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Sutures and surgical techniques in herniorrhaphy: an analysis of 18 057 sutured non-mesh repairs
Department of Surgery, Östersund Hospital, Östersund, Sweden.
Department of Surgery, Vrinnevi Hospital, Norrköping, Sweden.
Linköping University, Department of Biomedicine and Surgery, Surgery. Linköping University, Faculty of Health Sciences.
Department of Surgery, Motala Hospital, Motala, Sweden.
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Although mesh techniques are used with increasing frequency sutured repairs will continue to have a place in groin hemia surgery. Studies relating suture material to recurrence rate have yielded conflicting results. The aim of the present study was to analyse the influence of suture material and sutured non-mesh techniques on risk for reoperation in open groin hernia repair using data from the Swedish Hernia Register (SHR).

Methods: The relative risk for reoperation after sutured repairs using nonabsorbable, late absorbable and early absorbable sutures were compared in multivariate analyses taking into account known confounding factors.

Results: During 1992 -2000, 46,745 hernia repairs were recorded in the SHR. Of these 18,057 repairs were performed with open non-mesh methods and included in the analysis. With nonabsorbable suture as reference the relative risk for reoperation of early absorbable suture and of late absorbable suture was 1.50 (95% CI 1.22-1.83) and 1.03 (95% CI 0.83-1.28), respectively. Using the Shouldice repair as reference, other sutured repairs were associated with a significantly higher relative risk for reoperation 1.22 (95% CI 1.03-1.44).

Conclusion: For open non-mesh groin hernia repairs a nonabsorbable or a late absorbable suture is recommended. The Shouldice technique was found superior to other open methods.

National Category
Medical and Health Sciences
URN: urn:nbn:se:liu:diva-84502OAI: diva2:559831
Available from: 2012-10-10 Created: 2012-10-10 Last updated: 2012-10-10Bibliographically approved
In thesis
1. Groin hernia surgery: studies on anaesthesia and surgical technique
Open this publication in new window or tab >>Groin hernia surgery: studies on anaesthesia and surgical technique
2003 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The modem era of groin hernia surgery began with Eduardo Bassini who in the late 19th century, developed the first modem anatomically based hernia repair. Surgical technique, anaesthesia, suture and biomaterials have been matters of discussion ever since.

In recent decades new techniques using a mesh prosthesis as adjunct have, to a large extent, replaced sutured repairs in groin hernia surgery. The advantages and disadvantages of new methods and devices are not easy to establish. Excellent results from specialised hernia centres have frequently been presented in the form of retrospective series. However, hernia surgery is usually considered an area within general surgery and, therefore, often performed by non-specialised surgeons and trainees.

The Swedish Hernia Register (SHR), initiated in 1992 has today become nationwide and covers some 90 % of all Swedish units where hernia surgery is performed. Register data may be used for local audit, follow-up studies, and as background for RCTs. Register data reflect the results obtained by general surgeons with varying background and experience of hernia surgery. The present thesis comprises flve studies (I-V), three RCTs and two analyses of SHR data.

Paper I: The aim of this RCT trial was to compare the Shouldice procedure with the Lichtenstein repair with respect to recurrence rate, technical difficulty, convalescence and chronic pain. A further aim was to determine to what extent general surgeons in routine surgical practice are able to reproduce the excellent results reported from specialised hernia centres. The Lichtenstein repair resulted in fewer recurrences took less time to perform and was easier to learn. It seemed possible to achieve excellent results with this technique even in non-specialised general surgical units.

Paper II: Although mesh techniques are used with increasing frequency sutured repairs will continue to have a place in groin hernia surgery. Between 1992 and 2000 detailed information on 18,057 repairs with open sutured non-mesh methods was recorded in the SHR. The purpose of this study was to analyse the relative risk for reoperation with early absorbable, late absorbable, and nonabsorbable sutures, and to compare the relative risk of reoperation using the Shouldice technique with that of other sutured repairs. The relative risk for reoperation with early absorbable sutures was significantly higher than with other sutures. Among sutured repairs the Shouldice technique carried a lower risk for reoperation than other sutured repairs.

Paper III: Data from 59,823 hernia operations recorded in SHR from 1992 through 2001 were used to estimate the relative risk of reoperation for recurrence (or chronic pain) when using general anaesthesia (GA), regional anaesthesia (RA), and local anaesthesia (LA). Time trends for anaesthetic and operative methods and other variables affecting risk for reoperation were also analysed. LA was associated with an enhanced risk for reoperation in primary but not recurrent repair. The Lichtenstein technique carried a significantly lower risk of reoperation compared to other methods.

Paper IV: Within a three-armed multicentre RCT (n=616), perform by ten units all aligned to the SHR, surgical outcomes using the three anaesthetic alternatives were compared. LA was found to have considerable advantages over RA and GA. General surgeons in routine surgical practice could to a great extent, reproduce the favourable results obtained using LA in specialised hernia centres.

Paper V: As part of Study IV patient satisfaction and quality of life following hernia surgery under GA,RA, and LA was compared in an RCT (n= 138) using a specially designed questionnaire. With the exception of slight intraoperative pain, LA was found to be well tolerated and associated with significant advantages when compared with GA and RA.

Quality assessment of hernia surgery is essential. RCTs enable us to compare new surgical and anaesthetic alternatives. Register studies reflecting outcome in routine clinical practice can give this assessment a new dimension.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet, 2003. 65 p.
Linköping University Medical Dissertations, ISSN 0345-0082 ; 797
National Category
Medical and Health Sciences
urn:nbn:se:liu:diva-25695 (URN)10071 (Local ID)91-7373-487-X (ISBN)10071 (Archive number)10071 (OAI)
Public defence
2003-06-03, Elsa Brändström aulan, Hälsouniversitet, Linköping, 09:00 (Swedish)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-10-10Bibliographically approved

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