Differences in the outcomes of scrotal vs. lateral vs. medial inguinal hernias: a multivariable analysis of registry data

Is the annual hospital volume associated with recurrence and chronic postoperative inguinal pain (CPIP) syndrome after inguinal hernia repair in laparo-endoscopic or open mesh technique (Lichtenstein)?

BACKGROUND

In major surgery, several studies have shown a correlation between high annual hospital volume (hospital caseload) and better outcome. Therefore, centralization is recommended. However, in inguinal hernia surgery the data are limited.

METHODS

The study is based on a retrospective analysis of prospective data from the German Herniamed Registry collected between 2009 and 2018. Out of the total of 731,982 patients operated on in 737 institutions, patients who had undergone inguinal hernia repair in Lichtenstein or in laparo-endoscopic (TAPP/TEP) technique were included. Hospitals were divided into three annual caseload categories: Low volume: ≤ 75 cases; middle volume: 76-199 cases; high volume: ≥ 200 cases. The relationship between hospital volume and the outcome parameters was analyzed using multivariable binary logistic models.

RESULTS

222,487 patients were enrolled in analysis, with 70.4% hernias operated on in laparo-endoscopic technique and 29.6% cases in open mesh technique. Overall, the outcome after laparo-endoscopic repair was significantly favorable except for the intraoperative complications (worse) and recurrence rate (no significant difference). Descriptive and multivariable analysis identified a long operating time as the main factor associated with an unfavorable outcome. In low-volume hospitals the risk was higher for intraoperative complications as well as for postoperative complications in both techniques. There was a significantly favorable association between the recurrence rate and hospital volume but only after laparo-endoscopic repair. Patients who were operated on in a low-volume center experienced significantly less pain across all three pain categories, independently of the technique used.

CONCLUSIONS

While hospital volume has a favorable association with most outcome parameters, this varied in accordance with the operative technique used. In contrast to open surgery, laparo-endoscopic surgery in a low-volume hospital (≤ 75) has the disadvantage of a higher recurrence rate. Long operating time is the most detrimental factor, proving that surgeon proficiency is of paramount importance. However, chronic postoperative inguinal pain (CPIP) syndrome is significantly less frequent in patients operated on in low-volume hospitals; this result is difficult to explain but may be due to a closer patient-surgeon relationship in these institutions.

Are "European" Scrotal Hernias Repairable With the Minimal Open Pre-Peritoneal Technique?

Background

Minimally invasive open preperitoneal techniques are an alternative in groin hernia repair. Scrotal hernias (SH) are frequently difficult to repair laparoscopically, resulting in a significant conversion rate.

Methods

The aim of this exploratory monocentric retrospective study, based on data prospectively collected in the "Club-Hernie" registry, was to assess the feasibility, effectiveness and safety of the MOPP technique in SH repair compared with non-SH repair.

Results

All consecutive MOPP repairs performed from 11 September 2011 to 31 December 2022 were identified in which 2005 MOPP (126 SH and 1879 non-SH) met the inclusion criteria. The results were analysed "as treated" in 125 SH vs. 1879 non-SH. No statistically significant difference was observed between these two groups in terms of age, BMI, and ASA classification. Symptomatic hernias (84% vs. 73%; p < 0.001), and lateral hernias (87.80% vs. 62.81%; p < 0.0001) were more frequent in the SH group. The mean operating time was longer (58 min vs. 39 min; p < 0.0001) in the SH group. The SH procedures were performed under general anaesthesia with a laryngeal mask in 92% of cases. All postoperative complications, except one reoperation in the non-SH group, were classified as Clavien-Dindo Grade I/II. Superficial surgical site occurrences were more frequent in the SH group (14% vs. 3%; p < 0.0001). No peri-prosthetic infections were observed. The outpatient rate was 83% vs. 94% in the SH and non-SH groups, respectively. There were four rehospitalisations in the non-SH group and none in the SH group. The postoperative pain was low and similar in the two groups, except at M1, where the mean pain was lower in the SH group (p < 0.001). A total of 113 (90%) patients in the SH group vs. 1,553 (82%) in the non-SH group were followed for 1 year or more. The number of identified recurrences and reoperations was low and did not differ between the two groups studied. In total, 98% of patients in both groups assessed their surgery as excellent or good.

