|Year : 2020 | Volume
| Issue : 3 | Page : 131-137
The incidence of recurrence after inguinal hernia repair: A single-center experience
Ahmed Almumtin1, Hassan Alsaleem2, Zahara Al-Ali3, Sara Alsadah3, Alaa Alshareef3, Samar Alshammasi3
1 Department of Surgery, King Fahad Hospital of the University, Al Khobar, Saudi Arabia
2 Asan's Medical Centre, Seoul, South Korea
3 Department of Suregry, School of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
|Date of Submission||29-Apr-2021|
|Date of Acceptance||22-Jun-2021|
|Date of Web Publication||19-Jul-2021|
Dr. Ahmed Almumtin
Department of Surgery, Al Jubail Industrial, Al Jubail
Source of Support: None, Conflict of Interest: None
Importance: Despite the improvement of treatment modalities and technical aspects, recurrence following hernia repair remains one of the main problems for the surgical community. More specifically, previous Cochrane Systematic Review and large database studies compared Lichtenstein repairs. However, none of the relevant published reports were representative of the Saudi population.
Objective: This study's objective was to investigate the overall and gender-specific prevalence of recurrences in patients who had undergone Lichtenstein mesh repair of primary inguinal hernia (IH) in the KFHU Centre.
Design: This is a retrospective record review study conducted between January 2000 and December 2014.
Setting: The study was conducted at a single center located in Saudi Arabia, at King Fahed Hospital University KFHU center.
Participants: Adults (≥18 years of age), with IH, operated at KFHU using standard Lichtenstein open mesh repair, and had minimum follow-up of 2 years were included in the study. Laparoscopically operated cases, recurrent and emergently operated cases were excluded from the study.
Main Outcome (s) and Measure (s): Data were collected by records review and included sociodemographic characteristics (age, gender, and family history), hernia type and location, risk factors (body mass index [BMI], smoking, comorbidities, etc.), recurrence and other complications (pain, wound hematoma and seroma, infection, etc.).
Results: We report a recurrence rate of 1.3% following Liechtenstein mesh repair at our center. As for patient-related factors that were found to be significantly associated with the recurrence of an IH were older age, higher BMI, the existence of hypertension, chronic cough and diabetes, in addition to smoking and lifting heavy objects.
Conclusion: We have identified several likely factors associated with higher recurrence after hernia repair. A comparison of the rates of recurrence and complications between different procedures should, therefore, be an important topic to address in future studies.
Keywords: Inguinal hernia, recurrence, risk factor
|How to cite this article:|
Almumtin A, Alsaleem H, Al-Ali Z, Alsadah S, Alshareef A, Alshammasi S. The incidence of recurrence after inguinal hernia repair: A single-center experience. Saudi Surg J 2020;8:131-7
|How to cite this URL:|
Almumtin A, Alsaleem H, Al-Ali Z, Alsadah S, Alshareef A, Alshammasi S. The incidence of recurrence after inguinal hernia repair: A single-center experience. Saudi Surg J [serial online] 2020 [cited 2021 Nov 30];8:131-7. Available from: https://www.saudisurgj.org/text.asp?2020/8/3/131/321734
- Hernia is a common surgical disease and was known throughout the human history
- Despite the improvement of treatment modalities and technical aspects, recurrence following hernia repair remains one of the main problems for the surgical community
- Risk factors for recurrence have been extensively studied in order to reduce its incidence
- Lichtenstein repair has been a standard of care in surgical repair of inguinal hernia and represents a safe and effective approach
- Recurrence rates after mesh repair is well accepted in comparison with older and more complex anatomical tissue repairs.
| Introduction|| |
Inguinal hernia (IH) is the most commonly diagnosed hernia presenting mostly in the senior population with approximately 75% of overall hernias. The incidence of IH was reported higher among males when compared to females (ratio = 12:1), with the highest incidence after 40–50 years of age. Besides, the lifetime risk of developing an IH is only 3% in females, whereas it is high as 27% for males. Almost a third of IH patients are asymptomatic. Until this decade, IH management includes surgical repair is recommended even for asymptomatic cases because it is considered effective and safe, and it limits hernia complications (incarceration and strangulation). IH repair is the only definitive treatment and is one of the frequent ambulatory surgical procedures performed at surgical units worldwide; with a rate between 10/100,000 in the United Kingdom and 28/100,000 in the United States. It is performed by reinforcing the posterior wall of the inguinal canal, mostly utilizing a polypropylene mesh.
