Mortality after groin hernia surgery

The Partial Iliopubic Tract Resection Technique for Incarcerated Femoral Hernia: A Case Series and a Literature Review

Femoral hernias have a high incarceration rate, often necessitating urgent surgical intervention. In this report, we present a safe and reproducible laparoscopic technique for incarcerated femoral hernias with bowel involvement, including repair. Between December 2022 and May 2023, three female patients with incarcerated femoral hernias underwent urgent laparoscopic surgery. All patients presented with abdominal pain and were diagnosed with small bowel incarceration using computed tomography. Under laparoscopy, we confirmed intestinal incarceration and performed a standard transabdominal preperitoneal approach to identify the hernia defects. The iliopubic tract on the abdominal side of the hernia defect was carefully dissected using an energy device to enlarge the hernia orifice. A spontaneous reduction of the incarcerated intestine was achieved. After confirming the absence of bowel perforation, mesh was placed to repair the hernia. Following peritoneal closure, the affected part of the intestine was extracorporeally resected and anastomosed. We performed this technique on three patients, all of whom were later discharged without complications. In conclusion, for incarcerated femoral hernias with bowel obstruction, laparoscopic partial division of the iliopubic tract enables an easy, safe, and reproducible approach to incarceration release and subsequent hernia repair.

Association of socioeconomic vulnerability with clinical and financial outcomes following emergent hernia repair

BACKGROUND

While race and insurance have been linked with greater likelihood of hernia incarceration and emergent presentation, the association of broader social determinants of health (SDOH) with outcomes following urgent repair remains to be elucidated.

STUDY DESIGN

All adult hospitalizations entailing emergent repair for strangulated inguinal, femoral, and ventral hernias were identified in the 2016-2020 Nationwide Readmissions Database. Socioeconomic vulnerability was ascertained using relevant diagnosis codes. Multivariable models were developed to consider the independent associations between socioeconomic vulnerability and study outcomes.

RESULTS

Of ∼236,215 patients, 20,306 (8.6 ​%) were Vulnerable. Following risk-adjustment, socioeconomic vulnerability remained associated with greater odds of in-hospital mortality, any perioperative complication, increased hospitalization expenditures and higher risk of non-elective readmission.

CONCLUSIONS

Among patients undergoing emergent hernia repair, socioeconomic vulnerability was linked with greater morbidity, expenditures, and readmission. As part of patient-centered care, novel screening, postoperative management, and SDOH-informed discharge planning programs are needed to mitigate disparities in outcomes.

Strangulated Indirect Inguinal Hernia-Containing Bladder: A Case Report

Inguinal hernias involving the bladder are exceedingly rare and pose a diagnostic challenge. Identifying bladder involvement within an inguinal hernia is imperative to avoid iatrogenic bladder injuries and subsequent complications. Here we discuss a case of inguinal bladder herniation and bladder visualization using methylene blue dye intraoperatively. We present a case of a 45-year-old male who presented with a six-hour history of dysuria and a painful non-reducible right-sided groin mass that had previously been reducible for 17 years. Computed tomography demonstrated an irreducible indirect inguinal hernia-containing bladder. Open Lichtenstein repair was performed, and intraoperative methylene blue-dyed saline successfully identified the herniated bladder, preventing iatrogenic bladder injury. This case report demonstrates the importance of preoperative imaging and intraoperative visualization for the prevention of complications in a rare occurrence of a strangulated indirect inguinal hernia-containing bladder.

Transabdominal preperitoneal (TAPP) repair for emergency groin hernia: a systematic review

PURPOSE

Laparoscopic groin hernia repair has evolved and gained popularity and laparoscopic transabdominal preperitoneal (TAPP) procedure provides an opportunity to evaluate the peritoneal cavity and both inguinal areas without the need for additional dissection. There is still a paucity of evidence to support TAPP repair in the emergency setting. In this systematic review, we aim to evaluate the feasibility and safety of TAPP repair for incarcerated and strangulated groin hernias.

METHODS

PRISMA guidelines were followed for literature search and established inclusion and exclusion criteria were applied. Data were extracted and analyzed for the outcomes of interest.

RESULTS

Overall, 8 studies were included in the review, comprising 316 patients. Patients characteristics and outcomes were limitedly reported. Only 3 cases of conversion to open approach were reported and 2 recurrences were diagnosed. Postoperative complications are inconsistently reported but mostly refer to minor complications. There were no mortality cases. Visceral resections were performed in 25 cases due to ischemia, mostly extracorporeally.

CONCLUSION

Laparoscopy is a game changer and TAPP approach is a feasible, safe, and effective technique for the emergent repair of groin hernias. Further studies and prospective randomized data are needed to establish its role in the emergent groin hernia management.

Suture repair versus mesh repair in elderly populations with incarcerated or strangulated groin hernia

Tension-free hernia repair is the gold standard for groin hernia repair. However, the optimal surgical treatment for incarcerated or strangulated groin hernia in elderly populations is controversial. The aim of this study is to compare the clinical efficacy of mesh repair and suture repair in the treatment of incarcerated or strangulated groin hernia in elderly patients. Patients ≥ 65 years who underwent urgent surgical repair for incarcerated or strangulated groin hernia from January 2012 to June 2022 were included. Patients' demographic data and postoperative outcomes were retrospectively analyzed. Patients with limited life expectancy were screened from the elderly population for subgroup analysis. A total of 103 patients (median age: 84 years old, range 65-96; mean follow-up time: 36.8 ± 24.8 months) were included, involving 42 cases in the suture repair group and 61 cases in the mesh repair group. Suture repair and mesh repair had similar lengths of ICU and hospital stay, and rates of small bowel resection, chronic pain, surgical site infection, and surgical-related death. However, suture repair had a significantly higher recurrence rate than mesh repair (7% vs. 2%, P = 0.04). In our subgroup analysis, for patients with limited life expectancy (41 patients; median age: 88 years old, range: 80-96), suture repair had no statistical difference in postoperative outcomes compared with mesh repair. Mesh repair is suitable for elderly patients with acutely incarcerated or strangulated groin hernias. However, for elderly patients with limited life expectancy, suture repair and mesh repair showed similar clinical outcomes.

Quality of Surgical Care Within the Criminal Justice Health Care System

Importance

Individuals who are incarcerated represent a vulnerable group due to concerns about their ability to provide voluntary and informed consent, and there are considerable legal protections regarding their participation in medical research. Little is known about the quality of surgical care received by this population.

Objective

To evaluate perioperative surgical care provided to patients who are incarcerated within the Texas Department of Criminal Justice (TDCJ) and compare their outcomes with that of the general nonincarcerated population.

Design, Setting, and Participants

This cohort study analyzed data from patients who were incarcerated within the TDCJ and underwent general or vascular surgery at the University of Texas Medical Branch (UTMB) from 2012 to 2021. Case-specific outcomes for a subset of these patients and for patients in the general academic medical center population were obtained from the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) and compared. Additional quality metrics (mortality index, length of stay index, and excess hospital days) from the Vizient Clinical Data Base were analyzed for patients in the incarcerated and nonincarcerated groups who underwent surgery at UTMB in 2020 and 2021 to provide additional recent data. Patient-specific demographics, including age, sex, and comorbidities were not available for analysis within this data set.

Main Outcome and Measures

Perioperative outcomes (30-day morbidity, mortality, and readmission rates) were compared between the incarcerated and nonincarcerated groups using the Fisher exact test.

Results

The sample included data from 6675 patients who were incarcerated and underwent general or vascular surgery at UTMB from 2012 to 2021. The ACS-NSQIP included data (2012-2021) for 2304 patients who were incarcerated and 602 patients who were not and showed that outcomes were comparable between the TDCJ population and that of the general population treated at the academic medical center with regard to 30-day readmission (6.60% vs 5.65%) and mortality (0.91% vs 1.16%). However, 30-day morbidity was significantly higher in the TDCJ population (8.25% vs 5.48%, P = .01). The 2020 and 2021 data from the Vizient Clinical Data Base included 629 patients who were incarcerated and 2614 who were not and showed that the incarcerated and nonincarcerated populations did not differ with regard to 30-day readmission (12.52% vs 11.30%) or morbidity (1.91% vs 2.60%). Although the unadjusted mortality rate was significantly lower in the TDCJ population (1.27% vs 2.68%, P = .04), mortality indexes, which account for case mix index, were similar between the 2 populations (1.17 vs 1.12).

Conclusions and Relevance

Findings of this cohort study suggest that patients who are incarcerated have equivalent rates of mortality and readmission compared with a general academic medical center population. Future studies that focus on elucidating the potential factors associated with perioperative morbidity and exploring long-term surgical outcomes in the incarcerated population are warranted.

Inguinal hernia leads to worse immediate urinary continence after robot-assisted radical prostatectomy

OBJECTIVES

Patients with inguinal hernia (IH) may have voiding dysfunction and weak urethra-stabilizing periurethral fascial tissues, contributing to urinary incontinence. This study aimed to review the association between IH and urinary continence after robotic-assisted radical prostatectomy (RARP).

METHODS

This single-institution retrospective study included 251 consecutive cases of RARP between April 2019 and June 2022. Patients with concurrent IH or a history of adult IH repair were examined. The urine loss rate (ULR), defined as 24-h urine loss volume divided by the total urine volume immediately after urinary catheter removal (i.e., 6 or 7 postoperative days), was compared between the groups with (n = 33) and without IH (n = 214). Possible contributing factors for ULR were assessed, including age, body mass index (BMI), after benign prostatic hyperplasia surgery, prostate weight, and nerve-sparing. ULR was compared intergroup after propensity score matching countering selection biases.

