Diagnostic Laparoscopy Through Deep Inguinal Ring

<p dir="ltr">There is inequity in access to surgical treatment and quality of care globally and this is more pronounced in low-and middle-income countries (LMICs) especially among women. Prioritizing treatment of common surgical conditions like groin hernias in LMICs would improve this aspect.</p><p dir="ltr">Aims. The present aims were to assess groin hernia surgery outputs and practices in Uganda, to evaluate the relationship between parity and the incidence rate of groin hernia repair among women born in Sweden between 1956 and 1983, to compare the safety and effectiveness of open anterior mesh repair for groin hernia in adult women in Uganda to modified open anterior mesh repair through which both the inguinal and the femoral canal can be accessed and covered with a mesh flap. A further aim was to assess the cost and cost-effectiveness of the open anterior mesh repair in comparison to the modified open anterior mesh repair.</p><p dir="ltr">Methods. Studies I, III and IV were carried out in Uganda. Study II was carried out in Sweden. Study I was a hospital-based observational study to retrospectively review theatre records for groin hernia repairs in 2013 and 2014, and a questionnaire interview for the surgical providers. Study II was a population-based cohort study among women born in Sweden between 1956 and 1983 in which the Swedish Hernia Register, and the National Medical Birth Register were cross- matched to identify groin hernia repairs after childbirth. The follow up period was until 31st December 2022. Incidence rates and incidence rate ratios for inguinal and femoral hernia repairs were determined. Study III was a double- blinded randomized controlled trial among adult women in Uganda in which the safety and effectiveness of open anterior mesh repair were compared with those of modified open anterior mesh repair. Study IV was a cost-effectiveness study of the trial in Study III to compare the cost and cost-effectiveness of the two groin hernia repair methods.</p><p dir="ltr">Results. Study I, found that 5518 groin hernia repairs were performed in 2013 and 2014, with an annual repair rate of 7/100, 000 population. Most of the repairs were performed by non- specialized surgeons using suture techniques and almost 16% of the repairs were performed in women. In Study II, the mean incidence of inguinal hernia repair was 10.7 per 100,000 person-year and 2.6 per 100,000 person-year for femoral hernia repairs. The incidence rate and the incidence rate ratios for both inguinal and femoral hernia repairs increased with the number of births. In Study III, altogether, 200 participants were included. Nearly 45% had a femoral hernia. At one-year follow-up, overall recurrence was 5.6% and overall wound complications at two weeks follow-up were 10.1%. In Study IV, the cost per DALY averted in the open anterior mesh repair was 292.0 (SD, 264.4) USD compared to 328.8 (SD, 284.2) USD in the modified open anterior mesh repair.</p><p dir="ltr">In conclusion, groin hernia repair outputs in Uganda need to improve along with mesh-based methods. High parity levels may increase the risk of groin hernias. Opening of the transversalis fascia to inspect the femoral canal should be routinely done among women to detect femoral hernias. The modified open anterior mesh repair is an option to treat inguinal and femoral hernias in the absence of laparoscopy. While the open anterior mesh repair and its modified version are cost-effective, their application should depend on patient needs. However, the high possibility of femoral hernias among women in the study setting, calls for promotion of the modified open anterior mesh method.</p><h3>List of scientific papers</h3><p dir="ltr">I. Groin hernia Surgery in Uganda. Caseload and Practices at Hospitals Operating Within the Publicly Funded Health Care Sector. <b>Alphonsus Matovu</b>, Pär Nordin, Andreas Wladis, Mary Margaret Ajiko, Jenny Löfgren. World J.Surg (2020) 44:3277-3283. <a href="https://doi.org/10.1007/s00268-020-05633-9" rel="noreferrer" target="_blank">https://doi.org/10.1007/s00268-020-05633-9</a><br></p><p dir="ltr">II. Incidence of groin hernia repairs in women and parity. A population - based cohort study among women born in Sweden between 1956 and 1983. A. Matovu, J. Lofgren, A. Wladis, P. Nordin, G. Sandblom, H.J. Pettersson. Hernia (2024) 28:1231-1238.<a href="https://doi.org/10.1007/s10029-024-03011-1" rel="noreferrer" target="_blank"> https://doi.org/10.1007/s10029-024-03011-1</a></p><p dir="ltr">III. Open anterior mesh repair versus modified open anterior mesh repair for groin hernia in women. A randomized clinical trial. <b>Alphonsus Matovu</b>, Par Nordin, Andreas Wladis, Gabriel Sandblom, Moses Elaju, Fredrik Lindmark, Olof Bladin, Jenny Löfgren. [Manuscript]</p><p dir="ltr">IV. Cost-effectiveness of open anterior mesh repair compared to modified open anterior mesh repair for groin hernia repair in women in a low resource setting. A randomized clinical trial. <b>Alphonsus Matovu</b>, Zin Min Thet Lwin, Geoffrey Okello, Francis Lulu, Gabriel Sandblom, Moses Elaju, Olof Bladin, Filip Westling, Andreas Wladis, Pär Nordin, Jenny Löfgren. [Manuscript]</p>

