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29
I
Recurrence as a Problem of the Trainee
Many new training methods have been described
and are being developed internationally. In the OLVG
hospital in Amsterdam many of these methods have
been implemented and are used in the attempt to im-
prove the results of inguinal hernia surgery.
Surgical training starts in the first year with theo-
retical training and skillslabs. Residents must have
knowledge of the Dutch Guidelines [6, 7], learn the
anatomy and observe training videos that were devel-
oped by Dr. Amid of the Lichtenstein Hernia Insti-
tute. Part of this training is in the lab using models
and cadavers. There is an internet-based preparation
by residents with interactive learning of anatomy of
the abdominal wall and a test of their knowledge. In
the operation theatre residents are supervised by a
dedicated hernia surgeon.Usually around five or six
inguinal hernias will be performed by this surgeon
with one resident in one single operating day. The
resident must first observe the surgeon performing
the operation, then show knowledge of the procedure
by telling the surgeon how to perform it step by step
and after that he or she is supervised for 40–60 ingui-
nal hernias until qualified enough to perform simple
primary one-sided inguinal hernia with supervision
not at the operating table, but close by if necessary.
The method consists of knowing how, showing how,
performing unsupervised and teaching how (knows,
shows, does, teaches). Bilateral and recurrent hernias
are performed by a dedicated hernia surgeon training
only one senior resident at a time to perform endo-
scopic and other techniques. Dilution of expertise is
avoided respecting the long learning curve for difficult
hernia techniques.
Following this strategy, a study was performed to
compare the results of inguinal hernia surgery before
implementing the guidelines and during the period of
very infrequent supervision (1994–1996) with a pe-
riod after implementation of the guidelines and the new
training techniques (2002–2004).
Between these periods there was a significant in-
crease in the use of mesh and the supervision of resi-
dents (
⊡
Tables 2.2–2.4). The significant decrease in
operations for recurrent inguinal hernia is probably
due to the changes in strategy.
In a prospective study of 111 patients with primary
inguinal hernia operated in the OLVG all with a fol-
low-up by physical examination of 4 years (2000–2005)
the recurrence rate of Lichtenstein repair was 1.8%. In
1990–1994, a RCT was performed in the same hospi-
tal comparing modified Bassini and modified Shoul-
dice [8] with recurrence rates after 2 years follow-up
of respectively 10.7% and 5.6%. It was concluded that
changing of technique and better training with more
supervision improved the results. In a RCT studying
the value of prophylactic antibiotics performed in three
non-teaching and one teaching hospital, there were no
significant differences measuring recurrences after 4
years and quality of life (
⊡
Tables 2.5–2.7) [9–12].
The results show an increase in operating time in the
teaching hospital but comparable results for recurrence
and other complications.
In conclusion although it seems logical that resi-
dents perform less than attending surgeons, this is not
proven in literature. It could be that general surgeons
who do not perform dedicated hernia surgery have re-
sults comparable to residents. The fact is that in general
⊡
Tab le 2.4. Skill of operating surgeon in teaching hospital performing inguinal hernia repair
No hernias 1994–1998 %
(n = 650)
1999–2001 %
(n = 906)
2002–2004 %
(n = 979)
Surgeon [%] 157 (8.8) 164 (7.1) 170 (7.1)
Surgeon + resident [%] 127 (19.5) 234 (25.8)
a
283 (28.9)
Resident + surgeon [%] 301 (46.3) 382 (42.2) 461 (47.1)
a
Resident [%] 140 (21.5) 115 (24.9) 165 (16.9)
a
Unknown [%] 125 (3.9) 110 110
a
