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Quality assessment in groin hernia surgery: the role of a register
Linköping University, Department of Biomedicine and Surgery. Linköping University, Faculty of Health Sciences.
2001 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Ever since the Romans 2000 years ago the management of hernia surgery has remained a challenge to surgeons. Modern groin hernia treatment started with the Italian, Eduardo Bassini, around 1890 when he presented his method of repair. The most important innovations after Bassini are the Shouldice repair and introduction of prosthetic materials.

The last century has witnessed a continuous gap between, on the one hand excellent results repmted from dedicated hernia centres, and on the other outcome following hernia surgery in general surgical practice, in Sweden and elsewhere. One obstacle to quality assessment is the magnitude of hernia surgery. It is the most commonly performed procedure in Swedish general surgical practice with an incidence of around 17,000 to 20,000 repairs annually.

In 1992 a national quality register for hernia surgery was started, the Swedish Hernia Register (SHR). The general aim of this thesis is to study to what extent a quality register can be used for describing and analysing hernia surgery and can serve as a tool in the improvement process in non-specialised hospitals. Prospectively registered data in the SHR from 1992 to 1998 are the source of information for the six papers included.

The number of units participating in the SHR has increased from eight in 1992 to 65 in 2001, covering approximately 80% of units performing hernia surgery in Sweden. In January 2001 the database comprised almost 50,000 hernia repairs. Coverage of hernia operations in the SHR among participating units was high, 98%. Register participation, per se, improved the outcome of hernia surgery at aligned units during the early phase of the SHR.

In the studies forming the basis of this thesis we found that the use of mesh increased from 6 to 61% from 1992 to 1996-1998 and that the cumulative incidence of reoperation for recurrence decreased significantly during the same period. Recurrent hernia, absorbable suture, direct hernia and postoperative complication were identified as factors carrying an enhanced risk for reoperation.

SHR data show that femoral hernia is more common in females and associated with an enhanced risk for emergency operation. Mortality within 30 days of surgery, for men, was lower than that of the background population after elective inguinal hernia repair but increased after emergency operations, especially if bowel resection was undertaken.

Recurrent groin hernia still constitutes a significant quantitative problem for the surgical community, 15% of all repairs registered in 1996-1998 being repairs for recurrence. Anterior mesh repair according to Lichtenstein and laparoscopic methods were associated with a lower risk for reoperation following recurrent hernia repair.

In one hospital cohort from 1994, the recurrence rate was 10.5-14.6% 44 months after surgery, exceeding the reoperation rate by 1.7-2.3 times depending on definition of recurrence and method of follow-up. Fifteen per cent of patients in this cohort had pain related to previous hernia surgery, pain intensity being moderate or severe in 5 % of all patients followed-up.

The SHR, with reoperation as its main endpoint, may be used to describe and analyse hernia surgery and to stimulate local improvement. It has to be supplemented by questionnaire and/or physical examination in order to estimate rates of recurrence and chronic pain.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet , 2001. , 83 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 685
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-25653Local ID: 10029ISBN: 91-7219-974-1 (print)OAI: oai:DiVA.org:liu-25653DiVA: diva2:246201
Public defence
2001-09-21, Berzeliussalen, Universitetssjukhuset, Linköping, 09:00 (Swedish)
Opponent
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-09-10Bibliographically approved
List of papers
1. Methods of repair and risk for reoperation in Swedish hernia surgery from 1992 to 1996
Open this publication in new window or tab >>Methods of repair and risk for reoperation in Swedish hernia surgery from 1992 to 1996
1998 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 85, no 12, 1686-1691 p.Article in journal (Refereed) Published
Abstract [en]

Background

Difficulties in obtaining and analysing outcome measures in hernia surgery may be an obstacle to necessary progress in non-specialized hospitals. Against this background a voluntary register was initiated in 1992 with the aim of describing and evaluating hernia surgery in participating units.

Methods

Prospective registration of all hernia operations carried out in participating hospitals was undertaken using identification codes specific for each individual. Repair technique, complications, day surgery, type of anaesthesia, and reoperation for recurrence were recorded. Actuarial analysis was used to determine the cumulative incidence of reoperation. Relative risk for reoperation was estimated by the Cox proportional hazards model.