Despite the improvement of treatment modalities and technical aspects, recurrence following hernia repair remains one of the main problems for the surgical community. In the United States, a previous study reported a recurrence rate after hernia repair ranging between 0% and 3.7%. Furthermore, European reports based on data from the Swedish Hernia Register and Danish Hernia Database have outlined that almost 13%–15% of IHs repairs were performed for recurrences., The absolute reason for IHs recurrence persists unclear, and it has not been achievable to distinguish single parameters or risk factors as being responsible; it is most probably multifactorial. The identified risk factors for recurrence range widely and include both controllable technical (surgery related) and noncontrollable nontechnical (patient related) risk factors. Surgical risk factors include surgical technical and anesthesia methods, surgeon experience, mesh-fixation procedures, and hospital volume. The patient-related risk factors possess a major effect on the risk of recurrence including sex, family disposition, smoking, hernia anatomy and type, connective tissue composition, and degradation. Some of these technical and nontechnical risk factors could be optimized pre- and during the operation to lower the recurrence rate of hernia. In the majority of the countries, mesh repair method was described as the best method to decrease the risk of recurrence. More specifically, previous Cochrane Systematic Review and large database studies compared Lichtenstein repairs and other methods (Shouldice, nonmesh) favoring the mesh Lichtenstein approach with lower recurrence rate.
However, none of the relevant published reports were representative of the Saudi population. Therefore, this study's objective was to investigate the overall and gender-specific prevalence of recurrences in patients who had undergone Lichtenstein mesh repair of primary IH in the KFHU Centre.
| Materials and Methods|| |
Study design and participants
This is a retrospective record review study conducted on all IH cases underwent open Liechtenstein mesh repair at King Fahed Hospital University KFHU center between January 2000 and December 2014.
The inclusion criteria included adults (≥18 years of age), with IH, operated at KFHU using standard Lichtenstein open mesh repair, and had minimum follow up of 2 years. Laparoscopically operated cases, recurrent and emergently operated cases were excluded from the study.
Lichtenstein tension-free mesh IH repair is a noncomplex, safe, less painful, effective procedure, with extremely low early and late morbidity and remarkably low recurrence rate and therefore it is a preferred method for hernia repair.
Data were collected by records review and included sociodemographic characteristics (age, gender, and family history), hernia type and location, risk factors (body mass index [BMI], smoking, comorbidities, etc.), recurrence and other complications (pain, wound hematoma and seroma, infection, etc.).
First or second degree adult (aged between 18 and 60 years) with IH.
Smoked for at least 2 years (cigarettes of hookah).
Lifting heavy object
Occupational (not including one incident which provoked the hernia as emergency cases were excluded in the selection).
As per Rome III criteria include at least 2 of the following symptoms during ≥25% of defecations: Straining, lumpy or hard stools, sensation of incomplete evacuation, sensation of anorectal obstruction or blockage, relying on manual maneuvers to promote defecation, and having <3 unassisted bowel movements per week. For more than a year.,
Benign prostatic hyperplasia
Patients who are labeled by a urologists having Benign prostatic hyperplasia and on Tamsulosin and/or finasteride for enlarged prostate.
Cases on medications for hypertension.
Type 1 or 2 diabetics whether on insulin or oral hypoglycemic agent.
Chronic renal failure
Who are on dialysis (hemodialysis or peritoneal dialysis) or who fit the diagnostic criteria by the American Family physicians' association.
On Warfarin or any novel anticoagulation.
Hematoma under the skin flap bellow the wound
Clinically or radiologically: Within a month of the procedure.
Clinically or radiologically: Within a month of the procedure.
