Outcomes of primary and recurrent inguinal hernia repair with prosthetic mesh in a single region over 15 years

Abstract

Background

Sutured inguinal hernia repairs are now uncommon, with evidence suggesting that those augmented with mesh are associated with a lower recurrence rate. We aimed to explore the suggestion that the established use of mesh does indeed lower the rate of operation for recurrence in a single National Health Service region.

Method

We collected retrospective Office of Population Censuses and Surveys coded data across one region of all primary and recurrent inguinal hernia repairs over 15 years (2004–2019). Electronic records of recurrent repairs were scrutinised to identify year and type of previous primary repair.

Results

In total, 7,234 repairs were performed during this time, of which 289 (4%) were for symptomatic recurrence. Operations for primary repair increased year on year (111 in 2004 to 402 in 2019). Frequency of operation for recurrent herniation declined with increasing use of mesh (8.8% in 2004 to 3.5% in 2019). The majority of repairs (73%) for recurrence were by an open approach. As opposed to an open mesh repair, a primary laparoscopic repair was associated with an earlier recurrence.

Conclusions

Inguinal hernia repairs are increasing in frequency but operations for later symptomatic recurrence following an open primary prosthetic mesh repair are not.

Introduction

Inguinal hernia repair remains one of the most common procedures performed by general surgeons, with an estimated 70,000 repairs performed in the UK each year.¹ Traditional sutured repairs are now performed less commonly, with evidence suggesting that repairs augmented with mesh are associated with lower recurrence rates, shorter operating times and possibly fewer complications.²

Publications from the Danish Hernia Database describe recurrence rates of 8% for open non-mesh repairs as compared with 3% for Lichtenstein mesh repairs at 8 years.^3–5 However, these studies could be considered flawed as a Shouldice repair (the ‘gold standard’ of sutured repairs) was used in only 13% of cases. Furthermore, the concept of ‘reoperation’ was used as opposed to recurrence rates. Nevertheless, they do offer insights regarding outcomes in populations treated by general surgeons.

While the debate as to the best approach to inguinal hernia repair is clearly important, our patients wish for a speedy recovery in the short term, and a low recurrence rate in the longer term. As the use of mesh seems now widely established, we aimed to determine if its use does indeed lead to a lower operation rate for recurrence in one UK NHS region over a period of 15 years.

Methods

The Aneurin Bevan University Health Board (ABUHB) is responsible for the health and wellbeing of the residents of Blaenau Gwent, Caerphilly, Torfaen, Newport and Monmouthshire in South East Wales, UK. It was launched in 2009 following the merger of two large NHS providers. It provides healthcare services across a number of sites to a population of 639,000. Electronic operative records were introduced as part of a new theatre information system, ORMIS (Operating Room Management Information System) in 2004.

We collected retrospectively Office of Population Censuses and Surveys coded data for ABUHB patients for all primary (T2000 et al) and recurrent inguinal (T2100 et al) hernia repairs over 15 years (2004–2019). The electronic ORMIS records of all the recurrent repairs were scrutinised personally by the authors to identify year and type (mesh or otherwise) of previous inguinal hernia repair.

Results

A total of 6,945 primary inguinal hernia repairs were performed in ABUHB over the 15 years of the study. Also identified during this time were 289 repairs for symptomatic recurrence, giving an overall rate of operation for recurrence of 4%. Numbers of primary inguinal hernia repairs increased yearly over this time period, as did repairs for recurrent herniation. The rate of operation for recurrence declined throughout the time period, as demonstrated in Table 1 and Figure 1.

Table 1 .

Breakdown of primary repairs versus repairs for recurrence

Year	Number of primary repairs	Repairs for recurrence	Rate of repairs for recurrence
2004	111	9	8.1%
2005	216	15	6.9%
2006	504	10	2.0%
2007	344	15	4.4%
2008	474	10	2.1%
2009	512	12	2.3%
2010	423	18	4.3%
2011	451	26	5.8%
2012	500	15	3.0%
2013	511	17	3.3%
2014	475	13	2.7%
2015	615	25	4.1%
2016	559	32	5.7%
2017	502	29	5.8%
2018	402	31	7.7%
2019	346	12	3.5%

Figure 1 .