Conclusion

This exploratory study shows that the MOPP technique is feasible and safe in scrotal hernia repair, with similar results to those observed in non-scrotal hernias. Our next step will be to compare MOPP with laparoscopic and Lichtenstein techniques in scrotal hernia repair.

To close, not to close, or to act bigger? Managing the defect of large direct inguinal hernia to reduce the risk of recurrence during laparoscopic TAPP repair: a retrospective cohort study

Hernia recurrence is a common complication after inguinal hernia repair. Recent studies suggest that laparoscopic mesh repair with closure of direct hernia defects can reduce recurrence rates. Our study examines the effectiveness of this approach. A retrospective, multi-center cohort study was conducted on cases performed from January 2013 to April 2021. Patients with direct inguinal hernias (M3 according to EHS classification) undergoing TAPP were included. Three groups were present: closed-defect group, non-closed placing a standard-sized mesh group or non-closed placing an XL-sized mesh group. A 2-year follow-up was recorded. A total of 158 direct M3 inguinal hernias in 110 patients who underwent surgery were present. After propensity score matching at a 1:1 ratio, 22 patients for each group were analyzed. The mean age of patients was 62 years (41-84); with the majority being male (84.8%). 22 patients (40 hernias) underwent closure of the defect; 22 patients (39 hernias) did not undergo closure and used a standard-sized mesh; 22 patients (27 hernias) did not undergo closure and used an XL-sized mesh. There were 5 recurrences at 1 year post-operatively: all in the non-closure group with standard-sized mesh. This difference was statistically significant (p = 0.044). There were 7 recurrences (6.6%) at 2 years post-operatively: 6 in the non-closure group with standard-sized mesh and 1 in the non-closure group with XL-sized mesh (p = 0.007). Closing large direct inguinal hernia defects has shown promise in reducing early recurrence rates. However, conducting larger RCTs in the future could provide more conclusive evidence that might impact the way we approach laparoscopic inguinal hernia repair.

Open vs. robot-assisted preperitoneal inguinal hernia repair. Are they truly clinically different?

INTRODUCTION

Inguinal hernia repair lacks a standard repair technique, with laparo-endoscopic and open preperitoneal methods showing similar outcomes. Despite higher costs, the popularity of robotic surgery is on the rise, driven by technological advantages. Controversies persist in comparing open repair techniques with the robotic approach, given contradictory results. The objective of this study was to compare postoperative outcomes, including complications, chronic pain, and recurrence, between open and robotic-assisted preperitoneal inguinal hernia repair.

METHODS

This single-center retrospective study encompassed patients undergoing elective inguinal hernia repair in a specialized unit, employing both open preperitoneal and robotic-assisted laparoscopic approaches from September 2018 to May 2023. Comparative analysis of short- and long-term outcomes between these techniques was conducted. Additionally, multivariate logistic regression was employed to explore predictors of postoperative complications.

RESULTS

A total of 308 patients met the inclusion criteria. 198 (64%) patients underwent surgery using an open preperitoneal approach and 110 (36%) using robot-assisted laparoscopy. Patients in the robot-assisted group were younger (P = 0.006) and had fewer comorbidities (P < 0.001). There were no differences between the groups in terms of postoperative complications (P = 0.133), chronic pain (P = 0.463) or recurrence (P = 0.192). Multivariate analysis identified ASA ≥ III (OR, 1.763; 95%CI, 1.068-3.994; P = 0.027) and inguinoscrotal hernias (OR, 2.371, 95%CI, 1.407-3.944; P = 0.001) as risk factors of postoperative complications.

CONCLUSIONS

Both open preperitoneal and robotic-assisted laparoscopic approaches show similar outcomes for complications, chronic pain, and recurrence when performed by experienced surgeons. The open preperitoneal approach, with its quicker operative time, may be advantageous for high-comorbidity cases. Treatment choice should consider patient factors, surgeon experience, and healthcare resources.

