HERNIA REGISTERS AND SPECIALIZATION

doi:10.1016/S0039-6109(05)70375-3

Surgical Clinics of North America

Volume 78, Issue 6, 1 December 1998, Pages 1141-1155

https://doi.org/10.1016/S0039-6109(05)70375-3 Get rights and content

Since the time of Bassini,⁴ hernia surgeons have gained information about surgical techniques by examining their patients postoperatively. Few case series have reached the completeness of follow-up achieved by Bassini, and few surgeons who have used his eponym for their herniorrhaphies can claim better results on reducible hernias than he. For any unit (hospital or group of surgeons) to be able to follow the outcome of patients treated, it is necessary to use some form of registration more detailed than hospital discharge data. If such a registration is carried out on a larger scale, it may also provide information concerning the effectiveness of hernia surgery, that is, the outcome of techniques used in routine practice as distinct from their efficacy, that is, the outcome when the same methods are applied to appropriate patients by experts.²² This article discusses issues concerning hernia registers and specialization of hernia surgery.

A register is defined as “an official or formal list recording names, events, or transactions.”¹⁹ In this article, register is used in a restricted sense, indicating the prospective recording of information concerning diagnosis and operations of individual patients followed over time beyond the mere coding according to official classifications. Hospital discharge databases and administrative databases, therefore, are not discussed in this context, although these can provide valuable information concerning regional differences in operation rates and outcomes following common surgical procedures.7, 10, 27 Registers as just defined may have their usefulness greatly improved by linkage to sources of vital statistics, thereby connecting registers to epidemiology.

Whereas hernia registers have received little attention, specialization is frequently taken up when discussing outcomes reported from specialized and nonspecialized units. The authors' aim is to analyze prerequisites for hernia registers and to see whether conclusions reached with their help lend support to the proponents of specialization in hernia surgery. To achieve this goal, two main endpoints are used: (1) recurrence or its proxy variable reoperation for recurrence, and (2) outpatient surgery as a crude indicator of cost-effectiveness. This does not imply underestimation of the importance of convalescence and patient satisfaction; however, such data tend to be lacking in registers, and these variables are, to a great extent, influenced by advice given to patients26, 32, 43 and by socioeconomic factors.3, 42 Furthermore, when patients were asked whether they considered recurrence of hernia or speed of recovery to be most important, most regarded lack of recurrence to be the most important outcome.²⁸

Section snippets

MOTIVES FOR HERNIA REGISTERS

Officially produced statistics regarding hernia surgery are inadequate for many purposes. US data from the National Center for Health Statistics are based on a national sample of 5% of patients' medical records and do not include ambulatory surgery, information of which has been provided by the National Survey of Ambulatory Surgery for the years 1994 to 1996.³⁹ From these combined sources, an annual total of approximately 700,000 groin hernia operations has been calculated for the United

PREREQUISITES FOR HERNIA REGISTERS

In case series and randomized controlled trials, to identify and trace patients within the study is not a major problem, whereas data collection through follow-up may be a great challenge. For hernia registers working on a nationwide basis, identification of individuals through numbers unique for each citizen (Person Number or CPR number)30, 45 is of great importance, especially in studies in which patients are followed until death in life-table fashion with reoperation for recurrence as an

Background, Funding

In Sweden, the Federation of County Councils and the National Board of Health and Welfare have collaborated to create and support more than 30 so-called “quality registers.”⁴⁴ These have all undergone or are undergoing transition from serving local interests to becoming nationwide in scope. The quality registers respond to the requirements of the new statutes and rules concerning quality systems in Swedish health care that were mandated on January 1, 1997. The registers are not designed as

HERNIA REGISTERS IN OTHER COUNTRIES

In Denmark, a register similar to the Swedish one was initiated in 1998, with the important difference that, from the beginning, it included approximately 90% of all hernia repairs performed in Denmark (Kehlet H and Bay-Nielsen M, personal communication, 1998). The Danish register also incorporates randomized controlled trials among participating units. To the best of the authors' knowledge, registers using Person Numbers are not practiced elsewhere. One interesting example of a hernia register

