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Methods of repair and risk for reoperation in Swedish hernia surgery from 1992 to 1996
Department of Surgery, Motala Hospital, Motala, Sweden.
Department of Surgery, Vrinnevi Hospital, Norrköping, Sweden.
Department of Surgery, Motala Hospital, Motala, Sweden.
Department of Surgery, Motala Hospital, Motala, Sweden.
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]


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.


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.


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.


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.

Place, publisher, year, edition, pages
1998. Vol. 85, no 12, 1686-1691 p.
National Category
Medical and Health Sciences
URN: urn:nbn:se:liu:diva-81230DOI: 10.1046/j.1365-2168.1998.00886.xOAI: diva2:551092
Available from: 2012-09-10 Created: 2012-09-10 Last updated: 2012-09-10Bibliographically approved
In thesis
1. Quality assessment in groin hernia surgery: the role of a register
Open this publication in new window or tab >>Quality assessment in groin hernia surgery: the role of a register
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.
Linköping University Medical Dissertations, ISSN 0345-0082 ; 685
National Category
Medical and Health Sciences
urn:nbn:se:liu:diva-25653 (URN)10029 (Local ID)91-7219-974-1 (ISBN)10029 (Archive number)10029 (OAI)
Public defence
2001-09-21, Berzeliussalen, Universitetssjukhuset, Linköping, 09:00 (Swedish)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-09-10Bibliographically approved

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