RESULTS

Patients with IH were older (71.3 versus. 66.8 years, p < 0.01), had lower BMI (22.8 versus. 24.3, p < 0.01), and had higher ULR (14.5% versus. 5.1%, p < 0.01). In a multiple linear regression analysis (adjusted R2 = 0.084), IH (p < 0.01) was an independent contributing factor for ULR besides advancing age (p < 0.03). After propensity score matching adjusted for patient's age and nerve-sparing, patients with IH had higher ULR (14.1% versus. 5.7%, p < 0.03) as well.

CONCLUSIONS

This study first reported that IH may be one of the risk factors of urinary incontinence after RARP.

The economic burden associated with unmet surgical needs in Liberia: a retrospective macroeconomic analysis based on a nationwide enumeration of surgical procedures

OBJECTIVES

The economic consequences of untreated surgical disease are potentially large. The aim of this study was to estimate the economic burden associated with unmet surgical needs in Liberia.

DESIGN

A nationwide enumeration of surgical procedures and providers was conducted in Liberia in 2018. We estimated the number of disability-adjusted life years (DALYs) saved by operative activities and converted these into economic losses averted using gross national income per capita and value of a statistical life (VSL) approaches. The total, the met and the unmet needs for surgery were determined, and economic losses caused by unmet surgical needs were estimated. Finally, we valued the economic losses avoided by various surgical provider groups.

RESULTS

A total of 55 890 DALYs were averted by surgical activities in 2018; these activities prevented an economic loss of between US$35 and US$141 million. About half of these values were generated by the non-specialist physician workforce. Furthermore, a non-specialist physician working a full-time position for 1 year prevented an economic loss of US$717 069 using the VSL approach, while a specialist resident and a certified specialist saved US$726 606 and US$698 877, respectively. The burden of unmet surgical need was associated with productivity losses of between US$388 million and US$1.6 billion; these losses equate to 11% and 46% of the annual gross domestic product for Liberia.

CONCLUSION

The economic burden of untreated surgical disease is large in Liberia. There is a need to strengthen the surgical system to reduce ongoing economic losses; a framework where specialist and non-specialist physicians collaborate may result in better economic return than a narrower focus on training specialists alone.

The inheritance of groin hernias: an updated systematic review with meta-analyses

PURPOSE

The aim of this systematic review was to assess the inheritance of groin hernias.

METHODS

The primary outcome was to assess the inheritance based on the family history of groin hernias. We included studies that reported family history in patients with groin hernias, assessed the development of groin hernias in patients with a positive family history, or assessed the development of groin hernias in twins. Searches were conducted in PubMed, EMBASE, and Cochrane CENTRAL in November 2021. Results were synthesized narratively and with meta-analyses.

RESULTS

Twenty-two studies with unique participants were included. While two twin studies did not show convincing results of a genetic origin in children, database studies with low risk of bias showed that a positive history in parents or siblings increased the risk of inguinal hernia in children, and the risk was highest between mothers and daughters and between sisters. In adults, patients with inguinal hernia had higher odds of having a positive family history compared with patients without groin hernia (odds ratio 5.3, 95% confidence interval 3.3-8.7), and a nationwide study found the highest risk of inguinal hernia repair when a sister had been repaired compared with a brother. This study also found that having a sibling repaired for a groin hernia increased the risk of femoral hernia repair.

CONCLUSION

Despite studies being heterogeneous, there is overwhelming evidence that a positive family history is a risk factor for developing inguinal hernia in both children and adults, seemingly with a pronounced female-female inheritance pattern.

Mesh versus non-mesh for emergency groin hernia repair

BACKGROUND

A groin hernia is a collective name for inguinal and femoral hernias, which can present acutely with incarceration or strangulation of the hernia sac content, requiring emergency treatment. Timely repair of emergency groin hernias is crucial due to the risk of reduced blood supply and thus damage to the bowel, but the optimal surgical approach is unclear. While mesh repair is the standard treatment for elective hernia surgery, using mesh for emergency groin hernia repair remains controversial due to the risk of surgical site infection.

OBJECTIVES

To assess the benefits and harms of mesh compared with non-mesh in emergency groin hernia repair in adult patients with an inguinal or femoral hernia.

SEARCH METHODS

On 5 August 2022, we searched the following databases: CENTRAL, MEDLINE Ovid, and Embase Ovid, as well as two trial registers for ongoing and completed trials. Additionally, we performed forward and backward citation searches for the included trials and relevant review articles. We searched without any language or publication restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing mesh with non-mesh repair in emergency groin hernia surgery in adults. We included any mesh and any non-mesh repairs. All studies fulfilling the study, participant, and intervention criteria were included irrespective of reported outcomes.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology. We presented dichotomous data as risk ratios (RR) with 95% confidence intervals (CI). We based missing data analysis on best- and worst-case scenarios. For outcomes with sufficiently low heterogeneity, we performed meta-analyses using the random-effects model. We analysed subgroups when feasible, including the degree of contamination. We used RoB 2 for risk of bias assessment, and summarised the certainty of evidence using GRADE.

MAIN RESULTS

We included 15 trials randomising 1241 participants undergoing emergency groin hernia surgery with either mesh (626 participants) or non-mesh hernia repair (615 participants). The studies were conducted in China, the Middle East, and South Asia. Most patients were men, and most participants had an inguinal hernia (41 participants had femoral hernias). The mean/median age in the mesh group ranged from 35 to 70 years, and from 41 to 69 years in the non-mesh group. All studies were performed in a hospital emergency setting (tertiary care) and lasted for 11 to 139 months, with a median study duration of 31 months. The majority of the studies only included participants with clean to clean-contaminated surgical fields. For all outcomes, we considered the certainty of the evidence to be very low, mainly downgraded due to high risk of bias (due to deviations from intended intervention and missing outcome data), indirectness, and imprecision. Mesh hernia repair may have no effect on or slightly increase the risk of 30-day surgical site infections (RR 1.66, 95% CI 0.96 to 2.88; I² = 21%; 2 studies, 454 participants) when compared with non-mesh hernia repair, but the evidence is very uncertain. The evidence is also very uncertain about the effect of mesh hernia repair compared with non-mesh hernia repair on 30-day mortality (RR 1.38, 95% CI 0.58 to 3.28; 1 study, 208 participants). In summary, the results showed 70 more (from 5 fewer to 200 more) surgical site infections and 29 more (from 32 fewer to 175 more) deaths within 30 days of mesh hernia repair per 1000 participants compared with non-mesh hernia repair. The evidence is very uncertain about 90-day surgical site infections after mesh versus non-mesh hernia repair (RR 1.00, 95% CI 0.15 to 6.64; 1 study, 60 participants; very low-certainty evidence). No 30-day recurrences were recorded, and mesh hernia repair may not reduce recurrence within one year (RR 0.19, 95% CI 0.04 to 1.03; I² = 0%; 2 studies, 104 participants; very low-certainty evidence). Within 30 days of hernia repair, no meshes were removed from clean to clean-contaminated fields, but 6.7% of meshes (1 study, 208 participants) were removed from contaminated to dirty surgical fields. Among the four studies reporting 90-day mesh removal, no events occurred. We were not able to identify any studies reporting complications classified according to the Clavien-Dindo Classification or reoperation for complications within 30 days of repair.

AUTHORS' CONCLUSIONS

Our results show that in terms of 30-day surgical site infections, 30-day mortality, and hernia recurrence within one year, the evidence for the use of mesh hernia repair compared with non-mesh hernia repair in emergency groin hernia surgery is very uncertain. Unfortunately, firm conclusions cannot be drawn due to very low-certainty evidence and meta-analyses based on small-sized and low-quality studies. There is a need for future high-quality RCTs or high-quality registry-based studies if RCTs are unfeasible.

Comparison of patient characteristics and treatment approaches for femoral and inguinal hernias utilizing dynamic ultrasound at a single institution

PURPOSE

To assess the differences in management approach to femoral versus inguinal hernias and to identify patient characteristics associated with each hernia type.

METHODS

Imaging studies for patients who had undergone dynamic ultrasound evaluation for the symptom of groin pain between January 1, 2010, and March 31, 2019, at a single institution Musculoskeletal Department were analyzed. Positive femoral hernia imaging studies were compared to studies for inguinal hernias and matching medical records for imaging studies were analyzed. Association of patient characteristics (age, sex, smoking, diabetes) with hernia type was assessed. Primary outcomes were surgical versus non-surgical approach, type of surgery, number of follow-up visits, and pain resolution.

RESULTS

A total of 1319 patients presented with groin pain and were assessed with dynamic ultrasound (534 female; 785 male; mean [± SD] age 48.2 ± 16.5). While 409 (31.0%) patients had a femoral hernia detected, 666 (50.6%) had an inguinal hernia detected (p < .05). Significantly more inguinal hernias were surgically repaired than femoral hernias (65.0% vs 53.9% p = .008), and more inguinal hernias than femoral hernias were treated with open surgery (71.0% vs 57.7%; p = .014). Patients with femoral hernias had significantly more follow-up clinic visits than patients with inguinal hernias (mean [± SD] 2.65 ± 4.80 vs 1.76 ± 1.27; p = .010). No difference in the percentage of patients who had pain resolution was observed (82.2% inguinal vs 75.0% femoral; p = .13).

CONCLUSIONS

Femoral hernias were managed more conservatively than inguinal hernias at our institution.

Female Groin Hernia Repairs in the Swedish Hernia Register 1992-2022: A Review With Updates

Introduction: Groin hernias in women is much less common than in men; it constitutes only 9% of all groin hernia operations. Historically, studies have been performed on men and the results applied to both genders. However, prospectively registered operations within national registers have contributed to new knowledge regarding groin hernias in women. The aim of this paper was to investigate and present a body of literature based upon the Swedish Hernia Register together with recent data from the register's annual report. Patients and Methods: PubMed and Embase were searched for studies based on the Swedish Hernia Register between 1992 and 2023. Based on the initial reading of abstracts, studies that presented results separately for women were selected and read. Recent data were acquired from the 2022 annual report of the Swedish Hernia Register. Results: A total of 73 studies of interest were identified. Of these, 52 included women, but only 19 presented separate results for women. Four themes emerged and were analysed further: emergency surgery and mortality, femoral hernias, the risk of reoperation for recurrence, and chronic pain following female groin hernia repairs. Discussion: Studies from the Swedish Hernia Register clearly describe that both the presentation of hernias and outcomes after repair differ significantly between the two genders. The differences that have been identified over the years have been incorporated into the national guidelines. Register data indicates that the guidelines have been implemented and are fairly well adhered to. As a result, significant improvements in outcomes regarding recurrences have been made for women with groin hernias in Sweden.