Surgical training involves letting residents operate under supervision. Since hernia repair is a common procedure worldwide, it is a frequent part of the surgical curriculum. To assess the risk of reoperation for recurrence after elective primary groin and ventral hernia repair performed by supervised residents compared with that by specialists. This nationwide register-based cohort study included data from January 2016 to September 2021. Patients were followed up until reoperation, emigration, death, or the end of the study period. The study used data from the Danish Inguinal and Ventral Hernia Databases linked with data from the Danish Patient Safety Authority's Online Register via surgeons' unique authorization ID. The cohort included patients aged 18 years or older who underwent primary elective hernia repairs performed by supervised residents or specialists for inguinal, femoral, epigastric, or umbilical hernias. Hernia repairs were divided into the following 4 groups: Lichtenstein groin, laparoscopic transabdominal preperitoneal (TAPP) groin, open ventral, and laparoscopic ventral. Hernia repairs performed by supervised residents vs specialists. Reoperation for recurrence, analyzed separately for all 4 groups. A total of 868 specialists and residents who performed 31 683 primary groin and 7777 primary ventral hernia repairs were included in this study. The median age of patients who underwent hernia repair was 60 years (IQR, 48-70 years), and 33 424 patients (84.7%) were male. There was no significant difference in the adjusted risk of reoperation after Lichtenstein groin hernia repair (hazard ratio [HR], 1.26; 95% CI, 0.99-1.59), laparoscopic groin hernia repair (HR, 1.01; 95% CI, 0.73-1.40), open ventral hernia repair (HR, 0.89; 95% CI, 0.61-1.29), and laparoscopic ventral hernia repair (HR, 2.96; 95% CI, 0.99-8.84) performed by supervised residents compared with those by specialists. There was, however, a slightly increased unadjusted, cumulative reoperation rate after Lichtenstein repairs performed by supervised residents compared with those by specialists (4.8% vs 4.2%; P = .048). The findings of this study suggest that neither open nor laparoscopic repair of groin and ventral hernias performed by supervised residents appeared to be associated with a higher risk of reoperation for recurrence compared with the operations performed by specialists. This indicates that residents may safely perform elective hernia repair when supervised as part of their training curriculum.

The aim of this study was to evaluate chronic pain 1 year after surgery, and risk factors for chronic pain after groin hernia repair in women. Groin hernia surgery in women is less frequently studied than in men. Chronic pain is common after groin hernia surgery and remains an important area with room for improvement. Previous studies are small or inconclusive. Guidelines recommend timely repair of all female groin hernias. From the Swedish Hernia Register 4021 female and 37,542 male patients operated between September 1, 2012 and August 30, 2017 responded to a patient-reported outcome questionnaire (response rate 70.0%) 1 year after primary groin hernia surgery. Multivariable analysis was performed to compare chronic postoperative pain in women with men as a control group, and to evaluate risk factors for chronic pain in women. Among women operated for groin hernia, 18% suffered chronic postoperative pain. The risk for chronic pain was significantly higher for women [odds ratio 1.3 (95% confidence interval 1.16-1.46). Three risk factors for chronic pain in women were found: high body mass index, high American Society of Anesthesiologists classification, and femoral hernia. No differences in chronic pain in women were seen when comparing surgical methods or emergency versus elective surgery. Almost one-fifth of women suffered of chronic pain affecting daily activity after groin hernia repair. Chronic pain was more common for women than men. In view of the high-rate chronic postoperative pain, further research on management strategies in female groin hernia is warranted.

