramer's V.

RESULTS

If the questionnaire item 'lump/swelling' is considered as a surrogate for recurrence (clinically verified in our study), the results in primary hernias after HWM show a 6.0% recurrence rate and 7.3% after LWM (p = 0.487) with a mean follow up of 31,3 months in HWM and 29,2 months in LWM respectively. The questionnaire item 'pain impacting on work/leisure activities' was answered with Yes in 11.5% following HWM and in 10.5% following LWM (p = 0.665). After the evaluation of the overall surgical results, we did not find differences. Comparing primary and recurrent hernia repair we found below small effect size differences with respect to the items of the questionnaire.

CONCLUSIONS

The use of LWM in repairing elective unilateral primary hernias by the mesh plug technique does not result in less chronic pain and more recurrences when compared with HWM. Recurrent hernias repaired by the mesh plug technique may have same outcomes like in primary hernia repair when considering the magnitude of effect sizes.

Chronic pain and risk for reoperation for recurrence after inguinal hernia repair using self-gripping mesh

BACKGROUND

Improved recurrence rates after groin hernia surgery have led to chronic pain becoming the most troublesome postoperative complication. Self-gripping mesh was developed to decrease the risk for development of chronic pain. The aim of this nationwide cohort study was to compare recurrence rate and chronic pain 1 year after an open, anterior mesh repair of inguinal hernias with either a self-gripping mesh or other lightweight mesh.

METHOD

All operations registered as open anterior mesh repair (Lichtenstein) in the Swedish Hernia Registry between September 2012 and October 2016 were selected. At 1 year after repair, patients were sent a pain questionnaire assessing chronic pain. We compared the prevalence of chronic pain and reoperation for recurrence using lightweight, sutured mesh or self-gripping mesh.

RESULTS

We analyzed the 1,803 repairs using self-gripping mesh and 16,567 repairs using lightweight mesh. We found no difference in the prevalence of chronic pain 1 year after the hernia repair between self-gripping mesh and sutured lightweight mesh (OR 0.92, CI 95% 0.80-1.06, P = .257). There was no increase in reoperation for recurrence when using self-gripping mesh (HR 0.71, CI 95% 0.45-1.14, P = .156). Mean operation time was considerably less when using self-gripping mesh (43 vs 70 minutes; P > .001).

CONCLUSION

The use of self-gripping mesh does not decrease the incidence of chronic pain and reoperation for recurrence compared with lightweight, sutured mesh for open anterior mesh repair of inguinal hernias. Furthermore, the use of self-gripping mesh is associated with a clinically important, lesser operation time.

The PINCH-Phone: a new screenings method for recurrent incisional hernias

BACKGROUND

Debate persists on the optimal management of incisional hernias due to paucity of accurate recurrence rates. Reoperation rates implicate a severe underestimation of the risk of a recurrence. Therefore, long-term postoperative clinic visits allowing physical examination of the abdomen are deemed necessary. However, these are time and costs consuming. Aim of this study was to develop and evaluate a new screenings method for recurrent hernias, the 'PINCH-Phone' (Post-INCisional-Hernia repair-Phone).

METHODS

The PINCH-Phone is a telephone questionnaire. In this multicenter prospective study, the PINCH-Phone was answered by patients after incisional hernia repair. Afterwards the patients were seen at the clinic and physical examination was done to detect any recurrences.

RESULTS

The PINCH-Phone questions were answered by 210 patients with a median postoperative follow-up of 36 months. Fifty-six patients were seen after multiple incisional hernia repairs. In 137 patients who had replied positively to one or more questions, 28 recurrent incisional hernias were detected at physical examination. Six recurrences were noted in 73 patients who had replied negatively to all questions. The overall sensitivity and specificity of the PINCH-Phone were 82% and 38%, respectively.

CONCLUSION

The PINCH-Phone appears a simple and valuable screenings method for recurrences after incisional hernia repair and, hence, is recommended for implementation.

Groin Pain Characteristics and Recurrence Rates: Three-year Results of a Randomized Controlled Trial Comparing Self-gripping Progrip Mesh and Sutured Polypropylene Mesh for Open Inguinal Hernia Repair

OBJECTIVE

The aim of this study was to investigate long-term groin pain and inguinal hernia recurrence rates of 2 types of mesh and to describe the evolution of postoperative groin sensory disturbances.

