When to return to work after groin hernia repair

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.

<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>

Physician Reimbursement for General Surgical Procedures in the Last Century: 1906−2006

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.

To systematically review the published literature on the role of diagnostic laparoscopy through deep inguinal ring (DL-DR) during groin hernia repair. Standard electronic databases were searched reporting article in any language on the role of DL-DR during groin hernia repair regardless of the age and sex of patients. Thirty-one articles on 5745 patients undergoing DL-DR during groin hernia repair were retrieved from the electronic databases. There was 1 randomized, controlled trial, 7 case reports and 2 case series on 58 adult patients mainly targeting assessment of bowel viability following spontaneous reduction of the strangulated groin hernia. Twenty-one articles, either retrospective or prospective case series on 5687 were reported on pediatric patients aiming to detect a contralateral patent processus vaginalis or synchronous groin hernia. Overall, the laparoscopy group had a reduced operative time, reduced length of hospital stay, lower complication rate, and earlier return to normal activity. DL-DR success rates were reported in >95% of patients. Contralateral patent processus vaginalis indicative of inguinal hernia was found in >48% of children. There was no major morbidity reported in any group. DL-DR during groin hernia repair may be performed safely when indicated. The routine use of DL-DR is an established practice in pediatric surgery. There is still insufficient evidence to recommend the routine use of DL-DR in adults.

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.

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.

Groin hernia repair is the most common procedure performed by general surgeons. The open mesh technique generally represents the main technique for an inguinal repair, but a different approach is often required. Laparoscopy was found to be the answer to minimizing the impact of the preperitoneal open techniques described by Nyhus and Stoppa. The introduction of the totally extraperitoneal hernia repair (TEP) and transabdominal preperitoneal repair (TAPP) in the early 1990s started a new chapter in groin hernia surgery. The minimally invasive techniques vs. open mesh, and then one against the other, soon became a hot topic among abdominal wall surgeons. With time, the number of procedures and indications increased and are still increasing. This review aims to provide an overview of the two main laparoscopic techniques for groin hernia repair, answering the following questions: Who should perform them? What is the learning curve required to minimize complications and optimize operative time? When is a minimally invasive approach indicated, and which one (both in elective and in emergency setting)? How are they performed? The standard techniques have been described in detail, and personal observations from an abdominal wall surgery referral center were added. The main reviews from the early 2000s up to date, which compared the techniques, were analyzed, and the results reported, confirming the comparable safety and efficacy of both these techniques.

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 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.

Background: Groin hernia repair is considered to be one of the most commonly performed operations by general surgeons however, there is no gold standard operation for treatment of inguinal hernias. The optimal surgical approach must be selected individually for the patient, considering patient age, hernia size, unilaterality or bilaterality, primary or recurrent status, and type of anesthesia, occupation, and leisure activities. The laparoscopic revolution has increased the debate about the safest and most effective inguinal hernia repair. This revolution has broadened our understanding of inguinal anatomy and hernia repair. At the least, surgeons should be aware of the current indications and contraindications for laparoscopic inguinal hernia repair, because some hernias should have a laparoscopic repair. To increase versatility, surgeons should consider becoming skilled at both techniques, with the understanding that outcomes are optimal if one is committed to achieving expertise in laparoscopic repair. Objectives: Our objective in this study is to compare the outcome of mesh fixation using non-absorbable tacks versus absorbable tacks in transabdominal preperitoneal (TAPP) laparoscopic repair of inguinal hernia regarding their efficacy and postoperative complications to improve the outcome of patients undergoing surgery for inguinal hernia in Ain Shams University Hospitals. Patients and methods: The present study is a prospective, randomized comparative study that was conducted in Ain Shams University Hospitals in Egypt, and included sixty (60) patients who had inguinal hernia. The patients were divided into two groups each group including 30 patients. In the first group (Group A) titanium non-absorbable tacks were used and in the other group (Group B) absorbable tacks were used. The patients underwent a trans-abdominal preperitoneal (TAPP) laparoscopic repair of inguinal hernia using prolene mesh. The study was conducted from July 2016 to July 2017, with 12 months of follow-up post-operatively until July 2018. Results: The mean age of the patients was 36.93 ± 10.23 (19-55) and the mean BMI was 24.83 ± 2.79 (19-32). There was no significant difference between 2 groups as regard preoperative comorbidities. Patients presented mainly with swelling in the groin region 71.67%. Right sided hernia was 46.7% and bilateral hernia was 15%. There was no difference between 2 groups as regard the operative time (p-value=0.056) and intraoperative complications: bleeding (p-value=0.150) and bladder injury (p-value=0.313). Post-operative complications, postoperative hospital stay, time needed to return to normal activity and the recurrence were all alike between the 2 groups. Pain analysis was done four times, and revealed no significant difference between the 2 groups at any time of follow-up. Conclusion: Both non-absorbable tacks and absorbable tacks used in mesh fixation are similarly effective in terms of operative time, the incidence of recurrence, complications and pain at least in the first year of follow up, but it may be less painful after one year after the complete absorption of the absorbable tacks but this needs further investigations and studies containing more patients and with follow-up for longer time.

