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387
XI
Standard Procedures for Standard Patients?
Primary Lateral Inguinal Hernia
As seen in
⊡
Fig. 40.3
, re-operation rates are signifi-
cantly higher after conventional sutured repairs and
laparoscopic repairs than other mesh techniques. The
unexpectedly increased re-operation rate after laparo-
scopic repairs may be explained by insufficient surgical
technique, especially in bilateral hernias [3].
Recurrent Medial Inguinal Hernia
Re-operation rates after recurrent medial ingui-
nal hernia repairs are again significantly higher
with sutured repairs, but lower with a laparo-
scopic repair compared with other mesh techniques
(
⊡
Fig. 40.4).
Recurrent Lateral Inguinal Hernia
As shown in
⊡
Fig. 40.5, again sutured repairs have the
highest re-operation rates with no differences between
the three other mesh techniques.
Female Hernia
We have previously reported [4] that re-operation rates
are unexpectedly higher in female inguinal hernias than
in males, as also shown from data from the Swedish
Hernia Database [5].
⊡
Figure 40.6
shows again high
re-operation rates with conventional sutured repairs, but
unexpectedly high recurrence rates with a Lichtenstein
mesh repair. The uses of other meshes (plug) and lapa-
roscopic repairs have the lowest re-operation rates.
Femoral Hernia
In Denmark it has been recommended to use either
laparoscopy or a Lichtenstein-type mesh repair (ad
modum McVay or plug) for femoral hernias. As seen
in
⊡
Fig. 40.7, the lowest re-operation rates occurred
after a laparoscopic or mesh McVay repair.
Re-Operation Rates in High- vs. Low-Volume
Centres
In an ongoing analysis (unpublished), a linear rela-
tionship has been found between the risk of a re-op-
eration and the number of repairs performed in a
given department. Thus, in low-volume departments
(< 65 operations/year) an about 40% higher re-opera-
tion rate was found compared to high-volume depart-
ments (> 130 operation/year) analysed for Lichtenstein
repairs only. Although these data could not be analyzed
for surgeon volume, other data suggest again an about
40% lower re-operation rate after Lichtenstein repair
performed in the few Danish private clinics with pre-
dominantly high-volume surgeons compared to opera-
tions performed in hospitals with assumed lower-vol-
ume surgeons (unpublished).
months
0
5
15
re-operation rate [%]
0
10
20
12 24 36 48 60 72
84
CONV
LAP 1724
LICH 3514
OTHM 1319
766
⊡
Fig. 40.4. Elective recurrent medial in-
guinal hernia
388 What Can we Do to Improve Our Results?
40
Conclusions
When discussing standard operations for standard
patients in general practice, the conclusions based on
nationwide data must depend on the reality that most
operations are performed by relatively low-volume sur-
geons in median-volume departments. The data clearly
suggest that the Lichtenstein mesh repair has the lowest
re-operation rates (or comparable with the laparoscopic
technique) in both medial and lateral primary inguinal
hernias compared to other techniques, except that in
Denmark there is an apparent insufficient technique
when performing a laparoscopic repair of a bilateral/
lateral hernia [3]. For recurrent hernias the data support
the use of a Lichtenstein repair or a laparoscopic repair,
probably to some extent depending on type of previous
repair, where final results will be available from a large
(about 500 patients), just finished randomized trial. The
data in female inguinal repairs show an unexpectedly
higher re-operation rate, probably due to overlooked
femoral hernias [4, 5] and support the use of a laparo-
scopic technique or at least exploration for a concomi-
tant femoral hernia at the primary open operation. In
femoral hernias a laparoscopic repair or a mesh repair
a.m. McVay or plug is recommendable. Based upon the
nationwide data, sutured repairs should be abandoned,
months
0
2
4
re-operation rate [%]
0
6
12 24 36 48 60 72 84
CONV 1266
LAP
LICH 2787
OTHM 598
191
months
0
4
8
10
re-operation rate [%]
0
2
6
12
12 24 36 48 60 72 84
CONV
LAP
LICH 2262
OTHM 817
598
934
⊡
Fig. 40.5. Elective recurrent lateral in-
guinal hernia
⊡
Fig. 40.6. Elective female inguinal her-
nia
389
XI
Standard Procedures for Standard Patients?