Transverse colon and omental incarceration in femoral hernia: a case report

A femoral hernia is one of the groin hernias with a high chance of incarceration and strangulation due to its narrow neck. Here, we report a case of transverse colon incarceration. A 65-year-old female patient presented with groin mass that failed to reduce and a dragging pain. Elective open femoral herniorrhaphy was done with the finding of viable incarcerated massive momentum along with transverse colon. Femoral hernias have a female-to-male ratio of about 10:1. Postmenopausal, increasing age, and constipation were some of the risk factors identified in our patient. Various types of organs can be found in the femoral hernia sac but one of the rarely reported organ was found in our case: a transverse colon. Femoral hernia with a large bulky soft mass can get incarcerated easily but relatively less prone to strangulation.

Investigation of the clinical efficacy of thiol-disulfide homeostasis, delta neutrophil index, and ischemia-modified albumin in cases of incarcerated and strangulated hernia

BACKGROUND

The treatment of patients presenting with the diagnosis of incarcerated and/or strangulated inguinal hernia is mostly surgery. If strangulation and necrosis are present, the need for laparotomy arises, which may increase the risk of morbidity. Currently, it is not possible to clearly determine whether there is bowel ischemia and necrosis before surgery. In this study, we aimed to investigate the clinical efficacy of the thiol-disulfide homeostasis, delta neutrophil index (DNI), and ischemia-modified albumin (IMA) parameters in incarcerated and strangulated hernia cases.

METHODS

Patients that presented to the general surgery outpatient clinic due to inguinal hernia or to the emergency department of the hospital with a preliminary diagnosis of incarcerated and/or strangulated hernia in April 2021-November 2021 were included in the study. The patients were divided into the following four groups: patients that underwent elective repair for inguinal hernia (Group 1), those who were followed up without surgery due to incarcerated hernia (Group 2), those who underwent hernia repair without bowel resection due to incarceration (Group 3), and those who underwent bowel resection due to strangulation (Group 4). Group 1 was defined as the control group, while Groups 2, 3, and Group 4 were evaluated as the incarcerated/strangulated hernia group. The demographic data of the patients, length of hospital stay, body mass index, comorbidities, medical history and physical examina-tion findings, radiological examinations, treatments applied, white blood cell (WBC) count, lactate, and DNI, thiol-disulfide and IMA parameters were evaluated.

RESULTS

The WBC count, disulfide/native thiol, disulfide/total thiol, and IMA values were significantly higher in the incarcerated/strangulated hernia group than in the control group, while the native thiol and total thiol values were higher in the latter than in the former (P<0.05). There was no statistically significant difference between the groups in terms of lactate (P>0.05), but the mean WBC count was higher in Group 4 compared to Group 1, and the mean DNI was significantly higher among the patients who underwent bowel resection and anastomosis than in those that were followed up and discharged (P<0.05).

CONCLUSION

We consider that the preoperative evaluation of the thiol-disulfide homeostasis, IMA, and DNI parameters in incarcerated/strangulated hernia cases can be an effective and easily applicable method in predicting difficulties that may be encountered intraoperatively and the surgical procedure to be applied to the patient.

URGENCY HOSPITALIZATIONS FOR INGUINAL HERNIA IN BRAZIL FROM 2010 TO 2019: MORTALITY AND COSTS IN THE PUBLIC HEALTH SYSTEM

BACKGROUND

It is known that elective inguinal hernioplasties are safe procedures, but in an emergency setting, they have higher rates of complications and hospital costs. Despite this, quantitative studies on the subject in Brazil are still scarce.

AIMS

To evaluate the trend in hospitalization rates, hospital mortality, and costs for inguinal hernia in an emergency, regarding gender and age group.

METHODS

This is a time series study with data from the Unified Health System (SUS), at the national level, from 2010 to 2019.

RESULTS

The overall hospitalization rate (p=0.007; b<0,02) in all age groups (p<0.005; b<0) in both genders indicated a decreasing trend. The general mortality rate in both genders and in most age groups showed an increasing trend (p<0.005), as well as the cost of hospitalization in all age groups of both genders.

CONCLUSIONS

Urgent hospitalization rates for inguinal hernia in Brazil have shown a steady or decreasing trend; however, hospital mortality and costs per hospitalization have demonstrated an increasing trend in recent years.

Prevalence, incidence, repair rate, and morbidity of groin hernias in Sierra Leone: cross-sectional household study

BACKGROUND

Knowledge about the prevalence of groin hernias in sub-Saharan Africa is limited. Previous studies have demonstrated a higher incidence of the condition than the annual repair rate. This study aimed to investigate prevalence, incidence, annual repair rate, morbidity, and health-seeking behaviour of persons with groin hernias in Sierra Leone.

METHODS

This population-based, cross-sectional household survey on groin hernias in Sierra Leone was part of the Prevalence Study on Surgical Conditions 2020 (PRESSCO 2020). Those who indicated possible groin hernia were asked problem-specific questions and underwent physical examination to confirm or exclude the diagnosis.

RESULTS

3626 study participants were interviewed. The prevalence of untreated groin hernia was 1.1 per cent (95 per cent c.i. 0.8 to 1.5 per cent), whereas the prevalence of untreated and treated groin hernia was 2.5 per cent (95 per cent c.i. 2.0 to 3.0 per cent). The proportion of recurrence was 13.1 per cent. An incidence of 389 (95 per cent c.i. 213 to 652) groin hernia cases per 100 000 people per year was identified, while a population-based annual hernia repair rate estimation was 470 (95 per cent c.i. 350 to 620) per 100 000 people. Out of 39 participants with groin hernia, non-ignorable pain was reported by eight and 27 reported financial shortcomings as a reason for not seeking healthcare.

CONCLUSIONS

Groin hernias are common in Sierra Leone and although the repair rate might match the incidence, the existing backlog of untreated hernias is likely to remain. It may be possible to reduce the number of recurrences through improved management. Measures to reduce financial barriers to treatment seem crucial to improve the health of people with groin hernias in Sierra Leone.

Using an E-Health Application for Post-operative Monitoring After Inguinal Hernia Repair: A Feasibility Study

BACKGROUND

E-Health care is already well established in some (non-) surgical specialties and is considered as a means of improving patient-centred care. Considering the demand of remote health care changes, especially in the COVID-19 pandemic, it is essential to investigate the feasibility of e-Health care within one of the most performed surgery procedures: inguinal hernia repair.

METHODS

A total of 60 patients used the e-Health application in this study compliant. Primary objectives were to investigate the accuracy of the "deviating post-operative course" alerting by the e-Health application. Secondary objectives included patient perspective and e-Health costs analysis.

RESULTS

Forty-four patients reported no deviation in the post-operative course using the e-Health application of which 93.2% (n = 41) was in concordance with the findings during standard follow-up. Within 16 patients reporting a deviating post-operative course, a true complication was found in 25% (n = 4). Based on in-hospital costs, a hypothetical e-Health follow-up scenario was more expensive (€59.5 per patient) than current standard follow-up care (€28.2 per patient). Usage of the e-Health application showed a high perceived overall patient satisfaction: 4.2 (on a Likert-scale of 1-5).

CONCLUSION

An e-Health application is a promising tool for identifying patients who require in-person or phone follow-up assessment. Patients' perspectives surveys revealed high potential and willingness of using this application. A hypothetical e-Health follow-up scenario showed to be more expensive compared to current standard follow-up. If the identified (dis)advantages can be improved, e-Health follow-up care appears to be promising in terms of safety and feasibility. Future studies can leverage on this study and further investigate the use of e-Health within the field of general surgery.

Shared genetic architecture of hernias: A genome-wide association study with multivariable meta-analysis of multiple hernia phenotypes

Abdominal hernias are common and characterised by the abnormal protrusion of a viscus through the wall of the abdominal cavity. The global incidence is 18.5 million annually and there are limited non-surgical treatments. To improve understanding of common hernia aetiopathology, we performed a six-stage genome-wide association study (GWAS) of 62,637 UK Biobank participants with either single or multiple hernia phenotypes including inguinal, femoral, umbilical and hiatus hernia. Additionally, we performed multivariable meta-analysis with metaUSAT, to allow integration of summary data across traits to generate combined effect estimates. On individual hernia analysis, we identified 3404 variants across 38 genome-wide significant (p < 5×10-8) loci of which 11 are previously unreported. Robust evidence for five shared susceptibility loci was discovered: ZC3H11B, EFEMP1, MHC region, WT1 and CALD1. Combined hernia phenotype analyses with additional multivariable meta-analysis of summary statistics in metaUSAT revealed 28 independent (seven previously unreported) shared susceptibility loci. These clustered in functional categories related to connective tissue and elastic fibre homeostasis. Weighted genetic risk scores also correlated with disease severity suggesting a phenotypic-genotypic severity correlation, an important finding to inform future personalised therapeutic approaches to hernia.

Mortality after emergency versus elective groin hernia repair: a systematic review and meta-analysis

BACKGROUND

Emergency groin hernia repair is associated with increased mortality risk, but the actual risk is unknown. Therefore, this review aimed to investigate 30- and 90-day postoperative mortality in adult patients who had undergone emergency or elective groin hernia repair.

