Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Is a Technically Challenging Procedure More Likely to Fail? A Prospective Single-Center Study on the Short- and Long-Term Outcomes of Inguinal Hernia Repair

Is a Technically Challenging Procedure More Likely to Fail? A Prospective Single-Center Study on... Hindawi Surgery Research and Practice Volume 2018, Article ID 7850671, 6 pages https://doi.org/10.1155/2018/7850671 Research Article Is a Technically Challenging Procedure More Likely to Fail? A Prospective Single-Center Study on the Short- and Long-Term Outcomes of Inguinal Hernia Repair 1 2 3 M. R. Berndsen , Tomas Gudbjartsson, and Fritz Hendrik Berndsen Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland Department of General Surgery, HVE Akranes County Hospital, Akranes, Iceland Correspondence should be addressed to M. R. Berndsen; mrberndsen3@gmail.com Received 30 November 2017; Accepted 18 March 2018; Published 1 April 2018 Academic Editor: Giuseppe Marulli Copyright©2018M.R.Berndsenetal.'isisanopenaccessarticledistributedundertheCreativeCommonsAttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background and Aims. 'e aim of this prospective single-center study was to evaluate the outcome of inguinal hernia repair. Materials and Methods. A total of 485 inguinal hernias (452 patients and 33 patients with bilateral hernias) were operated between January 2004 and December 2010. Mean age was 56 years, and 93% were male. Patient demographics and operative data were collected, and the operating surgeon assessed the technical difficulty of the operation. Five years after surgery, a questionnaire evaluated recurrence and chronic discomfort according to the Cunningham scale. 372 responded (82%), and mean follow-up was 5.5 years. Results. 'ere were 390 repairs for a primary and 62 for a recurrent hernia. Totally extraperitoneal (TEP) operation was most frequently performed (56%), transabdominal preperitoneal (TAPP) operation in 31%, and Lichtenstein and Shouldice in 12% and 2%, respectively. At 5-year follow-up, the primary outcome of chronic discomfort was 19.5%. 'e independent positive predictors were young age and operation for a recurrent hernia (OR: 3.7), with TEP operation reducing the risk of chronic discomfort (OR: 0.5). 'e secondary outcome was the recurrence rate of 2.5%. Risk factors were strenuous work (OR: 13.7), technically difficult repairs (OR: 7.2), and chronic discomfort (OR: 6.7). Conclusions. Every fifth patient had chronic discomfort in long-term follow-up. 'e recurrence rate was 2.5%, and a technically difficult procedure was a risk factor. numerous studies with thorough long-term follow-up have 1. Introduction shown that the rate of chronic postoperative pain is high and Inguinal hernia repair is among the most common surgical that it is one of the major complications affecting patients that procedures performed worldwide [1], the estimated annual undergo hernia repairs [5, 10]. incidence of inguinal hernia repair being 130–160 operations Surgical technique and the level of operative difficulty per 100,000 inhabitants [2, 3]. Ninety percent of the patients can be of importance when evaluating long-term results. It are males, and the operations are most commonly per- has previously been shown that individual surgeon results formed in two age ranges: 1–5 years and 55–80 years [4]. can vary dramatically and this has been attributed to in- Today, the greatest challenge in inguinal hernia surgery is correct surgical technique [11]. However, it has not been to avoid recurrences and postoperative chronic groin assessed if there could be a correlation between the rate of pain/discomfort [5–8]. After prosthetic meshes were in- long-term complications and how difficult the repair was troduced in the early 1980s for hernia repair, recurrence of technically. inguinal hernia after herniorrhaphy has decreased by 50–75% 'e primary aim of this study was to prospectively assess [8, 9]. 'is is reflected in the Swedish Hernia Registry, where the short-term and long-term results of inguinal hernia the rate of reoperation due to recurrence of inguinal hernia surgery in a cohort of patients in Iceland. 'e main end- decreased from 16.4% in 1992 to 8.8% in 2014 [3]. However, points were the rates of recurrent hernia and chronic 2 Surgery Research and Practice 'e primary outcome variables of the study were chronic pain/discomfort together with analysis of risk factors, in- cluding the operations’ level of technical difficulty. pain/discomfort (yes/no and classified as mild, moderate, or severe according to the Cunningham scale) at 4-week and 5- year follow-up. Due to the small sample size of recurrences, 2. Materials and Methods the recurrence rate was a secondary outcome. If a patient reported having a recurrent hernia in the questionnaire, 2.1. Patients. Demographic and operative data, together he/she was contacted and was offered a clinical examination. with postoperative outcomes of 452 patients with a total of 485 inguinal hernias (33 bilateral hernias), were collected in a prospective database for consecutive patients who were 2.3. Statistics and Approvals. Data were registered in Excel, referred to Akranes County Hospital between 1 January and data analysis was performed using RStudio and 2004 and 31 December 2010. 'is was a prospective clinical R Statistics 3.2.2 ('e R Foundation, Austria). Probabilities case series study, mainly aimed at quality control. At the (p values) of less than 0.05 were considered to be statistically time of operation, the operating surgeon registered patient significant. data and intraoperative data. 'e hospital records were also Descriptive analysis of the data was applied with calcu- checked for complications and readmissions. lation of mean, median, and percentages. Unadjusted asso- Information on age, gender, employment status ciations between patient characteristics and the primary and (heavy/light occupational exertion and elderly), and pre- secondary outcomes were examined. Fisher’s exact test was operative physical status classification according to the used for categorical variables, and the Mann–Whitney U test American Society of Anesthesiologists (ASA) was registered. or Student’s t-test was used for continuous variables based on 'e hernia was classified as primary or recurrent and whether group size and normality of the distribution of the data. 'e it was right-sided, left-sided, or bilateral. Intraoperative data effect of independent variables on chronic pain/discomfort included the type of hernia (indirect, direct, femoral, or was evaluated using logistic regression analysis. combined) and the type of procedure (TAPP, TEP, Lich- 'e study was approved by the Icelandic National Bioethics tenstein, or Shouldice). Operativetime was definedas the time Committee and the Icelandic Data Protection Commission. from skin incision to completion of the wound dressing, in minutes. Type of admission (outpatient/inpatient) and hos- 3. Results pital stay in days were recorded. All the operations were done 3.1. Demographics and Intraoperative Data. Table 1 shows by the same surgeon, and at the end of each operation, the the demographics and intraoperative data for all patients same surgeon subjectively classified the operation as having according to the different operative techniques. 