Inguinal hernia repair in Spain. A population-based study of 263,283 patients: factors associated with the choice of laparoscopic approach

Laparoscopic vs. Open-Groin Hernia Repair in Romania-A Populational Study

Background/Objectives: Groin hernia repair is a common surgical procedure worldwide, with increasing adoption of minimally invasive techniques. However, the adoption of laparoscopic repair varies significantly across healthcare systems. This study aims to analyze trends in laparoscopic versus open-groin hernia repair in Romania over a five-year period (2019-2023), assessing differences in hospital types, reimbursement policies, and patient outcomes. Methods: This nationwide retrospective study examined 76,553 groin hernia repairs from the National Diagnosis-Related Group (DRG) database, including 231 public and 41 private hospitals. Patients were categorized as laparoscopic (13,282 cases) or open repair (63,271 cases). Statistical analysis included logistic regression and non-parametric tests to assess factors influencing surgical approach selection, hospitalization duration, and case complexity. Results: Laparoscopic repair accounted for 17.3% of all groin hernia procedures, with higher adoption in private hospitals (54.7%) than in public hospitals (14.6%). Laparoscopic procedures increased from 14.1% in 2019 to 20% in 2023. Hospitalization was shorter in private hospitals (1.78 vs. 4.80 days in public hospitals). Reimbursement rates showed minimal differentiation between laparoscopic and open repair, suggesting no financial incentive for minimally invasive surgery in public hospitals. Conclusions: Despite a steady increase in laparoscopic hernia repair, its adoption in Romania remains limited compared to Western Europe. Private hospitals lead in minimally invasive surgery, while public hospitals predominantly rely on open repair due to reimbursement policies and resource constraints. Adjusting DRG-based reimbursement, expanding training, and implementing a national hernia registry could improve outcomes and access to minimally invasive surgery.

Chronic inguinal pain post-hernioplasty. Laparo-endoscopic surgery vs lichtenstein repair: systematic review and meta-analysis

PURPOSE

Annually, over 20 million patients worldwide undergo inguinal hernia repair procedures. Surgery stands as the recommended treatment, however, a consensus on the optimal method is lacking. This study aims to conduct an updated systematic review and meta-analysis to compare the risk of chronic inguinal pain and recurrence between laparo-endoscopic mesh repair (TAPP and TEP) versus Lichtenstein repair for inguinal hernia.

METHODS

Searches were conducted in Ovid MEDLINE, PubMed, EBSCO, Cochrane, and Google Scholar. Inclusion criteria encompassed randomized controlled trials (RCTs) involving adults, published in English and Spanish, comparing surgical outcomes among the Lichtenstein open technique, TAPP, and/or TEP. Adherence to the PRISMA guidelines was maintained in the methodology, and the CASP tool was employed to assess the quality of the articles. Statistical analysis involved mean [± standard deviation (SD)], Odds Ratio (OR), and Confidence Interval (CI).

RESULTS

Eight RCTs encompassing 1,469 patients randomized to Lichtenstein repair (n = 755) and laparo-endoscopic repair (n = 714) were included. Laparo-endoscopic repair was associated with a lower likelihood of chronic inguinal pain compared to Lichtenstein repair (OR = 0.28, 95% CI [0.30-0.56], p = 0.0001). There were no significant differences in recurrence rates between the laparo-endoscopic and the Lichtenstein group (OR = 1.03, 95% CI [0.57-1.86], p = 0.92).

CONCLUSIONS

This systematic review and meta-analysis demonstrate that laparo-endoscopic hernia surgery leads to a lower incidence of chronic inguinal pain compared to Lichtenstein repair, while maintaining similar rates of recurrence.

Lichtenstein technique for inguinal hernia repair: ten recommendations to optimize surgical outcomes

PURPOSE

Approximately 20 million individuals worldwide undergo inguinal hernia surgery annually. The Lichtenstein technique is the most commonly used surgical procedure in this setting. The objective of this study was to revisit this technique and present ten recommendations based on the best practices.

METHODS

PubMed and Scientific Electronic Library Online were used to systematically search for articles about the Lichtenstein technique and its modifications. Literature regarding this technique and surgical strategies to prevent chronic pain were the basis for formulating ten recommendations for best practices during Lichtenstein surgery.

