Groin Hernias: Do all Need to be Fixed? Abeezar I Sarela MD FRCS
Groin Hernia Repair What are we seeking to achieve? <ul><li>Relief of discomfort or pain </li></ul><ul><li>Is pain truly d...
All licensed providers of NHS-funded Unilateral Hip replacements, Unilateral Knee replacements, Groin Hernia Surgery or Va...
<ul><li>self-completed questionnaires  administered to Patients to assess their self-reported health status before and aft...
 
Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia   ...
Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia   ...
Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia   ...
Risk factors for long-term pain after hernia surgery Ann Surg 2006;244:212-219 <ul><li>Swedish Hernia Registry: 2000 </li>...
Risk factors for long-term pain after hernia surgery Ann Surg 2006;244:212-219 <ul><li>Comparison with contra-lateral groi...
RCT: Observation or Operation for Patients with an Asymptomatic Inguinal Hernia O’Dwyer et al. Ann Surg 2006;244:167-173 <...
RCT: Observation or Operation for Patients with an Asymptomatic Inguinal Hernia O’Dwyer et al. Ann Surg 2006;244:167-173 <...
RCT: Observation or Operation for Patients with an Asymptomatic Inguinal Hernia O’Dwyer et al. Ann Surg 2006;244:167-173 <...
RCT: Observation or Operation for Patients with an Asymptomatic Inguinal Hernia O’Dwyer et al. Ann Surg 2006;244:167-173
RCT: Observation or Operation for Patients with an Asymptomatic Inguinal Hernia O’Dwyer et al. Ann Surg 2006;244:167-173 <...
RCT: Watchful Waiting versus Repair of Inguinal Hernia in Minimally Symptomatic Men Fitzgibbons et al.  JAMA . 2006;295(3)...
RCT: Watchful Waiting versus Repair of Inguinal Hernia in Minimally Symptomatic Men Fitzgibbons et al.  JAMA . 2006;295(3)...
RCT: Watchful Waiting versus Repair of Inguinal Hernia in Minimally Symptomatic Men Fitzgibbons et al.  JAMA . 2006;295(3)...
RCT: Watchful Waiting versus Repair of Inguinal Hernia in Minimally Symptomatic Men Fitzgibbons et al.  JAMA . 2006;295(3)...
Mortality after groin hernia surgery Ann Surg 2007;245:656-660 <ul><li>Standardized mortality ratio (SMR) = observed/expec...
Mortality after groin hernia surgery Ann Surg 2007;245:656-660 <ul><li>Swedish Hernia Registry: 1992-2004 </li></ul><ul><l...
<ul><li>Older patients are more likely to need emergency surgery than young patients </li></ul><ul><li>Women are more like...
Repeated Groin Hernia Recurrences Ann Surg 2009;249:516-518 <ul><li>Swedish Hernia Registry: 1992-2006 </li></ul><ul><li>R...
Re-recurrence after operation for recurrent inguinal hernia Ann Surg 2008;247:707-711 <ul><li>Danish Hernia Database: 1998...
<ul><li>Recurrence after Lichtenstein repair – should laparoscopic TEP repair be the accepted standard of care? </li></ul>...
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Groin hernia repair

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Groin hernia repair

  1. 1. Groin Hernias: Do all Need to be Fixed? Abeezar I Sarela MD FRCS
  2. 2. Groin Hernia Repair What are we seeking to achieve? <ul><li>Relief of discomfort or pain </li></ul><ul><li>Is pain truly due to a hernia? </li></ul><ul><li>Chronic groin pain after hernia repair </li></ul><ul><li>Prevention of future complications </li></ul><ul><li>?Sudden-onset strangulation is rare </li></ul>
  3. 3. All licensed providers of NHS-funded Unilateral Hip replacements, Unilateral Knee replacements, Groin Hernia Surgery or Varicose Vein Surgery (“Providers”) are expected to invite patients undergoing one of these procedures to complete a preoperative PROMs questionnaires from April 2009 in accordance with this guidance. For non-Foundation Trust NHS Acute Trusts, the PROMs data collection has been given mandatory collection status by the Review
  4. 4. <ul><li>self-completed questionnaires administered to Patients to assess their self-reported health status before and after certain elective healthcare interventions funded by the NHS. </li></ul><ul><li>provides an indication of the outcomes or quality of care delivered to NHS Patients. </li></ul>
  5. 6. Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia MRC Laparoscopic Groin Hernia Trial Group BJS 2004; 91 : 1570–1574 <ul><li>1994-1997 </li></ul><ul><li>27 surgeons in 26 hospital in the UK </li></ul><ul><li>Response </li></ul><ul><ul><li>2 yrs: 70% </li></ul></ul><ul><ul><li>5 yrs: 60% </li></ul></ul>928 patients Laparoscopic 468 patients (TEP 80%) Open 460 patients