'e mean been easy, medium, or difficult, according to how technically age was 55 years, and 418 (93%) of the patients were males. challenging it was. Altogether, 393 patients (87%) were classified as having ASA 'e open procedures were performed either according to physical status I-II, 20 patients (4%) as ASA class III, and one the Lichtenstein technique [12] or the Shouldice technique patient (0.2%) as ASA class IV. Out of 452 patients, 180 [13]. 'e laparoscopic procedures were either performed (40%) had occupational exertion that was classified as heavy with the transabdominal preperitoneal (TAPP) procedure and 140 patients (31%) as light, and 132 (30%) patients were with titanium staples for mesh fixation [14] or the totally retired, students, or disabled pensioners. extraperitoneal (TEP) procedure without fixation of the Unilateral hernia was diagnosed in 419 (93%) of the mesh except for bilateral hernias where the mesh was fixated patients, and most operations were primary repairs (389, with absorbable PDS tackers [15]. 87%). Of the 63 patients who were operated on for recurrent hernia, 50 had had the first recurrence, 11 had the second 2.2. Clinical Follow-Up. All patients were invited to par- recurrent hernia, one patient was diagnosed with the third ticipate in a follow-up programme whereby they would be recurrent hernia, and one patient had the fifth recurrence. examined at a 4-week follow-up and then receive a follow-up 'e most frequent type of hernia was indirect (228, 50%), questionnaire 5 years after the surgery. During the first 5 followed by direct (155, 34%), combined (56, 12%), and years of the study, patients received a follow-up question- femoral (8, 2%). naire both at 3 and 5 years after surgery, but then, the study 'e most frequent operation technique was laparoscopic, protocol was amended and included only a 5-year follow-up. or in 387 of the patients (86%); TEP repair was performed in For the patients that answered both the 3- and 5-year follow- 249 patients (55%) and TAPP repair in 138 patients (31%). up, the later answer was registered, and if patients only Conventional open hernia repair was performed in 65 pa- answered the 3-year follow-up that answer was registered. tients (14%) and Lichtenstein of which Shouldice operations Seventeen patients were not included in any follow-up, in 54 patients (12%) and 11 patients (2%), respectively. 'e and 63 patients were only included in the short-term follow- mean operative time was 45min (range: 14–180), 37 minutes up. A total of 372 patients (82%) were included in the long- for unilateral surgery (range: 14–165) and 57 minutes for term follow-up, with a mean follow-up time of 5.5 years bilateral repair (range: 30–180) (p<0.001). 'e mean oper- (range: 3.2–6.5). Of the 452 patients in the study, 27 (6%) ative time was 13min shorter for the laparoscopic procedure had died at the time of long-term follow-up. In total, 53 compared to the open group (40 versus 53min; p � 0.003). patients (12%) were lost to long-term follow-up, 13 of whom 'ree-quarters of the patients (n � 342, 76%) were op- had moved abroad (25% of those lost to follow-up). erated in an outpatient setting, and the other 110 patients Surgery Research and Practice 3 Table 1: Demographics and intraoperative data comparing laparoscopic and open hernia repair. Laparoscopic surgery (n � 387) Open surgery (n � 65) Total (n � 452) Mean age (range) (years) 56 (21–95) 53 (18–92) 55 (18–95) Male, n (%) 362 (94) 56 (86) 418 (93) Heavy occupational exertion, n (%) 160 (41) 26 (40) 186 (41) Mean operative time (range) (min) 40 (14–180) 53 (25–165) 45 (14–180) Outpatient setting 298 (77) 43 (66) 341 (75) Unilateral 356 (92) 63 (97) 419 (93) Primary repair 343 (87) 46 (71) 389 (87) Hernia type Indirect inguinal 180 (46) 48 (74) 228 (50) Direct 144 (37) 11 (17) 155 (34) Combined 45 (12) 5 (8) 50 (11) Femoral 7 (2) 1 (2) 8 (2) Technical difficulty Easy 243 (63) 42 (65) 285 (63) Medium difficult 101 (26) 12 (19) 113 (25) Difficult 43 (11) 10 (15) 53 (12) Numbers of patients are given with percentages in parenthesis, except for age and operation time, where mean with range in parenthesis is given. Lap- aroscopic surgery: TAPP and TEP; open surgery: Lichtenstein and Shouldice. (24%) were admitted to the hospital overnight. 'e patients operation were operated with an open procedure in the repair who were admitted were significantly older than the patients and vice versa. who were operated in an outpatient setting (mean age 74 'e univariate relationship between patient features and the risk of recurrent hernia is shown in Table 2. Patients who versus 49 years, resp.; p<0.001). 'e mean hospital stay was 2.6 days (median: 2, range: 1–15). had heavy occupational exertion were significantly more 'e operations were classified technically by the operating likely to have a recurrent hernia (OR:13.7, 95% CI:1.9–60.4). surgeon, whereby 285 (63%) were evaluated as having been 'ere was a significant correlation between a technically easy, 113 (25%) medium difficult, and 53 (12%) difficult. difficult operation, graded by the operating surgeon, just after the operation, and recurrent hernia at long-term follow-up (OR: 7.2, 95% CI: 1.6–32.7). Patients who had 3.2. Short-Term Follow-Up. Out of the 452 patients, 356 chronic pain at long-term follow-up were significantly more (79%) had a follow-up visit 4 weeks postoperatively, and none likely to have recurrent hernia (OR: 6.7, 95% CI: 1.5–33.1). of them had been diagnosed with a recurrent hernia, but at In total, 78 patients (19.5%) reported having chronic that time, 24 of the 356 patients (7%) reported having pain in pain/discomfort at long-term follow-up. Of those, 72 patients the operative (groin) area. 'e median duration of absence (18% of all patients) hadmild complaints that did not interfere from work was 10 days for laparoscopic hernia repair (range: with their daily lives; however, six patients (1.5%) reported 1–30) and 13 days for open surgery (range: 8–21) (p � 0.048). having occasional pain/discomfort that did interfere with Complications at 30 days were diagnosed in 22 patients their daily lives. No patients reported suffering from pain on (4.7%) and were divided into minor and major. 'e minor a daily basis. An analysis of the relationship between patient complications included 9 haematomas/seromas (1.9%) and features and chronic pain/discomfort is shown in Table 3. five cases of urinary retention (1.1%), with five other patients Patients with chronic pain/discomfort were 5 years younger being diagnosed with superficial wound infection (1.1%). No on average (OR: 0.98, 95% CI: 0.96–0.99; p � 0.02). Patients deep infections (including mesh infections) were diagnosed. who were operated for a recurrent hernia were significantly 'ree patients were diagnosed with a major complication more likely to have chronic pain/discomfort at follow-up (OR: (0.6%): a small bowel injury (0.2%) due to adhesions, acquired 3.7, 95% CI: 1.9–7.1; p<0.001). Patients who underwent at the entry to the abdomen in a TEP operation; a large a TEP operation had significantly less pain in long-term infected seroma after a TEP operation (0.2%); and intestinal follow-up than patients who underwent other types of op- obstruction due to adherence of small bowel between the eration (OR: 0.5, 95% CI: 0.3–0.9; p � 0.008). mesh and the abdominal wall after a TAPP repair (0.2%). In the multivariate analysis, young age (OR: 0.98, 95% 'e 30- and 90-day operative mortality was 0%. CI: 0.96–0.99; p � 0.009) and an operation performed for recurrent hernia (OR: 3.7, 95% CI: 1.9–6.9; p<0.001) were independent positive prognostic factors for chronic 3.3. Long-Term Follow-Up. A recurrent hernia was found in pain/discomfort at long-term follow-up. 10 patients’ groins at long-term follow-up, giving a recurrence rate of 2.5%, the rate being 2.3% for primary and 3.6% for 4. Discussion recurrent hernia, respectively (p � 0.64). 