Results

The number of participating hospitals and registered operations increased from eight and 1689 respectively in 1992 to 21 and 4056 in 1996. The use of mesh increased from 7 per cent of all operations in 1992 to 51 per cent in 1996. The proportion of operations done for recurrent hernia remained constant at 16–17 per cent throughout the 5-year study period. For all 12 542 herniorrhaphies registered, the cumulative incidence of reoperation at 2 years was 3 (95 per cent confidence interval 3–4) per cent. Postoperative complications, recurrent hernia, direct hernia and absorbable suture were associated with increased risk of reoperation for recurrence. An increased incidence of reoperation, although not statistically significant, was noted for conventional open repairs (Bassini, McVay, Marcy and others) versus the Shouldice technique.

Conclusion

In this prospective audit an increasing use of mesh was observed for open and laparoscopic surgery, especially for bilateral and recurrent hernia operations. Reoperation rates decreased significantly between 1992 and 1995.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-81230 (URN)10.1046/j.1365-2168.1998.00886.x (DOI)
Available from: 2012-09-10 Created: 2012-09-10 Last updated: 2017-12-07Bibliographically approved
2. Hernia Registers and Specialization
Open this publication in new window or tab >>Hernia Registers and Specialization
1998 (English)In: Surgical Clinics of North America, ISSN 0039-6109, E-ISSN 1558-3171, Vol. 78, no 6, 1141-1155 p.Article in journal (Refereed) Published
Abstract [en]

Registration of hernia surgery is useful in the demonstration of outcome quality provided reoperation is linked to the primary procedure. Prerequisites for a hernia register are discussed based on Swedish experience. Evidence indicates that register participation reduces reoperation rate and increases costeffectiveness. Monitoring of outcome quality is important for both specialized and nonspecialized hernia surgeons. Registers of the type discussed may assist general surgeons in their efforts to acheive levels defined by experts.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-81231 (URN)10.1016/S0039-6109(05)70375-3 (DOI)
Available from: 2012-09-10 Created: 2012-09-10 Last updated: 2017-12-07Bibliographically approved
3. Femoral hernias: a register analysis of 588 repairs
Open this publication in new window or tab >>Femoral hernias: a register analysis of 588 repairs
1999 (English)In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 3, no 3, 131-134 p.Article in journal (Refereed) Published
Abstract [en]

From 1 January 1992 to 31 December 1997 18,281 inguinal hernias and 588 femoral hernias were recorded in the Swedish Hernia Register. The aim of the present study was to characterise these femoral hernias and to evaluate the reoperation rate following their repair. 64% of all femoral hernias were located in the right groin and 36% in the left groin (p < 0.001). The male to female ratio for femoral hernia was 1:1.6; mean ages of patients with femoral and inguinal hernia were 63.4 ± 17.1 and 59.1 ± 16.4 years, respectively (p < 0.001). Emergency surgery and bowel resection at emergency surgery were more common with femoral than with inguinal hernia. The rate of ambulatory surgery was lower for femoral hernia than for inguinal hernia, mainly due to the higher emergency rate for femoral hernia. At three years the cumulative incidence of reoperation was 4.6% (95% confidence interval 2.4–6.8%) for femoral hernia and 4.0% (95% confidence interval 3.6–4.4%) for inguinal hernia (p > 0.05). Male sex and postoperative complications were associated with a significantly increased risk of reoperation following femoral hernia repair. The relative risk of reoperation was not affected by patient age, elective/emergency surgery, primary/recurrent hernia or hernia side. Repair techniques using mesh were associated with a lower reoperation rate than techniques without mesh, although the difference did not reach statistical significance.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-81232 (URN)10.1007/BF01195312 (DOI)
Available from: 2012-09-10 Created: 2012-09-10 Last updated: 2017-12-07Bibliographically approved
4. Mortality after elective and emergency surgery for inguinal and femoral hernia
Open this publication in new window or tab >>Mortality after elective and emergency surgery for inguinal and femoral hernia
1999 (English)In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 3, no 4, 205-208 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to investigate mortality following elective and emergency groin hernia surgery. Information concerning 17 591 inguinal and 579 femoral hernia operations, including death of patients within 30 days of surgery, were prospectively recorded in the Swedish Hernia Register over a period of six years. Elective surgery for groin hernia is known to be a low-risk procedure. Mortality within 30 days of surgery was compared with the mortality of the general Swedish population using the standard mortality rate (SMR). Of all inguinal and femoral hernia repairs 5.1 % and 35.2 % respectively, were performed as an emergency. Following elective inguinal hernia repair the SMR for men fell significantly below unity. No significant differences between observed and expected mortality were observed following inguinal hernia surgery on females or following elective femoral hernia surgery on either gender. The reduced SMR found after elective hernia repair in men is most likely attributable to patient selection. After elective surgery on patients 70 years or older there is a tendency towards a reduction in SMR of the same order of size as for patients analysed as one group which, however, did not reach statistical significance. Mortality following both inguinal and femoral emergency procedures is increased five- to ten-fold compared to the 30-day mortality in the general population. A further increase in postoperative mortality is noted following emergency surgery with bowel resection.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-81233 (URN)10.1007/BF01194428 (DOI)
Available from: 2012-09-10 Created: 2012-09-10 Last updated: 2017-12-07Bibliographically approved
5. Reoperation after recurrent groin hernia repair
Open this publication in new window or tab >>Reoperation after recurrent groin hernia repair
2001 (English)In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 234, no 1, 122-126 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To analyze reoperation rates for recurrent and primary groin hernia repair documented in the Swedish Hernia Register from 1996 to 1998, and to study variables associated with increased or decreased relative risks for reoperation after recurrent hernia.