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.

Mechanisms inherent in acute-to-chronic pain after surgery - risk, diagnostic, predictive, and prognostic factors

PURPOSE OF REVIEW

Pain is an expected consequence of a surgery, but it is far from being well controlled. One major complication of acute pain is its risk of persistency beyond healing. This so-called chronic post-surgical pain (CPSP) is defined as new or increased pain due to surgery that lasts for at least 3 months after surgery. CPSP is frequent, underlies a complex bio-psycho-social process and constitutes an important socioeconomic challenge with significant impact on patients' quality of life. Its importance has been recognized by its inclusion in the eleventh version of the ICD (International Classification of Diseases).

RECENT FINDINGS

Evidence for most pharmacological and non-pharmacological interventions preventing CPSP is inconsistent. Identification of associated patient-related factors, such as psychosocial aspects, comorbidities, surgical factors, pain trajectories, or biomarkers may allow stratification and selection of treatment options based on underlying individual mechanisms. Consequently, the identification of patients at risk and implementation of individually tailored, preventive, multimodal treatment to reduce the risk of transition from acute to chronic pain is facilitated.

SUMMARY

This review will give an update on current knowledge on mechanism-based risk, prognostic and predictive factors for CPSP in adults, and preventive and therapeutic approaches, and how to use them for patient stratification in the future.

Primary abandon of hernia sac for inguinoscrotal hernias: a safe way to cut corners

INTRODUCTION

Inguinoscrotal hernias (ISH) pose a challenge to surgeons with consistently higher rates of postoperative complications and recurrence rates. The aim of this study is to report our initial experience and early results with a new technique for inguinoscrotal hernia repair.

METHODS

A review of a prospectively maintained multi-center database was conducted in patients who underwent minimally invasive repair using the "primary abandon-of-the-sac" (PAS) technique for inguinoscrotal hernias from March 2021 to July 2022. Demographics and outcomes were analyzed. Univariate analysis and multivariate logistic regression were performed.

RESULTS

A total of 76 minimally invasive inguinal hernia repairs were performed. In 70 patients (92%) C-PAS was used as the technique to abandon the sac while in the remaining 6 patients, "pirate-eye-patch" technique was used. Median hernia ring was 3 (IQR 2.5-3.5) cm and median hernia sac was 9.5 (8-10.8) cm. Median operative time was 70 min (IQR 56-96). Seroma was present in 22 (28.9%) patients 7 days after surgery. Most had seroma only in the inguinal area (n = 19; 25%). Thirty days after surgery, 12 (15.8%) patients still had seroma in the inguinal area and 6 (7.9%) in the inguinoscrotal area. Ninety days after surgery, four (5.3%) patients had inguinal seroma, 2 (2.6%) scrotal seromas and 3 (3.9%) inguinoscrotal seromas. The size of the hernia sac was not associated with seroma formation 7 days after surgery (OR 1.06; 95% CI 0.89-1.2; P = 0.461) in the multivariate logistic regression. BMI was also not associated with seroma formation (OR 0.8; 95% CI 0.74-1.06; P = 0.2).

CONCLUSIONS

Planned abandon of the hernia sac is an interesting alternative and is associated with a low rate of complications and acceptable seroma formation rates.

