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Table of Contents
ORIGINAL ARTICLES
Year : 2021  |  Volume : 4  |  Issue : 4  |  Page : 218-223

Twenty-year retrospective audit of inguinal herniorrhaphy at the Victoria Hospital in Prince Albert, Northern Saskatchewan


Department of General Surgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada

Date of Submission06-Oct-2021
Date of Decision20-Oct-2021
Date of Acceptance25-Oct-2021
Date of Web Publication30-Nov-2021

Correspondence Address:
Prof. Yagan Pillay
Department of General Surgery, University of Saskatchewan, Health Sciences Building, 107 Wiggins Rd B419, Saskatoon, Saskatchewan S7N 0W8.
Canada
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAWhs.ijawhs_70_21

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  Abstract 

AIM: To perform a retrospective clinical audit of the long-term effects of inguinal herniorrhaphy at the Victoria hospital in Prince Albert, Saskatchewan. Our hope is that this will form a template for a possible hernia registry in Saskatchewan, Canada. PATIENTS AND METHODS: A telephonic audit was carried out for all hernia surgeries performed in the year 2000 at the hospital. Demographics such as age and sex as well as the type of surgery and the mesh used were recorded. Chronic complications were also recorded. The surgical questionnaire was adapted from an established short quality-of-life questionnaire (Qol), the EuroQol questionnaire. We then performed a chart audit to identify basic information including the surgical approach and any intraoperative complications. RESULTS: Overall, 119 herniorrhaphies were performed at the Victoria hospital in 2000; 18% of patients (21/119) responded to the telephonic survey. There was a 24% complication rate.All cases of hernial recurrence arose from an original open herniorrhaphy technique.Overall, 22% of patients (27/119) had demised since the surgery; five patients remained incarcerated; and six had dementia and could not respond to the survey.The chronic inguinodynia in four patients was managed with analgesia and non-steroidal anti-inflammatories (NSAIDs). There was no need for chemical or surgical nerve ablation procedures. CONCLUSION: Long-term clinical audits in surgery remain sparse. There remains a paucity of data for studies that are more than a decade long. This 20-year audit of inguinal herniorrhaphy is the first of its kind in Saskatchewan, Canada. We propose its use to establish a hernia database that will record chronic complications as well as surgical outcomes.This will hopefully facilitate an improved surgical technique and a universally established method of defining and documenting complications such as chronic inguinodynia and hernia recurrence. Hernia databases help to remove patient subjectivity as well as observer bias and to provide an objective scientific overview of outcomes.

Keywords: Chronic herniorrhaphy complications, chronic inguinodynia, hernia audit, hernia registry


How to cite this article:
Vetter C, Pillay Y, Fast H. Twenty-year retrospective audit of inguinal herniorrhaphy at the Victoria Hospital in Prince Albert, Northern Saskatchewan. Int J Abdom Wall Hernia Surg 2021;4:218-23

How to cite this URL:
Vetter C, Pillay Y, Fast H. Twenty-year retrospective audit of inguinal herniorrhaphy at the Victoria Hospital in Prince Albert, Northern Saskatchewan. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2022 Jan 20];4:218-23. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/4/218/331642




  Introduction Top


Inguinal hernias are a common surgical problem, with more than 50,000[1] inguinal herniorrhaphies performed annually in Canada and approximately 20 million globally.[2]

There are a few published studies that look at long-term data on inguinal herniorrhaphy and their surgical complications. With the evolution of herniorrhaphy from open to laparoscopic, hernia recurrence has given way to inguinodynia as the most significant chronic postoperative complication. Chronic inguinodynia can be debilitating for patients and impacts their Qol. The inguinodynia incidence rate can approach 20% over 10 years.[3] Longitudinal patient follow-up assumes a greater significance, allowing for technique modification, thereby decreasing the incidence of chronic inguinodynia, which remains difficult to manage.

As surgical laparoscopy evolves, studies have shown decreased chronic pain with a laparoscopic technique whereas others demonstrate a similar incidence rate to a Lichtenstein repair. Eker et al.[4] showed similar recurrence rates with open and laparoscopic techniques but an increased risk of intraoperative complications with a laparoscopic technique.

