Inguinal hernia repair in Switzerland

Inguinal hernia treatment in Switzerland: inpatient vs. outpatient setting - HerStAmb Study (prospective observational two-centre comparative study)

PURPOSE

Since 01/2018, AVOS (ambulant vor stationär = outpatient to inpatient) regulation has been progressively implemented in hernia surgery in Switzerland. The aim of this prospective, observational, two-centre comparative study was to compare the outcome of outpatient and inpatient post-operative care in terms of AVOS by examining the re-admission rate, complication rate and quality of life in patients with primary unilateral inguinal hernia repair.

METHODS

The study ran between 01/2019 and 04/2020 and included 237 patients with a primary unilateral inguinal hernia. Treatment setting was decided according to AVOS guidelines. Primary endpoint was re-admission rate within 6 weeks postoperatively. Secondary endpoints were the complication rate and patient outcome (quality of life) at 6 weeks follow-up postoperatively, as measured by the Short Form 36 Health Survey Questionnaire (SF-36).

RESULTS

Complications occurred in 11 (14%) inpatient patients, but none required re-admitting for revision until follow-up at 6 weeks after discharge. In the outpatient group, there were 27 (17%) complications reported, while 6 (4%) of these patients crossed over to the inpatient group immediately after surgery. None of the other complications required re-admission until follow-up at 6 weeks. No significant relationship between treatment setting and number of complications/re-admission rate (p=0.458, p=0.061) was observed. The mean outcome (SF-36) between the treatment groups was not significantly different (p=0.16-0.856).

CONCLUSION

In terms of AVOS selection criteria in Switzerland, primary unilateral inguinal hernia can be safely treated in both treatment settings. Re-admission rates, complications and quality of life do not significantly differ. Day surgery in terms of AVOS might be as effective and efficient, both from the patient's perspective and that of the institution.

TRIAL REGISTRATION NUMBER

NCT05234242.

Nationwide analysis of laparoscopic groin hernia repair in Italy from 2015 to 2020

Since its introduction, the minimally invasive treatment of groin hernias has become widely accepted as a viable alternative to open surgery. Still, the rates and reasons for its adoption vary highly among countries and the regions within a country. After almost thirty years since its introduction, its spread is still limited. The present study, conducted under the auspices of AGENAS (Italian National Agency for Regional Services), aims at giving a snapshot of the spreading of minimally invasive and robotic techniques for the treatment of groin hernia in Italy. This study is retrospective, with data covering the period from 1st January 2015 to 31st December 2020. AGENAS provided data using the operation and diagnosis codes used at discharge and reported in the International Classification of Diseases 9th revision (ICD9 2002 version). Admissions performed on an outpatient basis, i.e., without an overnight stay of at least one night in hospital, were excluded. A total of 33,925 laparoscopic hernia repairs were performed during the considered period. Overall, a slight increase in the number of procedures performed was observed from 2015 to 2019, with a mean annual change of 8.60% (CI: 6.46-10.74; p < 0.0001). The number of laparoscopic procedures dropped in 2020, and when considering the whole period, the mean annual change was - 0.98% (CI: - 7.41-5.45; p < 0.0001). Urgent procedures ranged from 335 in 2015 to 508 in 2020 referring to absolute frequencies, and from 0.87% to 9.8% in relative frequencies of overall procedures in 2017 and 2020, respectively (mean = 4.51%; CI = 3.02%-6%; p < 0.001). The most relevant observation that could be made according to our analysis was that the adoption of the laparoscopic approach knew a slow but steady increase from 2015 onward.

Learning curve of laparoscopic inguinal hernia repair: systematic review, meta-analysis, and meta-regression

BACKGROUND

Laparoscopic inguinal hernia repair has a long learning curve. It can be a technically challenging procedure and initially presents an unfamiliar view of inguinal anatomy. The aim of this review was to evaluate published literature relating to the learning curve of laparoscopic inguinal hernia repair and identify the number of cases required for proficiency. The secondary aim was to compare outcomes between surgeons before and after this learning curve threshold had been attained.

METHODS

A systematic literature search was conducted in databases of PubMed, Medline, Embase, Web of Science, and Cochrane Library, to identify studies that evaluated the learning curve of laparoscopic inguinal hernia repair. A meta-regression analysis was undertaken to identify the number of cases to achieve surgical proficiency, and a meta-analysis was performed to compare outcomes between cases that were undertaken during a surgeon's learning phase and experienced phase of the curve.

RESULTS

Twenty-two studies were included in this review, with 19 studies included in the meta-regression analysis, and 11 studies included in the meta-analysis. Mixed-effects Poisson regression demonstrated that there was a non-linear trend in the number of cases required to achieve surgical proficiency, with a 2.7% year-on-year decrease. The predicted number of cases to achieve surgical proficiency in 2020 was 32.5 (p < 0.01). The meta-analysis determined that surgeons in their learning phase may experience a higher rate of conversions to open (OR 4.43, 95% CI 1.65, 11.88), postoperative complications (OR 1.61, 95% CI 1.07, 2.42), and recurrences (OR 1.32, 95% CI 0.40, 4.30).