Systematic Review and Guidelines for Management of Scrotal Inguinal Hernias

Introduction: Of the more than 20 million patients undergoing groin hernia repair annually worldwide, 6% are scrotal hernias in high resource countries rising to 67% in low resource countries which represents a heavy disease burden on relatively young men during their most productive period of life. There are many open questions concerning management of scrotal hernia. These guidelines aim to improve the care for scrotal hernia patients by reducing recurrence rates, chronic pain and infection. Methods: After developing 19 key questions a systematic literature review was performed till 31 March 2021 for all relevant publications with search terms related to Scrotal Hernia. The articles were scored by all co-authors according to Oxford, SIGN and Grade methodologies. Statements and recommendations were formulated. Online Consensus meetings with 25 HerniaSurge members were organised with voting and grading Recommendations as "strong" (recommendations) or "weak" (suggestions) and by consensus, in some cases upgraded. Results: Only 23 articles (two level 2 registry and 21 level 3-5) were selected. It is proposed to define scrotal hernia as an inguinal hernia which has descended into and causes any scrotal distortion. A new classification for scrotal hernias was proposed based on hernia size, SI for upper third thigh, SII for middle thigh and SIII for lower third thigh or below. Irreducibility is denoted with IR. Despite weak evidence antibiotic prophylaxis is recommended. Urinary catheterization is recommended (upgraded) in complex cases (S2-3) due to prolonged operative time. Scrotal hernia repairs have higher associated morbidity and mortality compared to non-complex groin hernia repairs irrespective of surgical experience. Open anterior (mesh) approach is commonest technique and suture techniques in low resource countries. For minimally invasive approaches, TAPP resulted in less conversion to open approach compared to TEP. Conclusion: Although the evidence is scarce and often low quality scrotal hernia management guidelines aim to lead to better surgical outcomes irrespective of where patients live. This necessarily means a more tailored approach based on available resources and appropriate skills. The guidelines provide an impetus for future research where adoption of proposed classification will enable more meaningful comparison of different techniques for different hernia sizes.

Technical aspects of inguino scrotal hernia surgery in developing countries

PURPOSE

Technical aspects of inguinoscrotal herniorrhaphy performed in low to middle income countries (LMICs) are described here to help surgeons who will operate on these challenging hernias in austere settings.

METHODS

Technical considerations related to operative repair were delineated with the consensus of 7 surgeons with extensive experience in inguinoscrotal hernia repair in LMICs. Important steps and illustrations were prepared accordingly. The anatomical and pathologic differences and technical implications of operating in limited resource settings are emphasized with suggestions to approach anticipated challenges. Pre-operative evaluation, anesthetic considerations, and technical guidelines are offered in context.

RESULTS

The authors have cumulatively performed over 1775 inguinoscrotal Lichtenstein operations in LMICs. While dedicated, reliable, long-term follow-up is unavailable from LMICs, one author reports outcomes with 5 year follow-up from the HerniaMed registry using the identical technique in similarly classed hernias. In 90 inguinoscrotal Lichtenstein repair patients (78.3% follow-up), there was one recurrence, low rates of chronic pain (2.2% at rest, 4.4% with activity), and low rates of reintervention (1.1%).

CONCLUSION

There is a difference between inguinal hernias found in LMICs and those seen in high-income countries with larger, chronic, and more technically challenging pathology. The consequences of intra-operative complications can be catastrophic in a LMIC. Technical measures are offered to improve outcomes, avoid and manage complications, and provide optimal care to this important population.

Does closure of the direct hernia defect in laparoscopic inguinal herniotomy reduce the risk of recurrence and seroma formation?: a systematic review and meta-analysis

PURPOSE

Recurrence is a known complication to inguinal herniotomy with an incidence of 10 to 15 percent (Hernia Surge Group in Hernia 22:165, 2018). Previous studies have shown that direct hernia or large defects are risk factors for postoperative seroma formation (Morito et al. in Surg Endosc https://doi.org/10.1007/s00464-021-08814-2 , 2021). These types of defects are often closed during open herniotomy (Rosenberg et al. in Dan Med Bull 58: C4243, 2011). This is not routine during laparoscopic surgery. A recent study has indicated that closure of the medial defect during laparoscopy may reduce recurrence and seroma formation. As a result, we performed the present systematic review to evaluate the efficacy of this add on to the standard procedure.

METHODS

An extensive search was carried out in PubMed and Embase. All studies involving adults undergoing laparoscopic direct hernioplasty were enrolled and screened with predefined inclusion criteria, to be part of a systematic review with data synthesis and meta-analysis.