SUMMARY OF BACKGROUND DATA

Some patients with an inguinal hernia develop chronic pain following open mesh insertion. Previous trials comparing a semi-resorbable, self-gripping Progrip mesh with a standard sutured polypropylene mesh found conflicting results regarding recurrence rates and residual groin pain.

METHODS

Patients aged >18 years scheduled for open primary hernia repair were randomized to a self-gripping mesh (Progrip) or a polypropylene mesh (standard). Removal of the inguinal nerves was left to the discretion of the surgeon. Pain was measured using Visual Analogue Scale (VAS) over a 3-year period. Pain characteristics and hernia recurrences were determined using physical examination.

RESULTS

Data of 274 patients were complete (75% three-year follow-up rate). Pain steadily decreased over time in both groups in a similar fashion (moderate pain 3.7% in each group). Hyperesthesia was experienced by 2.2% and 3.7% and hypoesthesia in 12% and 19% in Progrip and standard group, respectively. One of seven Progrip patients reported a foreign body feeling versus 1 of 5 standard patients (P = 0.06). Altered skin sensations were not related to a neurectomy. Hernia recurrence rate was 11.5% in the Progrip and 5% in the standard group (P = 0.05).

CONCLUSIONS

Three years after insertion of a self-gripping Progrip mesh or a sutured polypropylene mesh for an open primary inguinal hernia repair, groin pain is minimal, although altered groin skin sensations and foreign body feeling are quite common. A Progrip hernia repair is associated with a high recurrence rate.

Feasibility study of open inguinal hernia repair using mesh plug by residents

BACKGRAUND/OBJECTIVE

Inguinal hernia repair by mesh-plug (MP) is one of the most common general surgeries, and even residents can perform it. The aim of this study was to investigate the postoperative outcome of MP repair by residents and risk factors related to the recurrence.

METHODS

This study included 658 patients underwent MP repair for inguinal hernia. We compared short- and long-term outcomes of the MP repair by residents who were postgraduate year two with those by non-residents. Late complications were investigated via questionnaire.

RESULTS

Among the patients, 206 patients (31%) underwent MP repair by residents, and the other 452 patients (69%) by non-residents. Operative time was significantly longer in the resident group (63 vs. 58 min, P = 0.004). Incidence of short- and long-term complications was not significantly different. The 3-year recurrence rate was significantly higher in the resident group (4.1 vs. 0.9%, P = 0.003). By multivariate analysis, independent perioperative risk factors related to recurrence were surgery by residents (Odds ratio 3.42, 95% CI 1.34-8.76, p = 0.010) and direct hernia (Odds ratio 7.69, 95% CI 2.83-20.83, p < 0.001).

CONCLUSION

The MP repair by residents and direct hernia were risk factors related to recurrence. Surgeons should provide very careful guidance to residents especially for direct hernia.

Chronic pain after reoperation of an inguinal hernia with Lichtenstein or laparoscopic repair following a primary Lichtenstein repair: A nationwide questionnaire study

BACKGROUND

The aim was to assess chronic pain after two Lichtenstein repairs for inguinal hernias (Lichtenstein-Lichtenstein) compared with Lichtenstein followed by a laparoscopic reoperation (Lichtenstein-Laparoscopy).

METHODS

In this cohort study, adults having an inguinal hernia reoperation were identified in a nationwide database. Lichtenstein-Lichtenstein was matched 1:3 with Lichtenstein-Laparoscopy and sent validated pain questionnaires. The primary outcome was difference in proportion of patients with chronic pain-related functional impairment. Secondary outcomes were differences in chronic pain prevalence and severity.

RESULTS

In total, 196 patients having Lichtenstein-Lichtenstein and 777 patients having Lichtenstein-Laparoscopy were included. There was no difference in the primary outcome, 26% with pain in Lichtenstein-Lichtenstein versus 19% in Lichtenstein-Laparoscopy (p = 0.051). However, a few of the secondary outcomes favored Lichtenstein-Laparoscopy.

CONCLUSIONS

A high proportion of patients in both groups had pain several years after the second repair. None of the analyses favored Lichtenstein-Lichtenstein, but a few of the secondary outcomes favored Lichtenstein-Laparoscopy.

Laparoscopic repair is superior to open techniques when treating primary groin hernias in women: a nationwide register-based cohort study

BACKGROUND

Few studies have described recurrence rates after groin hernia repair in women. Our aim was to investigate if laparoscopic repair of primary groin hernias in women results in a lower reoperation rate for recurrence compared with open repairs. Furthermore, we wished to compare hernia subtypes at primary repair and reoperation.