METHODS

This review was reported following PRISMA 2020 guidelines, and a protocol (CRD42021244412) was registered to PROSPERO. A systematic search was conducted in PubMed, EMBASE, and Cochrane CENTRAL in April 2021. Studies were included if they reported 30- or 90-day mortality following an emergency or elective groin hernia repair. Meta-analyses were conducted when possible, and subgroup analyses were made for bowel resection, sex, and hernia type. According to the study design, the risk of bias was assessed using either the Newcastle-Ottawa Scale or Cochrane Risk of Bias tool.

RESULTS

Thirty-seven studies with 30,740 patients receiving emergency repair and 457,253 receiving elective repair were included. The 30-day mortality ranged from 0-11.8% to 0-1.7% following emergency and elective repair, respectively. The risk of 30-day mortality following emergency repair was estimated to be 26-fold higher than after elective repair (RR = 26.0, 95% CI 21.6-31.4, I2 = 0%). A subgroup meta-analysis on bowel resection in emergency repair estimated 30-day mortality to be 7.9% (95% CI 6.5-9.3%, I2 = 6.4%). Subgroup analyses on sex and hernia type showed no differences regarding the mortality risk in elective surgery. However, femoral hernia and female sex significantly increased the risk of mortality in emergency surgery, both given by a risk ratio of 1.7.

CONCLUSION

The overall mortality after emergency groin hernia repair is 26-fold higher than after elective repair, but the increased risk is attributable mostly to female and femoral hernias.

TRIAL REGISTRATION

PROSPERO protocol (CRD42021244412).

Evaluation of Treatment Differences Between Men and Women Undergoing Ventral Hernia Repair: An Analysis of the Abdominal Core Health Quality Collaborative

BACKGROUND

Sex is emerging as an important clinical variable associated with surgical outcomes and decision making. However, its relevance in regard to baseline and treatment differences in primary and incisional ventral hernia repair remains unclear.

STUDY DESIGN

This is a retrospective cohort study using the Abdominal Core Health Quality Collaborative database to identify elective umbilical, epigastric, or incisional hernia repairs. Propensity matching was performed to investigate confounder-adjusted treatment differences between men and women. Treatments of interest included surgical approach (minimally invasive or open), mesh use, mesh type, mesh position, anesthesia type, myofascial release, fascial closure, and fixation use.

RESULTS

A total of 8,489 umbilical, 1,801 epigastric, and 16,626 incisional hernia repairs were identified. Women undergoing primary ventral hernia repair were younger (umbilical 46.4 vs 54 years, epigastric 48.7 vs 52.7 years), with lower BMI (umbilical 30.4 vs 31.5, epigastric 29.2 vs 31.1), and less likely diabetic (umbilical 9.9% vs 11.4%, epigastric 6.8% vs 8.8%). Women undergoing incisional hernia repair were also younger (mean 57.5 vs 59.1 years), but with higher BMI (33.1 vs 31.5), and more likely diabetic (21.4% vs 19.1%). Propensity-matched analysis included 3,644 umbilical, 1,232 epigastric, and 12,480 incisional hernias. Women with incisional hernia were less likely to undergo an open repair (60.2% vs 63.4%, p < 0.001) and have mesh used (93.8% vs 94.8%, p = 0.02). In umbilical and incisional hernia repairs, women had higher rates of intraperitoneal mesh placement and men had higher rates of preperitoneal and retro-muscular mesh placement.

CONCLUSIONS

Small but statistically significant treatment differences in operative approach, mesh use, and mesh position exist between men and women undergoing ventral hernia repair. It remains unknown whether these treatment differences result in differing clinical outcomes.

The Impact of the COVID-19 Pandemic on Hernia Surgery: The South-East Scotland Experience

Aim

The coronavirus disease 2019 (COVID-19) pandemic resulted in a lockdown in South East Scotland on 23 March 2020. This had an impact on the volume of benign elective surgery able to be undertaken. The degree to which this reduced hernia surgery was unknown. The aim of this study was to review the hernia surgery workload in the Lothian region of Scotland and assess the impact of COVID-19 on hernia surgery.

Methods

The Lothian Surgical Audit database was used to identify all elective and emergency hernia operations over a six-month period from 23 March 2020 and for the same time period in 2019. Data were collected on age, gender, anatomical location of the hernia, hernia repair technique, and whether elective or emergency operation. Statistical analysis was performed using the chi-squared test in R-Studio, with a p-value of <0.05 accepted as statistically significant.

Results

The total number of hernia repairs reduced considerably between 2019 and 2020 (570 vs 149). The majority of this can be explained by a decrease in elective operating (488 vs 87), with the percentage of elective repairs reducing significantly from 85.6% to 58.4% (p<0.001). The inguinal hernia subgroup had a 24% rise in emergency operations from 21 to 26 operations, despite a reduction from 270 to 84 total inguinal repairs. There were just two elective hernia repairs carried out in the first three months of the 2020 study period (5.6% of all operations for April-June) compared to 265 (87.7%) for the same period in 2019 (p<0.001). No statistically significant differences were observed in the rates of laparoscopic versus open operating techniques across the two study periods on any analysis. The age and gender of the patients were similar over the two time periods.

Conclusion

The COVID-19 pandemic led to a marked reduction in the number of elective hernia repairs (especially incisional hernia surgery), with the effect most pronounced over the first three months of lockdown. Despite an overall reduction in total emergency operative figures, possibly due to more widespread use of non-operative strategies, there was still an increase in emergency inguinal hernia repairs during the lockdown. Further studies are needed to evaluate if the delays to elective operating will result in a long-term increase in the rates of emergency presentation.

Cost-Effectiveness Analysis of Inguinal Hernia Repair With Mesh Performed by Surgeons and Medical Doctors in Ghana

OBJECTIVES

Task-sharing is the pragmatic sharing of tasks between providers with different levels of training. To our knowledge, no study has examined the cost-effectiveness of surgical task-sharing of hernia repair in a low-resource setting. This study has aimed to evaluate and compare the cost-effectiveness of mesh repair performed by Ghanaian surgeons and medical doctors (MDs) following a standardized training program.

METHODS

This cost-effectiveness analysis included data for 223 operations on adult men with primary reducible inguinal hernia. Cost per surgery was calculated from the healthcare system perspective. Disability weights were calculated using pre- and postoperative pain scores and benchmarks from the Global Burden of Disease Study 2017.

RESULTS

The mean cost/disability-adjusted life-year (DALY) averted in the surgeon group was 444.9 United States dollars (USD) (95% confidence interval [CI] 221.2-668.5) and 278.9 USD (95% CI 199.3-358.5) in the MD group (P = .168), indicating that the operation is very cost-effective when performed by both providers. The incremental cost/DALY averted showed that task-sharing with MDs is also very cost-effective (95% bootstrap CI -436.7 to 454.9). The analysis found that increasing provider salaries is cost-effective if productivity remains high. When only symptomatic cases were analyzed, the mean cost/DALY averted reduced to 232.0 USD (95% CI 17.1-446.8) for the surgeon group and 129.7 USD (95% CI 79.6-179.8) for the MD group (P = .348), and the incremental cost/DALY averted increased by 45% but remained robust.

CONCLUSIONS

Elective inguinal hernia repair with mesh performed by Ghanaian surgeons and MDs is a low-cost procedure and very cost-effective in the context of the study. To maximize cost-effectiveness, symptomatic patients should be prioritized over asymptomatic patients and a high level of productivity should be maintained.

Chances of Mortality Are 3.5-Times Greater in Elderly Patients with Umbilical Hernia Than in Adult Patients: An Analysis of 21,242 Patients

The goal of this study was to identify risk factors that are associated with mortality in adult and elderly patients who were hospitalized for umbilical hernia. A total of 14,752 adult patients (ages 18−64 years) and 6490 elderly patients (ages 65+), who were admitted emergently for umbilical hernia, were included in this retrospective cohort study. The data were gathered from the National Inpatient Sample (NIS) 2005−2014 database. Predictors of mortality were identified via a multivariable logistic regression, in patients who underwent surgery and those who did not for adult and elderly age groups. The mean (SD) ages for adult males and females were 48.95 (9.61) and 46.59 (11.35) years, respectively. The mean (SD) ages for elderly males and females were 73.62 (6.83) and 77.31 (7.98) years, respectively. The overall mortality was low (113 or 0.8%) in the adult group and in the elderly group (179 or 2.8%). In adult patients who underwent operation, age (OR = 1.066, 95% CI: 1.040−1.093, p < 0.001) and gangrene (OR = 5.635, 95% CI: 2.288−13.874, p < 0.001) were the main risk factors associated with mortality. Within the same population, female sex was found to be a protective factor (OR = 0.547, 95% CI: 0.351−0.854, p = 0.008). Of the total adult sample, 43% used private insurance, while only 18% of patients in the deceased population used private insurance. Conversely, within the entire adult population, only about 48% of patients used Medicare, Medicaid, or self-pay, while these patients made up 75% of the deceased group. In the elderly surgical group, the main risk factors significantly associated with mortality were frailty (OR = 1.284, 95% CI: 1.105−1.491, p = 0.001), gangrene (OR = 13.914, 95% CI: 5.074−38.154, p < 0.001), and age (OR = 1.034, 95% CI: 1.011−1.057, p = 0.003). In the adult non-operation group, hospital length of stay (HLOS) was a significant risk factor associated with mortality (OR = 1.077, 95% CI: 1.004−1.155, p = 0.038). In the elderly non-operation group, obstruction was the main risk factor (OR = 4.534, 95% CI: 1.387−14.819, p = 0.012). Elderly patients experienced a 3.5-fold higher mortality than adult patients who were emergently admitted with umbilical hernia. Increasing age was a significant risk factor of mortality within all patient populations. In the adult surgical group, gangrene, Medicare, Medicaid, and self-pay were significant risk factors of mortality and female sex was a significant protective factor. In the adult non-surgical group, HLOS was the main risk factor of mortality. In the elderly population, frailty and gangrene were the main risk factors of mortality within the surgical group, and obstruction was the main risk factor for the non-surgical group.

