The proportion of recurrent repairs in the total collective of inguinal hernia repairs among men is 11.3–14.3% and among women 7.0–7.4%. The rate of re-recurrences is reported to be 2.9–9.2%. To date, no case series has been published on second and ≥ third recurrences and their treatment outcomes. Only case reports are available.
Materials and methods
In an analysis of data from the Herniamed Registry the perioperative and 1-year follow-up outcomes of 16,206 distinct patients who had undergone first recurrent (n = 14,172; 87.4%), second recurrent (n = 1,583; 9.8%) or ≥ third recurrent (n = 451; 2.8%) inguinal hernia repair between September 1, 2009 and July 1, 2017 were compared.
Results
The intraoperative complication rate for all recurrent repairs was between 1–2%. In the postoperative complications a continuous increase was observed (first recurrence: 3.97% vs second recurrence: 5.75% vs ≥ third recurrence 8.65%; p < 0.001). That applied equally to the complication-related reoperation rates (first recurrence: 1.50% vs second recurrence: 2.21% vs ≥ third recurrence 2.66; p = 0.020). Likewise, the re-recurrence rate rose significantly (first recurrence: 1.95% vs second recurrence: 2.72% vs ≥ third recurrence 3.77; p = 0.005). Similarly, the rate of pain requiring treatment rose highly significantly with an increasing number of recurrences (first recurrence: 5.21% vs second recurrence: 6.70% vs ≥ third recurrence 10.86; p = < 0.001).
Conclusion
The repair of re-recurrences in inguinal hernia is associated with increasingly more unfavorable outcomes. For the first recurrence the guidelines should definitely be noted. For a second and ≥ third recurrence diagnostic laparoscopy may help to select the best possible surgical technique.
Hinweise
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Introduction
According to the guidelines of the HerniaSurge Group recurrence rates of inguinal hernia repair worldwide are still too high despite numerous innovations [1]. Recurrence rates vary in accordance with the length of follow-up [1, 2]. Recurrences after inguinal hernia repairs can occur even up to 50 years later [2]. In recent administrative data and registry analyses it was revealed that the proportion of recurrent repairs in the total collective of inguinal hernia repairs among men was 11.3–14.3% [3‐7] and in women 7.0–7.4% [4, 8]. By contrast, in systematic reviews and meta-analyses the recurrence rates were still far lower (1.2–3%) than those cited above since the included studies had a maximum follow-up time of 6 years [9‐11].
The guidelines of the HerniaSurge Group recommend that the first recurrence repair should be performed in an unoperated anatomic layer [1], i.e. laparo-endoscopic (TEP, TAPP) following previous open anterior repair and anterior open (Lichtenstein) following previous laparo-endoscopic repair. However, to date that recommendation is not adequately applied [5] and results in significantly higher rates of second recurrences [5].
Anzeige
The rates of second recurrences after recurrent inguinal hernia repair are reported in registry data and case series to be as high as 8.8% [12, 13]. In meta-analyses comparing open with laparo-endoscopic repair of first inguinal hernia recurrences the rates of second recurrences were between 2.9% and 9.2% [14‐17], depending on the follow-up time.
So far, no case series has been published on second recurrences and their treatment outcomes. Only case reports are available.
Based on the analysis of data from the Herniamed Registry, this paper now compares the treatment outcomes for second recurrences and ≥ third recurrences with those of first recurrences.
Materials and methods
The Herniamed quality assurance study is a multicenter, internet-based hernia registry [18, 19] into which 683 participating hospitals and surgeons engaged in private practice (Herniamed Study Group) in Germany, Austria and Switzerland (Status: August 1, 2018) have entered data prospectively on their patients who had undergone routine hernia surgery [20, 21]. All patients signed an informed consent agreeing to participate [20, 21]. As part of the information provided to patients regarding participation in the Herniamed Quality Assurance Study and signing the informed consent declaration, all patients are informed that the treating hospital or medical practice would like to be informed about any problem occurring after the operation and that the patient has the opportunity to attend clinical examinations [20, 21]. All postoperative complications occurring up to 30 days after surgery are recorded [20, 21]. At 1-year follow-up, postoperative complications are once again reviewed when the general practitioner and patient complete a questionnaire [20, 21]. At 1-year follow-up, the general practitioner and patient are also asked about any recurrences, pain at rest, pain on exertion, and chronic pain requiring treatment [20, 21]. If a recurrence or chronic pain is reported by the general practitioner or patient, the patient can be requested to attend clinical examination [20, 21]. One publication has provided impressive evidence of the role of patient-reported outcome for recurrence and chronic pain [22].