Significantly decreased or increased compared to the previous period (p ≤ 0.05)
30
2
Recurrence as an Important Endpoint
⊡
Tab le 2.5 . Patient and hernia characteristics of 254 patients divided between teaching and non teaching hospitals
No. of actual responders Teaching hospital
(n = 111)
Non-teaching
hospitals (n = 143)
Total
(n = 254)
No. of eligible patients 130 152 282
Age – years (mean ± SD) 157.5 ± 12.3 158.3 ± 11.2 157.9 ± 11.7
Sex – male [%] 104 (93.7) 138 (96.5) 242 (95.3)
Preoperative painful hernia [%]
VAS median (25–75% quartiles)
181 (73.0)
131 (0–60)
198 (68.5)
125 (0–50)
179 (70.5)
125 (0–50)
Operations in day surgery [%] 180 (72.1)
a
129 (20.3)
a
109 (42.9)
Level of surgical expertise no. [%]
Certified surgeon
Resident with surgeon
Unsupervised resident
110 (9.0)
a
188 (79.3)
a
113 (11.7)
a
136 (95.2)
a
117 (4.8)
a
110*
146 (57.5)
195 (37.4)
113 (5.1)
Duration of surgery [min]
Median (25–75% quartiles) 145 (40–60)
b
128 (24–40)
b
136 (25–45)
a
Chi-square test (Fisher’s exact test),
b
Mann-Whitney U test
⊡
Tab le 2.6 . The short-term postoperative complications and follow-up of 254 patients divided between teaching and
non teaching hospitals
Teaching hospital
(n = 111)
Non teaching
hospitals (n = 143)
p value
Re-operation no. [%]
▬ Postoperative bleeding
▬ Orchidectomie
10
10
11 (0.7)
11 (0.7)
0.56
a
0.56
a
Wound infection, no. (%) 11 (0.9) 12 (1.4) 0.59
a
Bladder retention – no. (%) 10 12 (1.4) 0.32
a
Percutaneous drainage of seroma,
no. (%)
11 (0.9) 12 (1.4) 0.59
a
Total of complications with inter-
vention
12 (1.8) 18 (5.6) 0.11
a
Follow-up 1 week, no. (%)
▬ Pain
▬ Swelling
▬ Haematoma
28 (25.2)
56 (50.5)
26 (23.4)
24 (16.8)
83 (58.0)
29 (20.3)
0.10
0.23
0.55
31
I
Recurrence as a Problem of the Trainee
⊡
Tab le 2.6 . Continued
Teaching hospital
(n = 111)
Non-teaching
hospitals (n = 143)
p value
Follow-up 2 weeks, no. (%)
▬ Pain
▬ Swelling
▬ Haematoma
10 (9.0)
38 (34.2)
19 (8.1)
14 (9.8)
45 (31.5)
18 (5.6)
0.83
0.64
0.43
Follow-up three months, no. (%)]
▬ Pain 19 (8.1) 16 (4.2) 0.28
a
Chi-square (Fisher’s exact test)
⊡
Tab le 2.7. The long-term (4 years) postoperative complications of 254 patients divided between teaching and
non-teaching hospitals
Teaching hospital
(n = 111)
Non-teaching
hospitals (n = 143)
p value
Physical examination at outpatient clinic
– no. [%]
94 (84.7) 116 (81.1) 0.46
Recurrence, no. (%) 12 (1.8) 112 (1.4) 0.59
a
Testicular atrophy, no. (%) 10 111 (0.7) 0.56
a
Mesh wrinkled or palpable cranial stitch,
no. (%)
18 (7.2) 111 (7.7) 0.88
Pain score pre-operatively
▬ Number with pain, no. (%)
▬ VAS median (25–90% quartiles)
81 (73.0)
31 (0–75)
198 (68.5)
125 (0–66)
0.44
0.10
b
Pain score (resting) 4 years post-
operatively
▬ Number with pain, no. (%)
▬ VAS median (25–90% quartiles)
21 (18.9)
10 (0–20)
113 (9.1)
110 (0–5)
0.02
0.04
b
Frequency of pain 4 years post-
operatively, no. (%)
▬ Never painful
▬ Sometimes
▬ Frequently
▬ Always
82 (73.9)
22 (19.8)
13 (2.7)
13 (2.7)
100 (69.9)
141 (28.7)
110
112 (1.4)
0.49
0.11
0.08
a
0.38
a
Some level of pain during, no. (%)
▬ Resting
▬ Coughing
▬ Standing up
▬ Weight lifting
▬ Sports activities
17 (6.3)
10 (9.0)
19 (8.1)
18 (16.2)
16 (14.4)
116 (4.2)
112 (1.4)
112 (1.4)
118 (12.6)
111 (7.7)
0.45
0.01
a
0.01
a
0.41
0.08
32
2
Recurrence as an Important Endpoint
practice results are far inferior to results described by
specialists although no RCTs have been performed. Na-
tional data bases from Sweden, Denmark and Scotland
show that re-operation rate yearly for recurrent inguinal
hernia is still 8–15% indicating that much effort has
to be put into training surgeons and residents to use
the best technique, the right way respecting the proven
learning curves for all techniques. Recurrences are thus
never a problem of the trainee. They are a problem of
insufficient training by the trainers. All efforts must be
put into excellent training and quality control by sound
scientific methods.