METHODS

This nationwide cohort study was reported according to the RECORD statement. We used prospectively collected data from the Danish Hernia Database to generate a cohort of females operated for a primary groin hernia from 1998 to 2017. Our primary outcome was reoperation for recurrence. The secondary outcome was subtype of hernia at primary repair and reoperation. All females had at least 6-month follow-up.

RESULTS

We included 13,945 primary groin hernia operations in women, of whom 649 had undergone a reoperation for recurrence. Median follow-up time was 8.8 years. The cumulative reoperation rates were lower after laparoscopic repair compared with the open techniques, for both inguinal hernias (1.8 vs. 6.3%, p < 0.001) and femoral hernias (2.2 vs. 5.5%, p = 0.005). After laparoscopic repair, 25% of inguinal hernias recurred as femoral, compared with 47% after Lichtenstein (p < 0.001). Direct inguinal hernias and femoral hernias had higher risk of reoperation for recurrence after open repair compared with indirect inguinal hernias. For laparoscopic procedures, hernia subtypes at the primary groin hernia repair had similar reoperation rates.

CONCLUSION

Laparoscopic repair of primary groin hernia in women had lower reoperation rates and fewer femoral recurrences than open repair techniques.

Surgical trends of groin hernia repairs performed for recurrence in medicare patients

BACKGROUND

The recurrence rate after groin hernia repair (GHR) has been estimated to be between 1-10% in adult patients. Neither national rates nor trends in recurrence over time have been reliably established for Medicare patients in the USA.

MATERIALS

We evaluated patients undergoing GHR (inguinal = IHR; femoral = FHR) from 2011 to 2014 from the Medicare Provider Analysis and Review database. Patients were identified using ICD-9 diagnosis and ICD-9 and CPT procedure codes, stratified both by primary vs. recurrent hernia repair and by sex. One-tailed Cochran-Armitage tests evaluated trends over time and a generalized estimating equation model estimated factors associated with recurrent IHR or FHR.

RESULTS

We identified 407,717 patients (87.0%, ≥ 65 years) who underwent an IHR and 11,578 (91.0%, ≥ 65 years) who underwent a FHR. The proportion of IHRs for recurrence decreased statistically from 14.3% in 2011 to 13.9% in 2014 (p < 0.01) in males and was increased, but not statistically so (7.0-7.4%) in females (p = 0.08). The proportion of FHRs for recurrence was decreased, but not statistically so (16.3-14.8%, p = 0.29) in males and increased in females (5.3-6.3%, p = 0.02). On multivariable analysis, males were more than twice as likely as females to undergo recurrent repair (IHR or FHR, both p < 0.01).

CONCLUSIONS

Within the Medicare population, recurrence rates after groin hernia repairs were found to be higher than previously reported but have remained clinically stable over time. Establishing and reducing this rate is important for patient outcomes and expectations.

Reoperation for inguinal hernia recurrence in Ontario: a population-based study

PURPOSE

Despite the frequency with which inguinal hernia repairs (IHR) are performed, the real-world comparative effectiveness of laparoscopic versus open repairs is not well established. We compared the rate of recurrent inguinal hernia after laparoscopic and open mesh procedures.

METHODS

We designed a population-based retrospective cohort study using linked administrative databases including adult patients in Ontario, Canada, who underwent primary IHR from April 1, 2003 to December 31, 2012. Patients were followed to August 31, 2014. Our primary outcome was reoperation for recurrent IHR, with covariate adjustment using Cox proportional hazards modeling. We constructed separate models to evaluate the effect of surgeon caseload on recurrence rates.

RESULTS

We identified 93,501 adults undergoing primary IHR (85.4% open with mesh and 14.6% laparoscopic) with a median follow-up of 5.5 years. The 5-year cumulative risk of recurrent IHR was 2.0% in the open group and 3.4% in the laparoscopic group. After adjusting for patient and surgeon factors, we found that patients who underwent laparoscopic repair had a higher risk of recurrent IHR than those who underwent open repair when annual surgeon volume in the preceding year was ≤25 technique-specific cases (HR 1.76; 95% CI 1.45-2.13) or 26-50 technique-specific cases (HR 1.78; 95% CI 1.08-2.93). Few high-volume laparoscopic surgeons (> 50 cases/year) could be identified. Laparoscopic IHR did not carry a higher risk of recurrence for patients whose surgeons had performed > 50 technique-specific cases in the preceding year (HR 1.21; 95% CI 0.45-3.26).