despite positive results in the literature from specialized
surgeons/clinics. Most importantly, the data suggest that
further improvements probably need further specializa-
tion, i.e. high-volume surgeons and high-volume depart-
ments with close monitoring of the results. Also there
is a need for future studies on other specific subgroups,
i.e. patients with increased body weight, as well as more
data are required on femoral hernias where recurrence
rates are higher than after inguinal hernia repairs. In this
context, collaborative efforts are important since femoral
hernias are relatively rare and therefore cannot be studied
sufficiently in single or a few centres. Finally, it must be
remembered that after the introduction of Lichtenstein
mesh repair and laparoscopic repairs, re-operation rates
are generally low (2–3%), except for a twofold higher risk
after surgery for a recurrence. This is in contrast to other
sequelae such as chronic pain problems [6, 7], which
must be considered of increasing importance, since they
occur at the same or higher rate, but where treatment
results so far are undocumented [8]. Therefore, despite
being a relatively small, although common operation,
groin hernia repair continues to demand further im-
provements in the general surgical profession.
References
1. EU Hernia Trial Lists Collaboration. Repair of groin hernia
with synthetic mesh: Meta-analysis of randomized controlled
trials. Ann Surg 2002; 235: 322–332
2. Bay-Nielsen M, Kehlet H, Strand L, et al. Quality assessment
of 26,304 herniorrhaphies in Denmark: A prospective na-
tionwide study. Lancet 2001; 358: 1124–1128
3. Wara P, Bay-Nielsen M, Juul P, Bendix J, Kehlet H. Prospective
nationwide analysis of laparoscopic vs Lichtenstein repair of
inguinal hernia. Br J Surg 2005; 92: 1277–1281
4. Bay-Nielsen M, Kehlet H. Inguinal herniorrhaphy in women.
Hernia 2006; 10: 30–33
5. Koch A, Edwards A, Haapaniemi S, Nordin P, Kald A. Prospec-
tive evaluation of 6895 groin hernia repairs in women. Br J
Surg 2005; 92: 1553–1558
6. Aasvang E, Kehlet H. Chronic postoperative pain: the case
of inguinal herniorrhaphy. Br J Anaesth 2005; 95: 69–76
7. Aasvang EK, Møhl B, Bay-Nielsen M, Kehlet H. Pain-related
sexual dysfunction after groin hernia repair. Pain 2006; 122:
258–263
8. Aasvang E, Kehlet H. Surgical management of chronic pain
after inguinal hernia repair. Br J Surg 2005; 92: 795–801
9. Wilkiemeyer M, Pappas TN, Giobbie-Hurder A, Itani KMF,
Jonasson O, Neumayer LA. Does resident post-graduate year
influence the outcomes of inguinal hernia repair? Ann Surg
2005; 241: 879–884
Discussion
Amid:
One of the standard steps of Lichtenstein repair
is looking for femoral hernia, no matter if the patient is
male or female. No relative to failure of Lichtenstein for
repairing of femoral hernia, most surgeons that I have
seen they used the standard-shaped mesh for femoral
hernia as well as for inguinal hernia, but that does not
work because if you suture the lower edge of the mesh to
the Cooper ligament then you are not going to be able to
overlap the mesh to the pubic tubercle. Because of that,
the shape of the mesh has been modified and the modified
shape of the mesh has been demonstrated in my slices and
months
0
4
8
10
re-operation rate [%]
0
2
6
12
12 24 36 48 60 72 84
CONV 498
LAP 155
“LICH” 255
OTHM 944
⊡
Fig. 40.7. Elective femoral hernia
390 What Can we Do to Improve Our Results?
40
my article. That mesh has a small dropdown triangular
extra mesh. The normal Lichtenstein mesh is placed over
the pubis tubercle and that dropdown which is triangu-
lar is sutured to the Cooper ligament. So I am sure that
the reason that they failed is the fact that they used the
standard-shaped mesh, not the modified one.
Kehlet: I agree.