References
1.
Davies BW, Campbell WB. Inguinal hernia repair: see one, do
one teach one? Ann R Coll Surg Engl 1995; 77(6 Suppl):299–
301
2. Simons MP, Hoitsma HFW, Mullan FJ. Primary inguinal hernia
repair in The Netherlands. Eur J Surg 1995; 161: 345–348
3. Danielsson P, Isacson S, Hansen MV. Randomized study
of Lichtenstein compared with Shouldice inguinal her-
nia repair by surgeons in training. Eur J Surg 1999; 165:
49–53
4. Neumayer L, Giobbie-Hurder A, Jonasson O, et al. Open mesh
versus laparoscopic mesh repair of inguinal hernia. N Engl J
Med 2004; 350: 1819–1827
5. Wilkiemeyer M, Pappas TN, Giobbie-Hurder A, Itani KM,
Jonasson O, Neumayer LA Does resident post graduate year
influence the outcomes of inguinal hernia repair? Ann Surg
2005; 241: 879–882
6. Lange de DH, Aufenacker ThJ, Roest M, Simmermacher RK,
Gouma DJ, Simons MP. Inguinal hernia surgery in The Nether-
lands: a baseline study before the introduction of the Dutch
Guidelines. Hernia 2005; 9: 172–177
7. Simons MP, de Lange D, Beets GL, van Geldere D, Heij HA,
Go PM. The ‘Inguinal Hernia’ guideline of the Association of
Surgeons of The Netherlands. Ned Tijdschr Geneeskd 2003;
147: 2111–2117
8. Simons MP, Koelemay MJW, Luitse JSK, Hoitsma HFW, Ober-
top H. Modified Shouldice versus modified Bassini by resi-
dents. A randomised study. Ned Tijdschr Heelkd, jaargang
8, nr. 6, December 1999;189–194
⊡
Tab le 2.7. Continued
Teaching hospital
(n = 111)
Non-teaching
hospitals (n = 143)
p value
Pain location on physical exam
▬
Pain pressing pubic tubercle, no. (%)
▬
VAS median (25–90% quartiles)
▬
Pain pressing Poupart’s ligament,
no. (%)
▬
VAS median (25–90% quartiles)
145 (40.5)
110 (0–36)
117 (15.3)
110 (0–10)
136 (25.2)
110 (0–15)
122 (15.4)
110 (0–10)
0.01
0.01
b
0.99
0.66
b
Physical exam (sensory), no. (%)
Reduced sensory function:
▬
On the scar
▬
Below the scar
Absent sensory function:
▬
On the scar
▬
Below the scar
117 (15.3)
126 (23.4)
111 (0.9)
111 (0.9)
128 (19.6)
110 (7.0)
112 (1.4)
111 (0.7)
0.38
0.46
0.59
a
0.68
a
Sensory disturbance associated
with nerves, no. (%)
▬
Ilioinguinal
▬
Iliohypogastric
▬
Genitofemoral
112 (1.8)
115 (4.5)
112 (1.8)
111 (0.7)
112 (1.4)
111 (0.7)
0.41
a
0.13
a
0.41
a
Satisfied with the operation
result, no. (%)
100 (90.1) 135 (94.4) 0.19
Wants the operation performed
in the same way
104 (93.7) 134 (93.7) 1.00
a
Chi-square test (Fisher’s exact test),
b
Mann-Whitney U test.