CONCLUSION

Laparoscopic IHR is generally associated with a higher risk of recurrence than open IHR. Though high-volume surgeons may be able to achieve equivalent results with laparoscopic and open techniques, few surgeons in our study population met this volume criterion for laparoscopic repairs.

Long-Term Follow-Up of Retromuscular Incisional Hernia Repairs: Recurrence and Quality of Life

PURPOSE

Incisional hernia repair (IHR) with a mesh is necessary to achieve low recurrence rates and pain relief. In the short term, quality of life (QoL) is restored by IHR. Two centers pioneered the IHR in Sweden with the highly standardized Rives-Stoppa technique using a retromuscular mesh. We assessed long-term follow-up of recurrence rate and QoL.

METHODS

Medical records were searched for IHRs performed from 1998 to 2006 and included living patients with midline repairs. Questionnaires about physical status, complaints, and QoL (SF-36) were mailed, offering a clinical examination. Assessment of medical records of later surgery was performed in 2015.

RESULTS

Three hundred and one patients with midline incisional repairs were identified, and 217 accepted participation. Of these, 103 attended a clinical examination. Follow-up was 7 years until examination and 11 years to reassessment of medical records. In 26%, recurrent hernias were repaired. Postoperative complications were 26% Clavien-Dindo grade I-II and 1% grade III-IV. Mesh infections occurred in 1.4% without mesh removals, and 4% were reoperated because of complications. Overall recurrence rate was 8.1% and two-third of which were diagnosed at clinical examination. Recurrence after primary and recurrent hernia repair was 7.1 and 10.9%, respectively. Of all patients, 80% were satisfied; dissatisfaction was primarily caused by recurrence and chronic pain. SF-36 scores were 0.2 SD lower than the norm in all subscales, similar to those with 1-2 chronic conditions.

CONCLUSIONS

Midline retromuscular mesh IHR has a low long-term recurrence rate even after recurrent repair. Patient satisfaction was high although QoL was reduced.

Lower recurrence rate with heavyweight mesh compared to lightweight mesh in laparoscopic totally extra-peritoneal (TEP) repair of groin hernia: a nationwide population-based register study

Purpose

Lightweight meshes (LWM) have shown benefits compared to heavyweight meshes (HWM) in terms of less postoperative pain and stiffness in open inguinal hernia repair. It appears to have similar advantages also in TEP, but concerns exist if it may be associated with higher recurrence rates. The aim of the study was to compare reoperation rate for recurrence of LWM to HWM in laparoscopic totally extra-peritoneal (TEP) repair.

Methods

All groin hernias operated on with TEP between 1 January 2005 and 31 December 2013 at surgical units participating in The Swedish Hernia Register were eligible. Data included clinically important hernia variables. Primary endpoint was reoperation for recurrence. Median follow-up time was 6.1 years (0–11.5) with minimum 2.5 years postoperatively.

Results

In total, 13,839 repairs were included for statistical analysis and 491 were re-operated for recurrence. Multivariate analysis demonstrated significantly increased risk of reoperation for recurrence in LWM 4.0% (HR 1.56, P < 0.001) compared to HWM 3.2%. This was most evident in direct hernias (HR 1.75, P < 0.001) and in hernia repairs with a defect > 3 cm (HR 1.54, P < 0.021). The risk of recurrence with use of LWM in indirect hernias and in hernia repairs with a defect < 1.5 cm was more comparable to HWM.

Conclusions

Lightweight meshes were associated with an increased risk of reoperation for recurrence compared to HWM. While direct hernias and larger hernia defects may benefit from HWM to avoid increased recurrence rates, LWM is recommended to be used in indirect and smaller hernia defects in TEP repair.

Proportion of femoral hernia repairs performed for recurrence in the United States

PURPOSE

Recurrence rates after femoral hernia repair (FHR) have not been reliably established in the USA. We sought to determine this trend over time.

METHODS

The proportion of primary and recurrent FHRs was determined for patients age ≥ 18 from: ACS-NSQIP (1/2005-12/2014), Premier (1/2010-09/2015), and institutional (1/2005-12/2014) data. Trends were analyzed using a one-tailed Cochran-Armitage test.

RESULTS

In the NSQIP database, 6649 patients underwent a FHR. In females, the proportion of FHRs performed for recurrence decreased from 14.0% in 2005 to 6.2% in 2014, p = 0.02. In males, there was no change: 16.7-16.1% 2005-2014 (p = 0.18). The Premier database included 4495 FHRs and our institution 315 FHRs. There was no difference for either gender over time in either data source, all p > 0.05.