Sarr: But how do you fix the mesh? You have raised the
question. Should there be an insert with the mesh that
has a picture drawn for a femoral hernia versus an in-
guinal hernia?
Amid: Well the insertion is very easy.
Sarr:
No, I mean should there be a picture in the package
of the mesh for a femoral hernia?
Amid:
There is no commercially available mesh for femo-
ral hernia repair. It has to be tailored by the surgeon in
the operating room. It is very easy. It takes 30 s to make
that little triangular dropdown.
Kehlet: Good advice.
Miserez:
We noticed that laparoscopy was mainly bad
in primary bilateral hernias. How do you explain this?
Are we talking about different surgeons even on a na-
tionwide level?
Kehlet:
Yes, different surgeons, but the volume of each
department is very, very low. Thirty operations a year
or so. We could not make any correlation between the
number of operations performed and the re-operation
rate in laparoscopic repair because the numbers were so
small. Again, remember we have just a few laparoscopic
operations in Denmark, just 5–6%.
Sarr:
But even in your volume data it was a 1% difference,
not a 15% difference.
Kehlet:
Yes, 1% is very small. But if we want to get the
recurrence rate down, even this 1% is important.
Deysine:
When the general surgeons were trained about
30 years ago to perform orthopedic procedures, there were
all kinds of operations with terrible results. Since they have
become a speciality their results are now magnificent.
Kehlet:
I totally agree. In Denmark we are five and a half
million inhabitants and we are doing this operation in a
about 70 departments and in 10 to 12 private clinics and
that should be in my opinion reduced to at least half.
Young: There is actually a mesh designed with excellent
characteristics for repair of femoral hernia, the PHS mesh.
This mesh has an underplayed portion that covers the
femoral area and it also has the overlay which essentially
covers the myopectineal orifice.
Kehlet: I agree. But as you see, we are trying to decrease
the number of techniques in order to increase experience.
So we should not like to introduce that without really
hard data showing that it is better.
Young: We are working on it.
Schumpelick:
Despite your trying to standardize your
technique you reduced your nationwide recurrence rate
from 18 to 14%. So you still have 14%. Everywhere the
same percentage, in Denmark, in Germany. How do you
explain that?
Kehlet:
Well, we are optimistic; we think that these are
the old failures. We have to analyze it again.
Schumpelick: Could it be a biological reason?
Kehlet: Could be. We still have a lot of open repair and
they have to finish.
Sarr: I think this is the question I hope to answer in the
next 15 min.
XI
41
Tailored Approach for Non-Standard Patients
C. P, S. S, K. J
Introduction
Many different therapeutic principles compete in the treat-
ment of inguinal hernias. Due to their training, many sur-
geons prefer just one kind of inguinal hernia repair. Many
institutions provide one single therapeutic principle in high
volumes. Examples are the Shouldice Hospital in Toronto,
which up to now has performed more than 270,000 suture
repairs, while specialized laparoscopic clinics do more than
1000 laparoscopic repairs every year. This principle of doing
one single operation at a high level of routine and standard-
ization for any patient may lead to a good quality of the
used procedure, but is not accepted everywhere. Due to
great variations in patients concerning body constitution,
size of the hernia or collagen metabolism, the idea of one
operation suitable for all patients has to be discussed.
It is accepted that the use of a mesh hernioplasty will
reduce recurrence rates, at least within the first 5–10 years
[3, 8]. On the other hand, there are certain mesh-related
complications reported in the literature. These include
late mesh infections with cutaneous fistulization and in-
flammatory changes of the spermatic cord. Therefore, one
standardized therapeutic procedure for all patients seems
to be no longer the best way. An individual approach in-
cluding patient-depending factors, which may lead to a
mesh implantation only in selected cases, seems to fit
better. The remaining question is: which patient is at risk
of developing a recurrency, and therefore benefits from
mesh implantation? This question has to be answered, if
therapy of the inguinal hernia is to be improved.
Identification of the Risk Population
The decision about the therapeutic procedure for any
hernia patient may be influenced by:
▬
Analysis of the collagen subtypes produced by the
individual.
▬ Estimation of the risk factors in the patient’s his-
tory.
▬ Suggestion by the surgeon.
