The Importance of Hernia Outcomes Research in Inguinal Hernia Surgery

Hernia Recurrence Outcome

What is the real recurrence rate for inguinal hernia surgery?  What are hernia outcomes that are important to patients? As an inguinal hernia surgery care team, we try to find out what is important to our patients and educate them about our outcomes. One hernia outcome measure that is widely used and publicized is recurrence rate ( failure rate) of the hernia surgery.  

Hernia repair

There are many different ways to repair an inguinal hernia. The lichtenstein mesh repair is most commonly performed in the United States, but other types include laparoscopic hernia repair, suture only repair, and open preperitoneal hernia repair. You can learn more about the different repairs here   Most surgeons, myself included, quote that the recurrence rate of inguinal hernia repair is about 1%. This number is based on the most optimistic outcomes reported in the literature.   

Recent Data On Recurrence Rates After Hernia Surgery:

How do we really know if this recurrence rate is realistic? Several articles have suggested that the overall recurrence rate may be as high as 5-10%. A recent review published last month in the journal Surgery examined several national database and found that 5-10% was the recurrence rate that is seen in the US.

In 2006 Fitzgibbons et al demonstrated that the recurrence rate for laparoscopic hernia repair with mesh was 10%, double the 5% recurrence rate of open hernia repair with mesh. The study also found that only surgeons who performed over 250 laparoscopic hernia operations were able to approach the outcomes of open surgery and have recurrence rates close to 5%.  

Setting Expectations for Hernia Surgery

Do we, as surgeons, set our patients’ expectations too high? That may be the case. We see many patients that have had their first hernia surgery elsewhere, and come to us for their recurrence. Are our patients doing the same? The only way to know the answers to these questions is to do serious hernia outcome studies.   The American Hernia Society, in 2017 added inguinal hernia outcomes to it’s 3 year old Quality Collaborative (AHSQC).  This as well as national registries like the ones in Europe have given hernia surgeons more insights about the care we provide.

Importance Of Data Collection

The Shouldice Hospital near Toronto utilized Ontario’s database to demonstrate that high volume surgeons doing a standardized no-mesh hernia repair have superior outcomes to other hospitals in Ontario. They published a study that has shown, with appropriate patient selection, their recurrence rates are as low as 1.15%. We recently conducted a study over several months looking at short term outcomes of our postoperative hernia patients. We were able to demonstrate very low short term recurrence rate in our patients who underwent the open preperitoneal hernia repair. This is the same repair that is performed laparoscopically, or with a robot, yet we do our repair under local anesthesia with sedation, rather than general anesthesia.  This repair leads to faster recovery.  Data collection can be onerous, and we need more long term data to be able to accurately quote our recurrence rate. Luckily, the AHSQC, has a goal of entering most  hernia patients into a national database to track important outcomes, including hernia recurrence. By participating in the AHSQC, we hope that data will lead to improvements in the quality of hernia care.