'e mean time from operation to recurrence was 24.3 months (range: 6–43 'is study shows a low recurrence rate with a correlation months). Patients who were operated for recurrent hernia between a recurrent hernia and a technically difficult with a laparoscopic (TAPP or TEP) procedure in the primary operation. Furthermore, a significant number of patients 4 Surgery Research and Practice Table 2: Univariate analysis of the risk factors for a recurrence of hernia following hernia repair. No recurrence (n � 390) Recurrence (n � 10) OR (95% CI) p value Age (years) 57 48 ns Operation time (min) 44 63 ns Heavy occupational exertion, n (%) 156 (40) 9 (90) 13.7 (1.9–60.4) 0.002 Recurrent hernia, n (%) 54 (14) 2 (20) 1.6 (0.2–8.1) ns Technical difficulty, n (%) Easy/medium 343 (88) 5 (50) Difficult 47 (12) 5 (50) 7.2 (1.6–32.7) 0.005 Chronic pain 71 (18) 6 (60) 6.7 (1.5–3 3.1) 0.005 ns: not significant. Table 3: Univariate and multivariate logistic regression analysis of risk factors for chronic pain following inguinal hernia repair. Univariate analysis Multivariate analysis No pain Chronic pain (n � 322) (n � 78) OR (95% CI) p value OR (95% CI) p value Age (years) 57 53 0.98 (0.96–0.99) 0.02 0.98 (0.96–0.99) 0.009 Recurrent hernia, n (%) 33 (8.5) 23 (25.7) 3.7 (1.9–7.1) <0.001 3.7 (1.9–6.9) <0.001 Operation type, n (%) TEP 184 (57) 32 (41) 0.5 (0.3–0.9) 0.008 0.6 (0.4–1.0) 0.059 Others 138 (43) 46 (59) Others: TAPP, Shouldice, and Lichtenstein. context, it is important to keep in mind that the rate depends reported having discomfort at long-term follow-up, but in most cases, the discomfort was described as minor. on how strict the definition of chronic pain/discomfort is, and this definition can differ between studies [18, 20]. In the 'e total recurrence rate in the study was 2.5% in long- term follow-up, 2.3 for a primary repair and 3.6 for recurrent present study, the answers were not evaluated independently repairs. Due to the small numbers of recurrences, a multi- and every patient who complained of discomfort was reg- variate analysis of potential risk factors to identify re- istered as having pain/discomfort, irrespective of how currences was not possible. To the best of our knowledge, the severe/mild the symptoms were. Still, most patients (92%) evaluation of the technical difficulty of the operation pre- with pain/discomfort in our study described having only sented here has not been done in any other study on inguinal mild symptoms that did not interfere with their daily lives. hernia repair [16]. 'e single-surgeon design of the study 'e univariate analysis showed that a TEP operation was required the operator to subjectively classify the technical protective against chronic pain/discomfort (OR: 0.5) in long-term follow-up. Several other studies have similar difficulty immediately after surgery. Although this evalua- tion was subjective, a correlation between a technically findings, and it can be presumed that the reason could be the absence of mesh fixation in the TEP repair compared to the difficult operation and long-term recurrence rate was found. Similar findings were reported by Kaafarani et al. who found other repairs [20, 22]. 'e difference in our study, however, a correlation between the rate of recurrence and the sur- was not statistically significant in the multivariate ana- geon’s level of frustration during 1,622 inguinal hernia re- lysis―most likely due to the small sample size and therefore pairs (808 open repairs and 813 laparoscopic repairs). 'ere a lack of statistical power. Young age and repeated hernia was also a significant correlation between frustration and repairs, however, turned out to be independent risk factors postoperative complications (OR: 1.27, 95% CI: 1.03–1.56), for chronic pain in the multivariate analysis, which is both for open repair and laparoscopic repair. We agree on consistent with the findings of other studies [18, 20, 23]. the authors’ conclusion that it is imperative to optimize the 'e operations took 45 minutes on average: 53 minutes for open repair and 40 minutes for laparoscopic repair. Some surgical technique and surroundings to minimize the risk of postoperative complications. 'e present univariate analysis randomized studies comparing open and laparoscopic repairs also showed that heavy occupational exertion was a signifi- have found a 5- to 14-minute longer operation time for cant risk factor for hernia recurrence. 'is is most likely laparoscopic repair [24, 25]. 'is probably reflects the fact that explained by the increased intra-abdominal straining with the laparoscopic operations have a longer learning curve as hard labor, as has previously been demonstrated [17]. other studies have shown that the operation time for a senior After the introduction of large randomized studies and surgeon in laparoscopic hernia surgery is comparable and registries, it has become evident that chronic pain and dis- even shorter than that required for open repair [3, 26]. comfort after inguinal hernia surgery is more prominent In the present study, the length of sick leave was shorter among patients than previously believed. In the present study, for laparoscopic repair than that for open repair, that is, 19.5% of the patients reported having discomfort in long-term 10 days on average for laparoscopic surgery (range: 1–30) as compared to 13 days for open surgery (range: 8–20). Nu- follow-up, which is in line with numerous studies―although both higher and lower rates have been reported [18–21]. In this merous other studies have shown an absolute difference in Surgery Research and Practice 5 inguinal hernias in a nationwide population in Denmark,” return to usual activities in favor of laparoscopic repair Surgery, vol. 155, no. 1, pp. 173–177, 2014. [18, 25, 26]. [9] F. Kockerling, ¨ B. Stechemesser, M. Hukauf, A. Kuthe, and C. Schug-Pass, “TEP versus Lichtenstein: which technique is better for the repair of primary unilateral inguinal hernias in 4.1. Limitations and Strengths. 