Trends in Australian inguinal hernia repair rates: a 15‐year population study

Contemporary Approaches to Hernia Repair: A Narrative Review in General Surgery

This narrative review offers a thorough and inclusive examination of modern techniques for hernia repair in general surgery. This exploration spans the development of new methods, substances, and technology, providing insight into the significant changes in hernia treatment in recent years. An extensive examination of peer-reviewed literature, encompassing historical advancements, conventional approaches, and the rise of contemporary surgical tactics, was undertaken. Key focus areas include integrating mesh technology, minimally invasive procedures, biological meshes, and 3D printing improvements. The overview explains the historical development from traditional open surgeries to the introduction of laparoscopic procedures, providing detailed information on several modern approaches. The presentation includes information on the utilization of mesh, concerns particular to individual patients, and the increasing importance of robots. An extensive analysis examines complications, obstacles, and current trends, thoroughly assessing safety profiles and patient outcomes. This review aims to consolidate existing information, highlight areas lacking research, and provide future paths to enhance outcomes for patients undergoing general surgery. At the same time, the field of hernia repair experiences significant changes. The integration of classic and contemporary approaches illustrates the changing character of hernia repair, enabling a nuanced understanding among physicians and academics alike.

Laparoscopic versus Open Inguinal Hernia Repair in Aging Patients: A Propensity Score Matching-Based Retrospective Study

Objective

Although laparoscopic repair has been widely carried out and promoted due to its minimally invasive advantages, open surgery is still popular compared to elderly patients. This study aims to compare the outcomes of laparoscopic (LIHR) vs open repair of inguinal hernias (OIHR) in elderly patients.

Methods

A retrospective analysis of the database was performed to identify elderly patients, from January 2021 through December 2022, who underwent surgery for an inguinal hernia. After a 1:1 propensity score matching (PSM) with a caliper of 0.1 was conducted to balance potential bias, binary logistic regressions were used for categorical and continuous outcomes.

Results

After PSM, 78 pairs of elderly patients were enrolled in this study, and there were no significant differences in baseline between LIHR and OIHR groups. Compared to OIHR, univariable and multivariable logistic regression analysis showed that LIHR was independently affected for reducing intraoperative hemorrhage (OR = 0.06, 95% CI: 0.02-0.18, P < 0.001) and shortening postoperative hospitalization time (OR = 0.29, 95% CI: 0.15-0.57, P < 0.001) in elderly patients. Furthermore, LIHR (OR = 0.28, 95% CI: 0.14-0.57, P < 0.001) and age (OR = 0.89, 95% CI: 0.82-0.96, P = 0.002) were independent affecting factors for relieving postoperative pain. Meanwhile, no obvious differences were detected in postoperative complications [LIHR 7.7% (6/78) vs OIHR 14.1% (11/78), P = 0.199].

Conclusion

LIHR was closely associated with reducing intraoperative hemorrhage and shortening postoperative hospitalization time. Whilst LIHR and age were independently affecting factors for relieving postoperative pain.

Trends in Incisional and Ventral Hernia Repair: A Population Analysis From 2001 to 2021

Background Incisional and ventral hernias are highly prevalent, with primary ventral hernias occurring in approximately 20% of adults and incisional hernias developing in up to 30% of midline abdominal incisions. Recent data from the United States have shown an increasing incidence of elective incisional and ventral hernia repair (IVHR) and emergency repair of complicated hernias. This study examines Australian population trends in IVHR over a two-decade study period. Methods This retrospective study was performed using procedure data from the Australian Institute of Health and Welfare and population data from the Australian Bureau of Statistics captured between 2000 and 2021 to calculate incidence rates per 100,000 population by age and sex for selected subcategories of IVHR operations. Trends over time were evaluated using simple linear regression. Results There were 809,308 IVHR operations performed in Australia during the study period. The cumulative incidence adjusted for population was 182 per 100,000; this increased by 9.578 per year during the study period (95%CI = 8.431-10.726, p<.001). IVHR for primary umbilical hernias experienced the most significant increase in population-adjusted incidence, 1.177 per year (95%CI = 0.654-1.701, p<.001). Emergency IVHR for incarcerated, obstructed, and strangulated hernias increased by 0.576 per year (95%CI = 0.510-0.642, p<.001). Only 20.2% of IVHR procedures were performed as day surgery. Conclusions Australia has seen a significant increase in IVHR operations performed in the last 20 years, particularly those for primary ventral hernias. IVHR for hernias complicated by incarceration, obstruction, and strangulation also increased significantly. The proportion of IVHR operations performed as day surgery is well below the target set by the Royal Australasian College of Surgeons. With the increasing incidence of IVHR operations and an increasing proportion of these being emergent, elective IVHR should be performed as day surgery when it is safe.