Collagen Test
A 5-mm skin specimen harvested in local anaesthesia
at the lumbar region is analyzed under Sirius red and
fast green stains. With colour spectroscopy, distinction
between collagen type I and type III is possible. Patients
with recurrent hernias present a larger amount of type-
III collagen, while the collagen I/III ratio is larger in
controls. We regarded any ratio > 10 as normal and any
ratio < 5 as pathological.
HEAD Score
The HEAD score (Hernia of the Adult Disease) was
developed to enable an objective and scientifically based
estimation of the individual risk to develop an inguinal
hernia recurrency. The score is based on the proven
risk parameters:
392 What Can we Do to Improve Our Results?
41
▬ Gender [9)
▬ Age [19)
▬ Presence of recurrency [13)
▬ Size of the hernial gap [19)
▬ Existence of several hernias [16)
▬ Smoking [22)
▬ Family-related disposition [12)
▬ Collagen disorders [1, 23)
We developed the score system according to the clinical
relevance of the single parameters (
⊡
Table 41.1).
In a retrospective evaluation we used the HEAD
score in 293 Shouldice repairs in 1992. The patients
were followed up for 10 years. We observed a recurrence
rate of 7.7% in the primary hernias. The patients with a
HEAD score of 15 or less presented a recurrence rate of
only 2.7%. Therefore, we regarded a score of more than
15 points as increased risk for recurrency.
Suggestion by the Surgeon
The decision about the surgical procedure is made dur-
ing the preoperative discussion between surgeon and pa-
tient. The following parameters may have an influence:
▬
Expectation of the patient. Most patients are in-
formed by papers, internet or friends about differ-
ent methods and have certain ideas about the best
proceeding.
▬
Provision by the surgeon. Due to their training or
conviction, many surgeons provide just one or two
surgical techniques.
▬ Results in world literature.
Guided by these points, surgeon and patient are to
chose the best procedure out of many current possi-
bilities (
⊡
Table 41. 2).
Prospective Study
Materials and Methods
The HEAD score was used in a county hospital within
a prospective study. During 17 months we performed
405 cases (
⊡
Table 41. 3
). Collagen testing was carried
out in 20 cases. Statistics were neglected due to the small
sample sizes.
We asked for all relevant risk factors using a stan-
dardized question form and calculated the individual
HEAD score. We used the score as an argument in the
pre-operative discussion with the patient about the sur-
⊡
Table 41.1. HEAD-Score
Gender Male
Female
3
1
Age > 50 years
< 50 years
3
1
Hernia Primary hernia
First recurrency
Multiple recurrency
2
4
8
Size > 3 cm
< 3 cm
3
1
Localization Several locations
One location
4
1
Smoking Yes
No
2
1
Family Occurance of hernias in
> 2 first-grade relatives
Occurance of hernias in
< 2 first-grade relatives
3
1
Collagen
disorders
Proved alteration in collagen
No evidence of alterations in
collagen
5
1
Total
⊡
Table 41.2. Current operative procedures (selection)
Suture repair Marcy/Zimmerman
Shouldice
Bassini
Lotheisen/McVay
Open mesh repair Lichtenstein
Plug repair Rutkow
Gilbert
Preperitoneal repair Ugahary
TIPP/Rives
Moran
Nyhus
Want z
Stoppa’s GPRVS
Endoscopic repair TAPP
TEP
393
XI
Tailored Approach for Non-Standard Patients
gical strategy. Mesh repair was suggested in scores of
more than 15: In bilateral and recurrent cases following
anterior repair TAPP (10), in all other cases open mesh
repair (2) was suggested. If the score was below 15 we
suggested a Shouldice repair (20). The final decision
about the surgical procedure was made by the patient.
All patients were invited for follow-up after 2 weeks
and 12 months. We asked about complaints, return to
physical activity, and operative re-intervention. Ultra-
sound of the inguinal region was added to the physical
examination.
Statistical analysis was done with the Mann-Whitney-
test. Statistical significance was assumed, if p < 0.05. All
data are presented as mean + standard deviation (SD).
