News Feed Discussions Patterns of recurrence associated with specific types of inguinal hernia repair Reply To: Patterns of recurrence associated with specific types of inguinal hernia repair

  • MarkT

    May 4, 2023 at 10:36 pm

    Keep in mind an abstract provides only a small amount of *some* key information that is essentially meant to allow a reader to determine if an article is likely to be relevant for their interests/purposes (i.e., if they should read the whole study).

    It is quite inappropriate to make assumptions about (never mind critique), a study from the contents of its abstract.

    I pulled a copy of the article and will try write up a more coherent summary later, but some points:

    The authors are rather clear what ‘open’ means when you actually read the article instead of making assumptions:

    “Open inguinal hernia repair includes any technique of primary open inguinal hernia repair excluding Shouldice and mesh repair, performed in patients above the age of 16 years.” For the purposes of this study, they categorized the primary surgeries as: Shouldice, open mesh, open tissue, laparoscopic, and childhood (all types).

    Keep in mind this is a retrospective study…data was pulled from existing medical records) rather than a prospective study where they could have chosen exactly what data to collect over its course (and this might explain why lap repairs were not broken down further?)

    As an aside, they provide some insight into how Shouldice Hospital allocates recurrence cases:

    “As this is a group-based practice, more complex cases are directed to surgeons according to their experience. In this categorical system, recurrent hernias are recognized as more complex than primary hernias. Among the recurrent inguinal hernias, previous primary hernia operations in childhood or via laparoscopy are considered low complexity, open (non-Shouldice) tissue repair is medium complexity, and open mesh repair or Shouldice repair is classified as high complexity.

    When facing difficult cases, sometimes intra-operative consultations were required. In this situation, a surgeon may request another of equal or higher seniority to come to the operating room to discuss options. The consultant surgeon may assist by providing directions/opinions, scrub in to assist or take over the role as main surgeon to finish the case, according to the circumstances. Senior surgeons have many years of experience in hernia repair and at least 1000 cases of inguinal hernia repair at this institution”.

    Among their findings was that “…open recurrent surgeries for previous open mesh and Shouldice repair were associated with higher intra-operative difficulties but not with worse early outcomes.” They hypothesize that this may be partly due to the way they allocate cases to more senior surgeons, and they conclude that “This information may allow adequate allocation of surgeon experience and choice of method (laparoscopic or open) based on the initial surgery”.

    Higher proportion of direct hernias in recurrent group vs. primary group…i.e. more likely to see direct hernias recur, which is in line with other research, and this was true for all groups regardless of previous primary repair type.

    Higher number of indirect recurrences were found only in group who had prev lap repair, which is also in line with prev research. “This may be due to case difficulty, technical errors during surgery (including missing small indirects or lipomas) and learning curve exploring the inguinal canal by laparoscopy…The higher incidence of direct recurrences for most of the
    patients is likely related with the primary characteristics of connective tissue from hernia patient”.

    In the discussion, they remind us that Shouldice is a high-volume specialized center..surgeons performing ~600 repairs per year, 85% of which are inguinal…while most repairs around the worlds are NOT performed in such a context, and that recurrence has been reported to be linked with volume (i.e. higher rates among low-volume surgeons). Given this, “…we agree with the general idea of laparoscopic surgery following open hernia repair recurrences (tissue or mesh repair)…The laparoscopic surgeon will find virgin territory and be able to perform a relatively easy operation. The degree of difficulty found by our senior surgeons in reoperations after Shouldice repair or open mesh repairs has triggered an internal reflection and will lead to further discussion about the surgical management of these cases”.

    There is prob still more to discuss…I’ll try to write more later.