Mesh versus non‐mesh for emergency groin hernia repair

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

An estrogen-sensitive fibroblast population drives abdominal muscle fibrosis in an inguinal hernia mouse model

Greater than 25% of all men develop an inguinal hernia in their lifetime, and more than 20 million inguinal hernia repair surgeries are performed worldwide each year. The mechanisms causing abdominal muscle weakness, the formation of inguinal hernias, or their recurrence are largely unknown. We previously reported that excessively produced estrogen in the lower abdominal muscles (LAMs) triggers extensive LAM fibrosis, leading to hernia formation in a transgenic male mouse model expressing the human aromatase gene (Aromhum). To understand the cellular basis of estrogen-driven muscle fibrosis, we performed single-cell RNA sequencing on LAM tissue from Aromhum and wild-type littermates. We found a fibroblast-like cell group composed of 6 clusters, 2 of which were validated for their enrichment in Aromhum LAM tissue. One of the potentially novel hernia-associated fibroblast clusters in Aromhum was enriched for the estrogen receptor-α gene (Esr1hi). Esr1hi fibroblasts maximally expressed estrogen target genes and seemed to serve as the progenitors of another cluster expressing ECM-altering enzymes (Mmp3hi) and to upregulate expression of proinflammatory, profibrotic genes. The discovery of these 2 potentially novel and unique hernia-associated fibroblasts may lead to the development of novel treatments that can nonsurgically prevent or reverse inguinal hernias.

The Risk of Incarceration During Nonoperative Management of Incisional Hernias: A Population-based Analysis of 30,998 Patients

OBJECTIVE

The aim of the study was to quantify the risk of incarceration of incisional hernias.

BACKGROUND

Operative repair is the definitive treatment for incisional ventral hernias but is often deferred if the perceived risk of elective operation is elevated secondary to comorbid conditions. The risk of incarceration during nonoperative management (NOM) factors into shared decision making by patient and surgeon; however, the incidence of acute incarceration remains largely unknown.

METHODS

A retrospective analysis of adult patients with an International Classification of Diseases, Ninth Revision or Tenth Revision diagnosis of incisional hernia was conducted from 2010 to 2017 in 15 hospitals of a single healthcare system. The primary outcome was incarceration necessitating emergent operation. The secondary outcome was 30-, 90-, and 365-day mortality. Univariate and multivariate analyses were used to determine independent predictors of incarceration.

RESULTS

Among 30,998 patients with an incisional hernia (mean age 58.1 ± 15.9 years; 52.7% female), 23,022 (78.1%) underwent NOM of whom 540 (2.3%) experienced incarceration, yielding a 1- and 5-year cumulative incidence of 1.24% and 2.59%, respectively. Independent variables associated with incarceration included: age older than 40 years, female sex, current smoker, body mass index 30 or greater, and a hernia-related inpatient admission. All-cause mortality rates at 30, 90, and 365 days were significantly higher in the incarceration group at 7.2%, 10%, and 14% versus 1.1%, 2.3%, and 5.3% in patients undergoing successful NOM, respectively.

CONCLUSIONS

Incarceration is an uncommon complication of NOM but is associated with a significant risk of death. Tailored decision making for elective repair and considering the aforementioned risk factors for incarceration provides an initial step toward mitigating the excess morbidity and mortality of an incarceration event.

Long-Term Follow-Up of Lichtenstein Repair of Inguinal Hernia in the Morbid Patients With Self-Gripping Mesh (ProgripTM)

Objective: This study aimed to demonstrate the safety and the efficacy of the self-gripping mesh (Progrip^TM) for inguinal hernia repair in morbid patients of the higher American Society of Anesthesiologists (ASA) classification (ASA III and IV). The incidence of chronic pain, postoperative complications, and hernia recurrence was evaluated.

Methods: Data were collected retrospectively from the files of the patient and were analyzed for 198 hernias in 147 patients. All the patients included in this study had undergone inguinal hernia repair by Lichtenstein approach with the self-gripping mesh (Progrip^TM) in the same clinical center. Preoperative, perioperative, and postoperative data were collected and a long-term follow-up of 31.8 ± 19.5 m (5–60 m) was performed. Complications, pain scored on a 0–10 numeric rating scale (NRS), and hernia recurrence were assessed.

Results: During the past 5 years, 198 hernias in 147 patients were repaired with the Lichtenstein procedure with the self-gripping mesh (Progrip^TM). The majority of the patients were high level of the ASA classification (ASA III and IV) (95.9%), with ASA III (10.2%) and IV (85.7%). The mean operation time was 71.2 ± 23.8 min. The mean length of postoperative stay was 2.5 ± 2.1 days. There were no intraoperative complications. About 14 cases (7.1%) suffered from postoperative surgical wound complications, which were limited to the skin and subcutaneous tissue and were cured with the conservative methods successfully; there was no mesh infection, the acute postoperative pain was low or mild [visual analog scale (VAS) score ≤ 4] and the chronic postoperative pain was reported in three patients (1.5%) and tolerable, hernia recurrence (femoral hernia recurrence) occurred in one patient half a year after during the follow-up period.

Conclusion: This study demonstrated the advantages of the self-gripping mesh in hernia repair of the high-risk patients with inguinal hernia (ASA III and IV) by Lichtenstein procedure under local anesthesia.

Short-Term Outcomes of Inguinal Hernia Repair in Older Patients: A Retrospective Review at a Tertiary Center

Objectives

Although inguinal hernia (IH) repair is low-risk surgery, older patients are occasionally offered watchful waiting because of their functional status and comorbidities. This study reviewed the surgical outcomes of IH repair in older patients in comparison with outcomes in younger patients.

Methods

This retrospective study included all patients who had IH repair from 2010 to 2020. The primary outcomes of interest were postoperative complications and recurrence.

Results

A total of 262 patients underwent IH repair during the study period; 40% were ≥60 years old. One patient had a recurrence. Among the 8% of patients who had postoperative complications, groin pain was the most common one (1.9%). Female patients had a significantly higher rate of complications than male patients did (38.5% female versus 6.4% male, p<0.001). The rate of complications was also higher for emergency surgery than for elective surgery (22.6% emergency versus 6.1% elective, p<0.001), as well for patients who needed concomitant bowel resection compared with those who did not. Patients who had emergency surgery or postoperative complications had a prolonged hospital stay. 

Conclusions

IH repair in older patients is low-risk surgery, comparable to that in younger patients. In this study, emergency surgery was more common in older than in younger patients and posed a higher risk of complications. We recommend offering elective hernia repair to older patients to avoid the higher complication rate associated with emergency repair.

Predictors of long-term mortality in octogenarian veterans following inguinal hernia repair

BACKGROUND

While elective inguinal hernia repair (IHR) in octogenarians carries a low 30-day mortality rate, long-term outcomes are uncharted. If on average, veteran octogenarians are expected to succumb to pre-existing cardiopulmonary disease within a year of diagnosis, watchful waiting might be advisable. This study interrogated long-term mortality and its predictors following elective IHR in veteran octogenarians.

MATERIALS AND METHODS

This is a retrospective analysis of 109 veterans (≥ 80 years of age), ten of which were nonagenarians who had an elective IHR. Data were dichotomized between deceased vs. non-deceased patients for univariable and multivariable analyses. Patient characteristics were also assessed in patients undergoing general (GA) vs. local (LA) anesthesia and corrected for unilateral repair and age. Kaplan-Meier curves were generated in corrected and uncorrected cohorts receiving GA vs. LA.

RESULTS

At the time of analysis, 46 (45.0%) octogenarians were deceased. The average time to death following IHR was 3.7 ± 2.9 years [range (37 days-12.4 years)]. Univariable analysis showed renal disease (19.9% vs. 5.3%), operative time (67.9 ± 29.0 vs. 56.1 ± 14.4 min) and use of GA (73.0% vs. 34.8%) associated with long-term mortality (all p < 0.01). Renal disease [odds ratio (95% confidence intervals) 4.1 (1.2-13.8)] and use of GA [5.0 (2.0-10.0)] were independent predictors of mortality. Patients undergoing LA (n = 62) were older, were more likely to have cardiac disease, and had a higher ASA compared to patients receiving GA (n = 47). After correcting for age, cardiac disease and higher ASA remained more common in patients submitting to LA. Long-term mortality was significantly higher in both matched and unmatched octogenarians undergoing GA.

CONCLUSION

Octogenarian veterans with a high burden of comorbid conditions are unlikely to experience short-term mortality because of their pre-existing conditions. Inguinal hernia repair should be offered to octogenarian veterans, but GA should be avoided whenever possible.

Analysis of risk factors for surgical site infection and postoperative recurrence following inguinal and femoral hernia surgery in adults

OBJECTIVE

We aimed to evaluate the causes of complications following surgery for inguinal and femoral hernia, using surgical site infection (SSI) and recurrence rate as indicators of outcomes to consider appropriate treatments.

METHODS

We retrospectively assessed the medical histories of 1,098 patients with adult inguinal and femoral hernias who underwent herniorrhaphy between July 2010 and March 2019. Using SSI and recurrence rate as indicators of outcomes, we statistically assessed the influence of preoperative and operative conditions on surgical outcomes.

RESULTS

The occurrence of postoperative SSI was significantly more frequent in patients who experienced a long surgical duration, excessive blood loss, and incarceration; underwent emergency surgery and bowel resection; and in whom no mesh sheet insertion was performed. There was no correlation between mesh use and SSI in cases that did not require emergency incarceration repair. For cases involving hernia incarceration, the use of a mesh sheet was avoided to prevent potential infection, which could explain the high incidence of SSI in cases where mesh was not used. The hernia may have recurred due to technical issues during the procedure, as well as failure to ligate the hernia sac.

