Female sex and ipsilateral reoperation risk following mesh-based inguinal hernia repair: a cohort study including 131,626 repairs in adults from an integrated healthcare system over a 10-year period.

PURPOSE: We sought to compare females and males for the risk of reoperation following different inguinal hernia repair approaches (open, laparoscopic, and robotic). METHODS: We conducted a retrospective cohort study including all patients aged ≥ 18 who underwent first inguinal hernia repair with mesh within a US integrated healthcare system (2010-2020). Data were obtained from the system's integrated electronic health record. Multiple Cox proportional-hazards regression was used to evaluate the association between sex and risk for ipsilateral reoperation during follow-up. Analysis was stratified by surgical approach (open, laparoscopic, and robotic). RESULTS: The study cohort was comprised of 110,805 patients who underwent 131,626 inguinal hernia repairs with mesh, 10,079 (7.7%) repairs were in females. After adjustment for confounders, females had a higher risk of reoperation than males following open groin hernia repair (hazard ratio [HR] = 1.98, 95% CI 1.74-2.25), but a lower reoperation risk following laparoscopic repair (HR = 0.70, 95% CI 0.51-0.97). The crude 5-year cumulative reoperation probability following robotic repair was 2.8% in males and no reoperations were observed for females. Of females who had a reoperation, 10.3% (39/378) were for a femoral hernia, while only 0.6% (18/3110) were for femoral hernias in males. CONCLUSION: In a large multi-center cohort of mesh-based inguinal hernia repair patients, we found a higher risk for reoperation in females after an open repair approach compared to males. Lower risk was observed for females through a minimally invasive approach (laparoscopic or robotic) and may be due to the ability to identify an occult femoral hernia through these approaches.

[Case of severe hypokalemia during emergency surgery caused by long-term administration of Shakuyaku-kanzo-to].

An 82-year-old female underwent emergency surgery for right femoral incarcerated hernia under general anesthesia. Anesthesia was induced and maintained with remifentanil and propofol. Her laboratory data showed severe hypokalemia (1.83 mEq x l(-1)) and metabolic alkalosis (HCO3 36.9 mmol x l(-1)). We suspected that the causes of such abnormalities were due to an endocrinological abnormality, but we could not ascertain the actual cause. Drip infusion of sodium chloride and saline solution infusion, to avoid supplying lactate or acetate, the source of bicarbonate ions, were chosen for palliative treatment. No adverse event occurred during surgery. After surgery, endocrinological functions were examined. Primary aldosteronism was ruled out because serum aldosterone and rennin activity were within normal ranges. The patient had been taking a Kampo preparation, Shakuyaku-kanzo-to, for two years. Glycyrrhizin, the main component of Shakuyaku-kanzo-to, has been reported to be a cause of pseudoaldosteronism by inhibiting the enzyme converting cortisol to cortisone. With these findings we confirmed that severe hypokalemia was induced by pseudoaldosteronism by long-term administration of Shakuyaku-kanzo-to.

Open 3-step local anesthesia technique is a more applicable method as compared with spinal anesthesia in inguinofemoral hernia repair.

OBJECTIVE: To compare the effects of spinal anesthesia with those of the open 3-step local anesthesia (TSLA) technique under visual control. METHODS: Between January 2005 and August 2006, the data of 55 patients undergoing groin hernia repair with either the TSLA technique or spinal anesthesia (SA) were collected via retrospective case note review at the General Surgical Unit of the Ardahan Military Hospital, Ardahan, Turkey. Patient characteristics, preoperative and postoperative measurements prior to discharge, average pain, and nausea during the postoperative hospital stay were recorded. RESULTS: While there was no preoperative preparation time for the induction of anesthesia in the TSLA method, it was found that a preparation time of 24.56±8.85 minutes was required for the SA preoperatively. The evaluation of the visual analogue scores of both groups yielded no significant differences between the eighth and twenty-fourth hours. When the postoperative complications in both groups were considered, 3 patients had headache whereas 2 had nausea, and 5 had complications of urinary retention in the SA group. CONCLUSION: Except for the negative factors such as patient refusal, allergic reaction history, previous vaso-vagal episode, or fainting during local anesthesia, incooperability caused by psychiatric disorder or language barriers, the results of the present study indicate that the TSLA is a safe, effective, and appropriate anesthetic technique in the adult age group.