Anzeige
In the current analysis, prospective data on patients with a first recurrent, second recurrent and ≥ third recurrent elective unilateral inguinal hernia were analyzed to compare the perioperative and 1-year follow-up outcomes.
The main inclusion criteria were minimum age of 16 years, unilateral first recurrent, second recurrent and ≥ third recurrent elective inguinal hernia repair using only the last recurrence per patient, all types of procedures, and availability of data at 1-year follow-up (Fig. 1).
×
All analyses were performed with the software SAS 9.4 (SAS Institute Inc., Cary, NC, USA) and intentionally calculated to a full significance level of 5%, i.e. no corrections were made for multiple testing and each p value ≤ 0.05 corresponds to a significant result.
Individual outcome and influence variables (risk factors, complications) were summarized as global variables. A general, intra- or postoperative complication or risk factor was deemed to apply if at least one such individual item was present.
Therefore, all categorical patient data are presented as absolute and relative frequencies for these categories in contingency tables.
For continuous data the mean value and standard deviation or, for log-transformed data, the mean value and range are presented.
For analysis of an individual influence variable on an individual outcome parameter unadjusted analyses were carried out. Here the focus was on the influence exerted by the first recurrent, second recurrent and ≥ third recurrent repair.
The chi-square test was performed for categorical outcome variables. ANOVA (analysis of variance) was used for continuous variables to analyze the influence exerted by the comparison groups.
Anzeige
Results
In total, 16,206 patients were selected between September 1, 2009 and July 1, 2017 (Fig. 1). Following patient selection 16,206 patients were ultimately included in the analysis comparing the outcomes for first recurrent, second recurrent and ≥ third recurrent inguinal hernia repair. Of these patients, 14,172 (87.4%) underwent first recurrent, 1,583 (9.8%) patients second recurrent and 451(2.8%) patients ≥ third recurrent inguinal hernia repair (Table 1).
Table 1
Patient population with 1. recurrence, 2. recurrence and ≥ 3. recurrence
N
%
1. Recurrence
14,172
87.4
2. Recurrence
1583
9.8
≥ 3. Recurrence
451
2.8
Total
16,206
100.0
Table 2 presents the descriptive statistics as well as the test results for the continuous variables age, BMI and operating time. While there are significant differences because of the large sample size, only the difference in the operating time is clinically relevant.
Table 2
Comparison of mean age, BMI and operation-time in patients with 1. recurrent versus 2. recurrent versus ≥ 3. recurrent inguinal hernia repair
1. Recurrence
2. Recurrence
≥ 3. Recurrence
p
Age (years)
N/mean ± STD
14,172/61.2 ± 15.2
1583/62.8 ± 14.5
451 / 62.1 ± 14.3
< .001
BMI (kg/m2)
N/mean ± STD
14,121/25.9 ± 3.5
1573/26.0 ± 3.6
450 / 26.4 ± 3.8
0.008
Log Operation-time [min]
N/MW[range]
14,029/52.3 [50.8; 53.8]
1573/57.3 [55.8; 58.9]
447 / 61.0 [59.3; 62.6]
< .001
Unadjusted analysis of the relationship between the first recurrent, second recurrent and ≥ third recurrent repair and the patient- and surgery-related variables (Table 3) revealed major differences, with the exception of the scrotal EHS classifications and most risk factors. The proportion of women rose significantly in line with the increase in the number of recurrences.
