BMJ  2004;329:1315-1316 (4 December), doi:10.1136/bmj.38282.675556.F7 (published 16 November 2004)

Paper

Surgical management of inguinal hernia: retrospective cohort study in southeastern Scotland, 1985-2001

¹ Charing Cross Hospital, London W6 8RF Department of Orthopaedic and Trauma Surgery, ² Department of Trauma and Orthopaedic Surgery, Bristol Royal Infirmary, ³ Department of General Surgery, St Mary's Hospital, London, ⁴ Department of Surgery, Royal Infirmary of Edinburgh

Introduction

Inguinal hernia repair (IHR) is the most common general surgical procedure in the United Kingdom, with an estimated 80 000 cases a year. The past decade has seen an increase in the use of prosthetic mesh in open and laparoscopic hernia repair based on the premise of a tension-free repair.¹ Conversely, although traditional repair with suturing using the Shouldice technique has been reported with low rates of recurrence, it is difficult to learn and often associated with high rates of recurrence when done in the wider community. Recent reports have indicated that laparoscopic repair is associated with less immediate postoperative pain and a faster return to normal activities, particularly for recurrent and bilateral hernias.² Large case series indicate recurrence rates for open and laparoscopic mesh repairs as low as 0.2%,³ and randomised trials of open primary IHR, with follow up as short as two years, have consistently found fewer recurrences associated with using mesh than not,^{2 4} with similar results reported for recurrent hernias.⁵ We examined these changing trends in IHR in southeastern Scotland between 1985 and 2001.

Participants, methods, and results

We retrospectively identified all patients undergoing IHR between January 1985 and January 2002 in six surgical centres in southeastern Scotland using the Lothian surgical audit database (available in all these hospitals for some or all of this period), hospital coding systems (OPCS3 and OPCS4), and data from the Information and Statistics Division of the Public Health Institute of Scotland. Population data were taken from the UK census and the General Register Office for Scotland. Poisson and logistic regression were used to analyse the data.

Overall, 16 450 patients had primary IHR (11 274 open suture repairs, 3885 open prosthetic mesh repairs, and 1291 laparoscopic mesh repairs). A further 1859 patients had recurrent IHR (1292 open suture repairs, 338 open mesh repairs, and 229 laparoscopic repairs). In 1993, less than 1% (8/1324) of all IHRs used mesh, increasing to more than 90% (1012/1114) by 2001 (figure).

View larger version (49K): [in this window] [in a new window]   Inguinal hernia repairs by open suture, open mesh, and open laparoscopic mesh techniques in southeastern Scotland from 1985 to 2001

 

Laparoscopic mesh IHR was first introduced to southeastern Scotland in 1993, and its use in primary repair increased to 18% (186/1027) by 1996, then remained static. For recurrent hernias, however, use continued to rise to 42% (41/98) by 2001. Up to this time no surgeon had done prophylactic contralateral IHR in the region.

In this period, the total number of primary repairs increased significantly at an average annual rate of 1.25% (P < 0.001), while the population within southeastern Scotland remained static at about 745 000 residents between 1985 and 1991, and increased by an average 0.49% a year from 1992 to 2001. The annual number of recurrent repairs did not change significantly, but the annual rate of recurrent repairs decreased significantly as a proportion of the total, from 11.7% to 8.8% (P < 0.001). The median patient age at time of surgery did not change significantly over the study period; Spearman's rank correlation r_s = -0.09, P = 0.72 (primary repairs) and r_s = 0.35, P = 0.16 (recurrent repairs).

Comment

The annual ratio of recurrent to primary repairs has significantly decreased in southeastern Scotland, during a period in which surgical technique has changed while selection criteria have remained the same. This ratio started falling before the introduction of mesh repair, indicating that other variables may be involved. Although changes in recurrence rates may lag up to 10 years behind changes in surgical technique, 40% occur within one year of surgery,⁴ and therefore it is likely that new techniques have influenced the recurrence rates in the 17 years of this study.

What is already known on this topic Using mesh in inguinal hernia repair has increased rapidly worldwide since 1989 and is associated with low recurrence rates What this study adds Use of mesh in the past decade in southeastern Scotland mirrors the global trend. The annual ratio of recurrent to primary repairs has significantly decreased perhaps partly because of newer techniques but also other factors, such as better supervision and training

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This article was posted on bmj.com on 16 November 2004: http://bmj.com/cgi/doi/10.1136/bmj.38282.675556.F7

We thank Stephanie C Lewis for her help and advice with the statistics.

Contributors: HDEA and SP-B designed the study. HDEA collected the data. HDEA, SGN, and SP analysed the data and wrote the initial draft. SGN and HDEA revised the draft and prepared the final manuscript. HDEA is guarantor.

Funding: None.

Competing interests: None declared.

Ethical approval: Not needed.

References

1. Lichtenstein IL, Shulman AG, Amid PK, Montlor HM. The tension-free hernioplasty. Am J Surg 1989;157: 188-93.[Medline]
2. McCormack K, Scott NW, Go PM, Ross S, Grant AM, Laparoscopic techniques versus open techniques for inguinal hernia repair. Cochrane Database Syst Rev 2003(1): CD001785.
3. Schumpelick V, Treutner KH, Arlt G. Inguinal hernia repair in adults. Lancet 1994;344: 375-9.[Web of Science][Medline]
4. EU Hernia Trialists Collaboration. Mesh compared with non-mesh methods of open groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000;87: 854-9.[CrossRef][Web of Science][Medline]
5. Bay-Nielsen M, Kehlet H, Strand L, Malmstrom J, Andersen FH, Wara P, et al. Quality assessment of 26304 herniorrhaphies in Denmark; a prospective nationwide study. Lancet 2001;358: 1124-8.[CrossRef][Web of Science][Medline]

(Accepted 31 July 2004)

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