'e main strength of this men?,” Surgical Endoscopy, vol. 30, no. 8, pp. 3304–3313, 2016. study was that the follow-up was long (mean: 5.5 years) and [10] L. Neumayer, A. Giobbie-Hurder, O. Jonasson et al., “Open the response rate was good (>80%). mesh versus laparoscopic mesh repair of inguinal hernia,” Due to the small sample size of recurrent hernias, New England Journal of Medicine, vol. 350, no. 18, multivariate analysis of risk factors could not be performed. pp. 1819–1827, 2004. In many previous studies, a questionnaire combined with [11] A. S. Eklund, A. K. Montgomery, I. C. Rasmussen, R. P. Sandbue, selective clinical examination has been used to evaluate the L. A. Bergkvist, and C. R. Rudberg, “Low recurrence rate after outcome of inguinal hernia surgery [6, 11, 27]. Some reports laparoscopic (TEP) and open (Lichtenstein) inguinal hernia have found this method to be unreliable although the ad- repair: a randomized, multicenter trial with 5-year follow-up,” vantage is the high follow-up rate achieved [28]. Further- Annals of Surgery, vol. 249, no. 1, pp. 33–38, 2009. [12] P. K. Amid, A. G. Shulman, and I. L. Lichtenstein, “Open more, it can also be assumed that patients with discomfort ‘tension-free’ repair of inguinal hernias: the Lichtenstein would attend a follow-up program regardless of its form. technique,” European Journal of Surgery, vol. 162, no. 6, pp. 447–453, 1996. 5. Conclusions [13] D. R. Welsh and M. A. Alexander, “'e Shouldice repair,” Surgical Clinics of North America, vol. 73, no. 3, pp. 451–469, 'is prospective single-center series shows a five-year re- currence rate of only 2.5%. A correlation between a tech- [14] M. E. Arregui, J. Navarrete, C. J. Davis, D. Castro, and nically difficult operation and recurrence in long-term R. F. Nagan, “Laparoscopic inguinal herniorrhaphy. Tech- follow-up was found, but further studies are needed to niques and controversies,” Surgical Clinics of North America, confirm this correlation. However, every fifth patient vol. 73, no. 3, pp. 513–527, 1993. [15] J. B. McKernan and H. L. Laws, “Laparoscopic repair of in- complains of chronic groin pain/discomfort at long-term guinal hernias using a totally extraperitoneal prosthetic ap- follow-up, although these complaints are minor for most proach,” Surgical Endoscopy, vol. 7, no. 1, pp. 26–28, 1993. patients. [16] Sniðma´t meistaraverkefnis HI - Marta Ro´s Berndsen.pdf, 2017, https://skemman.is/bitstream/1946/26999/1/Marta%20Ro%CC% Conflicts of Interest 81s%20Berndsen.pdf. [17] J. Flich, J. L. Alfonso, F. Delgado, M. J. Prado, and P. Cortina, All authors declare that they have no conflicts of interest. “Inguinal hernia and certain risk factors,” European Journal of Epidemiology, vol. 8, no. 2, pp. 277–282, 1992. [18] H. R. Langeveld, M. van’t Riet, W. F. Weidema et al., “Total References extraperitoneal inguinal hernia repair compared with Lich- tenstein (the LEVEL-Trial): a randomized controlled trial,” [1] I. M. Rutkow, “Demographic and socioeconomic aspects of Annals of Surgery, vol. 251, no. 5, pp. 819–824, 2010. hernia repair in the United States in 2003,” Surgical Clinics of [19] S. Alfieri, P. K. Amid, G. Campanelli et al., “International North America, vol. 83, no. 5, pp. 1045–1051, 2003. guidelines for prevention and management of post-operative [2] P. Primatesta and M. J. Goldacre, “Inguinal hernia repair: chronic pain following inguinal hernia surgery,” Hernia, incidence of elective and emergency surgery, readmission and vol. 15, no. 3, pp. 239–249, 2011. mortality,” International Journal of Epidemiology, vol. 25, [20] A. Eklund, A. Montgomery, L. Bergkvist, and C. Rudberg, no. 4, pp. 835–839, 1996. “Chronic pain 5 years after randomized comparison of lap- [3] Swedish Hernia Register, 2018, http://www.svensktbrackregister. aroscopic and Lichtenstein inguinal hernia repair,” British se/index.php?lang�en. Journal of Surgery, vol. 97, no. 4, pp. 600–608, 2010. [4] J. Burcharth, M. Pedersen, T. Bisgaard, C. Pedersen, and [21] N. Gutlic, P. Rogmark, P. Nordin, U. Petersson, and J. Rosenberg, “Nationwide Prevalence of Groin Hernia Re- A. Montgomery, “Impact of mesh fixation on chronic pain in pair,” PLoS One, vol. 8, no. 1, Article ID e54367, 2013. total extraperitoneal inguinal hernia repair (TEP): a nation- [5] K. McCormack, N. W. Scott, P. M. Go, S. Ross, and wide register-based study,” Annals of Surgery, vol. 263, no. 6, A. M. Grant, “Laparoscopic techniques versus open tech- pp. 1199–1206, 2016. niques for inguinal hernia repair,” Cochrane Database of [22] H. Lau, “Fibrin sealant versus mechanical stapling for mesh Systematic Reviews, no. 1, p. CD001785, 2003. fixation during endoscopic extraperitoneal inguinal hernio- [6] D. Arvidsson, F. H. Berndsen, L. G. Larsson et al., “Ran- plasty: a randomized prospective trial,” Annals of Surgery, domized clinical trial comparing 5-year recurrence rate after laparoscopic versus Shouldice repair of primary inguinal vol. 242, no. 5, pp. 670–675, 2005. [23] G. G. Koning, J. Wetterslev, C. J. H. M. van Laarhoven, and hernia,” British Journal of Surgery, vol. 92, no. 9, pp. 1085– 1091, 2005. F. Keus, “'e totally extraperitoneal method versus Lich- tenstein’s technique for inguinal hernia repair: a systematic [7] F. Bemdsen and D. Sevonius, “Changing the path of inguinal hernia surgery decreased the recurrence rate ten-fold. Report review with meta-analyses and trial sequential analyses of randomized clinical trials,” PLoS One, vol. 8, no. 1, 2013. from a county hospital,” European Journal of Surgery, vol.168, no. 11, pp. 592–596, 2002. [24] A. M. Grant, “Open mesh versus non-mesh repair of groin hernia: meta-analysis of randomized trials based on individual [8] J. Burcharth, K. Andresen, H.-C. Pommergaard, T. Bisgaard, and J. Rosenberg, “Recurrence patterns of direct and indirect patient data,” Hernia, vol. 6, no. 3, pp. 130–136, 2002. 6 Surgery Research and Practice [25] F. Berndsen, D. Arvidsson, L. K. Enander et al., “Postoperative convalescence after inguinal hernia surgery: prospective randomized multicenter study of laparoscopic versus Shouldice inguinal hernia repair in 1042 patients,” Hernia, vol. 6, no. 2, pp. 56–61, 2002. [26] A. Eklund, C. Rudberg, S. Smedberg et al., “Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair,” British Journal of Surgery, vol. 93, no. 9, pp. 1060–1068, 2006. [27] L. Y. Patel, B. Lapin, M. E. Gitelis et al., “Long-term patterns and predictors of pain following laparoscopic inguinal hernia repair: a patient-centered analysis,” Surgical Endoscopy, vol. 31, no. 5, pp. 2109–2121, 2017. [28] P. M. Vos, M. P. Simons, J. S. Luitse, D. van Geldere, M. J. Koelemaij, and H. Obertop, “Follow-up after inguinal hernia repair. Questionnaire compared with physical exam- ination: a prospective study in 299 patients,” European Journal of Surgery, vol. 164, no. 7, pp. 533–536, 2003. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Hindawi Publishing Corporation Hindawi Hindawi Hindawi Hindawi www.hindawi.com Volume 2018 http://www www.hindawi.com .hindawi.com V Volume 2018 olume 2013 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 International Journal of Journal of Immunology Research Endocrinology Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 Submit your manuscripts at www.hindawi.com BioMed PPAR Research Research International Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Hindawi Hindawi Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2013 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Neurology Research and Treatment Cellular Longevity Hindawi Hindawi Hindawi Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Surgery Research and Practice Hindawi Publishing Corporation

Is a Technically Challenging Procedure More Likely to Fail? A Prospective Single-Center Study on the Short- and Long-Term Outcomes of Inguinal Hernia Repair

Loading next page...
