What is the outcome of re-recurrent vs recurrent inguinal hernia repairs? An analysis of 16,206 patients from the Herniamed Registry

A new groin hernia classification with clinical relevance

INTRODUCTION

Groin hernia is one of the most commonly managed surgical diseases around the world. The typical question asked by patients is "Does my hernia require urgent surgery?". The currently available classifications are insufficient to stratify patients into different groups. We propose a new classification that incorporates diverse clinical elements together with anatomical and other vital information, which allows us to stratify patients into different groups.

METHOD

A task force was formed by the Hong Kong Hernia Society, working with international expert hernia surgeons. The framework of the classification system was formulated. Clinical elements that are important in groin disease stratification were identified. A comprehensive literature review was conducted using PubMed. Those which dictate the severity of the disease were selected and compiled to form the new proposed classification. Application of this classification model to a single hernia surgeon's registry in The Hong Kong Adventist Hospital Hernia Centre was done for initial evaluation.

RESULT

This new classification incorporates important clinical characteristics forming a total of nine grades of differentiation, together with the anatomical details and special information. This comprehensive system allows the stratification of patients into different groups based on disease severity. It also enables more accurate data collection for future audits, comparisons of disease progression over time, and the effect of different management strategies for different-stage patients.

CONCLUSION

This is the first classification system which incorporates essential clinical parameters, which allows the stratification of groin hernia into different stages. Further studies and validation should be performed to evaluate the usefulness and value of this classification in groin hernia management.

Risk factors for reoperation following inguinal hernia repair: results from a cohort of patients from an integrated healthcare system

PURPOSE

Inguinal hernia repair is one of the most common operations performed globally. Identification of risk factors that contribute to hernia recurrence following an index inguinal hernia repair, especially those that are modifiable, is of paramount importance. Therefore, we sought to investigate risk factors for reoperation following index inguinal hernia repair.

METHODS

125,133 patients aged ≥ 18 years who underwent their first inguinal hernia repair with mesh within a large US integrated healthcare system were identified for a cohort study (2010-2020). Laparoscopic, robotic, and open procedures were included. The system's integrated electronic health record was used to obtain data on demographics, patient characteristics, surgical characteristics, and reoperations. The association of these characteristics with ipsilateral reoperation during follow-up was modeled using Cox proportional-hazards regression. Risk factors were selected into the final model by stepwise regression with Akaike Information Criteria, which quantifies the amount of information lost if a factor is left out of the model. Factors associated with reoperation with p < 0.05 were considered statistically significant.

RESULTS

The cumulative incidence of reoperation at 5-year follow-up was 2.4% (95% CI 2.3-2.5). Increasing age, female gender, increasing body mass index, White race, chronic pulmonary disease, diabetes, drug abuse, peripheral vascular disease, and bilateral procedures all associated with a higher risk for reoperation during follow-up.

CONCLUSION

This study identifies several risk factors associated with reoperation following inguinal hernia repair. These risk factors may serve as targets for optimization protocols prior to elective inguinal hernia repair, with the goal of reducing reoperation risk.

Inguinal hernia in southern Brazil - challenges in follow-up and recurrence rates

INTRODUCTION

recurrence rates for primary hernia repair range from 0.5 to 15 percent depending upon the hernia site, type of repair, and clinical circumstances. Many risk factors are known and they must be considered before the procedure. In developing countries, follow up and maintenance of databases are critical to understand the real numbers.

METHODS

a retrospective cohort study analyzed adult patients who have undergone inguinal hernia repair at Hospital de Clínicas de Porto Alegre, a tertiary care government public hospital, between 2013 and 2015. Medical records, telephone, and letter contact have been reviewed in order to complete the minimum period of 5 years of follow-up. The analyzed data focused on the surgeon's experience and the recurrence rate in 5 years of follow-up.

