Audit of groin hernia repair

Sammanfattning: Inguinal hernia repair is the most frequent procedure in general surgery. In the USA approximately 700,000 groin hernioplasties are carried out annually and accounts for almost US$ 3 billion in annual health care revenue. In Sweden approximately 20,000 hernia operations are performed annually and more than 3,000 of them are recurrent hernias. The renewed interest in cost-effectiveness and the introduction of new techniques, among them laparoscopic surgery, underlines the importance of quality assurance in hernia surgery. The aim of this thesis was to establish an audit of hernia surgery in a defined population allowing evaluation of management, riskfactors, outcome and economy. The method of control and definition of recurrence was studied. When recurrence was classified as "a weakness in the operated area necessitating a further operation or provision of a truss", the predictive value for postitive (recurrence) and negative (no recurrence) answers in the questionnaire was 38 and 99%, respectively. Thus, by using a questionnaire to identify symptomatic recurrences only a minority of the patients (10%) had to be examined at a follow-up . A study of eight Swedish hospitals showed that it is possible to include more than 99% in a medical audit of hernia operations within the frame-work of routine registration. In a three-year follow-up study of these hospitals, the total recurrence rate was 9.6% with an interhospital variation between 3.1 and 20.5%. Postoperative complications, direct hernia and recurrent hernia were factors associated with an increased risk for recurrence. The re-operation rate for recurrence may be an appropriate surrogate endpoint, although this underestimates the real recurrence rate by approximately 40%. An audit scheme based on prospective registration, annual analysis of outcome, regular use of questionnaire and selective follow-up, can identify significant inter hospital differences in outcome as well as variables associated with increased risk for recurrence, thereby raising quality awareness and facilitating the process of improvement. The introduction of a new technique, laparoscopic hernia repair, was studied in one of the units participating in the overall prospective registration. Two surgeons performed over 90% of the operations. After an initial period with 6 recurrences in the first 31 patients (recurrence rate 22.6%), the results improved and only one recurrence was diagnosed in the following 395 patients who underwent 360 transabdominal and 98 totally extraperitoneal repairs (recurrence rate 0.2%) with a mean (SD) follow-up of 19 (10) months. In the treatment of recurrent hernias a tenfold difference in recurrence rate was obtained by one unit using the laparoscopic approach with a preperitoneal mesh, compared to the three-year follow-up results from the eight hospitals studied. Laparoscopic hernia repair was cost-effective compared to the Shouldice operation among employed patients, due to faster recovery, provided that hoth direct and indirect costs were included. If laparoscopic herniarepair is considered the totally extraperitoneal operation should be used because of the risk for serious intraabdominal complications with the transabdominal technique.