SPECIALIZATION IN HERNIA SURGERY

In the present survey, the percentage of hernia repairs performed for recurrence amounted to 16% annually, and similar high rates have been observed in several studies from defined populations.²³ This is in sharp contrast to recurrence rates over long periods of time reported by specialized units in North America using the Shouldice technique,⁶ the Lichtenstein tension-free technique,² or the plug method.⁴⁰ So far, these results have been reproduced in Europe for the Shouldice¹³ and the

ACKNOWLEDGMENT

In 1996, the following hospitals were aligned to the register: Falköping, Falun, Hudiksvall, Kalmar, Lidköping, Lindesberg, Linköping, Ludvika, Mora, Motala, Norrköping/ Finspong, Skene, S:t Görans sjukhus Stockholm, Säffle, Värnamo, Västervik/Oskarshamn, Västra Frölunda, and Östersund. The authors thank hernia surgeons in participating hospitals for their collaboration. Secretary Gunnel Nordberg and statistician Lennart Gustafsson, PhD, provided invaluable help during the preparation of the

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Sex Differences, Sleep Disturbance and Risk of Persistent Pain Associated With Groin Hernia Surgery: A Nationwide Register-Based Cohort Study
2021, Journal of Pain
Persistent pain after groin hernia repair is a major health problem. Sleep disturbance is associated with heightened pain sensitivity. The main objective of this study was to examine the role of sleep disturbance in the development and long-term maintenance of chronic postherniorrhaphy inguinal pain (CPIP), with exploration of sex differences. From 2012 to 2017, a national cohort of patients with prior groin hernia repair (n = 2084;45.8% females) were assessed for the development of CPIP 12 months after surgery. Patients then underwent long-term (median 5.0 years) follow-up to evaluate the contribution of sex and sleep disturbance on the maintenance of CPIP. Associations between pre- and postoperative sleep problems (assessed at long-term follow-up) and CPIP were tested using logistic regression. Females had higher rates of CPIP with negative impact on daily activities 12 months after surgery as compared to males (14.6 vs 9.2%, P < .0005), and were more likely to have moderate-severe CPIP in the long-term (3.1 vs 1.2%, P = .003). Preoperative sleep problems predicted development of CPIP 12 months after surgery (adjusted odds ratio [aOR] 1.76 [95%CI 1.26–2.46], P = .001) and CPIP in the long-term (aOR 2.20 [1.61–3.00] , P < .0001). CPIP was associated with insomnia and depression. Sleep disturbance may increase the risk for CPIP, and contribute to maintenance of postsurgical pain.
Females are at heightened risk for CPIP as compared to males. Increased severity of pain symptoms are linked to poorer sleep and psychiatric morbidity. Given the robust associations between sleep disturbance and CPIP, interventions which consolidate and promote sleep, especially in females, may improve long-term pain control.
Chronic pain and risk for reoperation for recurrence after inguinal hernia repair using self-gripping mesh
2020, Surgery (United States)
Improved recurrence rates after groin hernia surgery have led to chronic pain becoming the most troublesome postoperative complication. Self-gripping mesh was developed to decrease the risk for development of chronic pain. The aim of this nationwide cohort study was to compare recurrence rate and chronic pain 1 year after an open, anterior mesh repair of inguinal hernias with either a self-gripping mesh or other lightweight mesh.
All operations registered as open anterior mesh repair (Lichtenstein) in the Swedish Hernia Registry between September 2012 and October 2016 were selected. At 1 year after repair, patients were sent a pain questionnaire assessing chronic pain. We compared the prevalence of chronic pain and reoperation for recurrence using lightweight, sutured mesh or self-gripping mesh.
We analyzed the 1,803 repairs using self-gripping mesh and 16,567 repairs using lightweight mesh. We found no difference in the prevalence of chronic pain 1 year after the hernia repair between self-gripping mesh and sutured lightweight mesh (OR 0.92, CI 95% 0.80–1.06, P = .257). There was no increase in reoperation for recurrence when using self-gripping mesh (HR 0.71, CI 95% 0.45–1.14, P = .156). Mean operation time was considerably less when using self-gripping mesh (43 vs 70 minutes; P > .001).