IntroductionGroin hernia repair is a commonly performed surgical procedure in the western world but large-scaled epidemiologic data are sparse. Large-scale data on the occurrence of groin hernia repair may provide further understanding to the pathophysiology of groin hernia development. This study was undertaken to investigate the age and gender dependent prevalence of groin hernia repair.MethodsIn a nationwide register-based study, using data from the Civil Registration System covering all Danish citizens, we established a population-based cohort of all people living in Denmark on December 31st, 2010. Within this population all groin hernia repairs during the past 5 years were identified using data from the ICD 10th edition in the Danish National Hospital Register.ResultsThe study population covered n = 5,639,885 persons. During the five years study period 46,717 groin hernia repairs were performed (88.6% males, 11.4% females). Inguinal hernias comprised 97% of groin hernia repairs (90.2% males, 9.8% females) and femoral hernias 3% of groin hernia repairs (29.8% males, 70.2% females). Patients between 0–5 years and 75–80 years constituted the two dominant groups for inguinal hernia repair. In contrast, the age-specific prevalence of femoral hernia repair increased steadily throughout life peaking at age 80–90 years in both men and women.ConclusionThe age distribution of inguinal hernia repair is bimodal peaking at early childhood and old age, whereas the prevalence of femoral hernia repair increased steadily throughout life. This information can be used to formulate new hypotheses regarding disease etiology with regard to age and gender specifications.

Ambulatory groin and ventral hernia repair

After years of apparant concensus about the technique used to repair a groin hernia, different surgical innovations have completely changed the attitude towards this type of abdominal wall defect, resulting in an increase of interest in one of the most often performed surgical procedures. The introduction of non-absorbable meshes [1) which so far in humans did not show devastating side effects, the renaissance of surgical approaches to the back side of the myopectineal orifice of Frauchaud [2] and the evolution of the laparoscope assisted surgery completely overturned the Bassini technique for the repair of groin hernia, which has been the gold standard for decades. Therefore surgeons and patients are in search of a new standard operation for groin hernia. Before any technique can be recommended as a standard, many questions should be answered. One of the most important questi ons in this respect is the definition of »standard«, With a given definition, the technique under question should be tested whether it fulfills the conditions necessary to be seen as a standard in theory and in practice.

Objective: To assess the prevalence of chronic pain and sexual dysfunction after groin hernia repair in adolescents. Summary background data: Adolescents present unique challenges in groin hernia management due to their evolving anatomy, yet data on patient-reported outcomes remain limited. Methods: A nationwide survey was conducted in Denmark, linking patient-reported outcomes to the Danish National Patient Register and Civil Registration System. Patients who underwent primary unilateral groin hernia repair during adolescence (10–19 years) between 1992 and 2022 were identified. The primary outcome was chronic pain assessed with the short-form Inguinal Pain Questionnaire. Secondary outcomes included chronic pain assessed with the Activities Assessment Scale and sexual dysfunction assessed with the Sexual Inguinal Hernia Questionnaire. Results: Among 2,486 participants (response rate: 60.8%) completing the survey (80% male; median age at repair 16 [IQR, 12–19] years), 7.3% (95% CI, 6.3–8.4) reported chronic pain across all follow-up periods. In participants with less than 15 years of follow-up, 9% to 15% reported chronic pain depending on age at the time of repair and repair method. Chronic pain during sexual activity was reported by 8.6% (95% CI, 7.5–10) of participants. No significant differences in chronic pain or sexual dysfunction were observed between repair methods. Femoral hernia repairs were rare. Conclusions: Chronic pain and sexual dysfunction were common long-term complications of groin hernia repair in adolescents, regardless of repair methods. Optimizing outcomes could include a tailored, patient-centered approach by hernia experts, ensuring optimal care for this unique, young, low-volume population within hernia surgery.

The use of mesh for groin hernia repair has dramatically changed the way this common operation is performed. The aim of this study was to survey the methods of groin hernia repair in Scotland and to assess patient satisfaction with the operation. Between 1 April 1998 and 31 March 1999 all patients who underwent groin hernia repair in the National Health Service in Scotland were identified. As well as looking at the type of hernia repair performed and postoperative morbidity, patients were sent a Short Form-36 about 3 months after the operation to assess satisfaction and return to normal activity. Information was obtained on 5506 (97 per cent) of patients who underwent groin hernia repair during the study period. Eighty-five per cent of patients had an open mesh repair and 4 per cent had a laparoscopic repair. Most operations (85 per cent) were performed using general anaesthesia on an inpatient basis (78 per cent), and 8 per cent were for repair of a recurrent hernia. Potentially serious intraoperative complications were rare (seven patients), although they were significantly (P < 0. 001) more likely to be associated with a laparoscopic approach or repair of a femoral hernia: relative risk compared with open inguinal hernia repair 33 (95 per cent confidence interval (c.i.) 6-197) and 22 (95 per cent c.i. 3-152) respectively. Wound complications were common and 10 per cent of patients required a district nurse to attend the wound. Patients expressed a high degree of satisfaction; 94 per cent would recommend the same operation to someone else if required. An open mesh repair using general anaesthesia has become the repair of choice for a groin hernia in Scotland. Despite a high incidence of wound complications, patients are satisfied with this operation.