RESULTS

The search identified 108 publications of which four met the inclusion criteria. Two studies (Ng et al. in Hernia 24:1093-1098, 2020; Usmani et al. in Hernia 24:167-171, 2020) showed reduced risk of recurrence. The remaining studies (Zhu et al. in Surg Laparosc Endosc Percutan Tech 29:18-21, 2019; Li and Zhang in Surg Endosc 32:1082-1086, 2018) reported no recurrence in any of the patients included. Two articles (Usmani et al. in Hernia 24:167-171, 2020; Zhu et al. in Surg Laparosc Endosc Percutan Tech 29:18-21, 2019) showed a decrease in risk of postoperative seroma, one showed a significant increase (Ng et al. in Hernia 24:1093-1098, 2020). None of the included studies showed an increase in the risk of postoperative pain or postoperative complications.

CONCLUSION

This review suggests that closure versus non-closure of the medial hernia defect in laparoscopic inguinal hernioplasty reduces the risk of recurrence and seroma formation without an increase in postoperative pain or complications. Further randomized controlled trials are needed for further evaluation.

Association of Mesh and Fixation Options with Reoperation Risk after Laparoscopic Groin Hernia Surgery: A Swedish Hernia Registry Study of 25,190 Totally Extraperitoneal and Transabdominal Preperitoneal Repairs

BACKGROUND

International guidelines concerning mesh and mesh fixation options in laparoscopic totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) groin hernia repair are based on studies focusing on either mesh or fixation. We hypothesized that the value of such recommendations is limited by lacking knowledge on how mesh and fixation interact. The current registry-based nationwide cohort study compared different mesh/fixation combinations for relative risks for reoperation after TEP and TAPP groin hernia repair.

STUDY DESIGN

All TEP and TAPP registered in the Swedish Hernia Registry 2005 to 2017 with standard polypropylene (StdPPM) or lightweight (LWM) flat mesh, having tack, fibrin glue, or no fixation, were included. The endpoint was reoperation due to recurrence as of December 31, 2018. Multivariable Cox regression rendered relative risk differences between the exposures, expressed as hazard ratios (HR) with 95% CIs.

RESULTS

Of 25,190 repairs, 924 (3.7%) were later reoperated for recurrence. The lowest, mutually equivalent, reoperation risks were associated with StdPPM without fixation (HR 1), StdPPM with metal tacks (HR 0.8, CI 0.4 to 1.4), StdPPM with fibrin glue (HR 1.1, CI 0.7 to 1.6), and LWM with fibrin glue (HR 1.2, CI 0.97 to 1.6). Except for with fibrin glue, LWM correlated with increased risk, whether affixed with metal (HR 1.7, CI 1.1 to 2.7), or absorbable tacks (HR 2.4, CI 1.8 to 3.1), or deployed without fixation (HR 2.0, CI 1.6 to 2.6).

CONCLUSIONS

With StdPPM, neither mechanical nor glue fixation seemed to improve outcomes. Thus, for this mesh category, we recommend nonfixation. With LWM, we recommend fibrin glue fixation, which was the only LWM alternative on par with nonaffixed StdPPM.

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.

Do drains have an impact on the outcome after primary elective unilateral inguinal hernia repair in men?

INTRODUCTION

The use of drains continues to be a controversial topic in surgery. In a review of that topic for incisional hernia it was not possible to find sufficient evidence of the need for a drain. Likewise, for inguinal hernia surgery the data available are insufficient.

METHODS

In a multivariable analysis of data from the Herniamed Registry for 98,321 patients with primary elective unilateral inguinal hernia repair in men, the role of a drain was investigated.

RESULTS

A drain was used in 24.7% (n = 24,287/98,321) of patients. These patients were on average older, had higher BMI, longer operating time and received a smaller mesh. Drains were also used more often for patients with higher ASA score, risk factors, larger defects and scrotal hernia localization as well as for Lichtenstein, TEP and suture repair. The use of drains was highly significantly associated with intra- and postoperative complications as well as with complication-related reoperations. Hence, drains are used selectively in inguinal hernia repair for patients at higher risk of perioperative complications. Despite the use of drains, the outcome in this risk group is less favorable. It remains unclear if drains prevent further complications in high-risk patients.

CONCLUSION

Drains are used selectively in high-risk men with primary elective unilateral inguinal hernia repair. Drains are associated with intra- and postoperative complications rates and complication-related reoperation rate. Drains can serve as an indicator for early detection of complications.