Table 3
Comparison of demographic and surgery-related parameters and risk factors of patients with 1. recurrent versus 2. recurrent versus ≥ 3. recurrent inguinal hernia repair
1. Recurrence
2. Recurrence
≥ 3. Recurrence
p
n
%
n
%
n
%
Gender
Male
13,010
91.80
1437
90.78
399
88.47
0.019
Female
1162
8.20
146
9.22
52
11.53
Procedure
Bassini
37
0.26
11
0.69
3
0.67
< .001
Defect closure
4
0.03
0
0.00
1
0.22
Gilbert
160
1.13
21
1.33
1
0.22
Lichtenstein
5283
37.28
581
36.70
167
37.03
Plug
525
3.70
68
4.30
17
3.77
Shouldice
259
1.83
30
1.90
10
2.22
Sonstige
281
1.98
63
3.98
23
5.10
TAPP
5012
35.37
555
35.06
153
33.92
TEP
2416
17.05
222
14.02
60
13.30
TIPP
195
1.38
32
2.02
16
3.55
ASA score
I
3723
26.27
343
21.67
92
20.40
< .001
II
7893
55.69
934
59.00
263
58.31
III/IV
2556
18.04
306
19.33
96
21.29
Defect size
I (< 1.5 cm)
2897
20.44
316
19.96
99
21.95
0.020
II (1.5—3 cm)
8136
57.41
868
54.83
237
52.55
III (> 3 cm)
3139
22.15
399
25.21
115
25.50
EHS-classification medial
Yes
7312
51.59
899
56.79
254
56.32
< .001
No
6860
48.41
684
43.21
197
43.68
EHS-classification lateral
Yes
8208
57.92
796
50.28
226
50.11
< .001
No
5964
42.08
787
49.72
225
49.89
EHS-classification femoral
Yes
504
3.56
98
6.19
28
6.21
< .001
No
13,668
96.44
1485
93.81
423
93.79
EHS-classification scrotal
Yes
280
1.98
26
1.64
13
2.88
0.243
No
13,892
98.02
1557
98.36
438
97.12
Preoperative pain
Yes
9160
64.63
1093
69.05
325
72.06
< .001
No
3797
26.79
371
23.44
78
17.29
Unknown
1215
8.57
119
7.52
48
10.64
Drainage
Yes
4305
30.38
588
37.14
198
43.90
< .001
No
9867
69.62
995
62.86
253
56.10
Risk factors
Yes
4440
31.33
547
34.55
164
36.36
0.003
No
9732
68.67
1036
65.45
287
63.64
COPD
Yes
864
6.10
132
8.34
31
6.87
0.002
No
13,308
93.90
1451
91.66
420
93.13
Diabetes
Yes
848
5.98
100
6.32
30
6.65
0.744
No
13,324
94.02
1483
93.68
421
93.35
Aortic aneurysm
Yes
100
0.71
7
0.44
4
0.89
0.421
No
14,072
99.29
1576
99.56
447
99.11
Immunosuppression
Yes
132
0.93
9
0.57
3
0.67
0.302
No
14,040
99.07
1574
99.43
448
99.33
Corticoid treatment
Yes
164
1.16
22
1.39
3
0.67
0.432
No
14,008
98.84
1561
98.61
448
99.33
Smoking
Yes
1552
10.95
203
12.82
60
13.30
0.029
No
12,620
89.05
1380
87.18
391
86.70
Coagulopathy
Yes
270
1.91
24
1.52
12
2.66
0.265
No
13,902
98.09
1559
98.48
439
97.34
ASS/Plavix Antiplatelet medication
Yes
1448
10.22
155
9.79
51
11.31
0.639
No
12,724
89.78
1428
90.21
400
88.69
Anticoagulation therapy
Yes
393
2.77
46
2.91
19
4.21
0.188
No
13,779
97.23
1537
97.09
432
95.79
As regards the surgical techniques, the standard procedures TEP, TAPP and Lichtenstein declined somewhat in line with the rising number of recurrences, while the TIPP and other procedures increased.
Anzeige
Patients with a second recurrence or ≥ third recurrence had a significantly higher ASA score and EHS III defect size (> 3 cm).
The proportion of medial and femoral EHS classifications rose significantly for second recurrences and ≥ third recurrences.
Preoperative pain was identified significantly more often for second recurrences and ≥ third recurrences.
The rate of risk factors (COPD, diabetes, aortic aneurysm, immunosuppression, corticoidsteroid therapy, smoking, coagulopathy, antiplateled medication and anticoagulation therapy) was significantly increased for second recurrences and ≥ third recurrences compared with first recurrences (Table 3).
Anzeige
Significant differences were identified for all outcome variables in relation to the number of instances of recurrence with the exception of intraoperative complications (Table 4).