RESULTS

Ten recommendations were proposed based on best practices in the Lichtenstein technique: neuroanatomical assessment, chronic pain prevention, pragmatic neurectomy, spermatic cord structure management, femoral canal assessment, hernia sac management, mesh characteristics, fixation, recurrence prevention, and surgical convalescence.

CONCLUSION

The ten recommendations are practical ways to achieve a safe and successful procedure. We fell that following these recommendations can improve surgical outcomes using the Lichtenstein technique.

Outpatient Surgery and Unplanned Overnight Admission in Bilateral Inguinal Hernia Repair: A Population-based Study

PURPOSE

The use of outpatient surgery in inguinal hernia is heterogeneous despite clinical recommendations. This study aimed to analyze the utilization trend of outpatient surgery for bilateral inguinal hernia repair (BHIR) in Spain and identify the factors associated with outpatient surgery choice and unplanned overnight admission.

METHODS

A retrospective observational study of patients undergoing BIHR from 2016 to 2021 was conducted. The clinical-administrative database of the Spanish Ministry of Health RAE-CMBD was used. Patient characteristics undergoing outpatient and inpatient surgery were compared. A multivariable logistic regression analysis was performed to identify factors associated with outpatient surgery choice and unplanned overnight admission.

RESULTS

A total of 30,940 RHIBs were performed; 63% were inpatient surgery, and 37% were outpatient surgery. The rate of outpatient surgery increased from 30% in 2016 to 41% in 2021 (p < 0.001). Higher rates of outpatient surgery were observed across hospitals with a higher number of cases per year (p < 0.001). Factors associated with outpatient surgery choice were: age under 65 years (OR: 2.01, 95% CI: 1.92-2.11), hospital volume (OR: 1.59, 95% CI: 1.47-1.72), primary hernia (OR: 1.89, 95% CI: 1.71-2.08), and laparoscopic surgery (OR: 1.47, 95% CI: 1.39-1.56). Comorbidities were negatively associated with outpatient surgery. Open surgery was associated (OR: 1.26, 95% CI: 1.09-1.47) with unplanned overnight admission.

CONCLUSIONS

Outpatient surgery for BHIR has increased in recent years but is still low. Older age and comorbidities were associated with lower rates of outpatient surgery. However, the laparoscopic repair was associated with increased outpatient surgery and lower unplanned overnight admission.

Nationwide analysis of open groin hernia repairs in Italy from 2015 to 2020

INTRODUCTION

Inguinal hernia repair is one of the most commonly performed operations in general surgery. A total of 130.000 inguinal hernia repairs are performed yearly in Italy, and approximately 20 million inguinal hernias are treated worldwide annually. This report represents the trend analysis in inguinal hernia repair in Italy from a nationwide dataset for the 6-year period from 2015 to 2020.

MATERIALS AND METHODS

Based on regional hospital discharge records, all the inguinal hernia repairs performed in public and private hospitals in Italy between 2015 and 2020 were reviewed based on diagnosis and procedure codes. For the aim of this study, data from the AgeNas (The National Agency for Regional Health Services) data source were analyzed.

RESULTS

Elective inguinal hernia repairs outnumbered urgent operations over the 6-year study period, ranging from 122,737 operations in 2015 to 65,780 in 2020 as absolute numbers, and from 87.96 to 83.3% of total procedures in 2019 and 2020 respectively, with an annual change ranging from - 66.58%, between 2020 and 2019, to - 2.49%, between 2019 and 2018 (mean = - 18.74%; CI =- 46.7%-9.22%; p < 0.0001).

CONCLUSIONS

This large-scale review of groin hernia data from a nationwide Italian dataset provides a unique opportunity to obtain a snapshot of open groin hernia repair activity. More specifically, there is a trend to perform more elective than urgent procedures and there is a steady decrease in the amount of open hernia repairs in favor to laparoscopy.

Bilateral inguinal hernia repair by laparoscopic totally extraperitoneal (TEP) vs. laparoscopic transabdominal preperitoneal (TAPP)

BACKGROUND

The guidelines recommend laparoscopic repair for bilateral inguinal hernia. However, few studies compare the totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) techniques in bilateral inguinal hernias. This study aimed to compare the outcomes of TEP and TAPP in bilateral inguinal hernia.