CONCLUSION

Laparoscopic inguinal hernia repair has a well-defined learning curve. While learning surgeons demonstrated reasonable outcomes, supervision during this period may be appropriate given the increased risk of conversion to open surgery. These data may benefit learning surgeons in the skill development of minimally invasive inguinal hernia repairs.

Laparoscopic totally extraperitoneal hernia repair performed by surgical trainees: Overcoming the learning curve

BACKGROUND

Surgical trainees struggle to obtain experience in laparoscopic inguinal hernia repair (LIHR) due to a perceived steep learning curve. The purpose of this study was to compare outcomes in totally extraperitoneal (TEP) repair performed by surgical consultants and trainees under supervision as part of a standardised training regimen to assess the safety of residency training in this technique.

METHODS

A retrospective review of patients managed by TEP repair by either a consultant or a supervised trainee was performed. Demographic, perioperative and postoperative data were collected and compared. All trainees underwent a standardised approach to teaching TEP repair.

RESULTS

Trainees performed 133 procedures and consultants performed 121 procedures. Estimated blood loss was minimal in both cohorts. A significant difference was noted in mean operating time between consultants and trainees (33 vs. 50 min). However, it was also observed that the trainee mean operating time reduced significantly with experience (from 61 to 42 min). No statistically significant difference was demonstrated in postoperative complications, recurrence rate or length of stay. All trainees achieved the ability to complete a laparoscopic TEP repair under unscrubbed consultant supervision during a 1-year placement.

CONCLUSION

With senior supervision and in the presence of a structured training regimen, trainees can safely and effectively perform LIHR, progressing to performing the procedure under unscrubbed consultant supervision. This is valuable information that can serve to inform the structure and direction of surgical training programmes as the ability to offer LIHR is increasingly becoming an expectation of consultant surgeons.

Ten-year trends in minimally invasive hernia repair: a NSQIP database review

BACKGROUND

Utilization of minimally invasive techniques for ventral and inguinal hernia repairs continues to rise. The purpose of this study was to provide updates on national utilization trends and wound complications of minimally invasive versus open ventral and inguinal hernia repairs.

METHODS

Data were accessed from the 2006 to 2017 National Surgical Quality Improvement Program database. All CPT codes that correlated to laparoscopic and open inguinal and ventral hernia repairs were queried. The total number of cases and wound complications, including superficial surgical site infection (SSI), deep SSI, organ space SSI, and wound dehiscence, was collected for each respective CPT code and compared for each year. IBM SPSS Statistics Software and Microsoft Excel were used to collect and analyze the data.

RESULTS

Between 2009 and 2017, the percentage of minimally invasive inguinal hernia repairs increased from 23.1 to 37.8%, whereas the percentage of minimally invasive ventral hernias only increased from 31.5 to 36.6%. Open inguinal hernia repairs had a wound complication rate ranging from 0.60 to 0.74%, which was double the rate of minimally invasive repairs (0.24 to 0.49%) for nearly each respective year. Minimally invasive ventral hernia repairs had total wound complication rates ranging from 0.91 to 1.37%, whereas open ventral hernias had the highest total wound complication rates ranging from 5.07 to 6.26%.

CONCLUSIONS

Over the last ten years, the utilization of minimally invasive inguinal and ventral hernia repair has increased by nearly two-fold. A larger proportion of this increase has been secondary to minimally invasive inguinal compared to ventral hernia repairs. Wound complications across all techniques remained stable or improved, and remained significantly less in the minimally invasive compared to open approaches. This study highlights the continued growth of minimally invasive techniques in hernia repair over the last decade.

Evolution of the Surgical Residency System in Switzerland: An In-Depth Analysis Over 15 Years

BACKGROUND

The landscape of surgical training has been subject to many changes over the past 15 years. This study examines resident satisfaction, determinants of satisfaction, demographics, working hours and the teaching rate of common operations in a longitudinal fashion with the aim to identify trends, shortcomings and possible ways to improve the current training system.

METHODS

The Swiss Medical Association administers an annual survey to all Swiss residents to evaluate the quality of postgraduate medical training (yearly respondents: 687-825, response rate: 68-72%). Teaching rates for general surgical procedures were obtained from the Swiss association for quality management in surgery.

RESULTS

During the study period (2003-2018), the number of surgical residents (408-655 (+61%)) and graduates in general surgery per year (42-63 (+50%)) increased disproportionately to the Swiss population. While the 52 working hour restriction was introduced in 2005 reported average weekly working hours did not decline (59.9-58.4 h (-3%)). Workplace satisfaction (6 being highest) rose from 4.3 to 4.6 (+7%). Working climate and leadership culture were the main determinants for resident satisfaction. The proportion of taught basic surgical procedures fell from 24.6 to 18.9% (-23%).

CONCLUSIONS

The number of residents and graduates in general surgery has risen markedly. At the same time, the proportion of taught operations is diminishing. Despite the introduction of working hour restrictions, the self-reported hours never reached the limit. The low teaching rate combined with the increasing resident number represents a major challenge to the maintenance of the current training quality.

