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Audit of Groin Hernia Repair II
Linköping University, Department of Clinical and Experimental Medicine, Surgery. Linköping University, Faculty of Health Sciences.
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Groin hernia repair is one of the most common operations performed in general  surgery, and every fourth man is expected to have a hernia operation during his lifetime. Although 8% of all repairs are performed in women, there is little published literature relating specifically to female anatomy, risk factors and techniques. There is a continuing development of new mesh materials and health care reorganization with specialized surgical clinics changing the availability of basic surgery for surgeons under training.

In 1997 a thesis was published by Anders Kald, Audit of Groin Hernia Repair, which aimed to establish an audit of hernia surgery, evaluating management, risk factors, outcome and economy. The aim of this thesis was to continue the audit of hernia surgery in Sweden, allowing evaluation of gender issues, a new mesh material, and performance of surgeons under training.

Our data showed that women have a higher incidence of emergency groin hernia repair than men, and an increased rate of femoral recurrence after an inguinal hernia repair. Time to reoperation suggests that a primary misdiagnosis is common. Detection of femoral hernias could be increased by using preperitoneal techniques, visualizing all three groin hernia locations.

Patients who received a lightweight mesh at their hernia operation had a shorter convalescence, with faster return to work and normal activity.

It might be more efficient, but not necessarily better to let a specialized hernia surgeon perform the repair. Surgical trainees had more postoperative complications, but fewer patients had chronic pain at the long-term follow-up.

Abstract [sv]

Ljumskbråcksoperationen är en av de vanligaste operationerna inom allmänkirurgi och var fjärde man förväntas bli opererad för ett bråck under sin livstid. Trots att 8% av alla operationer utförs på kvinnor, finns det sparsamt med litteratur publicerat som rör kvinnlig anatomi, riskfaktorer och operationstekniker. Det utvecklas kontinuerligt nya nätmaterial och omorganisationer inom sjukvården med specialiserade kirurgiska kliniker har förändrat tillgängligheten på allmänkirurgi för kirurger under utbildning.

1997 publicerade Anders Kald sin avhandling, Audit of Groin Hernia Repair, vilken hade som syfte att etablera en kvalitetssäkring av bråckkirurgin, med utvärdering av handläggning, riskfaktorer, resultat och ekonomi. Syftet med denna avhandling var att fortsätta kvalitetssäkra bråckkirurgin i Sverige, med utvärdering av genusfrågor, ett nytt nätmaterial och prestationen hos kirurger under utbildning.

Våra data visade att kvinnor har högre incidens av akut bråckoperation än män, och ökad frekvens av femoralbråcksrecidiv efter en inguinalbråcksoperation. Tiden till reoperation tyder på en initial feldiagnos och preperitoneala tekniker rekommenderas för att öka identifieringen av femoralbråck.

Patienter som fått ett lättviktsnät vid sin bråckoperation hade en kortare konvalesens med snabbare återgång till arbete och normala aktiviteter.

Det kan vara effektivare, men inte nödvändigtvis bättre att låta en specialiserad bråckkirurg att utföra operationen. Kirurger under utbildning hade fler postoperativa komplikationer, men färre patienter med kronisk smärta vid långtidsuppföljningen.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2010. , 45 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1221
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-63645ISBN: 978-91-7393-262-2 (print)OAI: oai:DiVA.org:liu-63645DiVA: diva2:382081
Public defence
2010-12-15, Katastrofmedicinskt centrum, Hälsouniversitetet, Campus US, Linköpings universitet, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Note

On the day of the defence date the title of article III was: "Groin hernia repair with Titanium Coated Mesh compared to Prolene Mesh: A Prospective Randomized Controlled Trial".