 
/lp/hindawi-publishing-corporation/is-a-technically-challenging-procedure-more-likely-to-fail-a-0h3VGUcZzn

References (29)

Publisher
Hindawi Publishing Corporation
Copyright
Copyright © 2018 M. R. Berndsen et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ISSN
2356-7759
eISSN
2356-6124
DOI
10.1155/2018/7850671
Publisher site
See Article on Publisher Site

Abstract

Hindawi Surgery Research and Practice Volume 2018, Article ID 7850671, 6 pages https://doi.org/10.1155/2018/7850671 Research Article Is a Technically Challenging Procedure More Likely to Fail? A Prospective Single-Center Study on the Short- and Long-Term Outcomes of Inguinal Hernia Repair 1 2 3 M. R. Berndsen , Tomas Gudbjartsson, and Fritz Hendrik Berndsen Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland Department of General Surgery, HVE Akranes County Hospital, Akranes, Iceland Correspondence should be addressed to M. R. Berndsen; mrberndsen3@gmail.com Received 30 November 2017; Accepted 18 March 2018; Published 1 April 2018 Academic Editor: Giuseppe Marulli Copyright©2018M.R.Berndsenetal.'isisanopenaccessarticledistributedundertheCreativeCommonsAttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background and Aims. 'e aim of this prospective single-center study was to evaluate the outcome of inguinal hernia repair. Materials and Methods. A total of 485 inguinal hernias (452 patients and 33 patients with bilateral hernias) were operated between January 2004 and December 2010. Mean age was 56 years, and 93% were male. Patient demographics and operative data were collected, and the operating surgeon assessed the technical difficulty of the operation. Five years after surgery, a questionnaire evaluated recurrence and chronic discomfort according to the Cunningham scale. 372 responded (82%), and mean follow-up was 5.5 years. Results. 'ere were 390 repairs for a primary and 62 for a recurrent hernia. Totally extraperitoneal (TEP) operation was most frequently performed (56%), transabdominal preperitoneal (TAPP) operation in 31%, and Lichtenstein and Shouldice in 12% and 2%, respectively. At 5-year follow-up, the primary outcome of chronic discomfort was 19.5%. 'e independent positive predictors were young age and operation for a recurrent hernia (OR: 3.7), with TEP operation reducing the risk of chronic discomfort (OR: 0.5). 'e secondary outcome was the recurrence rate of 2.5%. Risk factors were strenuous work (OR: 13.7), technically difficult repairs (OR: 7.2), and chronic discomfort (OR: 6.7). Conclusions. Every fifth patient had chronic discomfort in long-term follow-up. 'e recurrence rate was 2.5%, and a technically difficult procedure was a risk factor. numerous studies with thorough long-term follow-up have 1. Introduction shown that the rate of chronic postoperative pain is high and Inguinal hernia repair is among the most common surgical that it is one of the major complications affecting patients that procedures performed worldwide [1], the estimated annual undergo hernia repairs [5, 10]. incidence of inguinal hernia repair being 130–160 operations Surgical technique and the level of operative difficulty per 100,000 inhabitants [2, 3]. Ninety percent of the patients can be of importance when evaluating long-term results. It are males, and the operations are most commonly per- has previously been shown that individual surgeon results formed in two age ranges: 1–5 years and 55–80 years [4]. can vary dramatically and this has been attributed to in- Today, the greatest challenge in inguinal hernia surgery is correct surgical technique [11]. However, it has not been to avoid recurrences and postoperative chronic groin assessed if there could be a correlation between the rate of pain/discomfort [5–8]. After prosthetic meshes were in- long-term complications and how difficult the repair was troduced in the early 1980s for hernia repair, recurrence of technically. inguinal hernia after herniorrhaphy has decreased by 50–75% 'e primary aim of this study was to prospectively assess [8, 9]. 'is is reflected in the Swedish Hernia Registry, where the short-term and long-term results of inguinal hernia the rate of reoperation due to recurrence of inguinal hernia surgery in a cohort of patients in Iceland. 'e main end- decreased from 16.4% in 1992 to 8.8% in 2014 [3]. However, points were the rates of recurrent hernia and chronic 2 Surgery Research and Practice 'e primary outcome variables of the study were chronic pain/discomfort together with analysis of risk factors, in- cluding the operations’ level of technical difficulty. pain/discomfort (yes/no and classified as mild, moderate, or severe according to the Cunningham scale) at 4-week and 5- year follow-up. Due to the small sample size of recurrences, 2. Materials and Methods the recurrence rate was a secondary outcome. If a patient reported having a recurrent hernia in the questionnaire, 2.1. Patients. Demographic and operative data, together he/she was contacted and was offered a clinical examination. with postoperative outcomes of 452 patients with a total of 485 inguinal hernias (33 bilateral hernias), were collected in a prospective database for consecutive patients who were 2.3. Statistics and Approvals. Data were registered in Excel, referred to Akranes County Hospital between 1 January and data analysis was performed using RStudio and 2004 and 31 December 2010. 'is was a prospective clinical R Statistics 3.2.2 ('e R Foundation, Austria). Probabilities case series study, mainly aimed at quality control. At the (p values) of less than 0.05 were considered to be statistically time of operation, the operating surgeon registered patient significant. data and intraoperative data. 'e hospital records were also Descriptive analysis of the data was applied with calcu- checked for complications and readmissions. lation of mean, median, and percentages. Unadjusted asso- Information on age, gender, employment status ciations between patient characteristics and the primary and (heavy/light occupational exertion and elderly), and pre- secondary outcomes were examined. Fisher’s exact test was operative physical status classification according to the used for categorical variables, and the Mann–Whitney U test American Society of Anesthesiologists (ASA) was registered. or Student’s t-test was used for continuous variables based on 'e hernia was classified as primary or recurrent and whether group size and normality of the distribution of the data. 'e it was right-sided, left-sided, or bilateral. Intraoperative data effect of independent variables on chronic pain/discomfort included the type of hernia (indirect, direct, femoral, or was evaluated using logistic regression analysis. combined) and the type of procedure (TAPP, TEP, Lich- 'e study was approved by the Icelandic National Bioethics tenstein, or Shouldice). Operativetime was definedas the time Committee and the Icelandic Data Protection Commission. from skin incision to completion of the wound dressing, in minutes. Type of admission (outpatient/inpatient) and hos- 3. Results pital stay in days were recorded. All the operations were done 3.1. Demographics and Intraoperative Data. Table 1 shows by the same surgeon, and at the end of each operation, the the demographics and intraoperative data for all patients same surgeon subjectively classified the operation as having according to the different operative techniques. 