Background: Groin hernia repair is considered to be one of the most commonly performed operations by general surgeons however, there is no "gold standard" operation for treatment of inguinal hernias. The optimal surgical approach must be selected individually for the patient, considering patient age, hernia size, unilaterality or bilaterality, primary or recurrent status, and type of anesthesia, occupation, and leisure activities. The laparoscopic revolution has increased the debate about the safest and most effective inguinal hernia repair. This revolution has broadened our understanding of inguinal anatomy and hernia repair. At the least, surgeons should be aware of the current indications and contraindications for laparoscopic inguinal hernia repair, because some hernias should have a laparoscopic repair. To increase versatility, surgeons should consider becoming skilled at both techniques, with the understanding that outcomes are optimal if one is committed to achieving expertise in laparoscopic repair. Objectives: Our objective in this study is to compare the outcome of mesh fixation using non-absorbable tacks versus absorbable tacks in transabdominal preperitoneal (TAPP) laparoscopic repair of inguinal hernia regarding their efficacy and postoperative complications to improve the outcome of patients undergoing surgery for inguinal hernia in Ain Shams University Hospitals. Patients and methods: The present study is a prospective, randomized comparative study that was conducted in Ain Shams University Hospitals in Egypt, and included sixty (60) patients who had inguinal hernia. The patients were divided into two groups each group including 30 patients. In the first group (Group A) titanium non-absorbable tacks were used and in the other group (Group B) absorbable tacks were used. The patients underwent a trans-abdominal preperitoneal (TAPP) laparoscopic repair of inguinal hernia using prolene mesh. The study was conducted from July 2016 to July 2017, with 12 months of follow-up post-operatively until July 2018. Results: The mean age of the patients was 36.93 ± 10.23 (19-55) and the mean BMI was 24.83 ± 2.79 (19-32). There was no significant difference between 2 groups as regard preoperative comorbidities. Patients presented mainly with swelling in the groin region 71.67%. Right sided hernia was 46.7% and bilateral hernia was 15%. There was no difference between 2 groups as regard the operative time (p-value=0.056) and intraoperative complications: bleeding (p-value=0.150) and bladder injury (p-value=0.313). Post-operative complications, postoperative hospital stay, time needed to return to normal activity and the recurrence were all alike between the 2 groups. Pain analysis was done four times, and revealed no significant difference between the 2 groups at any time of follow-up. Conclusion: Both non-absorbable tacks and absorbable tacks used in mesh fixation are similarly effective in terms of operative time, the incidence of recurrence, complications and pain at least in the first year of follow up, but it may be less painful after one year after the complete absorption of the absorbable tacks but this needs further investigations and studies containing more patients and with follow-up for longer time.

Inguinal Herniorrhaphy: Complications and Recurrences.

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.

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.