Available from: 2010-12-29 Created: 2010-12-29 Last updated: 2015-06-05Bibliographically approved
List of papers
1. Prospective evaluation of 6895 groin hernia repairs in women
Open this publication in new window or tab >>Prospective evaluation of 6895 groin hernia repairs in women
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2005 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 92, no 12, 1553-1558 p.Article in journal (Refereed) Published
Abstract [en]

Background: Although 8 per cent of groin hernia repairs are performed in women, there is little published literature relating specifically to women. This study compared differences in outcome between women and men after groin hernia repair.

Methods: Data collected prospectively in the Swedish Hernia Register between 1992 and 2003 were analysed, including 6895 groin hernia repairs in women and 83 753 in men.

Results: A higher proportion of emergency operations was carried out in women (16.9 per cent) than men (5.0 per cent), leading to bowel resection in 16.6 and 5.6 per cent respectively. During reoperation femoral hernias were found in 41.6 per cent of the women who were diagnosed with a direct or indirect inguinal hernia at the primary operation. The corresponding proportion for men was 4.6 per cent. The hernia repair was not classified as a standard operation (e.g. Shouldice, Lichtenstein, Plug/Mesh, TAPP/TEP) in 38.2 per cent of women and 11.2 per cent of men. Women had a significantly higher risk of reoperation for recurrence than men, and techniques associated with the lowest risk for reoperation in men had the highest risk in women.

Conclusion: A greater proportion of women than men require emergency groin hernia repair, with consequently higher rates of bowel resection, complications and death. Surgical techniques developed for use in men may put women at unnecessary risk. Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons Ltd.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-33238 (URN)10.1002/bjs.5156 (DOI)19237 (Local ID)19237 (Archive number)19237 (OAI)
Available from: 2009-10-09 Created: 2009-10-09 Last updated: 2012-09-10Bibliographically approved
2. Better outcome for female groin hernia patients when using preperitoneal techniques
Open this publication in new window or tab >>Better outcome for female groin hernia patients when using preperitoneal techniques
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: It is not known why women have higher frequencies of postoperative complications and reoperation than men after groin hernia repair. This study analyses postoperative results for female hernia in order to identify the appropriate techniques to attain adequate repair and improve operative outcome.

Method: A registry-based retrospective cohort study analysing data from 10 971 groin hernia repairs on women from the Swedish Hernia Register, 1992-2006.

Results: Our data showed that the risk for reoperation was significantly reduced (RR 0.6 95% CI 0.4-0.8) by using a preperitoneal repair, and three times as many femoral hernias were diagnosed in elective repairs. Time to reoperation was increased from a median of 1 year to 3.5 years (p=0.002) when using a preperitoneal repair, and time to reoperation for femoral recurrence after an inguinal primary hernia was increased from 1 year to 5.2 years (p=0.025).

Conclusions: Operative outcome for groin hernia repair in women was improved and risk for recurrence reduced by the utilisation of a preperitoneal approach. More femoral hernias were diagnosed in elective repairs and time to reoperation for femoral recurrence after an inguinal primary hernia was increased. We believe it is necessary to use a preperitoneal technique that visualizes all three locations for groin hernia in order to identify and adequately repair the hernia.

Keyword
Female, groin hernia repair, recurrence, outcome, technique, preperitoneal
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-63642 (URN)
Available from: 2010-12-29 Created: 2010-12-29 Last updated: 2010-12-29
3. Analysis of outcome of Lichtenstein groin hernia repair by surgeons in training versus a specialized surgeon
Open this publication in new window or tab >>Analysis of outcome of Lichtenstein groin hernia repair by surgeons in training versus a specialized surgeon
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2011 (English)In: Hernia, ISSN 1265-4906, E-ISSN 1248-9294, Vol. 15, no 3, 281-288 p.Article in journal (Refereed) Published
Abstract [en]

Purpose: Groin hernia repair is a common procedure in general surgery, and is taught to and performed by surgeons early in their training. The aim of this observational study was to compare hernia repair performance and results of surgical trainees with those of a specialized surgeon. The further aim sought to identify what factors may influence short and long-term outcome, and areas for improvement in surgical training.