'e mean been easy, medium, or difficult, according to how technically age was 55 years, and 418 (93%) of the patients were males. challenging it was. Altogether, 393 patients (87%) were classified as having ASA 'e open procedures were performed either according to physical status I-II, 20 patients (4%) as ASA class III, and one the Lichtenstein technique [12] or the Shouldice technique patient (0.2%) as ASA class IV. Out of 452 patients, 180 [13]. 'e laparoscopic procedures were either performed (40%) had occupational exertion that was classified as heavy with the transabdominal preperitoneal (TAPP) procedure and 140 patients (31%) as light, and 132 (30%) patients were with titanium staples for mesh fixation [14] or the totally retired, students, or disabled pensioners. extraperitoneal (TEP) procedure without fixation of the Unilateral hernia was diagnosed in 419 (93%) of the mesh except for bilateral hernias where the mesh was fixated patients, and most operations were primary repairs (389, with absorbable PDS tackers [15]. 87%). Of the 63 patients who were operated on for recurrent hernia, 50 had had the first recurrence, 11 had the second 2.2. Clinical Follow-Up. All patients were invited to par- recurrent hernia, one patient was diagnosed with the third ticipate in a follow-up programme whereby they would be recurrent hernia, and one patient had the fifth recurrence. examined at a 4-week follow-up and then receive a follow-up 'e most frequent type of hernia was indirect (228, 50%), questionnaire 5 years after the surgery. During the first 5 followed by direct (155, 34%), combined (56, 12%), and years of the study, patients received a follow-up question- femoral (8, 2%). naire both at 3 and 5 years after surgery, but then, the study 'e most frequent operation technique was laparoscopic, protocol was amended and included only a 5-year follow-up. or in 387 of the patients (86%); TEP repair was performed in For the patients that answered both the 3- and 5-year follow- 249 patients (55%) and TAPP repair in 138 patients (31%). up, the later answer was registered, and if patients only Conventional open hernia repair was performed in 65 pa- answered the 3-year follow-up that answer was registered. tients (14%) and Lichtenstein of which Shouldice operations Seventeen patients were not included in any follow-up, in 54 patients (12%) and 11 patients (2%), respectively. 'e and 63 patients were only included in the short-term follow- mean operative time was 45min (range: 14–180), 37 minutes up. A total of 372 patients (82%) were included in the long- for unilateral surgery (range: 14–165) and 57 minutes for term follow-up, with a mean follow-up time of 5.5 years bilateral repair (range: 30–180) (p<0.001). 'e mean oper- (range: 3.2–6.5). Of the 452 patients in the study, 27 (6%) ative time was 13min shorter for the laparoscopic procedure had died at the time of long-term follow-up. In total, 53 compared to the open group (40 versus 53min; p � 0.003). patients (12%) were lost to long-term follow-up, 13 of whom 'ree-quarters of the patients (n � 342, 76%) were op- had moved abroad (25% of those lost to follow-up). erated in an outpatient setting, and the other 110 patients Surgery Research and Practice 3 Table 1: Demographics and intraoperative data comparing laparoscopic and open hernia repair. Laparoscopic surgery (n � 387) Open surgery (n � 65) Total (n � 452) Mean age (range) (years) 56 (21–95) 53 (18–92) 55 (18–95) Male, n (%) 362 (94) 56 (86) 418 (93) Heavy occupational exertion, n (%) 160 (41) 26 (40) 186 (41) Mean operative time (range) (min) 40 (14–180) 53 (25–165) 45 (14–180) Outpatient setting 298 (77) 43 (66) 341 (75) Unilateral 356 (92) 63 (97) 419 (93) Primary repair 343 (87) 46 (71) 389 (87) Hernia type Indirect inguinal 180 (46) 48 (74) 228 (50) Direct 144 (37) 11 (17) 155 (34) Combined 45 (12) 5 (8) 50 (11) Femoral 7 (2) 1 (2) 8 (2) Technical difficulty Easy 243 (63) 42 (65) 285 (63) Medium difficult 101 (26) 12 (19) 113 (25) Difficult 43 (11) 10 (15) 53 (12) Numbers of patients are given with percentages in parenthesis, except for age and operation time, where mean with range in parenthesis is given. Lap- aroscopic surgery: TAPP and TEP; open surgery: Lichtenstein and Shouldice. (24%) were admitted to the hospital overnight. 'e patients operation were operated with an open procedure in the repair who were admitted were significantly older than the patients and vice versa. who were operated in an outpatient setting (mean age 74 'e univariate relationship between patient features and the risk of recurrent hernia is shown in Table 2. Patients who versus 49 years, resp.; p<0.001). 'e mean hospital stay was 2.6 days (median: 2, range: 1–15). had heavy occupational exertion were significantly more 'e operations were classified technically by the operating likely to have a recurrent hernia (OR:13.7, 95% CI:1.9–60.4). surgeon, whereby 285 (63%) were evaluated as having been 'ere was a significant correlation between a technically easy, 113 (25%) medium difficult, and 53 (12%) difficult. difficult operation, graded by the operating surgeon, just after the operation, and recurrent hernia at long-term follow-up (OR: 7.2, 95% CI: 1.6–32.7). Patients who had 3.2. Short-Term Follow-Up. Out of the 452 patients, 356 chronic pain at long-term follow-up were significantly more (79%) had a follow-up visit 4 weeks postoperatively, and none likely to have recurrent hernia (OR: 6.7, 95% CI: 1.5–33.1). of them had been diagnosed with a recurrent hernia, but at In total, 78 patients (19.5%) reported having chronic that time, 24 of the 356 patients (7%) reported having pain in pain/discomfort at long-term follow-up. Of those, 72 patients the operative (groin) area. 'e median duration of absence (18% of all patients) hadmild complaints that did not interfere from work was 10 days for laparoscopic hernia repair (range: with their daily lives; however, six patients (1.5%) reported 1–30) and 13 days for open surgery (range: 8–21) (p � 0.048). having occasional pain/discomfort that did interfere with Complications at 30 days were diagnosed in 22 patients their daily lives. No patients reported suffering from pain on (4.7%) and were divided into minor and major. 'e minor a daily basis. An analysis of the relationship between patient complications included 9 haematomas/seromas (1.9%) and features and chronic pain/discomfort is shown in Table 3. five cases of urinary retention (1.1%), with five other patients Patients with chronic pain/discomfort were 5 years younger being diagnosed with superficial wound infection (1.1%). No on average (OR: 0.98, 95% CI: 0.96–0.99; p � 0.02). Patients deep infections (including mesh infections) were diagnosed. who were operated for a recurrent hernia were significantly 'ree patients were diagnosed with a major complication more likely to have chronic pain/discomfort at follow-up (OR: (0.6%): a small bowel injury (0.2%) due to adhesions, acquired 3.7, 95% CI: 1.9–7.1; p<0.001). Patients who underwent at the entry to the abdomen in a TEP operation; a large a TEP operation had significantly less pain in long-term infected seroma after a TEP operation (0.2%); and intestinal follow-up than patients who underwent other types of op- obstruction due to adherence of small bowel between the eration (OR: 0.5, 95% CI: 0.3–0.9; p � 0.008). mesh and the abdominal wall after a TAPP repair (0.2%). In the multivariate analysis, young age (OR: 0.98, 95% 'e 30- and 90-day operative mortality was 0%. CI: 0.96–0.99; p � 0.009) and an operation performed for recurrent hernia (OR: 3.7, 95% CI: 1.9–6.9; p<0.001) were independent positive prognostic factors for chronic 3.3. Long-Term Follow-Up. A recurrent hernia was found in pain/discomfort at long-term follow-up. 10 patients’ groins at long-term follow-up, giving a recurrence rate of 2.5%, the rate being 2.3% for primary and 3.6% for 4. Discussion recurrent hernia, respectively (p � 0.64). 