The use of self-gripping mesh does not decrease the incidence of chronic pain and reoperation for recurrence compared with lightweight, sutured mesh for open anterior mesh repair of inguinal hernias. Furthermore, the use of self-gripping mesh is associated with a clinically important, lesser operation time.
Initial results of the National Registry of Incisional Hernia
2016, Cirugia Espanola
El objetivo de este estudio fue analizar los datos recopilados en el Registro Nacional de Hernia Incisional (EVEREG) para conocer la situación actual del tratamiento de esta dolencia en España.
EVEREG es una base de datos prospectiva online en la que, desde julio de 2012, se registraron de forma anónima los datos de las hernias incisionales intervenidas en España.
Hasta marzo de 2015, se han registrado 4.501 hernias en 95 de los 113 hospitales inscritos. La edad media de los casos fue de 62,7 años, un 56,5% mujeres, con un IMC medio de 30,2 kg/m² y un 29,8% de ellos con riesgo quirúrgico elevado (ASA III-V). Un 93,7% de las intervenciones fueron electivas, el 88,3% por cirugía abierta y el 22,2% fueron hernias recurrentes. El 66,9% correspondían a una hernia tras laparotomía media, en el 81,4% el diámetro transversal fue menor de 10 cm. Se empleó una prótesis en el 96,2% de los casos. La estancia postoperatoria fue de 5,3 días, con complicaciones en el 29,1% y con una mortalidad del 0,8%. Tras una mediana de seguimiento de 7,7 meses se ha detectado un elevado índice de recurrencias (20,7% al año), sobre todo en hernias intervenidas tras una reparación previa (18,1% primarias vs. 30,6% recidivadas; p = 0,004).
El registro EVEREG es una herramienta útil para conocer la situación actual del tratamiento de la hernia incisional. El análisis de los datos señala como principales elementos susceptibles de mejora el bajo índice de seguimiento y la elevada tasa de recurrencias.
The aim of this study was to the data from the National Registry of Incisional Hernia (EVEREG) to determine the reality of the treatment of this condition in Spain.
EVEREG is an online prospective database which has been functioning since July 2012; operations for incisional hernia are anonymously recorded.
Up to March 2015, 4501 hernias from 95 of the 113 participating hospitals were registered. The mean age of the patients was 62.7, and 56.5% were women, with a mean BMI of 30.2 kg/m²; 29.8% presented a high surgical risk (ASA III-V). A total of 93.7% were scheduled surgeries, 88.3% open surgery and 22.2% were recurrent incisional hernias. There were 66.9% hernias after a midline laparotomy, and 81.4% of a transverse diameter of less than 10 cm. A mesh was used in 96.2% of cases. Postoperative stay was 5.3 days and 29.1% presented a complication, with a mortality of 0.8%. After a median follow-up of 7.7 months a high rate of recurrence was detected (20.7% per year), especially in hernias that were operated on after a previous repair (18.1% primary vs. 30.6% recurrent; P=.004).
the EVEREG registry is a useful tool to know the current situation of incisional hernia treatment. Analysis of the data shows several points that could be improved: a low rate of follow-up and high recurrence rate.
Evidence-based surgery and incisional hernia
2013, Revista Hispanoamericana de Hernia
La cirugía basada en la evidencia (CBE) es crítica a la hora de guiar a los cirujanos hacia un adecuado tratamiento de la hernia incisional (HI). La CBE se fundamenta en cuatro puntos básicos, que son: 1) la mejor evidencia actual (los datos); 2) la toma de decisiones acerca de la atención médica; 3) el paciente individual, y 4) la competencia y juicio clínico. El objetivo de este trabajo es un análisis de la CBE de la HI desde el contexto previamente descrito.
Evidence-Based Surgery (EBS) is critical to guide surgeons to the proper treatment of Incisional Hernia. The EBS is based on four key points: 1) The best current evidence (data), 2) Decision making about medical care, 3) Individual patient, 4) Competition and clinical judgment. The aim of this paper is an analysis of the Evidence-based surgery for incisional hernia from the previous context.
Risk factors for bad outcomes in incisional hernia repair: Lessons learned from the National Registry of Incisional Hernia (EVEREG)
