Recurrent groin hernia - Outcome after surgery
Background: According to the Swedish Hernia Register (SHR), the reoperation rate after recurrent groin hernia is more than twice that following primary hernia repair. Aims: To study the impact of method of mesh repair used in recurrent groin hernia surgery on re-recurrence as well as chronic pain and physical disability. Methods: Papers 1 and 2 were based on nationwide data from the SHR 1992-2008. In Paper 1 the cumulative risk for reoperation was studied after repeated surgery for recurrent hernia. In Paper 2 the risk for reoperation was analysed in relation to the mesh method used for recurrent hernia repair, taking the previous (index) repair into account. Papers 3 and 4 were based on a cohort of 1st and 2nd recurrent repairs performed at 5 hospitals in the south-west region of Sweden 1998-2007. A follow-up was performed 2009 using the Inguinal Pain Questionnaire (IPQ) and a selective clinical examination. In Paper 3 the risk for a 2nd recurrence was studied in relation to Anterior (AMR) and Posterior Mesh Repairs (PMR) and in Paper 4 the hazard ratio for chronic pain and physical disability was studied in relation to type of mesh repair and mean surgeon´s annual volume. Results: Paper 1 The risk for a further reoperation increased with the number of recurrent repairs (p<0.001). Paper 2 Endoscopic (E-PMR) and open PMR (O-PMR) were associated with the lowest risk for reoperation when the index repair was an anterior repair (p<0.001) Paper 3. PMR was associated with a decreased 2nd recurrence rate compared with AMR (p=0.025). An increased risk for a subsequent 2nd recurrence was seen an after anterior index repair followed by an AMR (HR 3.21 (CI 1.33-7.44), p=0.009)) and a decreased risk after posterior index repair followed by an AMR (HR 0.08 (CI 0.01-0.94), p=0.045). In the O-PMR group there was a lower 2nd recurrence rate after a Nyhus approach (2.5 %) compared to a trans inguinal approach (TIPP) (28 %) (p=0.001). A mean surgeon´s annual volume ≤ 5 O-PMR resulted in a higher risk for a 2nd recurrence (p<0.001). Paper 4 The E-PMR was associated with a lower risk for chronic pain and physical disability compared to AMR, after a previous anterior index repair (OR 0.54 (CI 0.30-0.97), p=0.039). A mean surgeon´s annual volume > 5 O-PMR correlated with a lower risk for chronic pain compared to an surgeon´s annual volume ≤ 5 (OR 0.42 (CI 0.19-0.94), p=0.034). Having a 2nd recurrent repair was associated with a higher risk for chronic pain compared to a 1st recurrent repair (OR 2.89 (CI 1.21-6.88), p=0.017). Conclusions: A posterior mesh repair for recurrent groin hernia surgery was associated with a lower 2nd recurrence rate compared to anterior mesh repair. A posterior mesh repair for the 1st recurrent operation is recommended after an anterior index repair and an anterior mesh repair after a posterior index operation. Endoscopic repairs have the lowest risk for both a 2nd recurrence and chronic groin pain and physical disability. An O-PMR performed trough a Nyhus incision is preferred and the TIPP procedure should be avoided. An surgeon´s annual volume > 5 O-PMR resulted in a lower 2nd recurrence rate and a lower risk for chronic pain. The risk for further recurrence increases with increasing number of groin hernia operations and the risk for chronic pain increases after a 2nd recurrent repair.
Surgery, Groin hernia, inguinal hernia, recurrence, re-recurrence, mesh repair, chronic pain, hernia register
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Surgery, Faculty of Medicine, Lund University