CONCLUSIONS

Selecting the appropriate surgical method for hernia repair may reduce the incidence of SSI. If manual reduction of inguinal hernias is not possible, an appropriate surgical procedure should be determined based on laparoscopic findings in facilities where laparoscopic hernia surgeries are frequently performed. Moreover, in cases without infection and bowel resection, mesh use may be beneficial. Recurrence can be prevented by ligating the hernia sac during surgery and solving relevant technical problems.

Elective abdominal wall hernia repair surgical mortality-A systematic review of the literature and peer review of mortality in Australia

BACKGROUND

This study systematically reviewed the literature regarding perioperative mortality in human adults undergoing elective surgical abdominal wall hernia repair, including an audit of the Royal Australasian College of Surgeons (RACS) Australian and New Zealand Audit of Surgical Mortality (ANZASM) database.

METHODS

A systematic review was conducted in accordance with PRISMA guidelines for the reporting of systematic reviews and meta-analysis of observational studies. Cochrane Library, PubMed, MEDLINE and Embase database searches and data extraction were conducted from June 1979 to October 2019. Statistical analysis was undertaken utilising denominator values for elective hernia procedures derived from the Australian Institute of Health and Welfare (AIHW) data. Risk-adjusted perioperative mortality rates for the relevant procedures were also produced, using a binary logistic regression for the risk adjustment.

RESULTS

Through systematic review of the literature, it was established that the overall reported perioperative mortality in human adults undergoing elective surgical abdominal wall hernia repair was low (0.1%-0.5%). Using ANZASM and AIHW data, the calculated risk-adjusted mortality rate for Australian patients was found to be significantly lower (0.04%-0.06%, p < 0.001).

CONCLUSION

The risk-adjusted mortality rate for elective abdominal wall hernia surgery in Australia is very low and compares favourably to international cohorts. Despite low absolute numbers, the factors which were most significantly associated with increased perioperative mortality in patients undergoing elective surgical abdominal wall hernia repair were increased age, cardiorespiratory co-morbidity and incisional hernia repair.

Mortality After Extrahepatic Gastrointestinal and Abdominal Wall Surgery in Patients With Alcoholic Liver Disease: A Systematic Review and Meta-Analysis

AIMS

This meta-analysis aimed to define the perioperative risk of mortality in patients with alcoholic liver disease (ALD) undergoing extrahepatic gastrointestinal surgery.

METHODS

Systematic searches of Embase, Medline and CENTRAL were undertaken to identify studies reporting about patients with ALD undergoing extrahepatic gastrointestinal surgery published since database inception to January 2019. Studies were only considered if they reported on mortality as an outcome. Pooled analysis of mortality was stratified as benign and malignant surgery and specific operative procedures where feasible.

RESULTS

Of the 2899 studies identified, only five studies met inclusion criteria, representing cholecystectomy (one study), umbilical hernia repair surgery (one study) and oesophagectomy (three studies). The total number of patients with ALD in these studies was 172. Therefore, any study on liver disease patients undergoing extrahepatic surgery that crucially included a subset with alcohol aetiology was included as a secondary analysis even though they failed to stratify mortality by underlying aetiology. The total number of studies that met this expanded inclusion criteria was 62, reporting on 37,703 patients with liver disease of which 1735 (4.5%) had a definite diagnosis of ALD. Meta-analysis of proportions of in-hospital mortality in patients with ALD undergoing upper gastrointestinal cancer surgery (oesophagectomy) was 23% [95% confidence interval (CI) 14-35%, I2 = 0%]. In-hospital mortality following oesophagectomy in liver disease patients of all aetiologies was lower, 14% (95% CI 9-21%, I2 = 41.1%).

CONCLUSION

Postoperative in-hospital mortality is high in patients with liver disease and ALD in particular. However, the currently available evidence on ALD is limited and precludes definitive conclusions on postoperative mortality risk.

Perioperative outcome in groin hernia repair: what are the most important influencing factors?

INTRODUCTION

Using registry analyses, a large number of influencing factors on the perioperative outcome of groin hernia repair has been identified. The interactions between several influencing factors and differences in the influencing value have to date been inadequately investigated.

METHODS

This retrospective analysis of prospectively collected data from the Herniamed Registry included all fully documented cases with minimum age of 16 years and groin hernia repair. Patients were assigned to the risk groups unilateral, bilateral, recurrent and emergency groin hernia repair. Multivariable analysis was performed to investigate the influence of confirmatory defined patient- and procedure-related characteristics on the outcome parameters intraoperative, postoperative general and postoperative surgical complications, complication-related reoperation and total perioperative complications.

RESULTS

A highly significantly unfavorable association with the total perioperative complication rate was identified for emergency groin hernia repair, scrotal hernia, anticoagulant medication and coagulopathy. A significantly unfavorable relation with the total perioperative complication rate was found for recurrence procedure, bilateral repair, high age, ASA score III/IV, femoral hernia, antithrombotic medication, smoking, COPD and corticosteroid medication. A significantly favorable correlation with the total perioperative complication rate was observed for the laparo-endoscopic techniques, smaller defects, female gender, normal weight and medial hernia.

CONCLUSION

Both the number of potential influencing factors and their influencing value on the perioperative outcome should be considered when estimating the individual risk of a patient with groin hernia repair.

Trends in Emergent Groin Hernia Repair-An Analysis From the Herniamed Registry

Introduction: While the proportion of emergency groin hernia repairs in developed countries is 2.5–7.7%, the percentage in developing countries can be as high as 76.9%. The mortality rate for emergency groin hernia repair in developed countries is 1.7–7.0% and can rise to 6–25% if bowel resection is needed. In this present analysis of data from the Herniamed Registry, patients with emergency admission and operation within 24 h are analyzed.

Methods: Between 2010 and 2019 a total of 13,028 patients with emergency admission and groin hernia repairs within 24 h were enrolled in the Herniamed Registry. The outcome results were assigned to the year of repair and summarized as curves. The total patient collective is broken down into the subgroups with pre-operative manual reduction (taxis) of the hernia content, operative reduction of the hernia content without bowel resection and with bowel resection. The explorative Fisher's exact test was used for statistical assessment of significant differences with Bonferroni adjustment for multiple testing.

Results: The proportion of emergency admissions with groin hernia repair within 24 h was 2.7%. The percentage of women across the years was consistently 33%. The part of femoral hernias was 16%. The proportion of patients with pre-operative reduction (taxis) remained unchanged at around 21% and the share needing bowel resection was around 10%. The proportion of TAPP repairs rose from 21.9% in 2013 to 38.0% in 2019 (p < 0.001). Between the three groups with pre-operative taxis, without bowel resection and with bowel resection, highly significant differences were identified between the patients with regard to the rates of post-operative complications (4% vs. 6.5% vs. 22.7%; p < 0.0001), complication-related reoperations (1.9% vs. 3.8% vs. 17.7%; p < 0.0001), and mortality rate (0.3% vs. 0.9% vs. 7.5%; p < 0.001). In addition to emergency groin hernia repair subgroups female gender and age ≥66 years are unfavorable influencing factors for perioperative outcomes.

Conclusion: For patients with emergency groin hernia repair the need for surgical reduction or bowel resection, female gender and age ≥66 years have a highly significantly unfavorable influence on the perioperative outcomes.

Outcomes after emergency abdominal surgery in COVID-19 patients at a referral center in Brazil

Purpose

COVID-19 is associated with high morbidity and mortality in patients undergoing surgery. Contrary to elective procedures, emergency operations should not be postponed. We aim to evaluate the profile and outcomes of COVID-19 patients who underwent emergency abdominal surgery.

Methods

We performed a retrospective analysis of perioperative data of COVID-19 patients undergoing emergency surgery from April 2020 to August 2020.

Results

Eighty-two patients were evaluated due to abdominal complaints, yielding 22 emergency surgeries. The mean APACHE II and SAPS were 18.7 and 68, respectively. Six patients had a PaO₂/FiO₂ lower than 200 and more than 50% of parenchymal compromise on chest tomography.

The most common indications for emergency surgery were hernias (6; 27.2%). The median length of stay was 30 days, and only two patients required reoperation. Postoperatively, 10 (43.3%) patients needed mechanical ventilation for a mean of 6 days. The overall mortality rate was 31.8%.

Conclusion

Both postoperative morbidity and mortality are high in COVID-19 patients with respiratory compromise and abdominal emergencies.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13304-021-01007-5.

If laparoscopic technique can be used for treatment of acutely incarcerated/strangulated inguinal hernia?

Purpose

Laparoscopic treatment for acutely incarcerated/strangulated inguinal hernias is uncommon and controversial. In the present study, we assessed the safety and feasibility of transabdominal preperitoneal (TAPP) repair for the treatment of acutely incarcerated/strangulated inguinal hernias.

Methods

Patients with acutely incarcerated/strangulated inguinal hernias who underwent TAPP repair at the Department of Hernia and Abdominal Wall Surgery (Beijing Chaoyang Hospital) from January 2017 to December 2019 were retrospectively reviewed. Patients’ characteristics, operation details, and postoperative complications were retrospectively analyzed.

Results

In total, 94 patients with acutely incarcerated/strangulated inguinal hernias underwent TAPP repair. The patients comprised 85 men and 9 women (mean age, 54.3 ± 13.6 years; mean operating time, 61.6 ± 17.7 min; mean hospital stay, 3.9 ± 2.2 days). No patients were converted to open surgery. Hernia reduction was successfully performed in all patients. The morbidity of complications was 20.2% (19/94). Two bowel resections were performed endoscopically. Nine (9.6%) patients avoided unnecessary bowel resections during laparoscopic procedures. All patients recovered well without severe complications. No recurrence or infection was recorded during a mean follow-up period of 26.8 ± 9.8 months.