Results
In patients with a primary inguinal hernia the col-
lagen I/III ratio was smaller than in recurrent cases
(
⊡
Fig. 41.1
). Of course, primary hernias were more
often treated by suture repair than recurrent hernias
(
⊡
F
ig. 41.2
); 61.5% of all cases were operated using a
mesh repair. The correlation between the HEAD score
and the therapeutic procedure is shown in
⊡
Fig. 41.3.
Showing a score of more than 16, only 8 patients un-
derwent Shouldice repair; 351 patients (86.7%) could
be followed up 14 days after the operation. These results
are shown in
⊡
Table 41. 4
. Seroma was detected in more
than every third patient by clinical examination and
ultrasound. Intervention, however, was the exception.
Seromas occurred more often after open mesh implan-
tation than after laparoscopic operation (p = 0.001) or
after suture repair (p = 0.03) (
⊡
Fig. 41.4
). We observed
more seromas after any mesh repair (48.5%) than after
the Shouldice operation (16.6%).
All other complications were distributed simi-
larly to the operations. Surgical revision was neces-
sary because of bleeding in one patient and due to
wound infection in two cases. Two more patients un-
derwent a second operation of an ilioinguinalis syn-
drome.
In the second follow-up after 12 months 301 patients
(74.3%) took part. In the whole group we detected eight
recurrences (2.6%). Concerning return to full physi-
cal activity we observed only minor advantage for the
Lichtenstein repair without difference of statistical sig-
nificance (Shouldice: 5.5 + 6.3 weeks, Lichtenstein: 3.9
+ 4.2 weeks, TAPP: 4.2 + 3.5 weeks).
⊡
Table 41.3. Patients
Recruitment 01.06.2003 to 30.11.2004
Operations n = 405
Male/female 358/47
Age (mean, range) 57.0 (10–97) years
Hospital stay
(mean + SD)
4.4 + 2.3 days
Follow-up after 14 days n = 351 (86.7%)
Follow-up after 12
months
n = 301 (74.3%)
0
100
140
40
120
160
80
60
20
primary hernia recurrent hernia
collagen I/III ratio
⊡
Fig. 41.1. Collagen I/III ratio in hernia
patients (mean)
394 What Can we Do to Improve Our Results?
41
primary hernia
0
20
40
10
30
70
percentage
60
50
recurrent hernia
suture repair
open mesh repair
laparoscopic mesh repair
points
0
10
25
30
number
9
5
20
35
45
15
40
10 11 12 13 14 15 16 17 18 19 20 21 22
suture repair
open mesh repair
laparoscopic
mesh repair
seroma
0
20
40
10
30
70
percentage
60
50
revision
suture repair
open mesh repair
laparoscopic mesh repair
punctureinfectionhematoma
⊡
Fig. 41.2. Operations for primary and
recurrent inguinal hernia (%)
⊡
Fig. 41.3. HEAD score and operation
used
⊡
Fig. 41.4. Complications and different
methods of operation (%)
395
XI
Tailored Approach for Non-Standard Patients
Discussion
The tailored approach for the repair of an inguinal her-
nia is popular, but needs an objective tool to support
the correct decision. Pre-operative tests on a molecular
biological basis may help in certain cases, but they are
not 100% reliable and standardized, and are still in their
experimental stadium. Therefore we depend on anam-
nestic factors. The HEAD score developed on this basis
was used in a county hospital starting in June 2003. We
found it useful for the pre-operative discussion with the
patient. Many of them, however, believe to be informed
by the internet or other doctors. Their decision was
rarely changed by our information. This led to several
operations beyond our therapeutic concept.
The results of our follow-ups support the theory of
early physical recovery after mesh repair. On the other
hand, we observed a strong foreign-body reaction after
Lichtenstein repair. Lacking histological evaluation we
found the highest rate of seroma formation.
The rate of recurrence was small (2.6% after 1 year),
especially in a non-specialized county hospital. Under
comparable conditions, other authors observed rates
between 2.3% (TAPP) [6] and 3.5% (Lichtenstein) [7].
We concluded that despite a narrow indication for mesh
repair, the recurrence rate did not increase.
