Identifying postoperative complications after inguinal hernia repair with a smartphone application: a comparative cohort study.

PURPOSE: The Q1.6 Inguinal Hernia application continuously measures patient-reported outcomes (PROs) by sampling experiences through brief, digital and condition-specific questions, utilising micro-moments. This can overcome the limitations of current paper questionnaires and give real-time insight into patient recovery. This exploratory study compares data from the application with retrospective data from electronic medical records (EMRs) to provide information on its accuracy in detecting postoperative complications after inguinal hernia repair. METHODS: Patients were asked to use the application in addition to their usual care. The application employs twitch crowdsourcing to gather PROs. Questions from validated and frequently used questionnaires were integrated. A retrospective assessment of EMRs was combined with an additional telephone interview. The primary endpoints were the sensitivity and specificity of the application in detecting chronic postoperative inguinal pain, recurrence and surgical-site infection (SSI). RESULTS: A total of 215 patients were analysed. The sensitivity and specificity for detecting chronic postoperative inguinal pain were 100% (95% CI [47.8%, 100%]) and 93.7% (95% CI [88.3%, 97.1%]), respectively. For recurrence, the sensitivity was 77.8% (95% CI [40.0%, 97.2%]), and the specificity was 81.3% (95% CI [75.0%, 86.5%]). For SSI, the sensitivity and specificity were 75.0% (95% CI [19.4%, 99.4%]) and 89.8% (95% CI [84.8%, 93.6%]), respectively. CONCLUSION: This study demonstrates satisfactory measurement capabilities of the Q1.6 Inguinal Hernia application for identifying postoperative complications following inguinal hernia repair. However, certain aspects require further improvement, such as addressing error-prone questions, enhancing long-term compliance, and validating (pain) measurements through prospective control data. TRAIL REGISTRATION NUMBER: NL7813 (Dutch Trial Registry), 19 May 2019.

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.

Treatment of recurrent inguinal hernia after TransInguinal PrePeritoneal (TIPP) surgery: feasibility and outcomes in a case series.

BACKGROUND: TransInguinal PrePeritoneal (TIPP) inguinal hernia repair (IHR) combines an open anterior approach with a preperitoneal position of the mesh. Advantages include reduced chronic postoperative inguinal pain, low recurrence rates and quick recovery. Critics have expressed concerns that recurrent IHR after TIPP could be difficult and with an increased risk of complications due to the formation of scar tissue in both the anterior and posterior anatomical inguinal planes. This study reports feasibility and outcomes of recurrent IHR after TIPP repair. METHODS: Patients who underwent recurrent IHR after TIPP between January 2013 and January 2015 in a single hernia-dedicated teaching hospital were included. Exclusion criteria were femoral hernia, incarcerated hernia and reasons for unreliable follow-up. Electronic medical records were assessed retrospectively to register surgical outcomes and complications. RESULTS: Thirty-three patients underwent surgical repair of recurrent inguinal hernia after TIPP. Twenty patients were treated with a "re-TIPP when possible" strategy; resulting in 13 successful re-TIPPs and 7 conversions to Lichtenstein repair. Eleven patients underwent a primary Lichtenstein's repair, the remaining two patients underwent recurrent IHR using other techniques (TransREctus sheath PrePeritoneal and TransAbdominal PrePeritoneal repair). Mean time of surgery was 44.7 min (standard deviation 16.7). There was one patient (3.0%) with a re-recurrent inguinal hernia during follow-up. Other minor complications included urinary tract infection. CONCLUSION: These results indicate that after TIPP it is feasible and safe to perform re-surgery for recurrent inguinal hernia with an anterior approach again. For these recurrences, a Lichtenstein repair can be performed, or a "re-TIPP if possible" strategy can be applied by experienced TIPP surgeons, tailored to the intraoperative findings. Whether a re-TIPP has advantages over Lichtenstein should be evaluated in a prospective manner.

Perioperative monitoring of inguinal hernia patients with a smartphone application.