METHODS

We conducted a retrospective cohort study of patients operated on for bilateral inguinal hernia by TEP and TAPP repair from 2016 to 2020. Intraoperative complications, operative time, acute postoperative pain, hospital stay, postoperative complications, chronic inguinal pain, and recurrence were compared.

RESULTS

A total of 155 patients were included in the study. TEP was performed in 71 patients (46%) and TAPP in 84 patients (54%). The mean operative time was longer in the TAPP group than in the TEP group (107 min vs. 82 min, p < 0.001). The conversion rate to open surgery was higher in the TEP group than in the TAPP group (8.5% vs. 0%, p = 0.008). The mean hospital stay was longer in the TAPP group than in the TEP group (p < 0.001). We did not observe significant differences in the proportion of postoperative complications (p = 0.672), postoperative pain at 24 h (p = 0.851), chronic groin pain (p = 0.593), and recurrence (p = 0.471). We did not observe an association between the choice of surgical technique (TEP vs. TAPP) with conversion rate, operative time, hospital stay, postoperative complications, chronic inguinal pain, or hernia recurrence when performing a multivariable analysis adjusted for the male sex, age, BMI, ASA, recurrent hernia repair, surgeon, and hernia size > 3cm.

CONCLUSIONS

Bilateral inguinal hernia repair by TEP and TAP presented similar outcomes in our study.

EHS guidelines for inguinal hernia repair. The reality of the current situation in Spain. A proposal to standardize its implementation during surgical training

Laparoscopic inguinal hernia repairs are underused in our country and do not fulfil to the recommendations of the European Hernia Society (EHS) guidelines. Thus, it is essential to establish measures that increase its use. We propose that the Spanish Association of Surgeons (AEC) promote these actions and that they should be incorporated into the specialty program. The proposed measures include Standardization of learning; reinforce anatomical knowledge; regulated practices with simulators; promote the use of the open posterior approach; rotations through centers of excellence; accreditation of specialized units and use a registry of activity as quality control.

Impact of comorbidities on hospital mortality in patients with acute pancreatitis: a population-based study of 110,021 patients

BACKGROUND

The impact of pre-existing comorbidities on acute pancreatitis (AP) mortality is not clearly defined. Our study aims to determine the trend in AP hospital mortality and the role of comorbidities as a predictor of hospital mortality.

METHODS

We analyzed patients aged ≥ 18 years hospitalized with AP diagnosis between 2016 and 2019. The data have been extracted from the Spanish National Hospital Discharge Database of the Spanish Ministry of Health. We performed a univariate and multivariable analysis of the association of age, sex, and comorbidities with hospital mortality in patients with AP. The role of the Charlson and Elixhauser comorbidity indices as predictors of mortality was evaluated.

RESULTS

A total of 110,021 patients diagnosed with AP were hospitalized during the analyzed period. Hospital mortality was 3.8%, with a progressive decrease observed in the years evaluated. In multivariable analysis, age ≥ 65 years (OR: 4.11, p < 0.001), heart disease (OR: 1.73, p < 0.001), renal disease (OR: 1.99, p < 0.001), moderate-severe liver disease (OR: 2.86, p < 0.001), peripheral vascular disease (OR: 1.43, p < 0.001), and cerebrovascular disease (OR: 1.63, p < 0.001) were independent risk factors for mortality. The Charlson > 1.5 (OR: 2.03, p < 0.001) and Elixhauser > 1.5 (OR: 2.71, p < 0.001) comorbidity indices were also independently associated with mortality, and ROC curve analysis showed that they are useful for predicting hospital mortality.

CONCLUSIONS

Advanced age, heart disease, renal disease, moderate-severe liver disease, peripheral vascular disease, and cerebrovascular disease before admission were independently associated with hospital mortality. The Charlson and Elixhauser comorbidity indices are useful for predicting hospital mortality in AP patients.

Trends and predictors of laparoscopic bilateral inguinal hernia repair in Spain: a population-based study

BACKGROUND

International guidelines currently recommend laparoscopy for bilateral inguinal hernia repair (BIHR). Our study aims to evaluate the trends and factors associated with the choice of laparoscopy for BIHR in Spain.