Choosing Wisely Canada in association with the Canadian Association of General Surgeons (CAGS) advises that watchful waiting is an appropriate intervention in the management of inguinal hernias. It is, therefore, critical that surgeons carefully discuss the possible complications of hernia surgery as part of an informed consent for surgery. Studies have demonstrated that patients are satisfied with surgical herniorrhaphy and report a higher Qol postoperatively.[5],[6] There is a lack of data in the published literature on surgical outcomes beyond 5 years. This study aims at looking at 20-year outcomes post-inguinal herniorrhaphy. We believe that this is the first retrospective audit to look at 20-year herniorrhaphy outcomes in Saskatchewan Canada.


  Subjects and Methods Top


At a community hospital in Northern Saskatchewan, Canada, 119 inguinal herniorrhaphies were done in the year 2000 by three general surgeons. The surgeries were performed at the Victoria Hospital in Prince Albert, Saskatchewan, Canada. A short survey was developed to address the patient’s experience of their surgery, complications, and overall satisfaction. Ethics approval was obtained prior to the commencement of this audit.

The research was registered with and approved by the Prince Albert Parkland Ethics committee, and consent was obtained from the participants prior to their participation. Patient information data were securely stored in an Excel® spreadsheet under password protection. This study was performed in accordance with the principles stated in the Declaration of Helsinki.

We attempted to contact all 119 patients telephonically, and 21 completed the survey.

Overall, 18% of patients (21/119) responded to the survey [Table 1]. We were unable to include 42 patients [Table 2]. Prince Albert Parkland health region has a large migrant population. Another major issue is the advent of the electronic medical records (EMR) in our health region, which only began in 2012. Health records prior to this were all stored in hard copy, and there was great difficulty in obtaining the patient`s physical records. This is often an issue in longitudinal studies of this nature and is higher than historically published rates.[3]
Table 1: Patient distribution

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Table 2: Patients not included

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The surgical questionnaire was adapted from an established short Qol, the EuroQol questionnaire [Table 3].
Table 3: EuroQol questionnaire

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For patients who completed the survey we obtained their operative record to establish the technique used and identify any intraoperative complications.


  Results Top


Overall, 21 patients were contacted and completed a survey over the phone. Sixty seven percent of patients had their initial surgery between 40 and 65 years of age [Figure 1]. One (4.76%) was female and the remainder identified as male; 9.2% of the total patients were female [Figure 2]. Five patients (24%) reported complications [Figure 3]. One patient had a sensory anesthesia over his groin, and four had chronic inguinodynia. Of the 21 patients who responded to the survey, 100% were satisfied and 62% very satisfied with their surgical outcomes; 53% of the herniorrhaphies were performed for inguinodynia; 14% for difficulty working; and 14% for incarceration [Figure 4]. Two patients presented with tissue strangulation as a surgical .
Figure 1: Age distribution of the total number of patients who had surgery

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Figure 2: Sex distribution as a percentage of the total number of patients who had surgery

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Figure 3: Surgical complications of the 21 patients who answered the telephonic survey

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Figure 4: Indications for surgery in those patients answering the survey

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Four patients reported symptoms as slightly bothersome and one patient as moderately bothersome. This is higher than the published complication rates.[3] These findings are inconclusive, as preoperative pain scores were not recorded. None of the patients had debilitating pain that affected their daily activities of living. All five patients reported being satisfied with their surgical outcomes despite their postoperative complications.

The five hernial recurrences were over 6 years after their initial surgery, indicating low causality to surgical technique. All five patients opted for a second repair, and there were no recorded second hernial occurrences. The recurrences occurred in patients who had an initial open herniorrhaphy. 69% of herniorrhaphies were performed under a general anesthetic [Figure 5]. The surgical duration for the majority of surgeries was less than 60 min [Figure 6].
Figure 5: Type of anesthetic in all 119 patients

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Figure 6: Duration of surgery for all 119 patients