[Experiences from more than 2,100 hernia repair operations. How has the therapy changed in the last 15 years?]. / Erfahrungen aus über 2100 Hernienreparationen. Wie hat sich die Therapie in den letzten 15 Jahren verändert?

INTRODUCTION: Inguinal hernia (IH) surgery has changed fundamentally during the last 25 years due to tension-free repair, minimally-invasive approaches and growing influence of economy in medical decision making. Aim of the study was the documentation and analysis of changes in IH surgery during the last 15 years in our patient cohort. MATERIAL AND METHODS: Patients undergoing elective or emergency inguinal/femoral hernia repair from January 1995 to December 2009 were included in the study. Analysis of patient data was carried out by prospective online recording. RESULTS: A total of 1,908 patients with 2,124 IHs were treated in the study period and the number of IH repairs decreased continuously. The number of recurrent hernias peaked in 2005-2009 with 16.4%. The average preoperative hospital stay decreased from 2.4 to 0.4 days and the postoperative hospital stay from 7.0 to 3.3 days. The percentage of suture repairs declined from 54.9% in 1995 to 4.1% in 2009 and the percentage of open tension-free repairs rose to 52.9% in 1998. In the following years the majority of repairs were performed by minimally invasive procedures but in 2009 the percentage of conventional hernia repairs exceeded the rate of minimally invasive repairs. CONCLUSION: The main reason for these changes is the implementation of diagnosis-related groups which hampers inpatient repair of "simple" inguinal hernias, favors short hospital stay and does not adequately reimburse minimally invasive repairs.

Early experience of performing a modified Kugel hernia repair with local anesthesia.

PURPOSE: We report our results with the modified Kugel hernia repair, a relatively new and minimally invasive open technique offering the advantages of preperitoneal repair without the need for general anesthesia. METHODS: We performed 42 inguinal or femoral hernias (44 sides), including incarcerated femoral hernias, using this modified technique, giving the patient local anesthesia with very little sedation. We describe the operative techniques used and the postoperative complications encountered. RESULTS: The mean operation time was 55 +/- 26 min and the mean hospital stay was 4 days (2-8 days). There were no major postoperative complications and patients were followed up for a mean period of 1 year. Only one patient complained of mild discomfort in the inguinal area after 6 months. There was no incidence of recurrence. CONCLUSION: The modified Kugel hernia repair is easy to learn, and it seems to have a lower recurrence rate and fewer postoperative complications than conventional types of hernia repair. Moreover, it offers the advantage of allowing the patient to undergo preperitoneal inguinal hernia repair under local anesthesia, which is especially beneficial for older patients with preoperative morbidity.

Mortality after groin hernia surgery.

OBJECTIVE: To analyze mortality following groin hernia operations. SUMMARY BACKGROUND DATA: It is well known that the incidence of groin hernia in men exceeds the incidence in women by a factor of 10. However, gender differences in mortality following groin hernia surgery have not been explored in detail. METHODS: The study comprises all patients 15 years or older who underwent groin hernia repair between January 1, 1992 and December 31, 2005 at units participating in the Swedish Hernia Register (SHR). Postoperative mortality was defined as standardized mortality ratio (SMR) within 30 days, ie, observed deaths of operated patients over expected deaths considering age and gender of the population in Sweden. RESULTS: A total of 107,838 groin hernia repairs (103,710 operations), were recorded prospectively. Of 104,911 inguinal hernias, 5280 (5.1%) were treated emergently, as compared with 1068 (36.5%) of 2927 femoral hernias. Femoral hernia operations comprised 1.1% of groin hernia operations on men and 22.4% of operations on women. After femoral hernia operation, the mortality risk was increased 7-fold for both men and women. Mortality risk was not raised above that of the background population for elective groin hernia repair, but it was increased 7-fold after emergency operations and 20-fold if bowel resection was undertaken. Overall SMR was 1.4 (95% confidence interval, 1.2-1.6) for men and 4.2 (95% confidence interval, 3.2-5.4) for women, in accordance with a greater proportion of emergency operations among women compared with men, 17.0%, versus 5.1%. CONCLUSIONS: Mortality risk following elective hernia repair is low, even at high age. An emergency operation for groin hernia carries a substantial mortality risk. After groin hernia repair, women have a higher mortality risk than men due to a greater risk for emergency procedure irrespective of hernia anatomy and a greater proportion of femoral hernia.