METHODS

We performed a retrospective analysis of patients undergoing BIHR between 2016 and 2019. We used the national database of the Spanish Ministry of Health: RAE-CMBD. We performed a univariate and multivariable logistic regression analysis to identify the factors associated with the utilization of laparoscopy. We identified perioperative complications and the factors associated with their occurrence through multivariable logistic regression analysis.

RESULTS

A total of 21,795 BIHRs were performed: 84% by open approach and 16% by laparoscopic approach. Laparoscopic approach increased from 12% in 2016 to 23% in 2019 (p < 0.001). The 40% of hospitals did not use laparoscopy, and only 8% of the hospitals performed more than 50% of their BIHRs by laparoscopy. The utilization rate of laparoscopy was not related to the number of BIHRs performed per year (p = 0.145). The main factor associated with the choice of laparoscopy in multivariable logistic regression analysis was the patient's region of residence (OR 2.04, 95% CI 1.88-2.21). Other factors were age < 65 years (OR 1.65, 95% CI 1.52-1.79) and recurrent inguinal hernia (OR 1.31, 95% CI 1.15-1.49). The type of approach for BIHR was not independently associated with perioperative complications.

CONCLUSIONS

Despite a significant increase in recent years, laparoscopic BIHR in Spain remains low. The main factor associated with the utilization of laparoscopy was the patient's region of residence; this factor seems to be related to the presence of hospitals with a high rate of laparoscopic approaches where the patient lives. The type of approach was not independently associated with perioperative complications. More efforts are needed to increase laparoscopic use in patients with bilateral inguinal hernias.

Utilization of laparoscopic and open inguinal hernia repair at a large hernia center in China: a single-center observational study

BACKGROUND

The utilization of laparoscopic and open inguinal hernia repair in China remains unclear. We aim to investigate the rates of laparoscopic and open inguinal hernia repairs and its associated factors at a large hernia center.

METHODS

Data were obtained from the front sheet of medical records of Beijing Chaoyang hospital. Adult inguinal hernia inpatients who underwent hernia repairs between 2013 and 2020 were included. We calculated the overall rates of laparoscopic and open inguinal hernia repairs and compared the rate of laparoscopic repairs between different sex, age groups, types, and sides of inguinal hernias. Multivariable logistic regression was used to examine factors associated with the rate of laparoscopic repairs.

RESULTS

14,481 inpatients with inguinal hernia were included. 91.78% were male, 75.43% were more than 50 years, 75.20% were unilateral inguinal hernia, and 64.57% were indirect inguinal hernia. Overall, 49.47% underwent laparoscopic repairs and 50.53% underwent open repairs. Women had lower rate of laparoscopic repair than men, especially in those with unilateral hernias. Bilateral and direct inguinal hernia had higher rates of laparoscopic repair than unilateral and indirect inguinal hernia. Multivariable logistic regression showed that inpatients who were women, > 70 years, pantaloon inguinal hernia, with obstruction, and more comorbidities were less likely to have laparoscopic repairs.

CONCLUSION

Around 50% of inguinal hernia patients at a large hernia center underwent laparoscopic repairs, which was more commonly performed in male, young, bilateral inguinal hernia, and inpatients without comorbidities. More efforts were needed to increase the safe and effective laparoscopic utilization among female patients with inguinal hernias.

Outpatient inguinal hernia repair in Spain: a population-based study of 1,163,039 patients-clinical and socioeconomic factors associated with the choice of day surgery