33
I
Recurrence as a Problem of the Trainee
9. Aufenacker TJ, Geldere D van, Mesdag T van, et al. The role of
antibiotic prophylaxis in prevention of wound infection after
Lichtenstein open mesh repair of primary inguinal hernia. A
multi-center double-blind randomized controlled trial. Ann
Surg 2004; 240: 955–961
10. Aufenacker TJ, de Lange DH, Burg MD, Kuiken BW, Hensen EF,
Schoots IG, Gouma DJ, Simons MP. Hernia surgery changes
in the Amsterdam region 1994–2001. Decrease in operations
for recurrent hernia. Hernia 2005; 9(1): 46–50
11. Aufenacker TJ, Schmits SP, Gouma DJ, Simons MP. Do
guidelines influence results in inguinal hernia treatment?
A descriptive study of 2535 hernia repairs in one teaching
hospital from 1994–2004. Hernia (submitted)
12. Aufenacker TJ, van Geldere D, Scheijde E, Juttmann JW,
Gouma DJ, Simons MP. Complications after Lichtenstein
inguinal hernia repair. A comparison of teaching and non
teaching hospitals in a prospective study. Hernia (submit-
ted)
Discussion
Amid: One thing that Maarten forgot to say: Out of the
two or three patients that I have operated in Holland
there was one recurrence and that is a recurrence rate of
30–50%. What I really want to say the efficacy of Lich-
tenstein and laparoscopic repair is between 0 and 0,5%
recurrence rate. But when the operation goes to the sur-
geons at large it goes up to 4% with Lichtenstein and 10%
with laparoscopy, as the VA study showed. That means
really that training and experience are very important. As
a part of what I do every year I have to review approxi-
mately 500 operative reports for different reasons and
having reviewed thousands of operative reports, mainly
in the US, I can seriously say that surgeons do not know
how to do a hernia operation as you can clearly find out
while reading these useless, sketchy operative reports. It
is really the job of the educators to educate the young
surgeons so we get out of this mess.
Schumpelick: A very clear statement.
Jeekel: Excellent lecture. But I don’t agree with one con-
clusion, that the resident is inferior. As you said there is
one level-three evidence study from last year; one study is
no study. You found yourself the same results in teaching
hospitals as in non-teaching hospitals. So I don’t think
there is real evidence at all from one level-three study
that residents are inferior. Isn’t what you are saying more
that – besides technique – volume is so important and
we haven’t heard very much about volume today yet. But
volume – of course the technique principles should be
right – but then the volume is so important. So a resident
in his first year has less volume, but shouldn’t we just
focus a little bit more on the question of volume, volume
per surgeon. I agree very much with training the trainers
and have volume for the trainers and for everybody. We
know that volume often gives quality.
Simons:
I agree completely. What I found out is that
residents really enjoy following me for a month doing 1
day a week of hernia surgery and in 1 day six or seven
Lichtensteins one after another. So volume can be even
better if you combine it with all the other strategies, the
techniques that I showed here, and then the repetition
of doing it over and over again is, of course, enormously
important. This takes a lot of planning, seeing all the
challenges that we have getting the residents in to do
these operations. I think the problem is that volume will
never be available in general practice with large training
programs so you have to focus on all these other aspects
also. But your point is right and I am going to put it in
my next talk because we shouldn’t forget it.
Fitzgibbons:
There is a small trap in what you say, Prof.
Jeekel. In the academic centres sometimes we go to the
operation which is most teachable and maybe not the
best; for example, the Lichtenstein is a very teachable
operation where the Shouldice isn’t. So most of us like
to use the Lichtenstein in a training centre because it
is a very easy operation to supervise as opposed to the
Shouldice operation. I worry a little about this.