Association of hospital ownership with patient transfers to outpatient care under a prospective payment system in Taiwan.

Case payment, a prospective payment system akin to diagnosis-related groups (DRGs) has in-built incentives for hospitals to transfer inpatients to their own ambulatory care units following early discharge. This study used nation-wide inpatient claims data on a total of 100,730 patients treated in 2000 in (Taiwan): cesarean section (59,364 cases), femoral/inguinal hernia operation (18,675 cases), and hemorrhoidectomy (22,691 cases), all reimbursed by case payment, to explore the relationship between hospital ownership and patient transfers to outpatient treatment. For all three diagnoses, for-profit (FP) hospitals not only had lower lengths of stay (LOS) compared to public hospitals, but also showed very high odds of patient transfer to their own outpatient units, after controlling for institutional variables, (hospital level, teaching status, and geographic location), hospital competitive environment (the Herfindal-Hirschman index), and patient variables (gender, age, length of stay, and number of secondary diagnoses, a proxy for severity of illness). Similar, though slightly lower odds were observed with not-for-profit (NFP) hospitals relative to public hospitals. The findings support the property rights theory, suggesting that in Taiwan, institutional profit maximization motives may be driving patient transfers under the case payment diagnoses, rather than medical care needs. In NFP hospitals, their physician compensation mechanism, driven largely by care volumes provided by each physician, appears to be driving the disproportionately greater likelihood of patient transfer to outpatient care.

Local or general anesthesia for open hernia repair: a randomized trial.

OBJECTIVE: To compare patient outcome following repair of a primary groin hernia under local (LA) or general anesthesia (GA) in a randomized clinical trial. SUMMARY BACKGROUND DATA: LA hernia repair is thought to be safer for patients, causes less postoperative pain, cost less, and is associated with a more rapid recovery when compared with the same operation performed under GA. METHODS: All patients presenting to three surgeons during the study period with a primary groin hernia were considered eligible. Outcome parameters measured including tests of vigilance, divided attention, sustained attention, memory, cognitive function, pain, return to normal activity, and costs. RESULTS: Two hundred seventy-nine patients were randomized to LA or GA hernia repair; 276 of these had an operation, with 138 participants in each group. At 6, 24, and 72 hours postoperatively there were no differences in vigilance or divided attention between the groups. Similarly, memory, sustained attention, and cognitive function were not impaired in either group. Although physical activity was significantly impaired at 24 hours, this and return to usual social activities were similar in both groups. While patients in the LA group had significantly less pain on moving, at 6 hours they were less likely to recommend the same operation to someone else. GA hernia repair cost 4% more than the same operation under LA. CONCLUSIONS: There are no major differences in patient recovery after LA or GA hernia repair. Patients should be offered a choice of anesthesia, LA or GA, for repair of their groin hernia.

Feasibility of local infiltration anaesthesia for recurrent groin hernia repair.

