The inguinal region: anatomic differences in men and women with reference to hernia formation

Female sex and ipsilateral reoperation risk following mesh-based inguinal hernia repair: a cohort study including 131,626 repairs in adults from an integrated healthcare system over a 10-year period

PURPOSE

We sought to compare females and males for the risk of reoperation following different inguinal hernia repair approaches (open, laparoscopic, and robotic).

METHODS

We conducted a retrospective cohort study including all patients aged ≥ 18 who underwent first inguinal hernia repair with mesh within a US integrated healthcare system (2010-2020). Data were obtained from the system's integrated electronic health record. Multiple Cox proportional-hazards regression was used to evaluate the association between sex and risk for ipsilateral reoperation during follow-up. Analysis was stratified by surgical approach (open, laparoscopic, and robotic).

RESULTS

The study cohort was comprised of 110,805 patients who underwent 131,626 inguinal hernia repairs with mesh, 10,079 (7.7%) repairs were in females. After adjustment for confounders, females had a higher risk of reoperation than males following open groin hernia repair (hazard ratio [HR] = 1.98, 95% CI 1.74-2.25), but a lower reoperation risk following laparoscopic repair (HR = 0.70, 95% CI 0.51-0.97). The crude 5-year cumulative reoperation probability following robotic repair was 2.8% in males and no reoperations were observed for females. Of females who had a reoperation, 10.3% (39/378) were for a femoral hernia, while only 0.6% (18/3110) were for femoral hernias in males.

CONCLUSION

In a large multi-center cohort of mesh-based inguinal hernia repair patients, we found a higher risk for reoperation in females after an open repair approach compared to males. Lower risk was observed for females through a minimally invasive approach (laparoscopic or robotic) and may be due to the ability to identify an occult femoral hernia through these approaches.

Global, regional, and national burden of inguinal, femoral, and abdominal hernias: a systematic analysis of prevalence, incidence, deaths, and DALYs with projections to 2030

BACKGROUND

Hernias, particularly inguinal, femoral, and abdominal, present a global health challenge. While the Global Burden of Disease (GBD) study offers insights, systematic analyses of hernias remain limited. This research utilizes the GBD dataset to explore hernia implications, combining current statistics with 2030 projections and frontier analysis.

METHODS

We analyzed data from the 2019 GBD Study, focusing on hernia-related metrics: prevalence, incidence, deaths, and disability-adjusted life years (DALYs) across 204 countries, grouped into 21 GBD regions by the SDI (SDI). Data analysis incorporated relative change calculations, Annual Percentage Change (APC), Average Annual Percentage Change (AAPC), and Joinpoint Regression Analysis. The study also employed frontier analysis and the Bayesian Age-Period-Cohort model for trend prediction up to 2030. Analyses utilized R version 4.2.3.

RESULTS

From 1990 to 2019, global hernia cases surged by 36%, reaching over 32.5 million, even as age-standardized rates declined. A similar pattern was seen in mortality and DALYs, with absolute figures rising but age-standardized rates decreasing. Gender data between 1990 and 2020 showed consistent male dominance in hernia prevalence, even as rates for both genders fell. Regionally, Andean Latin America had the highest prevalence, with Qatar and Bulgaria noting significant increases and decreases, respectively. Frontier analyses across 204 countries linked higher SDIs with reduced hernia prevalence. Yet, some high SDI countries, like Qatar and the UK, deviated unexpectedly. Predictions up to 2030 anticipate increasing hernia prevalence, predominantly in males, while death rates are expected to decline. DALYs, after declining, are stabilizing.

CONCLUSIONS

Our analysis reveals a complex interplay between socio-demographic factors and hernia trends, emphasizing the need for targeted healthcare interventions. Despite advancements, vigilance and continuous research are essential for optimal hernia management globally.

Sex-based differences in inguinal hernia factors

BACKGROUND

Much of our knowledge about inguinal hernias is based on males. Meanwhile, it is established that women have worse outcomes after inguinal hernia repair, with more chronic pain and higher recurrences. Pediatric literature shows inguinal hernias in females are more likely to be bilateral, incarcerated, and carry a stronger genetic predisposition than males. We aimed to evaluate sex-based differences in inguinal hernia factors in adults, to help supplement the paucity of literature in the adult population.