The individualization of inguinal hernia therapy with
the help of the HEAD score did not increase complica-
tion rates. We believe that the risk for complications
associated to the mesh, which are still published as case
reports (colonic arrosion [5, 14], intestinal obstruction
(11, 18), bladder arrosion [4, 17]), will decrease with
a tailored approach. Especially young patients might
also be protected from possible urological side effects
of mesh implantation (obstructive azoospermia [21],
dysejaculation [15]).
References
1. Adye B, Luna G (1998) Incidence of abdominal wall hernia
in aortic surgery. Am J Surg 175: 400–402
2. Amid PK, Shulman AG, Lichtenstein IL (1994) Lichtenstein
herniotomy. Chirurg 65: 54–58
3. Bay-Nielsen M, Kehlet H, Strand L, Malmstrom J, Andersen
FH, Wara P, Juul P, Callesen T; Danish Hernia Database Col-
laboration (2001) Quality assessment of 26,304 herniorrha-
phies in Denmark: a prospective nationwide study. Lancet
358: 1124–1128
4. Bodenbach M, Bschleipfer T, Stoschek M, Beckert R, Sparwas-
ser C (2002) Intravesical migration of a polypropylene mesh
implant 3 years after laparoscopic transperitoneal hernio-
plasty. Urologe 41: 366–368
5. Celik A, Kutun S, Kockar C, Mengi N, Ulucanlar H, Cetin A
(2005) Colonoscopic removal of inguinal hernia mesh: report
of a case and literature review. J Laparoendosc Adv Surg Tech
15: 408–410
6. Czechowski A, Schafmayer A (2003) TAPP versus TEP: a retro-
spective analysis 5 years after laparoscopic transperitoneal
and total endoscopic extraperitoneal repair in inguinal and
femoral hernia. Chirurg 74: 1143–1149
7. Dieterich K, Eichhorn J (2004) Five hundred outpatient
hernioplasties using the Lichtenstein method. Chirurg 75:
890–895
8. EU Hernia Trialists Collaboration (2002) Repair of groin hernia
with synthetic mesh: meta-analysis of randomised controlled
trials. Ann Surg 235: 322–332
9. Eypasch E, Paul A (1997) Abdominal wall hernias: epidemiol-
ogy, economics and surgical technique – an overview. Zbl
Chir 122: 855–858
10. Felix EL, Michas CA, McKnight RL (1994) Laparoscopic her-
niorrhaphy. Transabdominal preperitoneal floor repair. Surg
Endosc 8:100–103
11. Ferrone R, Scarone PC, Natalini G (2003) Late complication of
open inguinal hernia repair: small bowel obstruction caused
by intraperitoneal mesh migration. Hernia 7: 161–162
12. Gong Y, Shao C, Sun Q, Chen B, Jiang Y, Guo C, Wei J, Guo Y
(1994): Genetic study of indirect inguinal hernia. J Med Genet
31: 187–192
13. Kald A, Nilsson E, Anderberg B, et al. (1998) Reoperation as
surrogate endpoint in hernia surgery. A three year follow-up
of 1565 herniorrhaphies. Eur J Surg 164: 45–50
14. Lange B, Langer C, Markus PM, Becker H (2003) Mesh pen-
etration of the sigmoid colon following a transabdominal
preperitoneal hernia repair. Surg Endosc 17: 157
15. Langenbach MR, Schmidt J, Lazika M, Zirngibl H (2003)
Urological symptoms after laparoscopic hernia rapair. Re-
duction with a variant of polypropylene mesh. Urologe 42:
375–381
16. Melis P, van der Drift DG, Sybrandy R, Go PM (2000) High
recurrence rate 12 years after primary inguinal hernia repair.