'e mean time from operation to recurrence was 24.3 months (range: 6–43 'is study shows a low recurrence rate with a correlation months). Patients who were operated for recurrent hernia between a recurrent hernia and a technically difficult with a laparoscopic (TAPP or TEP) procedure in the primary operation. Furthermore, a significant number of patients 4 Surgery Research and Practice Table 2: Univariate analysis of the risk factors for a recurrence of hernia following hernia repair. No recurrence (n � 390) Recurrence (n � 10) OR (95% CI) p value Age (years) 57 48 ns Operation time (min) 44 63 ns Heavy occupational exertion, n (%) 156 (40) 9 (90) 13.7 (1.9–60.4) 0.002 Recurrent hernia, n (%) 54 (14) 2 (20) 1.6 (0.2–8.1) ns Technical difficulty, n (%) Easy/medium 343 (88) 5 (50) Difficult 47 (12) 5 (50) 7.2 (1.6–32.7) 0.005 Chronic pain 71 (18) 6 (60) 6.7 (1.5–3 3.1) 0.005 ns: not significant. Table 3: Univariate and multivariate logistic regression analysis of risk factors for chronic pain following inguinal hernia repair. Univariate analysis Multivariate analysis No pain Chronic pain (n � 322) (n � 78) OR (95% CI) p value OR (95% CI) p value Age (years) 57 53 0.98 (0.96–0.99) 0.02 0.98 (0.96–0.99) 0.009 Recurrent hernia, n (%) 33 (8.5) 23 (25.7) 3.7 (1.9–7.1) <0.001 3.7 (1.9–6.9) <0.001 Operation type, n (%) TEP 184 (57) 32 (41) 0.5 (0.3–0.9) 0.008 0.6 (0.4–1.0) 0.059 Others 138 (43) 46 (59) Others: TAPP, Shouldice, and Lichtenstein. context, it is important to keep in mind that the rate depends reported having discomfort at long-term follow-up, but in most cases, the discomfort was described as minor. on how strict the definition of chronic pain/discomfort is, and this definition can differ between studies [18, 20]. In the 'e total recurrence rate in the study was 2.5% in long- term follow-up, 2.3 for a primary repair and 3.6 for recurrent present study, the answers were not evaluated independently repairs. Due to the small numbers of recurrences, a multi- and every patient who complained of discomfort was reg- variate analysis of potential risk factors to identify re- istered as having pain/discomfort, irrespective of how currences was not possible. To the best of our knowledge, the severe/mild the symptoms were. Still, most patients (92%) evaluation of the technical difficulty of the operation pre- with pain/discomfort in our study described having only sented here has not been done in any other study on inguinal mild symptoms that did not interfere with their daily lives. hernia repair [16]. 'e single-surgeon design of the study 'e univariate analysis showed that a TEP operation was required the operator to subjectively classify the technical protective against chronic pain/discomfort (OR: 0.5) in long-term follow-up. Several other studies have similar difficulty immediately after surgery. Although this evalua- tion was subjective, a correlation between a technically findings, and it can be presumed that the reason could be the absence of mesh fixation in the TEP repair compared to the difficult operation and long-term recurrence rate was found. Similar findings were reported by Kaafarani et al. who found other repairs [20, 22]. 'e difference in our study, however, a correlation between the rate of recurrence and the sur- was not statistically significant in the multivariate ana- geon’s level of frustration during 1,622 inguinal hernia re- lysis―most likely due to the small sample size and therefore pairs (808 open repairs and 813 laparoscopic repairs). 'ere a lack of statistical power. Young age and repeated hernia was also a significant correlation between frustration and repairs, however, turned out to be independent risk factors postoperative complications (OR: 1.27, 95% CI: 1.03–1.56), for chronic pain in the multivariate analysis, which is both for open repair and laparoscopic repair. We agree on consistent with the findings of other studies [18, 20, 23]. the authors’ conclusion that it is imperative to optimize the 'e operations took 45 minutes on average: 53 minutes for open repair and 40 minutes for laparoscopic repair. Some surgical technique and surroundings to minimize the risk of postoperative complications. 'e present univariate analysis randomized studies comparing open and laparoscopic repairs also showed that heavy occupational exertion was a signifi- have found a 5- to 14-minute longer operation time for cant risk factor for hernia recurrence. 'is is most likely laparoscopic repair [24, 25]. 'is probably reflects the fact that explained by the increased intra-abdominal straining with the laparoscopic operations have a longer learning curve as hard labor, as has previously been demonstrated [17]. other studies have shown that the operation time for a senior After the introduction of large randomized studies and surgeon in laparoscopic hernia surgery is comparable and registries, it has become evident that chronic pain and dis- even shorter than that required for open repair [3, 26]. comfort after inguinal hernia surgery is more prominent In the present study, the length of sick leave was shorter among patients than previously believed. In the present study, for laparoscopic repair than that for open repair, that is, 19.5% of the patients reported having discomfort in long-term 10 days on average for laparoscopic surgery (range: 1–30) as compared to 13 days for open surgery (range: 8–20). Nu- follow-up, which is in line with numerous studies―although both higher and lower rates have been reported [18–21]. In this merous other studies have shown an absolute difference in Surgery Research and Practice 5 inguinal hernias in a nationwide population in Denmark,” return to usual activities in favor of laparoscopic repair Surgery, vol. 155, no. 1, pp. 173–177, 2014. [18, 25, 26]. [9] F. Kockerling, ¨ B. Stechemesser, M. Hukauf, A. Kuthe, and C. Schug-Pass, “TEP versus Lichtenstein: which technique is better for the repair of primary unilateral inguinal hernias in 4.1. Limitations and Strengths. 