Independent of the type of anesthesia used.
Surgical site infection
Superficial incisional surgical site infection (SSI) must meet the following criteria:
Date of event occurs within 30 days after any NHSN operative procedure (where day 1 = the procedure date, AND involves only skin and subcutaneous tissue of the incision, AND patient has at least one of the following: (a) Purulent drainage from the superficial incision. (b) Organism (s) identified from an aseptically obtained specimen from the superficial incision or subcutaneous tissue by a culture or nonculture-based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (for example, not Active Surveillance Culture/Testing [ASC/AST]). (c) Superficial incision that is deliberately opened by a surgeon, physician or physician designee and culture or nonculture-based testing of the superficial incision or subcutaneous tissue is not performed, AND patient has at least one of the following signs or symptoms: Localized pain or tenderness; localized swelling; erythema; or heat, AND diagnosis of a superficial incisional SSI by a physicianor physician designee.
Deep incisional surgical site infection
The date of event occurs within 30 or 90 days after the operative procedure (where day 1 = The procedure date): AND involves deep soft tissues of the incision (for example, fascial and muscle layers) AND patient has at least one of the following: (a) Purulent drainage from the deep incision. (b) A deep incision that spontaneously dehisces, or is deliberately openedor aspirated by a surgeon, physician or physician designee AND Organism (s) identified from the deep soft tissues of the incision by a culture or nonculture-based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (for example, not ASC/AST) or culture or nonculture-based microbiologic testing method is not performed. A culture or nonculture-based test from the deep soft tissues of the incision that has a negative finding does not meet this criterion.
AND patient has at least one of the following signs or symptoms: Fever (>38°C); localized pain or tenderness, an abscess or other evidence of infection involving the deep incision that is detected on gross anatomical or histopathologic exam or imaging test.
Diagnosed intraoperatively or postoperatively.
Increased analgesic use, restriction of activities of daily living, significant effects on quality of life, and increased health-care utilization.
Recurrence assessed clinically or radiologically.
The study was approved by the local ethics committee. An informed consent was obtained from participants before the commencement of the study.
All statistical analyses were done using SPSS version 26, IBM, Endicott, New York, USA. Statistical significance was taken at the 95% level (P < 0.05) [Table 1]. Results were expressed as frequency and percentages for categorical variables. Differences in categorical variables were analyzed with the Pearson Chi-square test or with Fisher's exact test when conditions are not fulfilled.
| Results|| |
A total of 2436 hernia repairs were carried out during the study period using the Liechtenstein mesh method. The mean age of patients was 27.36 ± 10.02 years (range of 18–67 years), with a male-to-female ratio of 22 (95.7% male; 4.3% female). Only 8.8% had a family history of hernia. Chronic constipation was the most reported illness (5.5%), followed by hypertension (5.2%) and benign prostatic hyperplasia (4.1%). A total of 344 patients reported lifting heavy objects, while 178 patients were smokers [Table 1]. [Table 1], [Table 2], [Table 3], [Table 4] describes hernia characteristics and complications following Liechtenstein mesh repair. The majority of the cases were indirect hernia (85.4%) on the right side (66.8%). As for complications, recurrence was seen in 20 patients (1.3%), followed by urine retention with 18 cases (1.2%) and wound hematoma in 17 (1.1%).
|Table 4: Estimates of associations between significant variables and recurrence|
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Patients with recurrence had a significantly higher age (27.16 ± 9.84) than those with no recurrence (42 ± 12.12) (P < 0.0001, odds ratio [OR] =1.08). Similarly, patients with recurrence had a significantly higher BMI (31.23 ± 4.71) than those with no recurrence (24.27 ± 3.82) (P < 0.0001, OR = 1.30). When analyzed on a gender basis, male and female patients showed a similar recurrence rate of 10%. An analysis of patients' comorbidities revealed that patients with a history of hypertension, diabetes, and chronic cough had a significantly higher recurrence rate with an OR of 6.45, 6.29, and 6.41, respectively. In addition, recurrence was significantly seen more in smokers (P < 0.0001, OR = 45.86), those lifting heavy objects (P = 0.03, OR = 2.76), and those with a direct hernia (P < 0.0001, OR = 14.51). As for hernia-related factors associated with gender [Table 5], only the hernia type was found significantly associated where males had more indirect hernias and females had more direct hernias.