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  Discussion Top


Long-term follow-up of inguinal herniorrhaphies in the English literature remains sparse to date. Common reasons include poor patient compliance, population migration especially in a transient population such as ours in Northern Saskatchewan, and the loss of medical records as these surgical procedures predated the advent of EMR in our health region. We would like to put forward this audit as part of a regional hernia registry in our health region, which will benefit both patients and surgeons alike. There is ample evidence in the literature to support a reduction in surgical complications with the use of a hernia registry.[7] This helps to standardize the surgical management of groin hernias as well as document the quantifiable incidence of chronic inguinodynia in a reproducible and universally defined way.[8]

A unique factor of this study was the number of incarcerated patients (5/119) [Table 2]. There are three correctional facilities in Prince Albert, Saskatchewan and we were unable to reach out to any of the patients who remain incarcerated. The data match published demographic profiles with regards to age and sex distribution given the expected lifetime hernia occurrence of 27%-43% in men and only 3%-6% in women.[2] Another regional difference in northern Saskatchewan is that it is mainly an agricultural and mining region with a large percentage of male laborers. The heavy manual labor may have skewed the data toward the extremely high male surgical population, which is greater than in the published literature.[2]

A 100% satisfaction rate with surgical repair suggests that although watchful waiting is a reasonable approach, patients were happy with their surgical outcomes. If a patient is experiencing clinical symptoms, surgical herniorrhaphy remains a feasible option at our hospital.

It should be noted that the herniorrhaphies performed in the year 2000 predated the scientific literature on watchful waiting in groin hernia management.[1],[2] Overall, 19% of patients (4/21) were asymptomatic and may not have had surgery based on the current data of watchful waiting. When extrapolated to the total number of patients (23/119) having surgery in 2000, the financial savings alone would be significant to a rural health region such as ours as one in five patients would no longer require surgery. It should be noted, however, that in the watchful waiting studies 50% of patients became symptomatic over a 10-year period and required a surgical herniorrhaphy.

Shortcomings of this audit include the small patient cohort and the absence of pre-operative pain scores. The preoperative pain scores give a quantifiable effect of the patient’s inguinodynia and relies less on patient subjectivity. This helps to exclude other reasons for pain and helps to clearly elucidate chronic inguinodynia.[9],[10]

This allows for the early management of a complex issue, as chronic inguinodynia remains difficult to manage. None of the patients with chronic inguinodynia required any chemical or surgical nerve ablation procedures to manage their pain.[11] All responded to analgesia and NSAIDs, with little or no impact on their daily activities of living. The type of surgical herniorrhaphy was significant in that 56% of the repairs [Figure 7] were laparoscopic transabdominal preperitoneal (TAPP) repairs.[12],[13] At the beginning of this millennium, laparoscopic groin herniorrhaphy was in its infancy and the fact that the majority of surgical repairs were laparoscopic is a great testament to the surgical skill set of the surgeons involved in this rural community at the time.
Figure 7: Type of surgical herniorrhaphy in all 119 patients

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Overall, 91% of herniorrhaphies involved the insertion of a prosthetic mesh [Figure 8]. The mesh type was not recorded in 62% of repairs. SurgiPro mesh was commonly used in the remainder of the herniorrhaphies [Figure 9]. The sensory deficit was in a patient whose surgical indication was incarceration and therefore a repair of greater surgical complexity [Figure 10]. Fifty one percent of groin hernias were on the right and 6% were bilateral [Figure 11]. This study was significantly limited by the number of active participants, which remains a common challenge with long-term follow-up in surgical management. Many of the phone numbers on the charts were out of service, and some patient charts did not have a contact number. Twenty seven patients (23%) were deceased [Table 2] and those with advanced dementia (6/119) and were unable to complete the survey. What remains significant, however, is patient satisfaction with surgical herniorrhaphy, both open and laparoscopic even after two decades. This is a testament to the surgeons present at the time and their surgical skill set.
Figure 8: Prosthetic vs tissue repair in all 119 patients

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Figure 9: Types of mesh in open and laparoscopic herniorrhaphy in all 119 patients

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Figure 10: Factors increasing surgical complexity in 119 patients

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Figure 11: Hernial site lateralization for all 119 patients

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  Conclusion Top


We present our 20-year surgical audit of inguinal herniorrhaphy at the Victoria hospital in Northern Saskatchewan and envisage this as part of a hernia registry for Saskatchewan, Canada.[14] It is hoped that this documentation of our 20-year hernia surgery experience will contribute to a clearer understanding of inguinal herniorrhaphy and reduce our surgical complication rates to current acceptable standards.