Evaluation of the Reliability, Utility, and Quality of Information Used in Total Extraperitoneal Procedure for Inguinal Hernia Repair Videos Shared on WebSurg

Purpose The Internet is widely used by patients and physicians for obtaining medical information. WebSurg is a valuable information resource that can improve the learning experience of medical professionals if used appropriately. This study aimed to evaluate the quality and accuracy of videos on the total extraperitoneal procedure (TEP) for inguinal hernia repair. Methods We included 32 videos returned by the WebSurg search engine in response to the keyword "TEP." Video popularity was evaluated using the video power index (VPI). The videos' educational quality was measured using the DISCERN score, Journal of American Medical Association (JAMA) benchmark criteria, and Global Quality Score (GQS). Technical quality was measured using the TEP Scoring System (TepSS) by three surgeons who performed TEP routinely. Results All videos were obtained from medical doctors; 12.5% of the videos were uploaded from Belgium; 3.1%, China; 6.3%, Colombia; 6.3%, England; 59.4%, France; 9.4%, Germany; and 3.1%, Korea. No significant differences were noted in terms of the VPI, DISCERN scores, JAMA benchmark criteria, GQSs, and TepSS scores (p > 0.05). The mean VPI, DISCERN score, JAMA benchmark criteria, GQS, and TepSS score were 9454.53 ± 15085.57, 32.75 ± 6.99, 2.31 ± 0.47, 1±0, and 9.25 ± 2.36, respectively. No significant associations were noted between the VPI and DISCERN score, JAMA benchmark criteria, and GQS (p > 0.05). Similarly, there was no significant association between the VPI and TepSS scores (r = 0.100; p = 0.587). Conclusions The online information on TEP is of suboptimal quality. Although limited information is available on preoperative and postoperative processes, the educational potential of WebSurg cannot be ignored.

[Endoscopic surgery and laparoscopy are new insights of evolution of inguinal hernia repair (in Russian only)]

This article is devoted to general and particular problems of inguinal hernia repair through the analysis of statistical data and comparison of advantages and disadvantages of various methods of inguinal hernia repair. Particular attention is paid to the analysis of current options of mesh implant fixing during endoscopic hernia repair: TAPP, TER, e-TER. Long-term outcomes are essential to determine surgical technique. The authors consider that careful adherence to the basic principles of minimally invasive surgery can reduce the incidence of complications, recurrences and chronic pain syndrome after inguinal hernia repair. The main advantages of current surgical technologies are accelerated rehabilitation, earlier restoration of social activity, improvement of the quality of life.

Worldwide hernia repair: variations in the treatment of primary unilateral inguinal hernias in adults in the United Kingdom and in low- and middle-income countries

INTRODUCTION

In this invited commentary, we aim to quantify and explain the variation between, and also within, developed healthcare systems (using the UK as an example) and low- to middle-income countries (LMICs). Rather than including complex cases, we have looked only at 'uncomplicated' primary unilateral inguinal hernias, an area where limited variation may be identified.

METHODS

Data were obtained from Hospital Episode Statistics and structured surveys in the United Kingdom and in low- and middle-income countries.

CONCLUSION

There is widespread variation in the repair of 'uncomplicated' primary inguinal hernias worldwide and within developed healthcare systems.

International guidelines for groin hernia management

INTRODUCTION

Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery.

METHODS

An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group's first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as "strong" (recommendations) or "weak" (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term "should" refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with "watchful waiting" since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon's expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10-12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation "Hernia Center". From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients.

CONCLUSIONS

The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Laparoscopic mesh removal for otherwise intractable inguinal pain following endoscopic hernia repair is feasible, safe and may be effective in selected patients

BACKGROUND

Laparoscopic inguinal hernia repair is preferred over an open technique because of reduced recovery time, favorable cost effectiveness, and less chronic postoperative inguinal pain. Nevertheless, some patients develop a nociceptive inguinal pain syndrome possibly related to the presence of the mesh. This is the first study describing feasibility, safety, and effectiveness of laparoscopic mesh removal in patients with chronic pain after endoscopic hernia repair.

METHODS

Pre- and intraoperative data of chronic pain patients scheduled for endoscopic mesh removal were prospectively collected by a standard evaluation form. Long-term efficacy was determined using pain scores, patient satisfaction, and quality of life questionnaire. A Wilcoxon signed-rank test was used to determine significant differences between pre- and postoperative pain scores.

RESULTS

Fourteen patients were studied (11 males, median 52 years). Median operating time was 103 min. Conversion to open surgery was not required. One intraoperatively recognized bladder laceration was laparoscopically closed. Otherwise, no intraoperative or postoperative complications occurred. Eight months postoperatively (median), pain scores had dropped from eight to four (p < 0.01). Satisfaction was good or excellent in ten patients. A recurrent hernia developed in two patients requiring an open mesh repair in one.

CONCLUSIONS

Laparoscopic mesh removal is a feasible, safe, and effective option in selected patients with chronic groin pain after endoscopic hernia repair in the hands of an experienced surgeon.