RESULTS

a total of 1094 medical records were selected and a complete five years follow-up were possible in 454 patients - 538 inguinal hernia repairs due to bilateral approach in 84 patients. These 454 patients answered, in a validated questionnaire about symptoms of recurrence. The total recurrence rate was 9.29%. For the patients who had Nyhus IV, recurrence rate was 24.1% against 9.9% after primary hernia repair, with a 2.4 higher risk. There was no difference in recurrence between surgeons and training surgeons.

CONCLUSION

our data reveal an acceptable recurrence rate in a tertiary care hospital with residents, and to our knowledge is the first Brazilian report with long term follow up. An increased re-recurrent hernia was found when compared with primary hernia repair.

Hérnia inguinal no Sul do Brasil - desafios no seguimento e taxas de recorrência

RESUMO Introdução: a recorrência da hérnia inguinal após hernioplastia varia de 0,5 a 15 por cento, dependendo do local da hérnia, tipo de reparo e circunstâncias clínicas. Muitos fatores de risco são conhecidos e devem ser considerados antes do procedimento. Acompanhamento e adequado bancos de dados são fundamentais para entender a incidência de recidiva. Métodos: estudo de coorte retrospectivo analisou hernioplastias inguinais realizados no Hospital de Clínicas de Porto Alegre entre 2013 e 2015. Para concluir 5 anos de seguimento, analisamos o prontuário e fizemos contato telefônico e por correio. Resultados: o total de 1094 registros médicos foram selecionados e um seguimento de pelo menos 5 anos foi possível em 454 pacientes - 538 reparos de hérnia inguinal devido à abordagem bilateral em 84 pacientes. Os pacientes responderam um questionário validado sobre sintomas de recorrência. A taxa total de recorrência foi de 9,29%. No grupo masculino, a recorrência foi de 10% contra 4% no grupo feminino. Para os pacientes com hérnia Nyhus IV, a recidiva foi de 24% contra 8% após o reparo da hérnia primária, com um risco de 2,8 maior. Não houve diferença na recorrência entre cirurgiões experientes e em treinamento. Conclusão: nossos dados revelam uma taxa de recorrência aceitável em um hospital de ensino, e para o nosso conhecimento é o primeiro artigo com acompanhamento de longo prazo no sul do Brasil. A re-recidiva da hérnia foi maior quando comparada com o reparo da hérnia primária.

Local anesthesia as an alternative option in repair of recurrent groin hernias: An outcome study from the American College of Surgeons NSQIP® database

Introduction

There is a dearth of data about the benefits of local anesthesia (LA) and spinal anesthesia (SA) compared to general anesthesia (GA) in patients undergoing repair of recurrent groin (inguinal/femoral) hernias. We hypothesized that patients with recurrent hernias who undergo repair under LA and SA will have a better outcome.

Methods and procedures

Using the 2017 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP)® database, patients who underwent open repair of recurrent groin hernias were identified and divided into three groups: GA, SA, and LA. Outcomes evaluated included 30-day mortality and morbidity, operative time, total hospital length of stay (LOS), and reoperation and readmission rates.

Results

A total of 2169 patients were identified of which 1847 (85.2%) were in GA, 53 (2.4%) in SA, and 269 (12.4%) in LA groups. Overall, no statistically significant differences in demographics and comorbidities between the three groups were identified. However, patients in GA were younger and healthier with lower ASA Class (I-II) as compared to SA and LA groups. Patients in SA had a higher rate of COPD, and their overall operative time was shorter. However, LA patients had shorter LOS, and most LA patients were discharged home on the same day compared to GA, SA (92.2% vs. 77.9%, and 73.6%, p < 0.001). No differences in 30-day mortality and morbidity or reoperation and readmission rates between the three groups were noted.

Conclusion

There is an underutilization of LA in patients undergoing open repair of recurrent inguinal hernia despite favorable outcomes, even in high-risk patients, when compared to GA and SA. Further prospective studies are needed to explore the potential barriers and cost-effectiveness of implementing LA as a primary anesthetic technique in inguinal hernia repair.