  6. 7. Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia MRC Laparoscopic Groin Hernia Trial Group BJS 2004; 91 : 1570–1574 13% 19% 20% 22% Testis pain 2% 2% 2% 4% Severe pain 20% 18% 36% 28% Groin Pain Open Lap Open Lap 5 years 1 year
  7. 8. Five-year follow-up of a randomized trial to assess pain and numbness after laparoscopic or open repair of groin hernia MRC Laparoscopic Groin Hernia Trial Group BJS 2004; 91 : 1570–1574 9% 10% 11% 14% Numb thigh 25% 13% 40% 18% Numb groin Open Lap Open Lap 5 years 1 year
  8. 9. Risk factors for long-term pain after hernia surgery Ann Surg 2006;244:212-219 <ul><li>Swedish Hernia Registry: 2000 </li></ul><ul><li>10,000 hernia operation </li></ul><ul><li>Exclude: bilateral operations or previous/subsequent contralateral operation </li></ul><ul><li>Eligible: 7000 patients </li></ul><ul><li>Random selection: 3000 patients </li></ul><ul><li>Postal questionnaire (DIBS) - 2003 </li></ul>
  9. 10. Risk factors for long-term pain after hernia surgery Ann Surg 2006;244:212-219 <ul><li>Comparison with contra-lateral groin </li></ul><ul><ul><li>Some pain: 31% </li></ul></ul><ul><ul><li>Pain interfering with daily activity: 6% </li></ul></ul><ul><li>Predictors of pain </li></ul><ul><ul><li>Young (age below median) </li></ul></ul><ul><ul><li>High level of pre-op. pain </li></ul></ul><ul><ul><li>Any post-op complication </li></ul></ul><ul><ul><li>Open surgery </li></ul></ul>
  10. 11. RCT: Observation or Operation for Patients with an Asymptomatic Inguinal Hernia O’Dwyer et al. Ann Surg 2006;244:167-173 <ul><li>Inclusion </li></ul><ul><ul><li>Male > 55 years </li></ul></ul><ul><ul><li>No pain at rest or movement </li></ul></ul><ul><ul><li>Reducible </li></ul></ul><ul><li>Randomization of 160 patients </li></ul><ul><li>Operation: Open Lichtenstein repair </li></ul><ul><li>Observation: Crossover if pain, interference with activity, irreducibility </li></ul><ul><li>Primary end-point: Pain at one year </li></ul>
  11. 12. RCT: Observation or Operation for Patients with an Asymptomatic Inguinal Hernia O’Dwyer et al. Ann Surg 2006;244:167-173 <ul><li>No difference in pain at rest or movement at 12 months (~1/3 in both groups had pain > 2mm on a 10cm VAPS) </li></ul><ul><li>HRQoL (SF36) significantly improved after operation </li></ul>
  12. 13. RCT: Observation or Operation for Patients with an Asymptomatic Inguinal Hernia O’Dwyer et al. Ann Surg 2006;244:167-173 <ul><li>Crossovers from observation to operation </li></ul><ul><ul><li>26% at 15 months </li></ul></ul><ul><ul><li>Post-op complications </li></ul></ul><ul><ul><ul><li>MI (1 patient; died) </li></ul></ul></ul><ul><ul><ul><li>CVA (1 patient) </li></ul></ul></ul><ul><ul><li>Acute presentation: 1 patient </li></ul></ul><ul><li>No serious complications in operation arm </li></ul><ul><li>Cost: £400 more per patient in operation arm </li></ul>
  13. 14. RCT: Observation or Operation for Patients with an Asymptomatic Inguinal Hernia O’Dwyer et al. Ann Surg 2006;244:167-173
  14. 15. RCT: Observation or Operation for Patients with an Asymptomatic Inguinal Hernia O’Dwyer et al. Ann Surg 2006;244:167-173 <ul><li>Conclusion: Patients with asymptomatic hernias should be operated because </li></ul><ul><li>Operation does not impact incidence of chronic pain – but short follow-up study </li></ul><ul><li>Operation improves sense of well-being </li></ul><ul><li>Delay in operation pre-disposes to increased risk of post-operative complications - unsupported </li></ul>
  15. 16. RCT: Watchful Waiting versus Repair of Inguinal Hernia in Minimally Symptomatic Men Fitzgibbons et al. JAMA . 2006;295(3):285-292 <ul><li>Inclusion </li></ul><ul><ul><li>Men > 18 years </li></ul></ul><ul><ul><li>Absence of pain limiting activity </li></ul></ul><ul><ul><li>Chronic irreducibility </li></ul></ul><ul><li>Randomization of 724 patients </li></ul><ul><li>End-points: Pain and QoL at 2 years </li></ul>