2018, Cirugia Espanola
Los registros son herramientas potentes para identificar situaciones de riesgo de mala evolución. Nuestro objetivo ha sido analizar los datos del Registro Nacional de Hernia Incisional (EVEREG) para detectar situaciones de riesgo para el desarrollo de complicaciones y recidivas.
Se analizan los datos de la cohorte de hernias registradas en el período desde julio de 2012 hasta junio de 2014. Se realiza una comparación estadística entre las hernias que presentaron complicaciones y recidivas, y su relación con los pacientes, las características de las hernias y la técnica quirúrgica, para determinar cuáles de ellos pueden predecir malos resultados.
En el período de estudio disponemos de datos de 1.336 hernias (43,7% varones; 56,3% mujeres), con una edad media de 63,6 años (DE: 12,4) e IMC de 30,4 (DE: 5,4). En el estudio multivariante las variables asociadas a la presencia de complicaciones fueron: edad superior a 70 años, neoplasia, longitud del defecto mayor de 10 cm, reparación previa y resección intestinal. Las variables asociadas a recidiva fueron: las hernias paraestomales, la reparación previa, la cirugía urgente, la aparición de complicaciones postoperatorias y la reintervención quirúrgica. El uso de una separación de componentes fue el único factor protector en este tipo de análisis (OR: 0,438; IC: 0,27-0,71; p = 0,001).
La presencia de factores de riesgo para la aparición de complicaciones y recurrencias debe ser tenida en cuenta con el fin de proyectar la prehabilitación del paciente para la cirugía, planificar la técnica quirúrgica y su derivación a unidades especializadas.
Registries are powerful tools for identifying factors predicting bad results. Our objective was to analyse data from the Spanish Registry of Incisional Hernia (EVEREG) to detect risk situations for the development of complications and recurrences.
We have analysed data of the cohort of hernias registered during the period from July 2012 to June 2014. We have compared the data between complicated and non-complicated patients in the short and long term follow-up. Data compared were: patient demographics, comorbid condition, hernia defect characteristics and surgical technique to determine which of them may be predictors of poor outcomes.
During the period of study, we collected data from 1,336 hernias (43.7% males; 56.3% females) with a mean age of 63.6 years (SD 12.4) and BMI of 30.4 (SD 5.4). In the multivariate analysis, factors associated with complications were: age > 70 years, previous neoplasm, diameter greater than 10 cm, previous repair and bowel resection. Factors related with recurrences were: parastomal hernia, previous repair, emergency repair, postoperative complications and reoperation. A separation of components was the only protective factor for this type of analysis (OR 0.438; CI 0.27-0.71; p = 0.0001).
Risk factors for the development of complications and recurrences must be considered for promoting preoperative patient prehabilitation, planning the surgical technique and referring patients to specialized abdominal wall units.
Nationwide analysis of open groin hernia repairs in Italy from 2015 to 2020
2023, Hernia

View all citing articles on Scopus

Address reprint requests to Erik Nilsson, MD, PhD, FRCS, Department of Surgery, Motala Hospital, 591 85 Motala, Sweden

Financial support for the Swedish Hernia Register is received from the National Board of Health and Welfare and the Federation of County Councils, Sweden

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HERNIA REGISTERS AND SPECIALIZATION

Section snippets

MOTIVES FOR HERNIA REGISTERS

PREREQUISITES FOR HERNIA REGISTERS

Background, Funding

HERNIA REGISTERS IN OTHER COUNTRIES

SPECIALIZATION IN HERNIA SURGERY

ACKNOWLEDGMENT

Lancet

Am J Surg

Lancet

Surg Clin North Am

Surgery

Local anesthesia for inguinal hernia repair step-by-step procedure

Ann Surg

Open “tension-free” repair of inguinal hernias: The Lichtenstein technique

Eur J Surg

Ueber die Behandlung des Leistenbruches

Archiv für Klinische Chirurgie

Organisation and results of ambulatory surgery for inguinal hernia

Ugeskr Laeger

Symposium on the management of inguinal hernias: IV. The Shouldice technique: A canon in hernia repair

Can J Surg