CONCLUSIONS

The proportion of femoral hernia repairs performed for recurrence in the USA remained relatively constant in males in two large national databases between 2005 and 2015. In females, a decrease was seen in one of the large national databases.

The HerniaSurge Group. International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Patient-reported rates of chronic pain and recurrence after groin hernia repair

Background

The effectiveness of different procedures in routine surgical practice for hernia repair with respect to chronic postoperative pain and reoperation rates is not clear.

Methods

This was prospective cohort study based on a unique combination of patient-reported outcomes and national registry data. Virtually all patients with a groin hernia repair in Sweden between September 2012 and April 2015 were sent a questionnaire 1 year after surgery. Persistent pain, defined as at least ‘pain present, cannot be ignored, and interferes with concentration on everyday activities’ in the past week was the primary outcome. Reoperation for recurrence recorded in the register was the secondary outcome.

Results

In total, 22 917 patients (response rate 75·5 per cent) who had an elective unilateral groin hernia repair were analysed. Persistent pain present 1 year after hernia repair was reported by 15·2 per cent of patients. The risk was least for endoscopic total extraperitoneal (TEP) repair (adjusted odds ratio (OR) 0·84, 95 per cent c.i. 0·74 to 0·96), compared with open anterior mesh repair. TEP repair had an increased risk of reoperation for recurrence (adjusted OR 2·14, 1·52 to 2·98), as did open preperitoneal mesh repair (adjusted OR 2·34, 1·42 to 3·71) at 2·5-year follow-up. No other methods of repair differed significantly from open anterior mesh repair.

Conclusion

The risk of significant pain 1 year after groin hernia repair in routine surgical practice was 15·2 per cent. This figure was lower in patients who had surgery by an endoscopic technique, but at the price of a significantly higher risk of reoperation for recurrence.

Absorbable Meshes in Inguinal Hernia Surgery: A Systematic Review and Meta-Analysis

PURPOSE

Absorbable meshes used in inguinal hernia repair are believed to result in less chronic pain than permanent meshes, but concerns remain whether absorbable meshes result in an increased risk of recurrence. The aim of this study was to present an overview of the advantages and limitations of fully absorbable meshes for the repair of inguinal hernias, focusing mainly on postoperative pain and recurrence.

METHODS

This systematic review with meta-analyses is based on searches in PubMed, Embase, Cochrane, and Psychinfo. Included study designs were case series, cohort studies, randomized controlled trials (RCTs), and non-RCTs. Studies had to include adult patients undergoing an inguinal hernia repair with a fully absorbable mesh.

RESULTS

The meta-analyses showed no difference in recurrence rates (median 18 months follow-up) and chronic pain rates (1 year follow-up) between absorbable- and permanent meshes. Crude chronic pain rates for the RCTs were 2.1% for the absorbable meshes and 7.6% for the permanent meshes. For the absorbable meshes, medial hernias were more susceptible for recurrence compared with lateral hernias ( P < .0005). None of the studies reported allergic reactions or other serious adverse events related to the absorbable mesh.

CONCLUSIONS

Patients with an absorbable mesh seem to have less chronic pain following inguinal hernia surgery compared with permanent meshes, without increased risk of recurrence.

Low reoperation rates in young males after sutured repair of indirect inguinal hernia: Arguments for a tailored approach

BACKGROUND

The aim of this study was to investigate the reoperation rates after open indirect inguinal hernia repair with and without mesh in young males and other age groups. Younger males have higher risk of developing chronic pain after open inguinal hernia repair with mesh compared with older patients. Avoiding mesh among younger patients could be justified, if they have an acceptable low risk of recurrence compared with other groups and compared with Lichtenstein repair.

METHODS

Data were extracted from the nationwide Danish Hernia Database which is recording prospectively. Included were males with primary indirect inguinal hernia, repaired with Lichtenstein or annulorrhaphy from the period January 1, 1998 to December 31, 2015. Reoperation rate for recurrence was used as outcome.

RESULTS

In total 52,281 primary repairs of open indirect inguinal hernia were included of which 49,951 were Lichtenstein repairs and 2330 were annulorrhaphies. The overall reoperation rates increased year after year in both groups but the 18-29 year old males had a significant lower risk of reoperation after annulorrhaphy compared with all other age groups (cumulative reoperation rate 8.1% versus 12.5%, log rank p = 0.001).