Methods: A non-randomized parallel cohort study was designed to compare a specialized surgeon with surgical trainees, performing the Lichtenstein repair in adult males. Two hundred repairs were included, of which 96 were performed by surgical trainees. Patient characteristics, surgical experience, and operative data including duration of procedural parts and surgical complexity were noted at surgery. Postoperative complications, recurrence, chronic pain and residual symptoms were assessed at longterm follow-up after a median of 34.5 months.

Results: Surgical trainees had longer overall operative time consume, with an unproportionally longer time for mobilising the sac and cord. They perceived exposure and mobilisation as more difficult than the specialist, and also a greater demand on own experience during surgery. The trainee repairs had a higher rate of postoperative complications (14.7% versus 5.0%) but recurrence rate was the same as for specialist repairs. At long-term follow-up, specialist repairs had a higher symptom burden and more chronic pain.

Conclusions: Comparison of a specialized surgeon to surgical trainees in performance and outcome for inguinal hernia surgery shows it was more efficient, but not necessarily better to let a specialized surgeon perform the repairs. The better long-term outcome for surgical trainees stands in contrast to the prejudice that it is better to have an experienced surgeon to perform standard procedures. It seems likely that targeted training in dissection and mobilisation could decrease level of perceived complexity and shorten operative time consume for surgical trainees. We believe that adequately supervised hernia surgery should remain as a part of the surgical training.

Place, publisher, year, edition, pages
Springer, 2011
Keyword
Groin hernia, Surgical trainees, Lichtenstein, Pain
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-63643 (URN)10.1007/s10029-010-0780-y (DOI)000291603300006 ()
Available from: 2010-12-29 Created: 2010-12-29 Last updated: 2012-05-09
4. Randomized clinical trial of groin hernia repair with titanium-coated lightweight mesh compared with standard polypropylene mesh
Open this publication in new window or tab >>Randomized clinical trial of groin hernia repair with titanium-coated lightweight mesh compared with standard polypropylene mesh
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2008 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 95, no 10, 1226-1231 p.Article in journal (Refereed) Published
Abstract [en]

Background: Groin hernia repair is one of the commonest operations in general surgery. Existing techniques have very low and acceptable recurrence rates, but chronic pain and discomfort remain a problem for many patients. New mesh materials are being developed to increase biocompatibility, and the aim of this study was to compare a new titanium-coated lightweight mesh with a standard polypropylene mesh.

Methods: A randomized controlled single-centre clinical trial was designed, with the basic principle of one unit, one surgeon, one technique (Lichtenstein under general anaesthesia) and two meshes. Pain before and after surgery, and during convalescence (primary outcomes) was estimated in 317 patients. At 1-year clinical follow-up, recurrence, pain, discomfort and quality of life (secondary outcomes) were evaluated.

Results: Patients with the lightweight mesh returned to work after 4 days, compared with 6.5 days for the standard mesh (P = 0.040). The lightweight group returned to normal activity after 7 days, versus 10 days for the standard group (P = 0.005). There was no difference in postoperative pain or recurrence at the 1-year follow-up.

Conclusion: Patients with the lightweight mesh had a shorter convalescence than those with the standard heavyweight mesh. Registration number: ISRCTN36979348 (http://www.controlled-trials.com). Copyright © 2008 British Journal of Surgery Society Ltd Published by John Wiley & Sons Ltd.

Keyword
Adult Aged Hernia, Inguinal/*surgery Humans Male Middle Aged Pain Measurement Pain, Postoperative/etiology Polypropylenes/*therapeutic use Quality of Life Recurrence *Surgical Mesh Titanium/*administration & dosage Treatment Outcome
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-43370 (URN)10.1002/bjs.6325 (DOI)73656 (Local ID)73656 (Archive number)73656 (OAI)
Available from: 2009-10-10 Created: 2009-10-10 Last updated: 2010-12-29

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