OBJECTIVE: To describe the the feasibility of and patients' satisfaction with day case repair of recurrent inguinal hernias under unmonitored local anaesthesia. DESIGN: Prospective study. SETTING: Public service university hospital, Denmark. SUBJECTS: All patients with a reducible recurrent inguinal or femoral hernia unselectedly referred for elective repair during the 4-year period 1 September 1994 to 31 August 1998. INTERVENTIONS: Data were collected prospectively and consecutively from standardised, detailed files, a questionnaire 4 weeks postoperatively, and the Copenhagen Hospitals electronic patient data management system. MAIN OUTCOME MEASURES: Feasibility of local anaesthesia in the day case setting, patient satisfaction and morbidity. RESULTS: 215 consecutive operations for recurrent hernias were performed under unmonitored local anaesthesia. No conversion to general anaesthesia took place and no patients developed urinary retention. After 207 operations, the patients were discharged on the day of operation (96%), and the median time from the end of operation to discharge was 90 minutes (IQR 75-140). After 6 operations (3%), patients had complications that required surgical intervention. The 4-week questionnaire was returned after 208 operations (97%). 30 patients were dissatisfied, mainly because of intraoperative pain (17 patients, 8%). No mortality or cardiopulmonary morbidity was recorded during the first 30 days postoperatively. CONCLUSIONS: Open day-case repair of recurrent inguinal hernias can safely be conducted under unmonitored local anaesthesia with minimal morbidity. Intraoperative pain is the main topic that requires improvement.

Repair of concomitant inguinal and femoral hernias under local anaesthesia.

We describe the case of a 91-year-old patient with small bowel obstruction due to an obstructed groin hernia. It was decided to repair the hernia under local anaesthesia and sedation because of the patient's age and medical condition. At surgery, concomitant inguinal and femoral hernias were found and repaired. We discuss the technique of repairing groin hernias under local anaesthesia, especially in the elderly, and the previously reported incidence of concomitant hernias.

[Hernia repair with local anesthesia]. / La chirurgia delle ernie in anestesia locale.

The authors report the results of their own personal experience with inguinal and femoral hernioplasties (424 cases) performed under loco-regional anaesthesia. This anaesthetic approach together with the use of prosthetic techniques (tension-free and suture-less) represent the "Gold Standard" in the surgical treatment of hernia. The absence of mortality, the remarkable reduction in terms of postoperative complications, days of hospitalization (one day surgery) represent outstanding advantages. The cooperation of the patient and the stress test at the end of the operation are further advantages of the proposed technique.

Lichtenstein's Tension Free Herniorrhaphy in Adult Inguinal Hernia

BACKGROUND: Since the herniorrhaphy was performed by Bassini, that method has been the standard for herniorrhaphy for over a hundred year, although it has been modified by other surgeons. During recent decades, biomaterials were introduced to the medical field, and polypropylene mesh was applied to reconstruct the defective abdominal wall of an inguinal hernia in an adult. The Lichtenstein Hernia Institute is regarded as the leading group for the tension-free herniorrhaphy using Marlex mesh under local anesthesia. METHODS: We designed this study prospectively to investigate the characteristics of groin hernias and the results, including complications and recurrence after surgery. The primary method of surgery was a Lichtenstein's tension-free herniorrhaphy using Prolene mesh. We performed 196 hernioplasties in 180 patients having a groin hernia, which included 16 bilateral hernias. RESULTS: 139 indirect hernias, 51 direct hernias, and 3 femoral hernias were included; there were 15 recurrent hernias. A Lichtenstein's tension-free herniorrhaphy was performed in 84.2% of the cases, a preperitoneal mesh graft in 10.2%, and a Bassini's method in 4.6%. There were four recurrences; three were through the femoral canal after the repair of a direct hernia in a female, and one was a recurrent direct hernia in a male patient. CONCLUSIONS: With the use of a mesh prosthesis, a tension-free herniorrhaphy is possible with neither distortion of the normal anatomy nor suture-line tension. However, it should be carefully applied to a direct hernia only after thorough exploration of the groin through the retroinguinal space of Bogros to rule out coexisting intraparietal or femoral hernias. It is necessary to provide enough laxity for the mesh because prolene mesh can shrink up to 20%, and recurrence might be caused by the tension in the applied mesh.

Groin hernia surgery: a systematic review.