Table 4
Comparison of perioperative and 1-year follow-up outcomes in patients with 1. recurrent versus 2. recurrent versus ≥ 3. recurrent inguinal hernia repair
1. Recurrence
2. Recurrence
≥ 3. Recurrence
n
%
n
%
n
%
p
Intraoperative complication
Yes
187
1.32
29
1.83
7
1.55
0.239
No
13,985
98.68
1554
98.17
444
98.45
Postoperative complication
Yes
563
3.97
91
5.75
39
8.65
<.001
No
13,609
96.03
1492
94.25
412
91.35
Complication-related reoperation
Yes
213
1.50
35
2.21
12
2.66
0.020
No
13,959
98.50
1548
97.79
439
97.34
Recurrence on 1-year-follow-up
Yes
277
1.95
43
2.72
17
3.77
0.005
No
13,895
98.05
1540
97.28
434
96.23
Pain on exertion on 1-year-follow-up
Yes
2110
14.89
326
20.59
107
23.73
<.001
No
12,062
85.11
1257
79.41
344
76.27
Pain in rest on 1-year-follow-up
Yes
1170
8.26
156
9.85
53
11.75
0.004
No
13,002
91.74
1427
90.15
398
88.25
Pain requiring treatment on 1-year-follow-up
Yes
738
5.21
106
6.70
49
10.86
< .001
No
13,434
94.79
1477
93.30
402
89.14
Accordingly, the postoperative complication rate rose significantly from 3.97% for the first recurrence to 5.75% for the second recurrence and to 8.65% for the ≥ third recurrence (p < 0.001). That was also true for the complication-related reoperation rate (1.50% vs 2.21% vs 2.66%; p = 0.020). Likewise, re-recurrence increased significantly in relation to previous recurrences at 1-year follow-up (1.95% vs 2.72% vs 3.77%; p = 0.005). Pain at rest (p = 0.004), pain on exertion (p < 0.001) and chronic pain requiring treatment (p < 0.001) also rose significantly with each additional recurrence (Table 4). Chronic pain requiring treatment for the first recurrence was 5.21%, for the second recurrence 6.70% and for the ≥ third recurrence 10.86%.
Additional subgroup analysis of patients missing to follow-up.
To rule out selection bias patient subgroups with and without follow-up were compared with regard to influence factors and perioperative outcomes. The standardized differences showed a difference of > 0.1 only for the mean age and the proportion of Gilbert repairs (Fig. 2). Since no relevant deviations were noted for any of the other influence factors or for the perioperative outcome, selection bias can be neglected.
×
Discussion
Analysis of 16,206 inguinal hernia recurrent repairs revealed a proportion of 87.4% for first recurrences, 9.8% for second recurrences, and 2.8% for ≥ third recurrences. For the intraoperative complications the number of instances of recurrence was not found to have any significant influence on the outcome. By contrast, a significantly increasing rate of postoperative complications of up to 8.65% was identified for ≥ third recurrences. Likewise, the complication-related reoperation rate rose to 2.66% for ≥ third recurrences. The re-recurrence rate at 1-year follow-up also increased to 3.77% in patients with ≥ third recurrences. The number of instances of recurrence also had a greater influence on the pain rates. For example, for each additional recurrence the pain on exertion rate rose significantly to 23.73%, the pain at rest rate to 11.75% and the rate of chronic pain requiring treatment to 10.86%.
Due to the relatively small number of re-recurrences, data analyses were limited to tests unadjusted for potential confounders here. Thus, estimated differences in outcome between comparison groups may further be influenced by patient- and operation-related characteristics.
Nevertheless, to date, there are no comparable findings for these data in the literature. Only the proportion of re-recurrences of around 8% is also seen in the Danish Hernia Database [11]. The data impressively demonstrate just how demanding is inguinal hernia surgery for recurrences and re-recurrences. It requires extensive experience to avoid perioperative complications, re-recurrences and chronic pain rates. Therefore, according to the HerniaSurge Guidelines [1], an expert hernia surgeon should repair a recurrent inguinal hernia after a failed anterior and posterior repair. The HerniaSurge guidelines recommend for recurrence after failed posterior repair an anterior open technique (Lichtenstein) and a laparo-endoscopic repair (TEP, TAPP) after failed anterior tissue or Lichtenstein repair [1].
For second and ≥ third recurrences surgeons have used the standard procedures TEP, TAPP and Lichtenstein less, opting instead for the open preperitoneal and other techniques. The same trend was observed in the registry analysis of the Danish Hernia Database [12].
Important is the finding of more medial and femoral recurrent inguinal hernias with each succeeding repair. This may reflect a reluctance to place larger meshes with more medial overlap especialy at open repair and occult or missed primary femoral hernia present at the index or recurrent operation.
Diagnostic laparoscopy can be useful for second recurrences and ≥ third recurrences to decide which surgical access route offers the best outcome prospects for repair of a re-recurrence [23, 24]. The laparoscopy findings will make a valuable contribution when deciding whether a laparo-endoscopic procedure or an open technique assures better conditions.