Deysine:
First of all, Maarten, I have to congratulate
you on this wonderful speech. It is very interesting to see
how after these conferences a kind of thought develops
in people who are involved with hernias and we all come
out with just about the same conclusion, that training
teaching is the basis of success. I know of whole regions in
the area where I live that when the Shouldice procedure
was performed the transversal fascia was never opened,
which was exactly an old-fashioned Bassini. The problem
that we have is not to convince each other of something
that we already know. The difficulty we have is now how
are you going to convey your thoughts to people so they
will start training residents properly in the management
of these patients? To the previous speaker I can tell you
that whenever I had a recurrence I knew it already in the
operative room. I knew I had done something that was
not perfect, and my patient recurred.
Young:
One of the things that we do with PHS repairs
which hasn’t been mentioned yet is, in fact, you have the
opportunity to do an operation that is relatively easy to
perform and you have an opportunity to visualize the
anatomy while you do that, as one of the difficulties while
doing a Shouldice repair, which is very difficult to do
once you even find the anatomy or a Lichtenstein repair
obviously, you don’t get into the posterior space in that
situation.
Ferzli: I just want to confirm how important training is
and the experience in laparoscopic inguinal hernia in the
34
2
Recurrence as an Important Endpoint
United States. Dr. Fitzgibbons asked me to present to the
American College 3 years ago how we work at graduat-
ing chief residents in the United States over a 10-year
period when the laparoscopic inguinal hernia started.
Actually, graduating chief residents in the United States
graduate with two laparoscopic inguinal hernias on the
average exposure, while they graduate with about 50–60
laparoscopic cholecystectomy exposures. It poses a major
problem. I looked at the laparoscopic fellowship that I
currently presented in the United States, just to share
with you: less than 15% of them train in laparoscopic
hernia. I enjoyed your talk very much and I think it is
fundamental to see how a model can try to get the hernia
repair to another level when we are really not training
junior residents in the technique.
Simons:
One short comment. Exactly for that rea-
son I have agreed in my hospital that there is only
one older resident who helps me with the endoscopic
surgery because we only do the recurrences and the
bilateral and a few on request, that’s about 40 to 50 a
year. So only one resident follows me for 2 years and
after his term he will have done about 30 or 40 endo-
scopic repairs, the rest zero. It is just for one person
now.
I
3 Failures in Hernia Surgery Done by Experts
A.I. G, M.F. G, J. Y
Introduction
As an invitee to Dr. Volker Schumpelick’s fourth triennial
meeting in St. Moritz (2006), my assignment was to pres-
ent answers to why expert hernia surgeons don’t always
have perfect results. Stated another way, why do some
repairs done by experts fail? Clearly, this was one of the
most difficult topics I have been asked to write about.
Research in the printed surgical literature has been less
than fruitful. Textbooks and journals mention generally
accepted factors related to hernia repair failure, usually as
a prologue to the subject of recurrence. These articles and
texts do not distinguish causes of failure by experts from
non-expert hernia surgeons. Finding limited value from
the printed literature for answers to the assigned question,
I sought information directly from colleagues who have
demonstrated unusual interest, additional experience, or
have recognized expertise in herniology.
Methods
My first attempt to gather information regarding the
causes of failures by experts was by sending an e-mail
request to a specific group of surgeons asking for their
opinions (
⊡
Fig. 3.1
). This group (group 1) was com-
prised of
▬
senior authors of articles published in the past
3 years in Hernia, The World Journal of Hernia and
Abdominal Wall Surgery, and
▬ some other recognized hernia experts whose work
has contributed to the science.
Specifically, I asked for their opinions of the causes of
failure by experts who repair:
▬ groin hernias,
▬ primary abdominal wall hernias,
▬ incisional hernias, and
▬ hiatus hernias.
The answers rendered by surgeons in group 1 were
divided into four hernia-type categories (
⊡
Tables 3.1
to 3.4
). Within each category five different temporal
segments were designated (segments 1–5 in Tables
3.1–3.4). Mostly, the answers and terminology used
by the responder was recorded verbatim.
