Patient Satisfaction After Inguinal Hernia Surgery: Literature Review of an Overlooked Patient-Reported Outcome Measure

INTRODUCTION

Patient satisfaction after inguinal hernia surgery is currently underappreciated and not as well studied as other patient-reported outcome measures (PROMs) on this topic. This study aims to review the literature and summarize available data.

MATERIALS AND METHODS

A literature review was conducted using Medline with focus on patient-reported satisfaction after elective, inguinal hernia surgery in adults. All inguinal hernia repair techniques were considered. Small sample sizes and short follow-up periods were excluded. The methodology and results of the remaining articles were reviewed. Due to heterogeneity of reporting between articles, only a descriptive analysis was performed.

RESULTS

The available data from patient-reported outcome measures regarding satisfaction yields considerable heterogeneity and lacks validation. We found that 53% of all included studies used an asymmetrical response questionnaire. Although there is an overwhelming positive patient satisfaction, wide ranges of satisfaction were seen (78-100% more than averagely satisfied, compared to 0-15% less than averagely satisfied). The number of patients not willing to undergo inguinal hernia repair again ranges from 1-16%.

CONCLUSION

Our study demonstrates that patient-reported satisfaction after inguinal hernia surgery is not uniformly surveyed and remains unvalidated. Further research on patient-reported satisfaction would benefit from the reported raw data of a standardised, validated, and symmetrical five-point Likert or 11-point NRS scale on regular intervals pre- and postoperatively.

A Modified Fisherman's Knot for Laparoscopic Suturing

Suturing is an essential surgical technique, because there is no resection without the need for reconstruction. Therefore, every surgeon should master a set of suturing techniques so he can adapt his approach to the specificity of the situation. The development of laparoscopic surgery poses a new challenge as not all open techniques are amendable for laparoscopic use. We would like to propose a modified fisherman's knot, which has been optimised in our center for laparoscopic use. The technique can be used with every monofilament non-braided wire. The needle is placed through the tissue to be sutured and both wires are externalised through the trocar. First, a simple knot is placed by crossing the left over the right wire. Next, the left is turned around the right wire four times proximal to the starting knot and crossed to the left wire where an additional two turns are made moving away from the trocar. The knot is closed gently, making sure not to lock the knot. Then the instrument of Drouard is used to gently glide the knot over the right wire back through the trocar into the abdomen. After making sure that adequate pressure has been delivered to the knot, to firmly close the tissue, the wire must be cut at a length of at least 3 mm. A new wire should be used for every knot and in this manner several knots can be delivered to make sure the tissue is adequately closed. In our center, no known complications due to loosening or failure of these knots have occurred since we incorporated this knotting technique into our daily practice more than 20 years ago.

Initial Experience with a New Macroporous Partially Absorbable Mesh: Introducing Ultrapro® Advanced™

INTRODUCTION

The Ultrapro® Advanced™ mesh (Ethicon, Sommerville, NJ) is a new mesh design, using the best characteristics from the previous platform, while adding new, advanced features. Our centre, Imelda Hospital, Bonheiden, Belgium, was chosen as one of the first clinical testing sites. The aim of this study was to present our preliminary data on complication rate and patient satisfaction.

MATERIALS AND METHODS

From October 1, 2015 until January 31, 2016, we treated 57 patients, implementing 67 Ultrapro® Advanced™ meshes. One patient was excluded due to postoperative cerebral haemorrhage with aphasia. Only patients with more than one-month follow-up were included for further analysis, resulting in a population of 41 patients with 51 meshes. Of them, 35 were male and only 6 were female, with an average age of 61.4 years and an average BMI of 25.9. The indications were uni- and bilateral laparoscopic inguinal hernia repair (n = 23 and 10 respectively), open inguinal hernia repair (n = 3), and open incisional hernia repair (n = 5). Quality of life was measured preoperatively and at four weeks postoperatively, using the hernia specific Carolina Comfort Scale (CCS) questionnaire.

RESULTS

The primary endpoint was complication rate. Only two patients (4.8%) mentioned a mild scrotal hematoma and two patients (4.8%) demonstrated a seroma. There were no superficial wound infections nor early recurrent hernias. Our secondary endpoint was quality of life, measured by the CCS questionnaire, which differentiates between a symptomatic and an asymptomatic group. A total of 13 patients were asymptomatic, whilst 28 patients reported some sort of discomfort, ranging from mild (n = 25) to moderate and/or daily symptoms (n = 3). No patients were disabled by their symptoms.

CONCLUSION

The Ultrapro® Advanced™ is a sequel of the classic Ultrapro® mesh with similar characteristics: it is a "lightweight", macroporous, partially absorbable mesh built out of thin filaments, while maintaining sufficient strength. Its improvement is due to incorporation of evidence-based characteristics such as an increased mesh elasticity. Furthermore, the surgical manipulation is improved thanks to the increased mesh memory. Our prospective cohort study shows good initial and short-term results after implementation of the Ultrapro® Advanced™. However, further prospective research is mandatory on the long-term outcomes.

Endoscopic versus radiology-based location of rectal cancer

BACKGROUND

Rigid proctosigmoidoscopy is recommended for measuring the height of rectal neoplasms but appears to be performed in only a minority of patients. Our aim was to compare endoscopic and radiological measurement of rectal tumour location with a focus on differentiation between mid and high rectal cancer.

METHODS

Medical records of 66 rectal cancer patients were reviewed. Tumour location defined at colonoscopy (66 patients), rigid proctosigmoidoscopy (20 patients) and endorectal ultrasound (35 patients) was recorded. Rectilinear and curvilinear methods were used to estimate the distance between the lower tumour level and the anal verge on sagittal CT or MR images (66 patients). Agreement, intra- and inter-observer variation of radiology-based measurements were -assessed using intra-class correlation (ICC) and within-subject coefficient of variation (WSCV).

RESULTS

Tumour location was performed at rigid proctosigmoidoscopy in 30% of patients. Intra- and inter-observer agreement for radiology-based measurements were high. Tumour location using the rectilinear method or proctosigmoidoscopy was similar on average, for a difference of only 0.34 cm (SD 2.0 cm, p = 0.330), although agreement was -moderate (ICC = 0.54, WSCV = 16.7%). Measurements based on colonoscopy and the curvilinear radiological method were -characterized by a systematic overestimation of the location, increasing with tumour height.

CONCLUSIONS

Radiology-based measurement of the lower tumour level is a reproducible alternative for tumour location at rigid or flexible endoscopy. Its validity should be further assessed.