In view of the very unfavorable outcomes observed for second recurrent and ≥ third recurrent inguinal hernias, that additional investment is also justified. Only such supplementary diagnostic measures are able to improve the unfavorable outcomes for repair of second recurrent and ≥ third recurrent inguinal hernias, which should always be performed as mesh supported repair. Sometimes very individual solutions are necessary to treat a re-recurrent hernia [25].
What is true for a first inguinal hernia recurrence [1] is all the more true for a second and ≥ third inguinal hernia recurrence. Such a repair should only be undertaken by a highly experienced hernia surgeon while utilizing all diagnostic aids. The surgeon should have the necessary experience of all relevant surgical techniques (TEP, TAPP, Lichtenstein, open preperitoneal mesh).
Incorrect or missing data limit a registry [20]. Hospitals and surgeons participating in the Herniamed Registry sign a contract for data correctness and completeness [20]. As part of the certification process of hernia centers, experts control data entry [20].
On comparing the patient subgroups with and without 1-year follow-up to exclude selection bias, a standardized difference of > 0.1 was found only for the mean age and the proportion of Gilbert repairs. All other potential influence factors and the perioperative outcomes were comparable.
In summary, unadjusted comparison of the perioperative and 1-year follow-up outcomes for first recurrent vs second recurrent vs ≥ third recurrent inguinal hernia repairs showed significantly unfavorable results. Therefore, the guidelines should definitely be followed for the first recurrent inguinal hernia repair in order to avoid further recurrences. Furthermore, inguinal hernia recurrences should only be repaired by highly experienced hernia surgeons. Diagnostic laparoscopy can help to select the best possible procedure for the individual patient.
Compliance with ethical standards
Conflict of interest
Ferdinand Köckerling - Grants to fund the Herniamed Registry from Johson & Johnson, Norderstedt, Karl Storz, Tuttlingen, pfm medical, Cologne, Dahlhausen, Cologne, B. Braun, Tuttlingen, Menke Med, Munich, Bard, Karlsruhe. C. Krüger, I. Gagarkin, A. Kuthe, D. Adolf, B. Stechemesser, H. Niebuhr, D. Jacob, H. Riediger have no conflicts of interest to disclose.
Ethical approval
As only cases of routine hernia surgery are documented in the Herniamed Registry, an ethical approval was not neccessary.
Human and animal rights
This article does not contain any study with animals performed by any of the authors.
Informed consent
All patients with routine hernia surgery documented in the Herniamed Registry have signed an informed consent declaration agreeing to participate.
Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Mit der Zeitschrift Die Chirurgie erhalten Sie zusätzlich Online-Zugriff auf weitere 43 chirurgische Fachzeitschriften, CME-Fortbildungen, Webinare, Vorbereitungskursen zur Facharztprüfung und die digitale Enzyklopädie e.Medpedia.
Bis 30. April 2024 bestellen und im ersten Jahr nur 199 € zahlen!
Das Karpaltunnelsyndrom ist die häufigste Kompressionsneuropathie peripherer Nerven. Obwohl die Anamnese mit dem nächtlichen Einschlafen der Hand (Brachialgia parästhetica nocturna) sehr typisch ist, ist eine klinisch-neurologische Untersuchung und Elektroneurografie in manchen Fällen auch eine Neurosonografie erforderlich. Im Anfangsstadium sind konservative Maßnahmen (Handgelenksschiene, Ergotherapie) empfehlenswert. Bei nicht Ansprechen der konservativen Therapie oder Auftreten von neurologischen Ausfällen ist eine Dekompression des N. medianus am Karpaltunnel indiziert.
Das Webinar beschäftigt sich mit Fragen und Antworten zu Diagnostik und Klassifikation sowie Möglichkeiten des Ausschlusses von Zusatzverletzungen. Die Referenten erläutern, welche Frakturen konservativ behandelt werden können und wie. Das Webinar beantwortet die Frage nach aktuellen operativen Therapiekonzepten: Welcher Zugang, welches Osteosynthesematerial? Auf was muss bei der Nachbehandlung der distalen Radiusfraktur geachtet werden?
Inhalte des Webinars zur S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“ sind die Darstellung des Projektes und des Erstellungswegs zur S1-Leitlinie, die Erläuterung der klinischen Relevanz der Klassifikation EAES 2015, die wissenschaftliche Begründung der wichtigsten Empfehlungen und die Darstellung stadiengerechter Therapieoptionen.