My second attempt to gain answers to this question
was to send e-mail requests to the invitees to this St.
Moritz meeting. To reach them, I used their current e-
mail addresses as listed and furnished by the organizing
committee. In this request I asked for their personal
results with the technique(s) they had used most of-
ten. I included our own results as an example of the
information I sought.
36
3
Recurrence as an Important Endpoint
Results
The initial mailing was to 112 surgeons. I used the e-
mail addresses that were noted in each article. Twelve
e-mails were returned as undeliverable due to unrec-
ognized addresses. From the 100 e-mails that were not
returned as undeliverable I received 46 responses (46%).
The causes of hernia repair failures they reported are
itemized in
⊡
Tables 3.1–3.4
. I received no response
from the other presumed recipients.
The 46 responders (group 1) noted 180 answers
listing 46 different causes of groin hernia repair fail-
ure, 150 answers listing 27 different causes of primary
ventral hernia repair failure, 149 answers listing 31
causes of incisional hernia repair failure, and 132 an-
swers listing 35 causes of hiatus hernia repair failure.
Several responders noted many of the same causes.
For each type of hernia repair I separated the causes
of failure into the same five temporally related cate-
gories.
From my second attempt to gain answers from the 62
invitees to the 2006 St. Moritz meeting, I received only
14 responses (22.5%) to my e-mail inquiry (group 2).
The majority of surgeons in this group noted many
of the same causes noted by surgeons in group 1. The
causes of failures noted by group 2 experts are itemized
in
⊡
Table. 3.1.
Thirteen of the 14 furnished an overview
of their preferred techniques and their personal results.
Since anonymity was promised to the responders the
details of techniques and personal numeric results fur-
nished by each responder is not included.
Discussion
A true expert expects success, but always looks for his/
her own failures. I received information about recur-
rences from 13 of 14 surgeons in group 2. Despite my
specific request for the details of their own failures,
only 4 of the 13 furnished information of those causes.
Responses from surgeons in group 2 included faults
in Lichtenstein, plug, and laparoscopic repairs. These
causes were basically the same as furnished by group 1.
While group 1 surgeons noted metabolic defects, col-
Request for “Expert” Professional Assistance
As you are a published expert in the eld of herniology I am asking for your
input to assist me in preparing a presentation that deals with your views of
reasons for recurrence of abdominal hernias. I am sending this same survey
to many others who have expertise in this eld.
My topic is “Recurrence as a problem of the expert”. Note that the emphasis
is on EXPERT. The essence of the presentation leaves room for reference to
open and laparoscopic approaches to groin hernias, other primary abdo-
minal wall hernias, incisional hernias, and hiatus hernias. It requires answers
based on your individual experiences and observations.
Please EMAIL REPLY to me what you believe are the two or three main cau-
ses for failed repairs of each group by experts in each eld.
(Some causes may apply to all four groups):
Groin Hernias:
Primary Abdominal Wall Hernias:
Incisional Hernias:
Hiatus Hernias:
Excuse the BCC format of this correspondence. It is the simplest, quickest,
and least expensive way to get responses from a large group while keeping
your emails private.
Thank you for taking the time to answer this survey.
This will be the only questionnaire I will send.
Arthur I. Gilbert, M.D.
⊡
Fig. 3.1. Request for “Expert” Profes-
sional Assistance
37
I
Failures in Hernia Surgery Done by Experts
lagen disorders, and patient’s biological features as
some causes of failed repairs, the group 2 surgeons did
not attribute even one failure to poor patient selection
or to patients’ biological features. All attributed their
failed repairs to faulty personal observation or tech-
nique.
⊡
Tab le 3.1. Reasons for failure by experts (group 1)
– groin hernias
Reason for failure No.