INTRODUCTION: Patient Reported Outcomes have become standard in the evaluation of inguinal hernia repair. However, the chosen outcomes remain heterogeneous and the measurements time-consuming or inadequate. Perioperative measurement of pain and recovery could benefit from the contemporary possibilities that mobile health applications offer. METHODS: An application for smartphones and tablets was developed using the twitch crowdsourcing concept, classical questionnaires, experiences from randomised clinical trials, and patients' input. RESULTS: Dichotomous questions and numeric rating scales, both pre- and post-operative, were implemented in the freely available Q1.6 application. Content, timing and frequencies were adapted to the inguinal hernia patient's daily life and assumed recovery. Certain combinations of answers were set as alert notifications to detect adverse events. Data are displayed on a web-based dashboard enabling real-time monitoring. Legal aspects were examined and taken into account. DISCUSSION: The Q1.6 inguinal hernia app is an innovative tool for perioperative monitoring of pain and recovery of inguinal hernia patients. Previous limitations of classical measurements such as a large heterogeneity, retrospective data recording and different forms of bias can be eliminated. The `big data´ generated in this manner might be used for large-scale research to improve inguinal hernia surgery. The Q1.6 platform is not only hernia specific; it is also an innovative tool to measure PROs in any other domain.

Long-term results from a randomized comparison of open transinguinal preperitoneal hernia repair and the Lichtenstein method (TULIP trial).

BACKGROUND: The short-term results of the TULIP trial comparing transinguinal preperitoneal (TIPP) inguinal hernia repair with the Lichtenstein method have been reported with follow-up of 1 year. After TIPP repair, fewer patients had chronic postoperative inguinal pain (CPIP); they had better health status and lower costs. The present study reports the long-term outcomes of this trial. METHODS: All surviving patients initially randomized in the TULIP trial were contacted. Patients were interviewed by telephone and sent a questionnaire. Those reporting any complaints were invited for outpatient review. Chronic pain, hernia recurrence and reoperation were documented, along with any sensory change or disturbance of sexual activity. RESULTS: Of 302 patients initially randomized, 251 (83·1 per cent) were included in the analysis (119 TIPP, 132 Lichtenstein), with a median follow-up of 85 (range 74-117) months. Of 25 patients with chronic postoperative inguinal pain after 1 year, only one, who underwent Lichtenstein repair, still had groin pain at long-term follow-up. The overall hernia recurrence rate was 2·8 per cent (7 patients), with no difference between the groups. CONCLUSION: Both TIPP and Lichtenstein hernia repairs are durable. Patients with chronic postoperative inguinal pain after 1 year can be reassured that the groin pain tends to fade over time.

Outcomes of surgery on patients with a clinically inapparent inguinal hernia as diagnosed by ultrasonography.

BACKGROUND: Chronic post-operative inguinal pain (CPIP) is the most significant complication following inguinal hernia repair. Patients without a palpable hernia prior to surgery seemed to report more CPIP. Our aim was to evaluate the effects of surgery on patients with a clinically inapparent inguinal hernia as diagnosed using ultrasonography. METHODS: A total of 179 hernia repairs in patients with a positive ultrasonography but negative physical examination were analysed retrospectively. Patients with recurrent hernias, femoral hernias or previous surgery to the inguinal canal were excluded. The primary outcome was the presence of chronic postoperative inguinal pain (pain > 3 months postoperatively). Data on preoperative complaints, surgical technique and findings during ultrasonography and surgery were also studied in relation to the development of CPIP. RESULTS: A quarter (25.1%) of the patients reported chronic postoperative pain. Female gender (p = 0.03), high BMI (p = 0.04) and atypical symptoms prior to surgery (p < 0.001) were significant univariate risk factors for developing CPIP. Logistic regression showed a significant association between atypical symptoms and CPIP [OR = 6.31, p < 0.001, 95% CI (2.32, 17.16)], which was still present after correction for the significant univariate variables [OR = 4.23, p = 0.02, 95% CI (1.26, 14.21)]. CONCLUSION: Patients with a clinically inapparent inguinal hernia as diagnosed using ultrasonography report a high incidence of CPIP after elective hernia repair. Patients with atypical groin pain prior to surgery are especially prone to CPIP. It is questionable whether these hernias should be classified and treated as symptomatic inguinal hernias. The results advocate taking other causes of groin pain into consideration before choosing surgical treatment.