IntroductionIn a single centre evaluation of a novel hernia repair device, 200 consecutive patients underwent 247 laparoscopic (TAPP) groin hernia repairs (47 bilateral) using n-butyl-2-cyanoacrylate (Liquiband®Fix8™) for mesh fixation and peritoneal closure over a 2-year period by a single experienced laparoscopic surgeon.Patients and methodsAll groin hernia patients requiring TAPP repair were included in the study: Inguinal 142, Femoral 14, Spigelian 4, and Inguinal disruption 40. A retrospective review of the data was performed. There were 161 males and 39 females, mean age 55 years (range 20–89 years). Mesh fixation was successful in all 247 TAPP repairs, and 90% of patients had a successful peritoneal closure using the device (20 patients required the use of conventional tacks to complete closure).Follow-upPatients were followed up with an out-patient visit at 6 weeks post-op, followed by a Patient Initiated Follow Up programme, and a final Telephone follow-up. To date all patients have completed 1 year of follow-up, and 70% of patients 2 years of follow-up (median 29 months, range 14 to 40 months).ResultsThere were very few procedure-related adverse events: groin seromas 6 (2.4%), port site bleeding 2 (0.3%), port site hernia 2 (0.3%), and only 1 groin hernia recurrence (0.4%). Prospective surgeon scoring of satisfaction for mesh fixation, peritoneal closure, and device clogging was favourable and increased following the initial learning phase. Changes in the device design during the study period improved the efficacy of the device significantly.ConclusionThis retrospective study shows that mesh fixation and peritoneal closure using the Liquiband®Fix8™ device is feasible, safe, practical, and is easy to learn.

During laparoscopic groin hernia repair, the surgeon may transect the round ligament of uterus to facilitate mesh placement. Transection during open repair is rarer and anatomically further from the uterus. Our aim was to compare long-term genitourinary outcomes, particularly genital prolapse, between open and laparoscopic repair in women with a primary groin hernia. The study was reported according to RECORD guidelines. All women having received a primary anterior open or laparoscopic groin hernia repair from 1998 to 2014 were identified through The Danish Hernia Database and linked with data from The Danish National Patient Registry and the Danish Register of Causes of Death. Our outcome was postoperative genital prolapse and other long-term complications related to gynecology, urology, and infertility. We included 10,867 women having received a primary groin hernia repair, 7732 (71%) had an open anterior repair and 3135 (29%) a laparoscopic repair. The median (range) age was 59 (19-102) and 64 (18-105), respectively (p < 0.001). Median follow-up was 65 (range 0-203) months. After open repair, 313/7340 (4.2%) had a postoperative genital prolapse, and 46/2,934 (1.5%) after laparoscopic repair (p < 0.001). In multivariate Cox Regression analyses adjusting for age and hernia type, there were no difference between the two methods (p = 0.474). Women with an inguinal hernia had a higher risk of genital prolapse than women with a femoral hernia, independent of repair method [HR = 1.455 (1.143-1.853), p = 0.002]. We found no significant differences between open and laparoscopic methods in multivariate analyses assessing other long-term postoperative genitourinary and/or infertility outcomes. We found no differences in postoperative genital prolapse or other complications related to gynecology, urology, and/or infertility between open anterior and laparoscopic groin hernia repair in women. Assuming the round ligament of uterus is being transected more often in laparoscopic repair than in open, the urogenital consequences of transection seem to be minimal.

Recent international hernia guidelines state that work and leisure activities after inguinal hernia repair can be resumed after a convalescence of three to five days for most patients. There is no specific recommendation for convalescence duration before resuming sport and heavy lifting. This nationwide survey aimed to assess leading hernia surgeons' recommendations for convalescence after groin hernia repair and to explore their general opinions regarding convalescence. A validated questionnaire was sent to 32 leading groin hernia surgeons covering all Danish private and public hospitals. The primary outcome was convalescence recommendations following Lichtenstein and laparoscopic groin hernia repair for activities of daily living, light work, sport, and heavy lifting. A total of 29 surgeons (91%) responded to the questionnaire. The surgeons generally agreed on resuming daily activities and light work as soon as possible according to the level of pain. For resumption of sport, the surgeons recommended a median convalescence of 14days (IQR 10-23, range 7-30) after Lichtenstein repair and 14days (IQR 10-21, range 7-30) after laparoscopic repair. Most of the surgeons instructed patients with a defined number of days before resuming heavy lifting, which after Lichtenstein repair was median 14days (IQR 8-28, range 2-30) and after laparoscopic repair was median 21days (IQR 14-30, range 7-30). None of the surgeons routinely prescribed sick leave. Seventeen surgeons (61%) thought that recommending a too short convalescence could cause complications, primarily recurrence, hematoma, and pain. This study revealed that surgeons agreed on the resumption of daily activities and light work as soon as possible according to the level of pain. However, a broad spectrum of convalescence recommendations was revealed for sport and heavy lifting.