METHODS

An institutional database of patients undergoing repair of primary inguinal hernias was queried with focus on preoperative risk factors and operative characteristics. Multivariate analysis was performed looking for independent variables associated with a greater number of hernia defects found intraoperatively.

RESULTS

Among 494 patients, 202 (40.9%) were female. Number of risk factors among females was significantly higher than males (1.53 vs 1.2, p = 0.003). Females had significantly more constipation, GERD, and asthma and lower BMI than males. Family history of hernias was similar between both sexes. As expected, females had significantly less direct hernias (12.9% vs 32.9%, p < 0.001) and more femoral hernias (38.5% vs 12.2%, p < 0.001) than males. Bilaterality was similar. Females undergoing inguinal hernia repair averaged 1.23 prior deliveries. Regression analysis showed age, sex, BMI, and number of deliveries were not correlated with the number of defects.

CONCLUSIONS

Females undergoing primary inguinal hernia repair had more preoperative risk factors for inguinal hernia than males. In our population, there was no higher incidence of bilaterality or significant genetic predisposition in females as noted by family history of hernias. Age, sex, BMI and number of deliveries did not correlate with the number of hernia defects found. Our study promotes awareness of inguinal hernias in females and presents new data to quantify sex-based differences and predispositions to inguinal hernias.

Comparative Outcomes of Groin Hernia Repair by Sex Among Medicare Beneficiaries

OBJECTIVE

To compare the rates of operative recurrence between male and female patients undergoing groin hernia repair.

BACKGROUND DATA

Groin hernia repair is common but understudied in females. Limited prior work demonstrates worse outcomes among females.

METHODS

Using Medicare claims, we performed a retrospective cohort study of adult patients who underwent elective groin hernia repair between January 1, 2010 and December 31, 2017. We used a Cox proportional hazards model to evaluate the risk of operative recurrence up to 5 years following the index operation. Secondary outcomes included 30-day complications following surgery.

RESULTS

Among 118,119 patients, females comprised the minority of patients (n=16,056, 13.6%). Compared with males, female patients were older (74.8 vs. 71.9 y, P <0.01), more often white (89.5% vs. 86.7%, P <0.01), and had a higher prevalence of nearly all measured comorbidities. In the multivariable Cox proportional hazards model, we found that female patients had a significantly lower risk of operative recurrence at 5-year follow-up compared with males (aHR 0.70, 95% CI 0.60-0.82). The estimated cumulative incidence of recurrence was lower among females at all time points: 1 year [0.68% (0.67-0.68) vs. 0.88% (0.88-0.89)], 3 years [1.91% (1.89-1.92) vs. 2.49% (2.47-2.5)], and 5 years [2.85% (2.82-2.88) vs. 3.7% (3.68-3.75)]. We found no significant difference in the 30-day risk of complications.

CONCLUSIONS

We found that female patients experienced a lower risk of operative hernia recurrence following elective groin hernia repair, which is contrary to what is often reported in the literature. However, the risk of operative recurrence was low overall, indicating excellent surgical outcomes among older adults for this common surgical condition.

Groin Hernia in Females Routinely Treated by Totally Extraperitoneal Laparoscopic Approach

Background and Objectives:

There is a dearth of studies on laparoscopic treatment of female groin hernia. Our study assessed the outcome of groin hernia repair in females employing the totally extraperitoneal laparoscopic (TEP) access.

Methods:

Data of all females who were subjected to laparoscopic groin herniorrhaphy, from August 1998 to February 2020 were retrospectively obtained. Groin hernia repair was routinely started with TEP access.