'e main strength of this men?,” Surgical Endoscopy, vol. 30, no. 8, pp. 3304–3313, 2016. study was that the follow-up was long (mean: 5.5 years) and [10] L. Neumayer, A. Giobbie-Hurder, O. Jonasson et al., “Open the response rate was good (>80%). mesh versus laparoscopic mesh repair of inguinal hernia,” Due to the small sample size of recurrent hernias, New England Journal of Medicine, vol. 350, no. 18, multivariate analysis of risk factors could not be performed. pp. 1819–1827, 2004. In many previous studies, a questionnaire combined with [11] A. S. Eklund, A. K. Montgomery, I. C. Rasmussen, R. P. Sandbue, selective clinical examination has been used to evaluate the L. A. Bergkvist, and C. R. Rudberg, “Low recurrence rate after outcome of inguinal hernia surgery [6, 11, 27]. Some reports laparoscopic (TEP) and open (Lichtenstein) inguinal hernia have found this method to be unreliable although the ad- repair: a randomized, multicenter trial with 5-year follow-up,” vantage is the high follow-up rate achieved [28]. Further- Annals of Surgery, vol. 249, no. 1, pp. 33–38, 2009. [12] P. K. Amid, A. G. Shulman, and I. L. Lichtenstein, “Open more, it can also be assumed that patients with discomfort ‘tension-free’ repair of inguinal hernias: the Lichtenstein would attend a follow-up program regardless of its form. technique,” European Journal of Surgery, vol. 162, no. 6, pp. 447–453, 1996. 5. Conclusions [13] D. R. Welsh and M. A. Alexander, “'e Shouldice repair,” Surgical Clinics of North America, vol. 73, no. 3, pp. 451–469, 'is prospective single-center series shows a five-year re- currence rate of only 2.5%. A correlation between a tech- [14] M. E. Arregui, J. Navarrete, C. J. Davis, D. Castro, and nically difficult operation and recurrence in long-term R. F. Nagan, “Laparoscopic inguinal herniorrhaphy. Tech- follow-up was found, but further studies are needed to niques and controversies,” Surgical Clinics of North America, confirm this correlation. However, every fifth patient vol. 73, no. 3, pp. 513–527, 1993. [15] J. B. McKernan and H. L. Laws, “Laparoscopic repair of in- complains of chronic groin pain/discomfort at long-term guinal hernias using a totally extraperitoneal prosthetic ap- follow-up, although these complaints are minor for most proach,” Surgical Endoscopy, vol. 7, no. 1, pp. 26–28, 1993. patients. [16] Sniðma´t meistaraverkefnis HI - Marta Ro´s Berndsen.pdf, 2017, https://skemman.is/bitstream/1946/26999/1/Marta%20Ro%CC% Conflicts of Interest 81s%20Berndsen.pdf. [17] J. Flich, J. L. Alfonso, F. Delgado, M. J. Prado, and P. Cortina, All authors declare that they have no conflicts of interest. “Inguinal hernia and certain risk factors,” European Journal of Epidemiology, vol. 8, no. 2, pp. 277–282, 1992. [18] H. R. Langeveld, M. van’t Riet, W. F. Weidema et al., “Total References extraperitoneal inguinal hernia repair compared with Lich- tenstein (the LEVEL-Trial): a randomized controlled trial,” [1] I. M. Rutkow, “Demographic and socioeconomic aspects of Annals of Surgery, vol. 251, no. 5, pp. 819–824, 2010. hernia repair in the United States in 2003,” Surgical Clinics of [19] S. Alfieri, P. K. Amid, G. Campanelli et al., “International North America, vol. 83, no. 5, pp. 1045–1051, 2003. guidelines for prevention and management of post-operative [2] P. Primatesta and M. J. Goldacre, “Inguinal hernia repair: chronic pain following inguinal hernia surgery,” Hernia, incidence of elective and emergency surgery, readmission and vol. 15, no. 3, pp. 239–249, 2011. mortality,” International Journal of Epidemiology, vol. 25, [20] A. Eklund, A. Montgomery, L. Bergkvist, and C. Rudberg, no. 4, pp. 835–839, 1996. “Chronic pain 5 years after randomized comparison of lap- [3] Swedish Hernia Register, 2018, http://www.svensktbrackregister. aroscopic and Lichtenstein inguinal hernia repair,” British se/index.php?lang�en. Journal of Surgery, vol. 97, no. 4, pp. 600–608, 2010. [4] J. Burcharth, M. Pedersen, T. Bisgaard, C. Pedersen, and [21] N. Gutlic, P. Rogmark, P. Nordin, U. Petersson, and J. Rosenberg, “Nationwide Prevalence of Groin Hernia Re- A. Montgomery, “Impact of mesh fixation on chronic pain in pair,” PLoS One, vol. 8, no. 1, Article ID e54367, 2013. total extraperitoneal inguinal hernia repair (TEP): a nation- [5] K. McCormack, N. W. Scott, P. M. Go, S. Ross, and wide register-based study,” Annals of Surgery, vol. 263, no. 6, A. M. Grant, “Laparoscopic techniques versus open tech- pp. 1199–1206, 2016. niques for inguinal hernia repair,” Cochrane Database of [22] H. Lau, “Fibrin sealant versus mechanical stapling for mesh Systematic Reviews, no. 1, p. CD001785, 2003. fixation during endoscopic extraperitoneal inguinal hernio- [6] D. Arvidsson, F. H. Berndsen, L. G. Larsson et al., “Ran- plasty: a randomized prospective trial,” Annals of Surgery, domized clinical trial comparing 5-year recurrence rate after laparoscopic versus Shouldice repair of primary inguinal vol. 242, no. 5, pp. 670–675, 2005. [23] G. G. Koning, J. Wetterslev, C. J. H. M. van Laarhoven, and hernia,” British Journal of Surgery, vol. 92, no. 9, pp. 1085– 1091, 2005. F. Keus, “'e totally extraperitoneal method versus Lich- tenstein’s technique for inguinal hernia repair: a systematic [7] F. Bemdsen and D. Sevonius, “Changing the path of inguinal hernia surgery decreased the recurrence rate ten-fold. Report review with meta-analyses and trial sequential analyses of randomized clinical trials,” PLoS One, vol. 8, no. 1, 2013. from a county hospital,” European Journal of Surgery, vol.168, no. 11, pp. 592–596, 2002. [24] A. M. Grant, “Open mesh versus non-mesh repair of groin hernia: meta-analysis of randomized trials based on individual [8] J. Burcharth, K. Andresen, H.-C. Pommergaard, T. Bisgaard, and J. Rosenberg, “Recurrence patterns of direct and indirect patient data,” Hernia, vol. 6, no. 3, pp. 130–136, 2002. 6 Surgery Research and Practice [25] F. Berndsen, D. Arvidsson, L. K. Enander et al., “Postoperative convalescence after inguinal hernia surgery: prospective randomized multicenter study of laparoscopic versus Shouldice inguinal hernia repair in 1042 patients,” Hernia, vol. 6, no. 2, pp. 56–61, 2002. [26] A. Eklund, C. Rudberg, S. Smedberg et al., “Short-term results of a randomized clinical trial comparing Lichtenstein open repair with totally extraperitoneal laparoscopic inguinal hernia repair,” British Journal of Surgery, vol. 93, no. 9, pp. 1060–1068, 2006. [27] L. Y. Patel, B. Lapin, M. E. Gitelis et al., “Long-term patterns and predictors of pain following laparoscopic inguinal hernia repair: a patient-centered analysis,” Surgical Endoscopy, vol. 31, no. 5, pp. 2109–2121, 2017. [28] P. M. Vos, M. P. Simons, J. S. Luitse, D. van Geldere, M. J. Koelemaij, and H. Obertop, “Follow-up after inguinal hernia repair. Questionnaire compared with physical exam- ination: a prospective study in 299 patients,” European Journal of Surgery, vol. 164, no. 7, pp. 533–536, 2003. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Hindawi Publishing Corporation Hindawi Hindawi Hindawi Hindawi www.hindawi.com Volume 2018 http://www www.hindawi.com .hindawi.com V Volume 2018 olume 2013 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 International Journal of Journal of Immunology Research Endocrinology Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 Submit your manuscripts at www.hindawi.com BioMed PPAR Research Research International Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Hindawi Hindawi Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2013 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Neurology Research and Treatment Cellular Longevity Hindawi Hindawi Hindawi Hindawi Hindawi www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018 www.hindawi.com Volume 2018

Journal

Surgery Research and PracticeHindawi Publishing Corporation

Published: Apr 1, 2018

There are no references for this article.