Previous studies have shown a correlation between surgeons with high annual volume and better outcomes after various surgical procedures. However, the preexisting literature regarding groin hernia repair and annual surgeon volume is limited. The aim was to investigate how annual surgeon volume affected the reoperation rates for recurrence after primary groin hernia repair. This nationwide cohort study was based on data from the Danish Hernia Database and the Danish Patient Safety Authority's Online Register. Patients ≥ 18years undergoing laparoscopic or Lichtenstein primary groin hernia repair between November 2011 and January 2020 were included. Annual surgeon volume was divided into five categories: ≤ 10, 11-25, 26-50, 51-100, and > 100 cases/year. We included 25,262 groin hernia repairs performed in 23,088 patients. The risk of reoperation for recurrence after Lichtenstein repair was significantly higher for the volume categories of ≤ 10 (HR 4.02), 11-25 (HR 3.64), 26-50 (HR 3.93), or 51-100 (HR 4.30), compared with the > 100 category. The risk of reoperation for recurrence after laparoscopic repair was significantly increased for the volume categories of ≤ 10 (HR 1.89), 11-25 (HR 2.08), 26-50 (HR 1.80), and 51-100 (HR 1.58) compared with the > 100 category. The risk of reoperation for recurrence was significantly higher after Lichtenstein and laparoscopic repairs performed by surgeons with < 100 cases/year compared with > 100 cases/year. This indicates that higher surgeon volume minimizes the risk of reoperation for recurrence after groin hernia repair.

Totally extraperitoneal repair (TEP) is the preferred method of inguinal hernia repair for many surgeons worldwide. However, because of limited working space, there may be difficulties when operating on large and irreducible groin hernias and short stature patients. There are many ways in which the port positions can be modified during TEP for different kinds of hernias and according to the comfort of the surgeons. This is a retrospective analysis of prospectively collected data. We describe two different variations in port placement for TEP in patients with large irreducible hernias and short stature patients. A total of 19 procedures were performed with these port positions. Most of these were large irreducible hernias or patients with short stature. With these modified port positions, difficult hernias could be completed with extraperitoneal approach. We had no recurrence and 5 seromas that eventually settled in 1-3months. Modified port positions in TEP by shifting the ports farther away can be useful for hernias where the surgery is difficult due to limited working space and is a good alternative to TAPP.

Demographic and socioeconomic aspects of hernia repair in the United States in 2003

Minimal access approaches to inguinal hernia repair have added to the ongoing debate over the "best groin hernia repair." The present prospective randomized controlled trial was done to compare the totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) techniques of laparoscopic inguinal hernia repair. The present prospective randomized study was conducted between May 2007 and March, 2009 and included 100 patients suffering from uncomplicated primary groin hernia. Patients were randomized into group I (TEP) and group II (TAPP). Intraoperative variables and postoperative pain scores were recorded in a prestructured form. One hundred patients were included in the study (TEP, 53; TAPP, 47). Both groups were comparable in terms of demographic profile and hernia characteristics. The average operative time was higher in the TAPP group (p = 0.209). The pain scores at 1 h and 24 h after surgery and at 3-month follow-up were significantly higher in the TAPP group (p < 0.05). The average follow-up was 30.5 months. In the TEP group, 37.8% of patients had seroma compared to 18.3% in the TAPP group (p = 0.021). However, there was a higher incidence of scrotal edema in the TAPP group (16 vs. 9, p = 0.009). The wound infection rates were equal (2% vs. 3%). There has been no recurrence in either group during the follow-up period of 44 months. Overall, the patients were more satisfied with TEP rather than TAPP (p < 0.05). In the present study, TEP had a significant advantage over TAPP for significantly reduced postoperative pain up to 3 months, which resulted in a better patient satisfaction score. The other intraoperative complications, postoperative complications, and cost were similar in both groups. In terms of results, both repair techniques seemed equally effective, but TEP had an edge over TAPP.