Results from patient-reported outcome measures are inconsistently reported in inguinal hernia trials: a systematic review

Impact of abdominal compliance on surgical stress and postoperative recovery in laparoscopic groin hernia repair: a retrospective cohort study

PURPOSE

The role of abdominal compliance in pneumoperitoneum is not fully understood. This study aimed to clarify the association between abdominal wall stretching tendency and surgical stress in laparoscopic groin hernia repair.

METHODS

We conducted a retrospective single-center cohort study, evaluating 51 patients who underwent elective transabdominal preperitoneal groin hernia repair. Abdominal compliance was assessed using the abdominal compliance index (ACI; insufflated intra-abdominal volume [L] / body surface area [m²]) at 8 mmHg intra-abdominal pressure. Surgical stress and recovery were evaluated with patient-reported outcome measures (PROMs), including QOR-15 and pain visual analog scale (VAS) scores. Associations between ACI, PROMs, and clinical outcomes were analyzed.

RESULTS

The median ACI was 1.229 L/m² (0.369-2.091). Eleven patients (21.6%) above the 75th percentile cutoff (1.576 L/m²) were categorized as high ACI. While body constitution was similar between groups, the high ACI group had significantly greater insufflated intra-abdominal volume (2.88 L vs. 1.89 L, P < 0.0001). Pre-operative QOR-15 scores were similar. However, on postoperative day 1, the high ACI group had significantly lower QOR-15 scores (90.2 vs. 110.1, P = 0.017), with subcategory analysis showing reduced physical well-being. Multivariate analysis indicated that high ACI was a significant predictor of poorer QOR. The high ACI group also reported higher, though not statistically significant, postoperative pain.

CONCLUSION

Abdominal walls with greater elasticity, which stretch excessively under pneumoperitoneum, were more susceptible to surgical stress. Further studies are warranted to evaluate the efficacy of tailored pneumoperitoneum pressure adjustment based on abdominal compliance to mitigate surgical stress.

ENGINE-An EHS Project for Future Guidelines

Clinical guidelines are evidence-based recommendations developed by healthcare organizations or expert panels to assist healthcare providers and patients in making appropriate and reliable decisions regarding specific health conditions, aiming to enhance the quality of healthcare by promoting best practices, reducing variations in care, and at the same time, allowing tailored clinical decision-making. European Hernia Society (EHS) guidelines aim to provide surgeons a reliable set of answers to their pertinent clinical questions and a tool to base their activity as experts in the management of abdominal wall defects. The traditional approach to guideline production is based on gathering key opinion leader in a particular field, to address a number of key questions, appraising papers, presenting evidence and produce final recommendations based on the literature and consensus. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) method offers a transparent and structured process for developing and presenting evidence summaries and for carrying out the steps involved in developing recommendations. Its main strength lies in guiding complex judgments that balance the need for simplicity with the requirement for complete and transparent consideration of all important issues. EHS guidelines are of overall good quality but the application of GRADE method, began with EHS guidelines on open abdomen, and the increasing adherence to the process, has greatly improved the reliability of our guidelines. Currently, the need to application of this methodology and the creation of stable and dedicated group of researchers interested in following GRADE in the production of guidelines has been outlined in the literature. Considering that the production of clinical guidelines is a complex process, this paper aim to highlights the primary features of guideline production, GRADE methodology, the challenges associated with their adoption in the field of hernia surgery and the project of the EHS to establish a stable guidelines committee to provide technical and methodological support in update of previously published guideline or the creation of new ones.

Comparing functional outcomes in minimally invasive versus open inguinal hernia repair using the army physical fitness test

PURPOSE

The advantages of minimally invasive inguinal hernia repair (MIHR) over open hernia repair (OHR) continue to be debated. We compared MIHR to OHR by utilizing the Army Physical Fitness Test (APFT) as an outcome measure.

METHODS

The APFT is a three-component test scored on a normalized 300 point scale taken semiannually by active-duty military. We identified 1119 patients who met inclusion criteria: 588 in the OHR group and 531 in the MIHR group. Changes in APFT scores, time on post-operative duty restrictions (military profile), and time interval to first post-operative APFT were compared using regression analysis.