The global, regional, and national burden and its trends of inguinal, femoral, and abdominal hernia from 1990 to 2019: findings from the 2019 Global Burden of Disease Study - a cross-sectional study

BACKGROUND

Inguinal, femoral, and abdominal hernia repairs are the most common surgical procedure worldwide. However, studies on hernia disease burden are notably limited, in both developed and low-income and middle-income countries (LMICs). We investigated temporal trends in the incidence and prevalence of inguinal, femoral, and abdominal hernias at global, regional, and national levels in 204 countries and territories from 1990 to 2019 using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019).

MATERIALS AND METHODS

Annual incident cases, prevalent cases, age-standardized incidence rates (ASIRs), and age-standardized prevalence rates (ASPRs) of inguinal, femoral, and abdominal hernias between 1990 and 2019 were extracted from the GBD 2019 study and stratified by sex, age, and location. Percentage changes in incident cases and prevalent cases, and the estimated annual percentage changes of ASIRs and ASPRs were calculated to quantify the trends in the incidence and prevalence of inguinal, femoral, and abdominal hernias. Data analysis for the present study was conducted from 15 June 2022 to 15 July 2022.

RESULTS

Globally, there were 32.53 million [95% uncertainty interval (UI): 27.71-37.79] prevalent cases and 13.02 million (10.68-15.49) incident cases of inguinal, femoral, and abdominal hernias in 2019, which increased by 36.00% and 63.67%, respectively, compared with 1990. Eighty-six percent of the incident cases were males, the male-to-female ratio was 6 : 1, and most patients were aged 50-69 years. India (2.45 million), China (1.95 million), and Brazil (0.71 million) accounted for more than one-third (39%) of the incident cases worldwide. From 1990 to 2019, the ASIR and ASPR showed a decreasing trend worldwide, except in Central Sub-Saharan Africa, which had an increasing trend in ASIR and ASPR.

CONCLUSION

The global incident cases and prevalent cases of inguinal, femoral, and abdominal hernias increased substantially from 1990 to 2019, with a heavier burden observed in males, older adults, and in LMICs such as India and China. In addition, the ASIR and ASPR increased substantially in Central Sub-Saharan Africa. More efforts are warranted for hernia management to reduce the burden of inguinal, femoral, and abdominal hernias, such as by providing safe hernia surgical treatment for males, older adults, and LMICs.

Laparoscopic versus open inguinal hernia repair in infants: an initial experience

BACKGROUND

Inguinal hernia repair is a common operation performed in children. In Australia, open repair (OR) continues to be the preferred method of treatment in infants, despite laparoscopic repair (LR) gaining popularity amongst some international centres. Our aim was to analyse initial outcomes with LR at our paediatric centre.

METHODS

We conducted a retrospective review of all patients <1 year of age who received LR or OR between January 2017 and July 2021 at our institution. Data were retrieved from both electronic and scanned medical records. Data were analysed using an unpaired t-test, Mann-Whitney test, Fisher's exact test or simple linear regression. A P-value <0.05 was considered significant.

RESULTS

A total of 376 patients were identified: LR was performed in 73 patients, and OR in 303 patients. Bilateral repair was more common amongst patients receiving LR: 56.2% versus 21.5%, P = 0.0001, treating either a symptomatic hernia or an intra-operative contralateral inguinal defect (70%). All LR patients received general anaesthetic, compared to 82.8% of patients in the OR group, P = 0.0001. There were no recurrences following LR and 3 with OR (P = 1.0). The metachronous contralateral inguinal hernia rate following OR was 10% (21/206). There was no significant difference in other complications, including wound infection, haematoma, testicular atrophy, and hydrocele formation.

CONCLUSION

In our population OR was performed more often than LR. Operative complication rates were equivalent between OR and LR groups. However, infants that underwent OR were significantly more likely to develop a MCIH.

Extremely Late-Onset Deep Infection Post-inguinal Hernia Repair After Panendoscopy

Mesh infection after hernia repair is a well-known complication, which can have morbid consequences. This report presents a case of a gentleman with mesh infection many years after initial surgery, potentially from bacterial translocation post-colonoscopy, and describes his successful treatment. This case emphasizes the need to consider mesh infection regardless of time from surgery to presentation.

Proctored preceptorship model for learning eTEP repair for inguinal hernia for general surgery residents

BACKGROUND

Enhanced-view total extra-peritoneal (eTEP) inguinal hernia repair is a technically demanding procedure with a steep learning curve.

AIM

Examine the feasibility and effectiveness of an instructor approach to teaching residents how to perform laparoscopic eTEP independently following a dedicated course of individual teaching.

METHODS

Prospective analysis of eTEP procedures performed by residents between March 2018 and September 2020. Six residents dispersed into three groups-Group A: two junior residents, Group B: two mid-level residents and Group C: two senior residents. All residents performed a unilateral IHR comprised of five core steps. Data reviewed for each procedure included the time of each step, total time and autonomy degree as assessment for every step: 1st degree-dependent (physical assistance), 2nd degree-partially dependent (vocal assistance) and 3rd degree-independent. Early and late procedures were divided at 50% of cases.