1. Surgeon’s personal preparation
Poor understanding of anatomy/patho-
physiology
17
Poor training in lap hernia repair 17
Surgeon’s limited knowledge, experience, skill 16
Poor training in open hernia repair 15
Failure to recognize multiple defects 14
Ignorance of MPO 13
Poor teaching of residents 12
Surgeon’s age-related factors 11
Non expert pressured to do LIH vs. lose case 11
2. Patient profile and habits
Collagen disorders 14
Smoking 13
Obesity 12
Genetic factors 12
Ascites 11
3. Various intra-operative factors
Inadequate dissection 13
Repair without mesh 10
Inadequate size of mesh 10
Technical mistakes 19
Inadequate overlap of mesh 19
Errant fixation of mesh 17
⊡
Table 3.1. Continued
Reason for failure No.
3. Various intra-operative factors
Plug migration 6
Tension in repair 5
Plug not in pp space for direct hernias 5
Choice of wrong procedure 4
Missed hernia sac 4
Mesh wrongly placed 3
Lichtenstein poor shutter reconstruction 3
No coverage of femoral canal from groin 3
Incision too small 2
Unrecognized lateral hernias 2
Lichtenstein poor overlap at pubis 2
LIH poor closure of keyhole 2
Wrong anesthetic modality 2
Not fully creating pp space for mesh 1
4. Wound problems
Infection 8
Mesh shrinkage 3
Hematoma 2
Use of absorbable suture material 2
Intestinal obstruction 1
Seroma 1
5. Postoperative events
Strenuous activity too soon 3
38
3
Recurrence as an Important Endpoint
Regarding ventral hernia repairs, Awad [1] identified
certain technical causes of failure. Inlay mesh repairs
were associated with higher failure rates compared to
onlay, sublay, and sandwich techniques. The lowest rate
of failure was in the sandwich technique. Infection,
lateral detachment of the mesh, and inadequate fixation
of the mesh were shown to be the most common factors
related to failed repairs.
At the 2003 St. Moritz meeting of hernia experts,
the question was posed to the group, “Do you believe
you can always prevent a hernia recurrence by doing
the procedure properly?”; 24% of attendees responded
they thought they could; 76% did not feel they could.
The audience proffered that failures were related to poor
technical skill in 83% of failures, to poor teaching in
57% of failures, and to the patient’s defective biological
features in 28% of cases.
My personal observations of causes of failed groin
preperitoneal hernia repairs by experts include the
surgeon’s failure to sufficiently develop the preperito-
neal space (Bogros space) in doing TEP, TAPP, Ugahary,
Kugel, or PHS repairs. Other causes in open repairs
were related to inadequate mesh size and poor mesh
fixation. I personally was responsible for two failed PHS
repairs due to my own poor knot tying.
Causes for failed Lichtenstein repairs were detailed by
Amid [2], and Read [2, 3]. With the help of ultrasonog-
raphy I have identified persistent hernia sacs under the
onlay mesh of patients who had Lichtenstein tension-
free hernioplasties and presented complaining of inter-
⊡
Tab le 3. 2. Reasons for failure by experts – primary
abdominal wall hernias
Reason for failure No.
1. Surgeon’s personal preparation
Poor understanding of anatomy
and physiology
17
Surgeon’s limited knowledge, experience,
and skill
15
Surgeon underestimating extent of hernia 14
2. Patient profile and habits
Genetic factors 17
Obesity 14
Collagen disorders 14
Previous contaminated or infected wound 13
Smoking 11
Concurrent diastasis recti 11
3. Various intra-operative factors
Failure to use mesh 14
Mesh too small 13
Tension on repair 12
Inadequate fixation of mesh 12
⊡
Tab le 3. 2. Continued
Reason for failure No.
3. Various intra-operative factors
Inadequate overlap of mesh 10
Using onlay method of mesh repair 17
Overlooked multiple defects 15
Failure to use component separation tissue
repairs
13
Poor exposure 12
Inadequate dissection 12
Wrong anesthetic modality 12
Rapidly absorbing suture material 12
Lap hernia poor alignment of mesh 11
Fascia not strong enough for repair 11
4. Wound problems
Infection 11
Seroma 13
Hematoma 12
5. Postoperative events
Resuming forceful activity too soon 12
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