RESULTS

Postoperatively, no APFT score change difference was observed between the OHR or MIHR groups (- 7.3 ± 30 versus - 5.5 ± 27.7, p = 0.2989). Service members undergoing OHR and MIHR underwent their first post-operative APFT at equal mean timeframes (6.6 ± 5 months versus 6.7 ± 5.1, p = 0.74). No difference was observed for time in months spent on an official temporary duty restriction (military profile) for either OHR or MIHR (0.16 ± 0.16 versus 0.15 ± 0.17, p = 0.311). On adjusted regression analysis, higher pre-operative APFT scores and BMI ≥ 30 were independently associated with reduction in post-operative APFT scores. Higher-baseline APFT scores were independently associated with less time on a post-operative profile, whereas higher BMI (≥ 30) and lower rank were independently associated with longer post-operative profile duration. Higher-baseline APFT scores and lower rank were independently associated with shorter time intervals to the first post-operative APFT.

CONCLUSION

Overall, no differences in post-operative APFT scores, military profile time, or time to first post-operative APFT were observed between minimally invasive or open hernioplasty in this military population.

Clinical feasibility of the Q1.6 Inguinal Hernia application: a prospective cohort study

PURPOSE

Patient-reported outcomes (PROs) are essential to evaluate inguinal hernia surgery. There is a need for digital and disease-specific PRO measurement. Current measuring instruments (PROMs) have several disadvantages, for example, fixed measuring moments with a chance of recall bias. The Q1.6 Inguinal Hernia application has been developed to overcome these challenges. This pilot study reports the first clinical feasibility results.

METHODS

All surgically treated inguinal hernia patients were eligible for inclusion. The application uses "twitch crowdsourcing"; after unlocking a smartphone or tablet, a single short question is asked. This can easily be repeated multiple times a day/week/month. Questions from validated questionnaires were implemented. The adaptive question engine generates an individualised set of questions. Alerts are generated when a complication is suspected.

RESULTS

A total of 229 patients were given over 50.000 questions of which 92% were answered. Pre- and postoperative patient characteristics and their reported clinical outcomes confirmed a standard inguinal hernia population. Compliance with the application was 91.7% after 14 days, 69.0% after 3 months and 28.8% after one year. After months 3, 6 and 11, respectively, 3.0%, 4.4% and 4.5% of patients reported inguinal pain or discomfort (NRS ≥ 4). Patients were highly satisfied (92.8% preferred the app over standard care).

CONCLUSIONS

This smartphone application shows promising results for clinical practice. It might allow for continuous digital patient-reported outcome measurement using non-intrusive, concise questions. Remote monitoring may become standard postoperative care after (inguinal hernia) surgery. The current application will be further improved and evaluated for cost-effectiveness, safety and validity.

Current practices in complex abdominal wall reconstruction in the Americas: need for national guidelines?

BACKGROUND

Component separation (CS) procedures have become an important part of surgeons' armamentarium. However, the exact criteria for training, procedure/mesh choice, as well as patient selection for CS remains undefined. Herein we aimed to identify trends in CS utilization between various cohorts of practicing surgeons.

STUDY DESIGN

Members of the Americas Hernia Society were queried using an online survey. Responders were stratified according to their experience, practice profile (private vs academic, general vs hernia surgery), and volume (low (< 10/year) vs high) of CS procedures. We used Chi-squared tests to evaluate significant associations between surgeon characteristics and outcomes.

RESULTS

275 responses with overwhelming male preponderance (88%) were collected. The two most common self-identifiers were "general" (66%) and "hernia" (28%) surgeon. PCS was the most commonly (67%) used type of CS; endoscopic ACS was least common (3%). Low-volume surgeons were more likely to utilize the ACS (p < 0.05). Only 7% of respondents learned PCS during their residency, as compared to 36% that use ACS. 65% felt 0-10 cases was sufficient to become proficient in their preferred technique. 10 cm-wide defect was the most common indication for CS; 23% used it for 5-8 cm defects. Self-identified "hernia" and high-volume surgeons were more likely to use synthetic mesh in the setting of previous wound infections and/or contaminated field (p < 0.05). More general/low-volume surgeons use biologic mesh. Contraindications to elective CS varied widely in the cohort, and 9.5% would repair poorly optimized patients electively. Severe morbid obesity was the most feared comorbidity to preclude CS.

CONCLUSION

The use of CS varies widely between surgeons. In this cohort, we discovered that PCS was the most commonly used technique, especially by hernia/high-volume surgeons. There are differences in mesh utilization between high-volume and low-volume surgeons, specifically in contaminated fields. Despite its prevalence, CS training, indications/contraindications, and patient selection must be better defined.