RESULTS

Participants performed 44 procedures (220 steps). Late procedures presented with a significant improvement in all degrees of autonomy (1st degree p = 0.002, 2nd degree p = 0.007 and 3rd degree p < 0.0001) and in every step (Step 1 p = 0.015, Step 2 p = 0.006, Step 3 p < 0.0001, Step 4 p < 0.0001, Step 5 p = 0.002). There was no significant difference in surgery duration between early and late procedures (p = 0.32). At early procedures, junior residents needed significantly higher rates of physical intervention (1st degree) compared to the senior residents (p = 0.004). Conversely, there was no significant difference in 2nd degree of autonomy (p = 0.46), 3rd degree (p = 0.06) and surgery duration (p = 0.16). The last three procedures performed by all participants had no significant difference between the seniority groups in autonomy (1st degree p = 0.1, 2nd degree p = 0.18 and 3rd degree p = 0.1).

CONCLUSION

Dedicated course with an individual instructor's approach is effective in achieving competence, autonomy and confidence in performing eTEP in a short time.

Australian general surgical trainee experience with inguinal hernia surgery: a review of international training programmes and the learning curve

BACKGROUND

There are no publications addressing the level of experience Australian surgical trainees achieve in inguinal hernia surgery. Internationally, some training boards have set minimum competency requirements, but this is not true in Australia. The longer learning curve for laparoscopic inguinal hernia repairs (LIHRs) compared to open inguinal hernia repairs (OIHRs) has placed greater demands on trainees.

METHODS

Logbook data on OIHR and LIHR for Australian surgical trainees who graduated as fellows between 2013 and 2018 were obtained. A literature review was performed to analyse international published logbook numbers for surgical trainees from the past decade. International training board requirements, estimations of the learning curve and hernia society guidelines for each procedure were reviewed.

RESULTS

In total, 7946 operations were recorded from 58 trainees. On average 49.2 OIHRs (range 13-101), 21.5 LIHRs (range 1-94) and 71.1 inguinal hernia repairs overall (range 25-129) were performed during training. The European Hernia Society recommends that at least 30-50 of each procedure be performed during training. The learning curves for LIHRs (50-100 procedures) have been shown to be longer than for OIHRs (40-64 procedures).

CONCLUSION

Australian general surgical trainees are achieving adequate primary operator logbook numbers for OIHRs but are not completing the required number of LIHRs. The tailored approach to inguinal hernia repair requires skill in both open and laparoscopic repairs. This may not be possible with the current training structure in Australia.

Impact of ultrasound on inguinal hernia repair rates in Australia: a population-based analysis

BACKGROUND

Inguinal hernias are a common pathology that often requires surgical management. The use of groin ultrasound (GU) to investigate inguinal hernias is a growing area of concern as an inefficient use of healthcare resources. Our aim was to assess changes in the rates of GU and the impact on surgical practice.

METHODS

Medicare Item Reports and the Australian Institute of Health and Welfare Database were used to estimate annual GU and inguinal hernia repair (IHR) rates per 100 000 population for the period 2000/2001-2017/2018. Pearson's correlation coefficients and linear regression analyses were performed to assess associations between these variables.

RESULTS

Over the 18-year period, GU rates increased 13-fold from 88 to 1174 per 100 000 population. Overall, total IHR rates decreased from 217 to 192 per 100 000. Overall, unilateral IHR rates have decreased (182-146 per 100 000), bilateral IHRs have increased (35-46 per 100 000), laparoscopic IHR has increased (30-86 per 100 000) and open surgery has declined (187-106 per 100 000). The increase in GU rates were strongly associated with the decrease in unilateral (r = -0.936, P = <0.001) and increase in bilateral IHR rates (r = 0.924, P = <0.001).

CONCLUSION

The use of GU has increased substantially, potentially representing an unnecessary cost to the healthcare system. Rising GU rates are not associated with an increase in IHR, however, may contribute to the increasing rates of bilateral IHRs. This study supports the opinion that more extensive clinical and health policy initiatives are needed in Australia to address this health issue.

Occult Para-Psoas Hernia during Routine Endoscopic Totally Extraperitoneal Inguinal Hernia Repair

Background and Objectives:

Advantage of the total extraperitoneal (TEP) technique over open inguinal hernia repair allows for exploration of other anatomical regions in search for occult hernias (OH).

Methods:

Our institutional practice is to routinely explore the obturator and femoral regions for occult hernias. In addition to this technique, we routinely expose the psoas muscle extensively to perfect mesh placement followed by fibrin glue fixation on both ‘triangles of doom and pain’. The use of this technique has led to the identification of three incidental occult para-psoas hernias (PPH) out of a total of 800 TEP repairs performed in a high-volume specialist hernia center.

Conclusions:

The purpose of this article is to demonstrate that occult parapsoas hernias (PPH) can be easily identified and safely repaired with mesh glue fixation, using the standard TEP technique during inguinal hernia repair.