Eur J Surg 166: 313–314
17. Rieger N, Brundell S (2002) Colovesical fistula secondary to
laparoscopic transabdominal preperitoneal polypropylene
(TAPP) mesh hernioplasty. Surg Endosc 16: 218–219
18. Rink J, Ali A (2004) Intestinal obstruction after totally ex-
traperitoneal laparoscopic inguinal hernia repair. JSLS 8:
89–92
⊡
Table 41.4. Early postoperative results (14 days,
n = 265)
n%
Seroma 140 39.9
Hematoma 28 8.0
Infection 8 2.3
Puncture 11 3.1
Revision 5 1.4
396 What Can we Do to Improve Our Results?
41
19. Rios A, Rodriguez JM, Munitiz V, Alcaraz P, Perez D, Parrilla P
(2001) Factors that affect recurrence after incisional hernior-
rhaphy with prosthetic material. Eur J Surg 167: 855–859
20. Schumpelick V (1984) Shouldice repair in inguinal hernia.
Chirurg 55: 25–28
21. Shin D, Lipshultz LI, Goldstein M, et al. (2005) Herniorrhaphy
with polypropylene mesh causing inguinal vasal obstruction:
a preventable cause of obstructive azoospermia. Ann Surg
241: 553–558
22. Sorensen LT, Friis E, Jorgensen T, Vennits B, Andersen BR,
Rasmussen GI, Kjaergaard J (2002) Smoking is a risk factor
for recurrence of groin hernia. World J Surg 26: 397–400
23. Uden A, Lindhagen T (1988) Inguinal hernia in patients with
congenital dislocation of the hip. A sign of general connec-
tive tissue disorder. Acta Orthop Scand 59: 667–668
Discussion
Kehlet:
I think it is a nice hypothesis, but I am a little
concerned about so few numbers and with a follow-up
rate of 75%. That makes it a little dangerous to make
conclusions when you miss 25%.
Peiper:
No one can compete with your database. I had
the same impression. I also think that a follow-up of 75%
is not enough. But the problem is, if you want to make it
higher you have to go home to every patient and perform
your investigation there. And we made no questionnaire,
we examined every patient because in our opinion it is
the only way to get the real recurrence rate.
Kehlet:
Well the approach is very nice with the HEAD
score and so but that’s a good topic for collaboration be-
tween different centres to get higher numbers and really
get some good answers.
Simons:
Maybe I missed a slide. But how many surgeons
performed these operations? Do you have residents or are
there dedicated surgeons that do more operations than
others?
Peiper:
It is just a regular county hospital and we are
nine surgeons including residents at the beginning of their
residency. And everyone is doing these operations. Not
the laparoscopic one, but the opens ones were performed
by any.
Simons: I think we showed that in a residency program
you can get your recurrence rate down and after four
years to 1.8% by a less tailored approach with residents
in general surgery and I think the tailoring is that en-
doscopic surgery is only done by one surgeon. So all the
difficult and the high risk patients stay in expert’s hands
and general surgery can do the others techniques.
Peiper:
I think if you just focus on the recurrence rate
as we just heard by Prof. Kehlets talk there is no way
except of the Lichtenstein technique. But I think there
are additional problems we just discussed also. And that’s
why I think that it is not correct just to focus on the
recurrence rate. The other problems are not evaluated.
No one asks for testicular pain of dysejaculation or any-
thing else. These data are not published but might be a
problem.
Simons:
That is the whole point. We do not know exactly
if these problems are only mesh related.
Kehlet:
And if people will follow your score really need to
have some specialised surgeons for the open repair.
Kurzer:
I think everybody agrees that it makes sense that
you have to perform the operation for the patient and so
you have to have surgeons who can deal with a range
of operations, because if your patients really requires a
laparoscopic repair and comes to a surgeon who does
not do a laparoscopic repair we all know that in the real
world this surgeon does not want to loose his patient and
he will not send his patient to a laparoscopic surgeon
even knowing that this patient should have a laparoscopic
repair.
Peiper:
If you want to do the best for the patient you
should include a laparoscopic surgeon in your team.
This would be the best. But even on the other hand. If
a laparoscopic surgeon does not provide a Shouldice or
Lichtenstein repair in local anaesthesia he should refer
his patients who are suitable for this to someone else.
This would be good team work. Of course it is difficult
in reality, I know.
Kurzer: So it would be easier to have one surgeon doing
all this operations.
Peiper: Would be the best way. I learned hernia surgery
also in a kind of monoculture but you can learn it.
Sarr:
One of the ways that might happen is that the insur-
ance companies might be the one that determine who does
the operation. The chair of the department might be.
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