Results:

A total of 2,399 patients who underwent laparoscopic groin herniorrhaphy, 254 (10.6%), were females. Most females (n = 191; 75.2%) had single hernia and the remaining (n = 63; 24.8%) had bilateral hernias, making a total of 317 hernias operated. Indirect inguinal hernia was the most common hernia type (72.5%), followed by femoral hernia (17.4%) and direct hernia (10.1%). Prior lower abdominal operations were recorded in 97 (38.2%) patients. Conversion to a laparoscopic transabdominal preperitoneal procedure was performed due to technical difficulties to dissect the preperitoneal space in 17 patients (6.7%) and to open procedure in only one patient (0.4%) with incarcerated femoral hernia in whom an incidental perforation of the small bowel occurred. Intra- and postoperative complications occurred in 12 (4.7%) and 15 (5.9%) patients, respectively. There was no mortality. Most patients (n = 221; 87%) were discharged on the same day of the operation. Hernia recurrence was diagnosed in 6 patients (2.4%).

Conclusion:

It is concluded that females with groin hernia may be successfully treated with totally extraperitoneal laparoscopic access, with low conversion and complication rates.

Groin Hernias in Women-A Review of the Literature

Background: To date, there are few studies and no systematic reviews focusing specifically on groin hernia in women. Most of the existing knowledge comes from registry data. Objective: This present review now reports on such findings as are available on groin hernia in women. Materials and Methods: A systematic search of the available literature was performed in September 2018 using Medline, PubMed, Google Scholar, and the Cochrane Library. For the present analysis 80 publications were identified. Results: The lifetime risk of developing a groin hernia in women is 3-5.8%. The proportion of women in the overall collective of operated groin hernias is 8.0-11.5%. In women, the proportion of femoral hernias is 16.7-37%. Risk factors for development of a groin hernia in women of high age and with a positive family history. A groin hernia during pregnancy should not be operated on. The rate of emergency procedures in women, at 14.5-17.0%, is 3 to 4-fold higher than in men and at 40.6% is even higher for femoral hernia. Therefore, watchful waiting is not indicated in women. During surgical repair of groin hernia in females the presence of a femoral hernia should always be excluded and if detected should be repaired using a laparo-endoscopic or open preperitoneal mesh technique. A higher rate of chronic postoperative inguinal pain must be expected in females. Conclusion: Special characteristics must be taken into account for repair of groin hernia in women.

Recurrence Rates After Repair of Inguinal Hernia in Women: A Systematic Review

Importance

To our knowledge, a systematic review has not yet been performed that specifically addresses the management of inguinal hernia in women. Recurrence after repair of inguinal hernia is not unusual in women and may be a previously undiagnosed femoral hernia, which is rarely seen in men.

Objective

To investigate rates and types of recurrences in women who had undergone repair of primary inguinal hernia.

Evidence Review

PubMed, Embase, and the Cochrane databases were searched in September 2017 for studies reporting recurrences after repair of primary inguinal hernia in women. Crude rates of recurrence (number of recurrences/number of women) were calculated after open and laparoscopic repairs, and the type of recurrent hernia was registered, if noted in the studies. This review is reported according to the PRISMA guideline.

Findings

A total of 55 studies were included, comprising 43 870 women (mean age, 42-69 years; median age, 57 years). Five studies were randomized clinical trials, 14 were prospective cohort studies, 7 were prospective database studies, and 29 were retrospective cohort studies. Twenty studies reported recurrence after laparoscopic repair, with a crude recurrence rate of 1.2% (27 of 2257) (range, 0%-5%) and a median follow-up of 24 months. Thirty-seven studies reported open repair, with a crude recurrence rate of 2.4% (818 of 33 971) (range, 0%-12.5%) and a median follow-up of 36 months. The crude recurrence rate in randomized clinical trials and prospective studies was 1.2% (18 of 1525) after laparoscopic repair compared with 4.9% (490 of 10 058) after open repair. The recurrent inguinal hernia was a femoral hernia in 203 of 496 patients (40.9%) after open repair, compared with 0% of patients after laparoscopic repair. Recurrence rates were similar when open mesh vs nonmesh techniques were used.

Conclusions and Relevance

Recurrence rates after repair of primary inguinal hernia in women are lower after laparoscopic repair compared with open repair. Intraoperative findings during repair of recurrent inguinal hernia are often femoral hernias in women.

International guidelines for groin hernia management

INTRODUCTION

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

METHODS

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

CONCLUSIONS

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