CONCLUSIONS

The cumulative reoperation rate after annulorrhaphy for 18-29 year old males was significantly lower compared with all other age groups. When taken into consideration, that young males at the same time have the highest risk of developing chronic pain after mesh repair the results indicate, that annulorrhaphy could be a valid option for young men with indirect inguinal hernias. Thus, we propose a tailored approach for this patient group.

Repair of recurrent hernia is often performed at a different clinic

PURPOSE

The aim of this study was to assess the extent of reoperations after hernia repair in Denmark that are being performed at a different facility than the primary repair and thereby investigate whether or not reoperation is a reliable basis for assessment of personal- or facility recurrence rates.

METHODS

On a national level, we included all groin hernia repairs that had been reoperated a least once from January 1, 1998, to August 19, 2015.

RESULTS

A total of 14,264 hernia repairs were included comprising a total of 7371 reoperations. We found that 26 % (n = 1883) of all reoperations were performed at a different healthcare facility. Time to reoperation, age at time of repair and having the primary repair performed at a private facility were all independent risk factors for being reoperated at a different facility in a logistic regression model.

CONCLUSION

One in four patients underwent repair for recurrent hernia at a different facility than the prior repair. Having the primary repair performed at a private hospital increased the risk of being reoperated at a different facility compared to having it performed at a public facility. This indicates that personal or institutional reoperation rates are underestimating the true reoperation rates, unless they can be followed in central registries or personal contact is made to all patients.

Surgical approach for recurrent inguinal hernias: a Nationwide Cohort Study

PURPOSE

Guidelines recommend that the reoperation of a recurrent inguinal hernia should be by the opposite approach (anterior-posterior) than the primary repair. However, the level of evidence supporting the guidelines is partially low. The purpose of this study was to compare re-reoperation rates between repairs performed according to the guidelines with the ones performed against it.

METHODS

This cohort study was based on the Danish Hernia Database, including 4344 patients with two inguinal hernia repairs in the same groin. Four groups were compared as follows: Lichtenstein-Lichtenstein vs. Lichtenstein-Laparoscopy, and Laparoscopy-Laparoscopy vs. Laparoscopy-Lichtenstein. The outcome was re-reoperation rates, which were compared by crude rates, cumulated rates, and hazard ratios.

RESULTS

There was no difference in the re-reoperation rates when the primary repair was laparoscopic, regardless of the type of reoperation. However, Lichtenstein-Lichtenstein had a significantly higher re-reoperation rate compared with Lichtenstein-Laparoscopy (crude rate 8.7 vs. 3.1 %, p value <0.0005; Hazard Ratio 2.46, 95 % CI 1.76-3.43). Further analysis showed that the higher risk of re-reoperation for Lichtenstein-Lichtenstein was only seen if the primary hernia was medial.

CONCLUSIONS

A primary Lichtenstein repair of a primary medial hernia should be reoperated with a laparoscopic repair. A primary Lichtenstein repair of a primary lateral hernia can be reoperated with either a Lichtenstein or a laparoscopic repair according to surgeon's choice. For a primary laparoscopic operation, the method of repair of a recurrent hernia did not affect the re-reoperation rate.

Recurrence of inguinal hernias repaired in a large hernia surgical specialty hospital and general hospitals in Ontario, Canada

BACKGROUND

The effect of hospital specialization on the risk of hernia recurrence after inguinal hernia repair is not well described.

METHODS

We studied Ontario residents who had primary elective inguinal hernia repair at an Ontario hospital between 1993 and 2007 using population-based, administrative health data. We compared patients from a large hernia specialty hospital (Shouldice Hospital) with those from general hospitals to determine the risk of recurrence.

RESULTS

We studied 235 192 patients, 27.7% of whom had surgery at Shouldice hospital. The age-standardized proportion of patients who had a recurrence ranged from 5.21% (95% confidence interval [CI] 4.94%-5.49%) among patients who had surgery at the lowest volume general hospitals to 4.79% (95% CI 4.54%-5.04%) who had surgery at the highest volume general hospitals. In contrast, patients who had surgery at the Shouldice Hospital had an age-standardized recurrence risk of 1.15% (95% CI 1.05%-1.25%). Compared with patients who had surgery at the lowest volume hospitals, hernia recurrence among those treated at the Shouldice Hospital was significantly lower after adjustment for the effects of age, sex, comorbidity and income level (adjusted hazard ratio 0.21, 95% CI 0.19-0.23, p < 0.001).