Number of primary inguinal hernia repairs and recurrent inguinal hernia repairs from 2004 to 2019

Of the 289 repairs for recurrence, there were initially 149 sutured and 140 mesh repairs. The number of recurrences being repaired, following an earlier sutured repair, decreased year on year, and the number of repairs for recurrence following a primary mesh repair increased over time (Figure 2).

Figure 2 .

Number of operations for recurrence split by percentage of primary suture vs mesh repairs per year

Of the 140 mesh repairs that had operations for recurrence, the majority (n = 102; 72%) underwent a further open repair. The remaining 38 underwent a laparoscopic repair.

The records of these 140 patients were scrutinised further to assess the interval between the primary repair and subsequent reoperation for symptomatic recurrence. Following a primary open repair, the mean time to reoperation was 8 years, as compared with 2 years if the primary operation had been performed laparoscopically.

Discussion

There is little doubt that patients wish for a speedy recovery from their inguinal hernia repair. This can be achieved with either an open or laparoscopic approach, both of which are augmented with prosthetic mesh. While traditional sutured repairs may be used, these are not performed on a regular basis in the UK.⁶ In the longer term, our patients wish for a robust outcome in terms of a low recurrence rate, which is afforded by those repairs augmented with mesh. However, such repairs can affect the patient’s quality of life due to chronic symptoms. This is clearly undesirable and we are duty bound to counsel patients appropriately as to the benefits and risks of any type of repair.

In this population-based study, although there was some annual variation, the number of primary inguinal hernia repairs increased over this 15-year period. However, as illustrated in Figure 1, it appears that the number of hernias repaired decreased, or at least plateaued, during the last 5 years of this time. The reason for this is uncertain, but we suspect it to be due to the application of a ‘watch and wait’ policy to minimally symptomatic hernias that was debated frequently during that period.⁷ Nevertheless, over these 15 years, the rate of operation for symptomatic recurrence fell, indicative of a causal link between a primary mesh repair and a reduction in the rate of operation for a later recurrence.

Overall, the average rate of reoperation for recurrence was 4%. This is somewhat higher than those from the Danish Hernia Database, where reoperation rates at 30 months were 2.2% and 2.6% for anterior mesh repair and laparoscopic repairs, respectively.³ It is important to note, however, that we placed no timeframe on reoperation, nor differentiated between reoperation following a primary or recurrent repair. Furthermore, the concept of reoperation, as previously mentioned, differs from recurrence rate as it does not include every patient with recurrence but rather reflects those with recurrence who are deemed suitable for operation, either through symptoms or perceived later increased risk of complications. It is worth remembering that reoperation itself carries a risk of further recurrence^3–5 and an increased risk of chronic groin pain (CGP).⁸

The results of this type of database scrutiny have limitations that are worth mentioning. While we were able to eliminate incorrectly coded procedures, primary repairs coded as non-hernia repairs would have been missed. Likewise, we may have missed primary or recurrent inguinal hernia repairs that were initially and incorrectly coded as another intervention. This is clearly an obstacle, but is also present when analysing registry databases where asymptomatic recurrence is not recorded or managed surgically.

There is little doubt that the use of prosthetic mesh in primary inguinal hernia repair is well established. However, there remains genuine concern among surgeons and patients regarding the issue and frequency of ‘mesh-induced’ CGP.⁹ Fortunately a recent Cochrane review of 25 studies has demonstrated no difference in rates of CGP between sutured repairs and mesh augmented open or laparoscopic repairs.² In addition, there is good evidence that rates of CGP increase with each subsequent operation for recurrence,⁶ suggesting that we can influence the frequency of CGP by employing a technique that reduces later recurrence.

How can we further decrease recurrence rates at extended follow up? Clearly it is time to consider the appointment of surgeons who concentrate on the repair of abdominal wall hernias.¹⁰ It is timely to recall the words of Sir Cecil Wakeley, former President of the Royal College of Surgeons of England, who said ‘a surgeon can do more for the community by operating on hernia cases than by operating on cases of malignancy’. This long forgotten proposal from specialist groin hernia centres¹¹ has now come to be supported by both surgeon and hospital volume data.^12,13 Unless such changes are considered by healthcare providers, we suspect future studies will demonstrate similar results and incur unnecessary and increasing healthcare costs.