BACKGROUND: An extensive volume of clinical research has been undertaken on the use of surgery for groin hernias. For many years there has been a large number of different methods of repairing hernias and, with the introduction of laparoscopic surgery, this has increased further. It is uncertain which method is the best in terms of safety and effectiveness. OBJECTIVES: This review was undertaken to compare the outcomes following different surgical procedures to treat groin hernias in adults. It sought answers to six questions: 1)Which method of surgery (including open procedures and laparoscopic surgery) is the safest and most effective for inguinal hernia repair? 2) Is local anaesthesia a safe and effective alternative to general anaesthesia? 3) Is there a difference in outcome between specialist and non-specialist surgeons? 4) Is day-case as safe and effective as inpatient surgery? 5) Is synchronous bilateral hernia repair as safe and effective as delayed repair? 6) Which method of surgery is the safest and most effective for femoral hernia repair? METHODS: The primary measure of effectiveness used was the proportion of hernia repairs in which there was a recurrence. Secondary outcome measures included complications, post-operative pain, wound infection, time to return to normal activities and/or return to work. A systematic search of the literature (up to February 1996) was undertaken using a variety of approaches. the methodological quality of all prospective comparative studies (45 randomised trials and 26 non-randomised trials/prospective cohort studies) was assessed using a standard checklist. RESULTS: Some of the variation in findings from different studies is likely to be due to methodological differences rather than differences in the effectiveness of the surgical procedures. The main methodological shortcomings of the studies that have been performed are: lack of agreed method for assessing severity of hernias; failure to take confounding into account in non-randomised studies; variation in length of follow-up; poor external validity; lack of objective measures of outcome; and inadequate statistical power. These problems severely limit the conclusions that can be drawn from the literature.

[Organizational and surgical-technical aspects of the service of abdominal hernioplasty]. / Aspetti organizzativi e tecnico-chirurgici di un servizio di chirurgia delle ernie addominali.

The authors guided by the experience matured from 1/01/94 to 30/06/97 (435 abdominal hernioplasties performed, mainly inguinal and femoral) illustrate the organizational formalities and the technical aspects of a Hernia Surgery Service. In particular, they highlight the advantages of the routine use of local anaesthesia and of tension-free techniques, carried out on a day surgery rule (immediate rehabilitation, greater facilitation to elective surgery, access to the elderly at high anaesthetic risk). Eventually, they emphasize the remarkable reduction of sanitary costs and the outstanding social, practical and didactic value of such Hernia Centers.

Hernia repair in elderly patients.

BACKGROUND: This study evaluates a 5-year experience of the management of the most frequent abdominal wall hernias in an elderly population. METHODS: From April 1990 to December 1995, 231 inguinal, 12 femoral and seven umbilical hernias were repaired in 221 patients (mean age 74 (range 66-93) years). Concomitant diseases were present in 157 patients. A mesh repair was performed with 'tension-free' or 'plug' techniques in all but 23 inguinal and two femoral hernia repairs, in which the Bassini or Shouldice procedures were adopted. Ten emergency hernia repairs were performed for strangulation. A total of 232 operations, including four emergency hernia repairs, were carried out under local anaesthesia. RESULTS: There was no perioperative mortality. Acute intestinal bleeding occurred 2 days after surgery in a patient with colonic diverticular disease. Urinary retention occurred once following emergency hernia repair under general anaesthesia and twice after elective hernia repair under local anaesthesia. Local complications included four scrotal haematomas (2 per cent), three wound infections (1 per cent) and one case of orchitis with atrophy after repair of a recurrent hernia. There was one recurrence after a Bassini repair and one after Shouldice inguinal herniorrhaphy. No recurrence was observed after mesh repair. CONCLUSION: Local anaesthetic mesh hernia repair is safe and effective in elderly patients. Age should be no bar to elective hernia repair. This policy should avoid the complications of emergency operation.

[Surgery of inguinal and femoral hernia in the elderly]. / La chirurgia dell'ernia inguinale e crurale nell'anziano.