CONCLUSION

Inguinal hernia repair at Shouldice Hospital was associated with a significantly lower risk of subsequent surgery for recurrence than repair at a general hospital. While specialty hospitals may have better outcomes for treatment of common surgical conditions than general hospitals, these benefits must be weighed against potential negative impacts on clinical care and the financial sustainability of general hospitals.

Recurrence mechanisms after inguinal hernia repair by the Onstep technique: a case series

PURPOSE

Inguinal hernia repairs should have few complications and a short learning curve. A new operation called Onstep has promising results, but still some recurrences. The aim of the study was to find reasons for recurrence, by studying the re-operations.

METHODS

The study is a case series, where 565 patients operated with Onstep at six hospitals between December 2011 and April 2015 were identified. If a recurrence had occurred, the description of the re-operation was studied and compared to the primary Onstep operation.

RESULTS

We found 26 inguinal hernia recurrences, giving a recurrence rate of 4.6 %. The reasons for recurrence were a cranial displacement of the mesh in five patients, a caudal displacement in three patients, a folded mesh in one patient, and broken sutures in the mesh laterally in six patients. We found indications of a learning curve, since 70 % of the recurrences had their primary operation among the first half of the total Onstep procedures. Another finding was that 30 patients had complaints from the ring in the mesh, and most of these patients were slender. Fifteen patients have had the ring removed, and for six patients with a follow-up, the complaints have been reduced or disappeared.

CONCLUSIONS

The main reasons for recurrence may be broken sutures in the mesh laterally or a suboptimal size of the opening in fascia transversalis medially, enabling the mesh to displace. Furthermore, the results suggest a learning curve. These findings may guide further improvement in the Onstep method for inguinal hernia repair.

Laparoscopic Repair of Primary Inguinal Hernia Performed in Public Hospitals or Low-Volume Centers Have Increased Risk of Reoperation for Recurrence

BACKGROUND

Inguinal hernia repair is traditionally carried out as either open or laparoscopic repair. Laparoscopic repair has been shown to be superior in terms of pain and discomfort, but has a higher risk of reoperation. Quality of inguinal hernia repair is related to factors such as method of repair, characteristics of patients, and possibly the annual volume of procedures performed by a center. The aim of this study was to test the hypothesis that hospital volume and type of hospital (private vs public) could influence the reoperation rate for recurrence as a marker of surgical quality of care.

METHODS

This study was based on data from the Danish Hernia Database covering the period from January 1, 1998, to December 31, 2013. Hernia repairs included in this study were laparoscopic repair of primary, inguinal hernias in the elective setting, performed on adult male patients.

RESULTS

A total of 14 532 laparoscopic repairs were included for analysis. Centers reporting less than 50 procedures a year had a significantly higher cumulative reoperation rate compared with centers reporting more than 50 procedures a year (9.97% vs 6.06%), P < .0001. Private centers had a lower cumulative reoperation rate compared with public centers: 5.36% versus 8.53%, P ≤ .0001. Type of center and center volume were both independent risk factors for reoperation in a Cox regression model.

CONCLUSION

Hospital volume had an effect on the reoperation rate for recurrence after laparoscopic inguinal hernia repair. Furthermore, private centers performed better than public centers irrespective of volume.

Patient-Related Risk Factors for Recurrence After Inguinal Hernia Repair

Background. Several factors influence the risk of recurrence after inguinal hernia surgery; however, a systematic review and meta-analysis of patient-related risk factors for recurrence after inguinal hernia surgery has not been performed earlier. Methods. MEDLINE, Embase, and Cochrane databases were searched in June 2013 for studies evaluating patient-related risk factors for recurrence after inguinal hernia operation. Observational studies evaluating nontechnical patient-related risk factors for recurrence after inguinal hernia surgery were included. Outcome variables were grouped under patient demographics, hernia characteristics, connective tissue composition and degradation, habits and social relations, and conditions related to inguinal hernia recurrence. Results. From a total of 5061 records screened, we included 40 observational studies enrolling 720 651 inguinal hernia procedures in 714 917 patients in the systematic review. Of the 40 studies, 14 studies were included in 8 meta-analyses evaluating sex, hernia type, hernia size, re-recurrence, bilaterality, mode of admission, age, and smoking as risk factors for recurrence after inguinal hernia surgery in a total of 378 824 procedures in 375 620 patients. Conclusions. We found that female sex, direct inguinal hernias at the primary procedure, operation for a recurrent inguinal hernia, and smoking were significant risk factors for recurrence after inguinal hernia surgery. This knowledge of patient-related risk factors for recurrence after inguinal hernia surgery could be implemented in clinical practice.