  16. 17. RCT: Watchful Waiting versus Repair of Inguinal Hernia in Minimally Symptomatic Men Fitzgibbons et al. JAMA . 2006;295(3):285-292 <ul><li>No significant difference in pain interfering with activity in patients assigned to operation (2.2%) vs. waiting (5.1%) </li></ul><ul><ul><li>Both groups had less pain at 2 years than at baseline </li></ul></ul><ul><ul><li>For crossovers, significant decrease in pain after operation </li></ul></ul><ul><li>No significant difference in HRQoL (SF36) </li></ul><ul><ul><li>Crossovers had significantly greater improvement than assigned operation </li></ul></ul>
  17. 18. RCT: Watchful Waiting versus Repair of Inguinal Hernia in Minimally Symptomatic Men Fitzgibbons et al. JAMA . 2006;295(3):285-292 <ul><li>Crossovers from waiting to operation: 23% </li></ul><ul><ul><li>Beyond 2 years: 4% crossover/year </li></ul></ul><ul><ul><li>One acute event (no obstruction) < 2 years </li></ul></ul><ul><ul><li>One acute event (obstruction) > 2 years </li></ul></ul><ul><ul><li>No difference in complications after assigned vs. crossover operations </li></ul></ul><ul><li>Crossover from assigned operation to waiting: 17% </li></ul>
  18. 19. RCT: Watchful Waiting versus Repair of Inguinal Hernia in Minimally Symptomatic Men Fitzgibbons et al. JAMA . 2006;295(3):285-292 <ul><li>Conclusion </li></ul><ul><li>A strategy of watching waiting is an acceptable option and should be offered to men with asymptomatic or minimally symptomatic hernias </li></ul><ul><ul><li>Does this apply to the elderly, infirm, incapable? </li></ul></ul><ul><ul><li>Does size of the hernia matter? </li></ul></ul><ul><ul><li>What about women? </li></ul></ul>
  19. 20. Mortality after groin hernia surgery Ann Surg 2007;245:656-660 <ul><li>Standardized mortality ratio (SMR) = observed/expected death within 30 days for surgery adjusted for age and gender </li></ul><ul><li>No increase in SMR after elective surgery, even in older patients </li></ul><ul><li>SMR increased 6-9X after emergency op. </li></ul><ul><li>SMR increased 20X after emergency op. with bowel resection </li></ul>
  20. 21. Mortality after groin hernia surgery Ann Surg 2007;245:656-660 <ul><li>Swedish Hernia Registry: 1992-2004 </li></ul><ul><li>1,08,000 patients </li></ul><ul><li>Femoral hernias </li></ul><ul><ul><li>Men (1%) vs. Women (22%) </li></ul></ul><ul><ul><li>Older patients than inguinal hernias </li></ul></ul><ul><li>Emergency operations </li></ul><ul><ul><li>Inguinal (5%) vs. Femoral (36%) </li></ul></ul><ul><ul><li>Bowel resection: Inguinal (5%) vs. Femoral (23%) </li></ul></ul><ul><ul><li>Men (5%) vs. Women (17%) </li></ul></ul><ul><ul><li>Significantly older than elective patients </li></ul></ul>
  21. 22. <ul><li>Older patients are more likely to need emergency surgery than young patients </li></ul><ul><li>Women are more likely to need emergency surgery than men </li></ul><ul><li>Increased risk of post-operative mortality after emergency surgery </li></ul><ul><li>The elderly are not at increased risk of mortality after elective surgery </li></ul>
  22. 23. Repeated Groin Hernia Recurrences Ann Surg 2009;249:516-518 <ul><li>Swedish Hernia Registry: 1992-2006 </li></ul><ul><li>Recurrent hernia repair: 17,000/142,000 </li></ul><ul><li>Cumulative risk of re-operation </li></ul><ul><ul><li>After first recurrence: 7.5% </li></ul></ul><ul><ul><li>After second recurrence: 10% </li></ul></ul><ul><ul><li>After third recurrence: 13% </li></ul></ul><ul><ul><li>After fourth recurrence: 16.5% </li></ul></ul><ul><li>Risk of re-operation is significantly lower if </li></ul><ul><ul><li>Laparoscopic TEP repair </li></ul></ul><ul><ul><li>High volume surgeon </li></ul></ul>
  23. 24. Re-recurrence after operation for recurrent inguinal hernia Ann Surg 2008;247:707-711 <ul><li>Danish Hernia Database: 1998-2005 </li></ul><ul><li>Primary elective operations: 67,000 </li></ul><ul><ul><li>Lichtenstein (70%); other open (26%); laparoscopic (4%) </li></ul></ul><ul><li>Re-operation: 3% </li></ul><ul><li>Re-re-operation: 9% </li></ul><ul><li>Cumulative re-operation rate was significantly lower for laparoscopic repair vs. any open repair </li></ul>
  24. 25. <ul><li>Recurrence after Lichtenstein repair – should laparoscopic TEP repair be the accepted standard of care? </li></ul><ul><li>Limited data for treatment of recurrences after laparoscopic repair or open non-Lichtenstein repair </li></ul>
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