Old people are continuously increasing in frequency but age is not a significant factor to value the operative risk in hernia surgery. From June 1985 to December 1996, 189 patients, aged > 80-year, were submitted to hernia surgery. No complications were noted when elective surgery was performed. Emergent procedure was undertaken in 7% of the patients major perioperative complications and one death were registered in this group of patients. Mean hospital stay has decreased in the period of the study: was 2.2 days in the last two years. Local anesthesia permitted a day surgery procedure in 60% of cases.

[Prosthetic repair of inguinal and crural hernias]. / La riparazione con protesi delle ernie inguinali e crurali.

335 inguino-femoral hernias were repaired with polypropylene mesh from December 1991 through December 1995. Eleven patients underwent mesh reinforced Bassini, 167 modified Lichtenstein's technique and 108 Trabucco's repair. Forty-three patients were treated under regional anesthesia. Bilateral hernia was diagnosed in 33 patients and in 20 out of 33 the surgical procedure was entirely performed under regional anesthesia. Early complications referred were 32 scrotal hematomas which spontaneously healed. Two patients showed a recidive hernia and were retreated with and additional mesh; plug rejection (early experience) was referred in one patient who was reoperated on employing a mesh. The indications for the more suitable technique were directly deducted from Nyhus' hernia classification. The authors finally point out the: 1) importance of regional inguinal anesthesia; 2) correct cutting and application of the mesh in the inguinal canal; 3) internal inguinal ring repair; 4) bilateral hernia repair under regional anesthesia.

[6 years of experience in inguinal and femoral hernioplasty in patients over 65 years of age]. / Sei anni di esperienza di ernioplastica inguinale e femorale nei soggetti con oltre 65 anni di età.

From April 1990 to November 1996, 313 inguinal and 14 femoral hernias were repaired in 295 subjects with a mean age of 74 years (66 to 97). Concomitant diseases increasing the operative risk were present in 206 subjects (70 per cent). A mesh repair was performed with "tension-free" or "plug" techniques in all but 23 inguinal and 2 femoral herniorrhaphies where the Bassini or the Shouldice procedures were adopted. Fifty-two inguinal hernias were recurrent, 11 emergency herniorrhaphies were performed for strangulation. Almost all operations (305), including 9 emergency herniorrhaphies, were carried out under local anaesthesia. There was no perioperative mortality. Acute intestinal bleeding occurred after surgery in a subject with colon diverticulosis. One urinary retention following emergency hernia repair under general anaesthesia and 2 following elective hernia repair under local anaesthesia in 2 subjects with hypertrophy of the prostate were observed. Some episodes of hypotension and/or bradycardia were observed either during or after surgery. Local complications following inguinal hernioplasty were 5 (1.5%) scrotal hematomas, 3 (0.9%) wound infections and 1 case (0.4%) of orchitis with atrophy after repair of a recurrent hernia. There were 1 recurrence after Bassini, 1 after Shouldice, and 1 (0.4%) after mesh inguinal hernioplasty. Using local anaesthesia and a mesh repair elective surgery of inguinal and femoral hernias can be safely and effectively performed in elderly patients. Consequently, early elective surgery should be recommended to avoid the risk of an emergency operation.

[Transinguinal preperitoneal mesh-plasty in inguinal hernia using local anesthesia]. / Transinguinale präperitoneale Netzplastik (TIPP) beim Leistenbruch in Lokalanaesthesie.

Between January 1994 and December 1995 inguinal and femoral hernias were repaired in 689 adults. In 58 patients (4 primary hernias, 54 recurrent hernias, 1st-7th recurrence) a mesh prosthesis (Marlex) was implanted in the preperitoneal space using an open inguinal approach (TIPP). After intraoperative classification of the hernia, the indications for TIPP were L/M/Mc and F III type hernias and a weak or destroyed transverse fascia. The operative technique of TIPP is described in detail. Half of the procedures were done with the patient under local anesthesia. There were no intraoperative complications. Besides an increased number of seromas the postoperative course following TIPP was comparable with that after Shouldice procedures performed in the same period. During a follow-up period of 3-24 months to date, no recurrence has been observed. If intraoperative hernia classification is performed, TIPP is an appropriate technique for recurrence-prone inguinal and femoral hernias.