Conclusions

TAPP appears to be safe and feasible for treatment of patients with acutely incarcerated/strangulated inguinal hernias. However, it requires performed by experienced surgeons in laparoscopic techniques.

OPEN VS LAPAROSCOPIC HERNIA REPAIR IN THE BRAZILIAN PUBLIC HEALTH SYSTEM. AN 11-YEAR NATIONWIDE POPULATION-BASED STUDY

BACKGROUND

Abdominal wall hernia is one of the most common surgical pathologies. The advent of minimally invasive surgery raised questions about the best technique to be applied, considering the possibility of reducing postoperative pain, a lower rate of complications, and early return to usual activities.

OBJECTIVE

To evaluate the frequency of open and laparoscopic hernioplasties in Brazil from 2008 to 2018, analyzing the rates of urgent and elective surgeries, mortality, costs, and the impact of laparoscopic surgical training on the public health system.

METHODS

Nationwide data from 2008 to 2018 were obtained from the public health registry database (DATASUS) for a descriptive analysis of the selected data and parameters.

RESULTS

2,671,347 hernioplasties were performed in the period, an average of 242,850 surgeries per year (99.4% open, 0.6% laparoscopic). The economically active population (aged 20-59) constituted the dominant group (54.5%). There was a significant reduction (P<0.01) in open surgeries, without a compensatory increase in laparoscopic procedures. 22.3% of surgeries were urgent, with a significant increase in mortality when compared to elective surgeries (P<0.01). The distribution of laparoscopic surgery varied widely, directly associated with the number of digestive surgeons.

CONCLUSION

This study presents nationwide data on hernia repair surgeries in Brazil for the first time. Minimally invasive techniques represent a minor portion of hernioplasties. Urgent surgeries represent a high percentage when compared to other countries, with increased mortality. The data reinforce the need for improvement in the offer of services, specialized training, and equalization in the distribution of procedures in all regions.

Emergency hernia surgery at a high-volume tertiary centre: a 3-year experience

BACKGROUND

Hernia surgery is often considered minor. However, emergency abdominal wall hernia (AWH) surgery is associated with significant morbidity. This study reviews a high-volume centre's experience.

METHODS

This is a retrospective review of all emergency AWH operations performed between 2014 and 2017. The following were analysed: patient demographics, ASA grade, type of hernia, time from admission to surgery, use of pre-operative imaging, sac content, details of bowel resection, rate of admission to high dependency unit (HDU)/intensive care unit (ICU), length of stay and morbidity/mortality.

RESULTS

A total of 198 cases were included. Median age was 67.4 years (range 19-95). 52.2% of patients were ASA III or above. Median time from admission to surgery was 13 h (range 1-341) and median length of stay was 4 days (range 1-75). The sac contained bowel in 93 cases (47.0%). These patients had longer length of stay (P < 0.01) and were more frequently admitted to HDU/ICU (P < 0.01). Thirty-one patients underwent bowel resection (33.3% of those with bowel involvement and 15.7% of the total). Twenty-seven patients (13.6%) were admitted to HDU/ICU post-operatively. Six patients (3.0%) had an unplanned return to theatre and 66 patients (33.3%) had a post-operative complication. Inpatient mortality was three (1.51%).

CONCLUSIONS

Patients who undergo emergency AWH surgery represent a relatively aged and co-morbid group. This surgery is associated with significant morbidity and consumes considerable hospital resources. Efforts should be made to identify the higher risk subgroup with bowel involvement. Elderly and co-morbid patients should be listed for timely elective surgery wherever suitable.

Outcomes After Elective Inguinal Hernia Repair Performed by Associate Clinicians vs Medical Doctors in Sierra Leone: A Randomized Clinical Trial

IMPORTANCE

Task sharing of surgical duties with medical doctors (MDs) without formal surgical training and associate clinicians (ACs; health care workers corresponding to an educational level between that of a nurse and an MD) is practiced to provide surgical services to people in low-resource settings. The safety and effectiveness of this has not been fully evaluated through a randomized clinical trial.

OBJECTIVE

To determine whether task sharing with MDs and ACs is safe and effective in mesh hernia repair in Sierra Leone.

DESIGN, SETTING, AND PARTICIPANTS

This single-blind, noninferiority randomized clinical trial included adult, healthy men with primary inguinal hernia randomized to receiving surgical treatment from an MD or an AC. In Sierra Leone, ACs practicing surgery have received 2 years of surgical training and completed a 1-year internship. The study was conducted between October 2017 and February 2019. Patients were followed up at 2 weeks and 1 year after operations. Observers were blinded to the study arm of the patients. The study was carried out in a first-level hospital in rural Sierra Leone. Data were analyzed from March to June 2019.

INTERVENTIONS

All patients received an open mesh inguinal hernia repair under local anesthesia. The control group underwent operations performed by MDs, and the intervention group underwent operations performed by ACs.

MAIN OUTCOMES AND MEASURES

The primary end point was hernia recurrence at 1 year. Outcomes were assessed by blinded observers at 2 weeks and 1 year after operations.

RESULTS

A total of 230 patients were recruited (mean [SD] age, 43.0 [13.5] years), and all but 1 patient underwent inguinal hernia repair between October 23, 2017, and February 2, 2018, performed by 5 MDs and 6 ACs. A total of 114 patients were operated on by MDs, and 115 patients were operated on by ACs. There were no crossovers between the study arms. The follow-up rate was 100% at 2 weeks and 94.1% at 1 year. At 1 year, hernia recurrence occurred in 7 patients (6.9%) operated on by MDs and 1 patient (0.9%) operated on by ACs (absolute difference, -6.0 [95% CI, -11.2 to 0.7] percentage points; P < .001).

CONCLUSIONS AND RELEVANCE

These findings demonstrate that task sharing of elective mesh inguinal hernia repair with ACs was safe and effective. The task sharing debate should progress to focus on optimizing surgical training programs for nonsurgeons and building capacity for elective surgical care in low- and middle-income countries.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN63478884.

Asymptomatic abdominal wall and incisional hernias: Is therapeutic decision consensual? An international survey

Introduction

Hernia pathology is one of the leading causes of surgery worldwide. For asymptomatic patients, surgery remains questionable. The objective of this study was to evaluate the practices of a large population of digestive surgeons with asymptomatic hernia.

Methods

Between October 2016 and March 2017, French-speaking digestive surgeons were invited to respond to an online survey consisting of 13 common clinical situations concerning primary or asymptomatic incisional hernia pathology where a therapeutic decision was requested. A consensual attitude was defined by identical care by at least 75% of surgeons.

Results

Of the 204 surgeons responding to the study, 44% were under 45 years of age. The therapeutic attitude was consensual in 2 out of 13 clinical cases: surgical abstention was chosen consensually for inguinal hernia in the elderly with comorbidities while surgical treatment was consensually chosen for incisional hernia in a young patient in remission of pancreatic cancer. The under-45s were more likely to undergo surgical repair (5 cases of 13 vs 4 cases of 13, p = 0.03).

Conclusion

Although frequent, the management of primary and incisional hernias of the abdominal wall does not reach consensus in the surgical community. Specific recommendations for indications of surgical management or watchful waiting are required.

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There is a great heterogeneity among surgeons in management of asymptomatic abdominal wall pathology, without any consensus.

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While a surgical indication should be retained in women with a femoral hernia, the consensus threshold has not been reached.

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The age of the surgeons has an impact on their therapeutic decision, the young surgeons favoring an intervention.

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The type of care structure does not imply modifications of therapeutic practices of asymptomatic hernias among the surgeons.

Outcomes of Emergent Inguinal Hernia Repair in Veteran Octogenarians

Outcomes from emergent inguinal hernia (IH) repair in veteran octogenarians are not well described. We reviewed outcomes for this cohort from 2005 to 2012 at the VA North Texas Health Care System. There were 15 emergent (Group I) and 86 elective (Group II) operations performed in octogenarians. Age and American Society of Anesthesiologists status were similar in both groups. The rate of minor and major complications was higher in Group I compared with Group II (33 and 19% vs 22 and 2%, respectively; both Ps < 0.001). Hospital length of stay (LOS) and intensive care unit LOS were also longer in Group I compared with Group II (6.7 ± 7.0 and 2.5 ± 4.4 vs 0.8 ± 1.9 and 0.12 ± 0.6 days, respectively; both Ps < 0.001). Thirty-day mortality was 13 per cent for Group I and 0 per cent for Group II. Despite the high rate of comorbid conditions in our group, the risk associated with elective repair of IH was not prohibitive. In contrast, we observed that 15 per cent of patients presented with an incarcerated hernia during the study period and the mortality rate was 13 per cent in this cohort. Factors that might predict incarceration in veteran octogenarians need to be further investigated.

Risk of hernia formation after radical prostatectomy: a comparison between open and robot-assisted laparoscopic radical prostatectomy within the prospectively controlled LAPPRO trial

Purpose

In addition to incisional hernia, inguinal hernia is a recognized complication to radical retropubic prostatectomy. To compare the risk of developing inguinal and incisional hernias after open radical prostatectomy compared to robot-assisted laparoscopic prostatectomy.

Method

Patients planned for prostatectomy were enrolled in the prospective, controlled LAPPRO trial between September 2008 and November 2011 at 14 hospitals in Sweden. Information regarding patient characteristics, operative techniques and occurrence of postoperative inguinal and incisional hernia were retrieved using six clinical record forms and four validated questionnaires.

Results

3447 patients operated with radical prostatectomy were analyzed. Within 24 months, 262 patients developed an inguinal hernia, 189 (7.3%) after robot-assisted laparoscopic prostatectomy and 73 (8.4%) after open radical prostatectomy. The relative risk of having an inguinal hernia after robot-assisted laparoscopic prostatectomy was 18% lower compared to open radical retropubic prostatectomy, a non-significant difference. Risk factors for developing an inguinal hernia after prostatectomy were increased age, low BMI and previous hernia repair. The incidence of incisional hernia was low regardless of surgical technique. Limitations are the non-randomised setting.