Methods: Data were retrieved for all groin hernia repairs prospectively recorded in the Swedish Hernia register from 1996 to 1998. Actuarial analysis adjusted for patients' death was used for calculating the cumulative incidence of reoperation. Relative risk for reoperation was estimated using the Cox proportional hazards model.

Results: From 1996 to 1998, 17,985 groin hernia operations were recorded in the Swedish Hernia Register, 15% for recurrent hernia and 85% for primary hernia. At 24 months the risk for having had a reoperation was 4.6% after recurrent hernia repair and 1.7% after primary hernia repair. The relative risk for reoperation was significantly lower for laparoscopic methods and for anterior tension-free repair than for other techniques. Postoperative complications and direct hernia were associated with an increased relative risk for reoperation. Day-case surgery and local infiltration anesthesia were used less frequently for recurrent hernia than for primary hernia.

Conclusions: Recurrent groin hernia still constitutes a significant quantitative problem for the surgical community. This study supports the use of mesh by laparoscopy or anterior tension-free repair for recurrent hernia operations.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-47312 (URN)10.1097/00000658-200107000-00018 (DOI)
Available from: 2009-10-11 Created: 2009-10-11 Last updated: 2017-12-13Bibliographically approved
6. Recurrence and pain three years after groin hernia repair: Validation of postal questionnaire and selective physical examination as a method of follow-up
Open this publication in new window or tab >>Recurrence and pain three years after groin hernia repair: Validation of postal questionnaire and selective physical examination as a method of follow-up
2002 (English)In: European Journal of Surgery, ISSN 1102-4151, E-ISSN 1741-9271, Vol. 168, no 1, 22-28 p.Article in journal (Refereed) Published
Abstract [en]

Objectives:

To evaluate recurrence rate and chronic groin pain three years after hernia repair and to validate a postal questionnaire with selective physical examination as a method of follow-up.

Design:

Prospective cohort study.

Setting:

County hospital, Sweden.

Patients:

Prospective data were retrieved from the Swedish Hernia Register for patients aged 15–80 years at the time of groin hernia repair, operated on during 1994.

Interventions:

Three years after operation patients were mailed a three-item questionnaire and invited to have a physical examination. Those examined answered a detailed questionnaire about pain and functional impairment. When appropriate an extended physical examination was undertaken to find out the probable cause of the pain.

Main outcome measures:

Recurrence, pain, and functional impairment.

Results:

272 hernias were repaired in 264 patients. 24 patients had died and 16 had a recurrence before the follow-up examination. After a median observation time of 44 months, 218 patients with 223 repairs (96%) were examined. Depending on the definition of recurrence and completeness of physical examination (selective or all patients) the recurrence rate varied between 10% (25/239) and 15% (35/239) including recurrences diagnosed before follow-up. 40 patients (18%) reported groin pain at follow-up, which was considered to be caused by a previous hernia repair in 34 (15%), 12 of whom (5%) had moderate or severe pain. Postoperative complications were associated with an increased risk of chronic pain, whereas type of hernia and use of mesh had no influence.

Conclusions:

The incidence of recurrence and chronic pain after hernia repair requires continuous audit in non-specialised units. Participation in a register and follow-up by a three-item questionnaire and selective physical examination provides a solid basis for quality control.

Keyword
Follow-up, Functional impairment, Groin hernia, Pain, Questionnaire, Recurrence
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-47036 (URN)10.1080/110241502317307535 (DOI)
Available from: 2009-10-11 Created: 2009-10-11 Last updated: 2017-12-13Bibliographically approved

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