Acknowledgments

A vote of great appreciation for Ms. Carmen Krawec and Ms. Charity Blechinger from the Victoria hospital, Prince Albert, Saskatchewan for the help they provided in obtaining the relevant patient data and OR reports.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Barkun J, Neville A, Fitzgerald GWN, Litwin D, Evidence-Based Reviews in Surgery Group; Canadian Association of General Surgeons; American College of Surgeons. Canadian association of general surgeons and American college of surgeons. Evidence based reviews in surgery. 26. Watchful waiting versus repair of inguinal hernia in minimally symptomatic men. Can J Surg 2008;51:406-9.  Back to cited text no. 1
    
2.
HerniaSurge Group. International guidelines for groin hernia management. Hernia2018;22:1-165.  Back to cited text no. 2
    
3.
Sevonius D, Montgomery A, Smedberg S, Sandblom G, Zwaans W, Perquin C, et al. Inguinal hernia: Post OP chronic pain. Hernia 2015;19:S99-103.  Back to cited text no. 3
    
4.
Eker H, Langeveld H, Klitsie P, Riet M, Stassen L, Weidema W, et al. Randomized clinical trial of total extraperitoneal inguinal hernioplasty vs Lichtenstein repair. Arch Surg 2012;147:256-60.  Back to cited text no. 4
    
5.
Hair A, Duffy K, McLean J, Taylor S, Smith H, Walker A, et al. Groin hernia repair in Scotland. Br J Surg 2002;87:1722-6.  Back to cited text no. 5
    
6.
Gitelis ME, Patel L, Deasis F, Joehl R, Lapin B, Linn J, et al. Laparoscopic totally extraperitoneal groin hernia repair and quality of life at 2-year follow-up. J Am Coll Surg 2016;223:153-61.  Back to cited text no. 6
    
7.
Nilsson H, Holmberg H, Nordin P. Groin hernia repair in women - A nationwide register study. Am J Surg 2018;216:274-9.  Back to cited text no. 7
    
8.
Staerkle RF, Vuille-Dit-Bille RN, Fink L, Soll C, Villiger P. Chronic pain and quality of life after inguinal hernia repair using the COMI-hernia score. Langenbecks Arch Surg 2017;402:935-47.  Back to cited text no. 8
    
9.
Mitura K, Śmietański M, Kozieł S, Garnysz K, Michałek I. Factors influencing inguinal hernia symptoms and preoperative evaluation of symptoms by patients: Results of a prospective study including 1647 patients. Hernia 2018;22:585-91.  Back to cited text no. 9
    
10.
Mier N, Helm M, Kastenmeier AS, Gould JC, Goldblatt MI. Preoperative pain in patient with an inguinal hernia predicts long-term quality of life. Surgery 2018;163:578-81.  Back to cited text no. 10
    
11.
Andresen K, Rosenberg J. Management of chronic pain after hernia repair. J Pain Res 2018;11:675-81.  Back to cited text no. 11
    
12.
Peitsch WKJ. Modified TAPP is the standard procedure for complex inguinal and femoral hernias: Late results and patient satisfaction. Eur Surg 2020;52:74-87.  Back to cited text no. 12
    
13.
Scheuermann U, Niebisch S, Lyros O, Jansen-Winkeln B, Gockel I. Transabdominal preperitoneal (TAPP) versus lichtenstein operation for primary inguinal hernia repair - A systematic review and meta-analysis of randomized controlled trials. BMC Surg 2017;17:55.  Back to cited text no. 13
    
14.
Kyle-Leinhase I, Köckerling F, Jørgensen LN, Montgomery A, Gillion JF, Rodriguez JAP, et al. Comparison of hernia registries: The CORE project. Hernia 2018;22:561-75.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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