| Discussion|| |
During recent decade, significant changes were observed regarding IH surgical techniques with excellent findings, however, the rate of surgeries performed for recurrence has not decreased significantly and this still remains a clinical problem. Previous evidence favored the use of tension-free Lichtenstein (L) mesh repair procedure for IH, as recurrence rates have repeatedly been reported to be very minimal, ranging between 1% and 2%. Similar to these findings, we report a recurrence rate of 1.3% following Liechtenstein mesh repair at our center. Hernia recurrence was accounted for sufficient clinical relevance to justify reoperation. Another substitute approach, the bi-layer mesh Prolene Hernia System (PHS), showed the possibility of lower recurrence rates. Nevertheless, once the recurrence post-PHS happens, the reoperation will become much difficult technically and associated with a higher risk of complications, as both the anterior and posterior space have been covered. It is suggested that the recurrences after applying the mesh technique (Lichtenstein) must be performed by an experienced surgeon to give extra attention to internal exfoliation and fixation. The term “surgical care” suggests surgical complications. Only 74 out of 2436 had complications following hernia repair including mostly recurrence (1.3%), urine retention (1.2%), wound hematoma (1.1%), and scrotal hematoma (0.7%). These most often occurring complications were also reported in the past evidence.,
As there is no definitive cause for recurrence after IH surgery, several risk factors were suggested being responsible. Patient-related factors that were found to be significantly associated with the recurrence of an IH were older age, higher BMI, the existence of hypertension, chronic cough, and diabetes, in addition to smoking and lifting heavy objects. Junge et al. reported similar factors found to increase the recurrence rate such as age >50 years, smoking, the presence of >2 similarly affected relatives, and the existence of a recurrent hernia. Our findings showed that a higher BMI was significantly linked with higher risk to undergo recurrent hernia repair. This was in agreement with many investigations, yet on other hand, results in the literature suggested that BMI has no effect on recurrence following hernia repair. The probable explanation for these mixed results is the heterogeneity of the study population., This contributes to our result that diabetics are more likely to have a repair for recurrence. However, a previous study reported an opposed association with the possible etiology is that their comorbidities regarding diabetes prevent them from undergoing surgeries.
We found that the female gender was associated with a higher recurrence rate, albeit not significantly. This finding was significantly found in a previous study quantifying the existing evidence on the patient-related risk factors for recurrence. The reason why combines pathophysiology, ana-pathology and technical aspects. The higher risk of recurrence in association to smoking might be due to modification in changed composition probably caused by temporary tissue hypoxia. Some studies declined the relationship between age and recurrence rate, while others had suggested that older age was significantly related to a recurrence following IH repair., Our findings suggest the hypothesis of impaired wound healing in older patients. Besides recurrence, the lifetime risk of getting an IH is much higher in males (27%) than females (3%). However, the female gender has been reported to increase the risk of hernia recurrence which aligns with our results, yet the relationship was not statistically significant. Furthermore, the complications following hernia repair were equally distributed between males and females with no predominance. As far as, we know no previous study stratifying these complications according to gender.
The current study embedded several limitations including the retrospective design, resulting in the risk of underreporting data, incomplete data collection, insufficient information on the possible confounder, and missing information on data quality. It is also important to point out that the study was conducted in a single-center, therefore limiting the generalizability of its findings. The main strong points are the very large size of the study and the long 14-year-period.
| Conclusion|| |
The aim of this study was to investigate the rates of recurrence after Lichtenstein mesh repair overall and to evaluate if there is any gender-specific difference in these patients. We have identified several likely factors associated with higher recurrence after hernia repair such as older age, higher BMI, the existence of comorbidities, in addition to smoking. A comparison of the rates of recurrence and complications between different procedures should, therefore, be an important topic to address in future studies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]