Conclusions

We found no difference in incidence of inguinal hernia after open retropubic and robot-assisted laparoscopic radical prostatectomy. The low incidence of incisional hernia after both procedures did not allow for statistical analysis. Risk factors for developing an inguinal hernia after prostatectomy were increased age and BMI.

Electronic supplementary material

The online version of this article (10.1007/s10029-020-02178-7) contains supplementary material, which is available to authorized users.

Influencing Factors on the Outcome in Female Groin Hernia Repair: A Registry-based Multivariable Analysis of 15,601 Patients

OBJECTIVE

Based on an analysis of data from the Herniamed Registry, this study aims to identify all factors influencing the outcome in female groin hernia repair.

BACKGROUND

In a systematic review and meta-analysis of observational studies, female sex was found to be a significant risk factor for recurrence. In the guidelines, the totally extraperitoneal patch plasty (TEP) and transabdominal preperitoneal patch plasty (TAPP) laparo-endoscopic techniques are recommended for female groin hernia repair. However, even when complying with the guidelines, a less favorable outcome must be expected than in men. To date, there is no study in the literature for analysis of all factors influencing the outcome in female groin hernia repair.

METHODS

In all, 15,601 female patients from the Herniamed Registry who had undergone primary unilateral groin hernia repair with the Lichtenstein, Shouldice, TEP or TAPP technique, and for whom 1-year follow-up was available, were selected between September 1, 2009 and July 1, 2017. Using multivariable analyses, influencing factors on the various outcome parameters were identified.

RESULTS

In the multivariable analysis, a significantly higher risk of postoperative complications, complication-related reoperations, recurrences, and pain on exertion was found only for the Lichtenstein technique. No negative influence on the outcome was identified for the TEP, TAPP, or Shouldice techniques. Relevant risk factors for occurrence of perioperative complications, recurrences, and chronic pain were preoperative pain, existing risk factors, larger defects, a higher body mass index (BMI), higher American Society of Anesthesiologists (ASA) classification and postoperative complications. Higher age had a negative association with postoperative complications and positive association with pain rates.

CONCLUSIONS

Female groin hernia repair should be performed with the TEP or TAPP laparo-endoscopic technique, or, alternatively, with the Shouldice technique, if there is no evidence of a femoral hernia. By contrast, the Lichtenstein technique has disadvantages in terms of postoperative complications, recurrences, and pain on exertion. Important risk factors for an unfavorable outcome are preoperative pain, existing risk factors, higher ASA classification, higher BMI, and postoperative complications. A higher age and larger defects have an unfavorable impact on postoperative complications and a more favorable impact on chronic pain.

The reality of general surgery training and increased complexity of abdominal wall hernia surgery

INTRODUCTION

The Accreditation and Certification of Hernia Centers and Surgeons (ACCESS) Group of the European Hernia Society (EHS) recognizes that there is a growing need to train specialist abdominal wall surgeons. The most important and relevant argument for this proposal and statement is the growing acceptance of the increasing complexity of abdominal wall surgery due to newer techniques, more challenging cases and the required 'tailored' approach to such surgery. There is now also an increasing public awareness with social media, whereby optimal treatment results are demanded by patients. However, to date the complexity of abdominal wall surgery has not been properly or adequately defined in the current literature.

METHODS

A systematic search of the available literature was performed in May 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, with 75 publications identified as relevant. In addition, an analysis of data from the Herniamed Hernia Registry was performed. The percentage of patients with hernia- or patient-related characteristics which unfavorably impacted the outcome of inguinal and incisional hernia repair was also calculated.

RESULTS

All present guidelines for abdominal wall surgery recommend the utilization of a 'tailored' approach. This relies on the prerequisite that any surgical technique used has already been mastered, as well as the recognized learning curves for each of the several techniques that can be used for both inguinal hernia (Lichtenstein, TEP, TAPP, Shouldice) and incisional hernia repairs (laparoscopic IPOM, open sublay, open IPOM, open onlay, open or endoscopic component separation technique). Other hernia- and patient-related characteristics that have recognized complexity include emergency surgery, obesity, recurrent hernias, bilateral inguinal hernias, groin hernia in women, scrotal hernias, large defects, high ASA scores, > 80 years of age, increased medical risk factors and previous lower abdominal surgery. The proportion of patients with at least one of these characteristics in the Herniamed Hernia Registry in the case of both inguinal and incisional hernia is noted to be relatively high at around 70%. In general surgery training approximately 50-100 hernia repairs on average are performed by each trainee, with around only 25 laparo-endoscopic procedures.

CONCLUSION

A tailored approach is now employed and seen more so in hernia surgery and this fact is referred to and highlighted in the contemporaneous hernia guidelines published to date. In addition, with the increasing complexity of abdominal wall surgery, the number of procedures actually performed by trainees is no longer considered adequate to overcome any recognized learning curve. Therefore, to supplement general surgery training young surgeons should be offered a clinical fellowship to obtain an additional qualification as an abdominal wall surgeon and thus improve their clinical and operative experience under supervision in this field. Practicing general surgeons with a special interest in hernia surgery can undertake intensive further training in this area by participating in clinical work shadowing in hernia centers, workshops and congresses.

Network meta-analysis of urinary retention and mortality after Lichtenstein repair of inguinal hernia under local, regional or general anaesthesia

BACKGROUND

Urinary retention and mortality after open repair of inguinal hernia may depend on the type of anaesthesia. The aim of this study was to investigate possible differences in urinary retention and mortality in adults after Lichtenstein repair under different types of anaesthesia.

METHODS

Systematic searches were conducted in the Cochrane, PubMed and Embase databases, with the last search on 1 August 2018. Eligible studies included adult patients having elective unilateral inguinal hernia repair by the Lichtenstein technique under local, regional or general anaesthesia. Outcomes were urinary retention and mortality, which were compared between the three types of anaesthesia using meta-analyses and a network meta-analysis.

RESULTS

In total, 53 studies covering 11 683 patients were included. Crude rates of urinary retention were 0·1 (95 per cent c.i. 0 to 0·2) per cent for local anaesthesia, 8·6 (6·6 to 10·5) per cent for regional anaesthesia and 1·4 (0·6 to 2·2) per cent for general anaesthesia. No death related to the type of anaesthesia was reported. The network meta-analysis showed a higher risk of urinary retention after both regional (odds ratio (OR) 15·73, 95 per cent c.i. 5·85 to 42·32; P < 0·001) and general (OR 4·07, 1·07 to 15·48; P = 0·040) anaesthesia compared with local anaesthesia, and a higher risk after regional compared with general anaesthesia (OR 3·87, 1·10 to 13·60; P = 0·035). Meta-analyses showed a higher risk of urinary retention after regional compared with local anaesthesia (P < 0·001), but no difference between general and local anaesthesia (P = 0·08).

CONCLUSION

Local or general anaesthesia had significantly lower risks of urinary retention than regional anaesthesia. Differences in mortality could not be assessed as there were no deaths after elective Lichtenstein repair. Registration number: CRD42018087115 ( https://www.crd.york.ac.uk/prospero).

Association of Patient Frailty With Increased Morbidity After Common Ambulatory General Surgery Operations

Importance

Frailty is a measure of decreased physiological reserve that is associated with morbidity and mortality in major elective and emergency general surgery operations, independent of chronological age. To date, the association of frailty with outcomes in ambulatory general surgery has not been established.

Objective

To determine the association between frailty and perioperative morbidity in patients undergoing ambulatory general surgery operations.

Design, Setting, and Participants

A retrospective cohort study was conducted of 140 828 patients older than 40 years of age from the 2007-2010 American College of Surgeons National Surgical Quality Improvement Program Participant Use File who underwent ambulatory and 23-hour-stay hernia, breast, thyroid, or parathyroid surgery. Data analysis was performed from August 18, 2016, to June 21, 2017.

Main Outcomes and Measures

The association between the National Surgical Quality Improvement Program modified frailty index and perioperative morbidity was determined via multivariable logistic regression with random-effects modeling to control for clustering within Current Procedural Terminology codes.

Results

A total of 140 828 patients (80 147 women and 60 681 men; mean [SD] age, 59.3 [12.0] years) underwent ambulatory hernia (n = 71 455), breast (n = 51 267), thyroid, or parathyroid surgery (n = 18 106). Of these patients, 2457 (1.7%) experienced any type of perioperative complication and 971 (0.7%) experienced serious perioperative complications. An increasing modified frailty index was associated with a stepwise increase in the incidence of complications. In multivariable analysis adjusting for age, sex, race/ethnicity, anesthesia type, tobacco use, renal failure, corticosteroid use, and clustering by Current Procedural Terminology codes, an intermediate modified frailty index score (0.18-0.35, corresponding to 2-3 frailty traits) was associated with statistically significant odds ratios of 1.70 (95% CI, 1.54-1.88; P < .001) for any complication and 2.00 (95% CI, 1.72-2.34; P < .001) for serious complications. A high modified frailty index score (≥0.36, corresponding to ≥4 frailty traits) was associated with statistically significant odds ratios of 3.35 (95% CI, 2.52-4.46; P < .001) for any complication and 3.95 (95% CI, 2.65-5.87; P < .001) for serious complications. Anesthesia with local and monitored anesthesia care was the only modifiable covariate associated with decreased odds of serious 30-day complications, with an adjusted odds ratio of 0.66 (95% CI, 0.53-0.81; P < .001).

Conclusions and Relevance

Frailty is associated with increased perioperative morbidity in common ambulatory general surgery operations, independent of age, type of anesthesia, and other comorbidities. Surgeons should consider frailty rather than chronological age when counseling and selecting patients for elective ambulatory surgery.