Occupational mechanical exposures and reoperation after first-time inguinal hernia repair: a prognosis study in a male cohort

PURPOSE

The aim of this study was to evaluate exposure-response relationships between occupational mechanical exposures and risk of reoperation after inguinal hernia repair.

METHODS

Using register information, we identified all men born in Denmark 1938-1988, who had their first inguinal hernia repair 1998-2008, and who were 18-65 years old and active in the labour market at the time of surgery. The Danish Hernia Database provided information on repairs and reoperations. We used registered occupational codes and a job exposure matrix based on experts' ratings to estimate total load lifted per day, frequency of heavy lifting, and number of hours per day spent standing/walking. We also obtained register information on sickness absence. Multivariable Cox regression analysis was used.

RESULTS

The cohort comprised 34,822 patients. We did not reveal exposure-response relationships between occupational mechanical exposures and the hazard ratio (HR) of reoperation. The percentage of patients with >2 weeks of sickness absence within 8 weeks after surgery increased with total load lifted per day from 15 to 53%. Longer sickness absence was associated with an increased HR of reoperation, but within strata of sickness absence, we found no increase in the HR of reoperation with increasing exposures.

CONCLUSION

We did not find indications that the HR of reoperation was related to occupational mechanical exposures, even after accounting for a potential protective effect of sickness absence. Hence, the exposure-related prolonged duration of sickness absence could not be explained by exposure-related complications that led to reoperation.

Short- and long-term outcomes of open inguinal hernia repair: comparison of the Prolene Hernia System and the Mesh Plug method

PURPOSE

Tension-free mesh repair of adult inguinal hernias has become a standard procedure, but there have been few comparisons of the postoperative outcome after hernia repair using the Prolene Hernia System (PHS) vs. the Mesh Plug (MP) method in a large number of patients from a single institution.

METHODS

We reviewed the medical records of patients to investigate the short- and long-term outcomes of the different types of hernia repair. Late symptoms were evaluated by questionnaire. A total of 1,141 repairs performed from 1999 to 2008 (PHS in 957 and MP in 184 repairs) were evaluated.

RESULTS

There were 93 early postoperative complications (8.2%). A subcutaneous hematoma was found more frequently after MP repair compared with after PHS repair (3.8 vs. 1.3%, P = 0.013). Seven hundred and ten patients (62.2%) could be followed up for more than 2 years. Recurrence was detected in 14 patients with PHS repair and two patients with MP repair (1.5 vs. 1.1%, P = 0.956). Wound infections occurred in three patients (0.3%) with PHS repair vs. none with MP repair (P > 0.999). Patients with PHS and MP repair showed no significant differences in the long-term wound pain.

CONCLUSIONS

The recurrence and wound infection rates were similar after hernia repair using the PHS and MP methods. Patients undergoing PHS repair developed fewer subcutaneous hematomas. An older age (≥65 years) was a significant independent risk factor for recurrence.

Lower reoperation rates with the use of fibrin sealant versus tacks for mesh fixation

BACKGROUND

Groin hernia repair may be associated with long-term complications such as chronic pain, believed to result from damage to regional nerves by tissue penetrating mesh fixation. Studies have shown that mesh fixation with fibrin sealant reduces the risk of these long-term complications, but data on recurrence and reoperation rates after the use of fibrin sealant compared with tacks are not available. This study aimed to determine whether fibrin sealant is a safe and feasible alternative to tacks with regard to reoperation rates after laparoscopic groin hernia repair.

METHODS

The current study compared reoperation rates after laparoscopic groin hernia repair between fibrin sealant and tacks used for mesh fixation. The study used data collected prospectively from The National Danish Hernia Database and analyzed 8,314 laparoscopic groin hernia repairs for reoperation rates. Mesh fixation was performed with fibrin sealant (n = 784) or tacks (n = 7,530).

RESULTS

The findings showed a significantly lower reoperation rate for the fibrin sealant than for the tacks (0.89 vs 2.94 %, p = 0.031). The median follow-up period was 17 months (range, 0-44 months) for the fibrin sealant group and 21 months (range, 0-44 months) for the tacks group.

CONCLUSIONS

Fibrin sealant was superior to tacks for mesh fixation in laparoscopic groin hernia repair with regard to reoperation rates. The study could not differentiate between different hernia defect sizes, and future studies should therefore explore whether the superior effect of fibrin sealant applies for all hernia types and sizes.