Reducing inpatient admissions and health care costs is a central aspiration of worldwide health systems. This study aimed to evaluate trends in outpatient surgery in inguinal hernia repair (IHR) and factors related to the outpatient setting in Spain. A retrospective cohort study (Record-Strobe compliant) of 1,163,039 patients who underwent IHR from January 2004 to December 2019 was conducted. Data were extracted from the public clinical administrative database CMBD ("Conjunto Mínimo Básico de Datos"). The primary outcome was the outpatient surgery rate. Univariate and multivariable analyses were performed to identify clinical and socioeconomic factors related to the outpatient setting. The overall proportion of outpatient repairs was 30.7% in 2004 and 54.2% in 2019 (p < 0.001). Treatment in a public hospital was the most remarkable factor associated with the likelihood of receiving an outpatient procedure (OR 3.408; p < 0.001). There were also significant differences favouring outpatient procedures for patients with public insurance (OR 2.351; p < 0.001), unilateral hernia (OR 2.903; p < 0.001), primary hernia (OR 1.937; p < 0.0005), age < 65 years (OR 1.747; p < 0.001) and open surgery (OR 1.610; p < 0.001). Only 9% of patients who pay for their intervention privately or 15% of those covered by private insurance were treated as outpatients. Spain has significantly increased the rate of outpatient IHR over the last 16 years. However, the figures obtained still leave a significant margin for improvement. Important questions about the acceptance of outpatient settings remain to be answered. Outpatient inguinal hernia repair in Spain. A population-based study of 1,163,039 patients: clinical and socioeconomic factors associated with the choice of day surgery.

The transition from open to laparoscopic surgery for bilateral inguinal hernia repair: how we did it

PURPOSE

To describe the transition process from open repair (OR) to laparoscopic repair (LR) of bilateral inguinal hernia in a small basic general hospital METHODS: We describe the technical details and training strategy used to facilitate the transition to systematic LR of bilateral inguinal hernia. We conducted a retrospective analysis of prospectively collected data from all patients undergoing bilateral inguinal hernia repair between January 2017 and December 2020. We analysed the evolution of LR and compared the surgical outcomes: complications, acute pain (24 h), chronic pain (> 3 months), and recurrence (1 year) of the patients operated on by OR and LR.

RESULTS

We performed 132 bilateral inguinal hernia repairs, 55 (41.7%) ORs, and 77 (58.3%) LRs. A significant difference was observed in the choice of LR over time (2017: 9%, 2018: 32%, 2019: 75%, 2020: 91%, p < 0.001). The mean operative time was shorter in the OR group than in the LR group (56 min vs. 108 min, p < 0.001). However, the operative time of the LR decreased over the years. No significant differences were observed in complications or recurrence. LR was associated with lower acute postoperative pain at 24 h (2.2 vs. 3.1 points, p = 0.021) and lower chronic groin pain than OR (1.3% vs. 12.7%, p = 0.009).

CONCLUSION

A structured and systematized training process made the transition from OR to LR of bilateral inguinal hernias feasible and safe in a small basic general hospital. This transition did not increase complications or recurrence. Additionally, LR was associated with a decrease in postoperative pain and chronic groin pain.

Inguinal hernia repairs performed for recurrence in Spain: population-based study of 16 years and 1,302,788 patients

PURPOSE

The objective of this study was to assess data on inguinal hernia repairs (IHR) performed for recurrence over a 16 year period (2004-2019) in Spain.

METHODS

A retrospective cohort study of 1,302,788 patients who underwent IHR from January 2004 to December 2019 was conducted. Data were extracted from the Spanish Minimum Basic Data Set (MBDS) of the Health Ministry database. The primary objective was to analyse the proportion of IHR performed by recurrence. As secondary objectives, we evaluated factors related to recurrent hernia (analysed by univariate analysis and multivariable logistic regression analysis) and trends in the recurrent case rate over the 16 year period.

RESULTS

We identified 95,025 patients (7.3% of all IHR) who underwent surgery for recurrent inguinal hernia. Patients undergoing recurrent IHR were more likely to be male (OR 1.687, 95% CI 1.645-1.730), elderly (age > 74 years), and more complicated when they arrived in the operating room (gangrene OR 3.951, 95% CI 3.734-4.180; occlusion OR 1.905, 95% CI 1.853-1.960), and thus had more surgical site occurrences and related mortality. The proportion of IHR performed for recurrence has been dropping over the years (8.7% in 2004 vs. 6.5% in 2019, p < 0.005).

CONCLUSION

The rate of recurrent IHR in Spain (2004-2019) is 7.3%. Recurrent IHR correlates to emergent and complicated surgery and thus to a worst outcome. The trend of this 16 year period is of decreasing operated recurrent inguinal hernia. This is good news even though the improvement is slight and certainly insufficient. Establishing and optimising the rate of hernia recurrence is important for patients and for the health-care system.