Morten Bay-Nielsen

Pain and functional impairment 1 year after inguinal herniorrhaphy: a nationwide questionnaire study.

ObjectiveTo determine the incidence of groin pain 1 year after inguinal herniorrhaphy and to assess the influence of chronic groin pain on function. Summary Background DataThe reported incidence of chronic pain after inguinal herniorrhaphy varies from 0% to 37%. No cross-sectional cohort studies with high follow-up rates have addressed this problem, and there is a lack of assessment of the functional consequences of chronic groin pain after herniorrhaphy. MethodsTwo sets of self-administered questionnaires were mailed 1 year after surgery. The first established the incidence of chronic groin pain. The second characterized the pain and the effect of the pain on the function of those reporting pain. The study population comprised patients older than age 18 years registered in the Danish Hernia Database who underwent surgery between February 1, 1998, and March 31, 1998. ResultsThe response rate to the first questionnaire was 80.8%. Pain in the groin area was reported by 28.7%, and 11.0% reported that pain was interfering with work or leisure activity. Older patients had a lower incidence of pain. There were no differences in the incidence of pain with regard to the different types of hernia, the different types of surgical repairs, or the different types of anesthesia. The second questionnaire was returned by 83%. Of these, 46 (4%) reported constant pain. The intensity of pain while at rest was moderate or severe in 40 (3%); with physical activity, pain was moderate or severe in 91 (8%). Impairment of specific daily activities as a result of pain was reported by 194 (16.6%). Pain characteristics were predominantly sensory, with a low use of affective terms. ConclusionOne year after inguinal hernia repair, pain is common (28.7%) and is associated with functional impairment in more than half of those with pain. These factors should be addressed when discussing the need for surgical intervention for an inguinal hernia.

Quality assessment of 26 304 herniorrhaphies in Denmark: a prospective nationwide study

BACKGROUND Groin hernia repair is one of the most frequent operations, but there is no consensus about surgical or anaesthetic technique. Furthermore, no nationwide studies have been done. Our aim was to investigate outcome results of groin hernia surgery to improve quality of treatment. METHODS We prospectively recorded 26304 groin hernia repairs done in Denmark from Jan 1, 1998, to June 30, 2000, in a nationwide Danish hernia database. FINDINGS 93% of all groin herniorrhaphies done in Denmark in the 30 months of the study were recorded in the database. Kaplan-Meier estimates of reoperation rates 30 months after anterior mesh repair and laparoscopic repair were significantly lower than after sutured posterior wall repairs in primary inguinal hernia (2.2% and 2.6% vs 4.4%; p<0.0001). Reoperation rates were also lower with anterior mesh repair (6.1%; p<0.0001) and laparoscopic repair (3.4%; p<0.0001) than with sutured posterior wall repair (10.6%) after recurrent hernia. Use of Lichtenstein mesh repair increased from 33% in January, 1998, to 62% in June, 2000, whereas use of laparoscopic repair remained constant at about 5%. Kaplan-Meier estimates of reoperation rates were 2.8% in the first 15 months and 1.6% in the second (p=0.03). For elective repairs, only 59% of patients were treated on an outpatient basis, and only 18% had local anaesthesia. INTERPRETATION Mesh repairs have a lower reoperation rate than conventional open repairs. Systematic prospective recording of treatment and outcome variables in a national clinical database improved the overall quality of surgical care. However, there is a large potential for cost savings and more efficient patient care with extended use of mesh techniques, outpatient surgery, and local anaesthesia.

Re-recurrence After Operation for Recurrent Inguinal Hernia. A Nationwide 8-Year Follow-up Study on the Role of Type of Repair

Objectives:We analyze, on a nationwide basis, the risk of re-reoperation with reference to previous inguinal hernia repair technique. Summary Background Data:Operation for a recurrent inguinal hernia is common and the risk of re-recurrence is high. There are no large-scale data evaluating the surgical strategy and results after recurrent inguinal hernia repairs. Methods:Prospective recording of all primary and subsequent recurrent inguinal hernia repairs from January 1, 1998 to December 31, 2005, in the national Danish Hernia Database, using the reoperation rate as a proxy for recurrence. The re-reoperation rate was analyzed with reference to the technique of primary and recurrent inguinal hernia repair. Results:After 67,306 primary hernia repairs there were 2117 reoperations (3.1%) and 187 re-reoperations (8.8%). The cumulated re-reoperation rate after primary Lichtenstein repair (n = 1124) was significantly reduced after laparoscopic operation for recurrence (1.3% (95% CI: 0.4–3.0)) compared with open repairs for recurrence (Lichtenstein 11.3% (8.2–15.2), nonmesh 19.2% (14.0–25.4), mesh (non-Lichtenstein) 7.2% (4.0 – 11.8)). After primary nonmesh (n = 616), non-Lichtenstein mesh (n = 277), and laparoscopic repair (n = 100) there was no significant difference in re-reoperation rates between a laparoscopic repair and all open techniques of repair for recurrence. Conclusion:Laparoscopic repair is recommended for reoperation of a recurrence after primary open Lichtenstein repair.

Pain related sexual dysfunction after inguinal herniorrhaphy

Abstract To determine the incidence of pain related sexual dysfunction 1 year after inguinal herniorrhaphy and to assess the impact pain has on sexual function. In contrast to the well‐described about 10% risk of chronic wound related pain after inguinal herniorrhaphy, chronic genital pain, dysejaculation, and sexual dysfunction have only been described sporadically. The aim was therefore to describe these symptoms in a questionnaire study. A nationwide detailed questionnaire study in September 2004 of pain related sexual dysfunction in all men aged 18–40 years undergoing inguinal herniorrhaphy between October 2002 and June 2003 (n = 1015) based upon the nationwide Danish Hernia Database collaboration. The response rate was 68.4%. Combined frequent and moderate or severe pain from the previous hernia site during activity was reported by 187 patients (18.4%). Pain during sexual activity was reported by 224 patients (22.1%), of which 68 (6.7%) had moderate or severe pain occurring every third time or more. Genital or ejaculatory pain was found in 125 patients (12.3%), and 28 (2.8%) patients reported that the pain impaired their sexual activity to a moderate or severe degree. Pain during sexual activity and subsequent sexual dysfunction represent a clinically significant problem in about 3% of younger male patients with a previous inguinal herniorrhaphy. Intraoperative nerve damage and disposition to other chronic pain conditions are among the most likely pathogenic factors.

Operative findings in recurrent hernia after a Lichtenstein procedure

BACKGROUND Recurrence after inguinal herniorraphy continues to be a problem, although the Lichtenstein technique (anterior, open fixated sheet mesh) is associated with reduced recurrence rates. Recurrence after Lichtenstein repair is suspected to be caused by insufficient fixation and overlap at the pubic tubercle. METHODS A review was made of 87 records from operations for recurrence after a previous Lichtenstein procedure, based upon national and large area data bases, recording 95% (Denmark) and 50% (Sweden) of all inguinal hernia operations. RESULTS Direct recurrences were found in 62%, whereas the remaining recurrences were either indirect (17%), femoral (13%), or other/unclassified (8%). CONCLUSION The most plausible explanation for the development of the direct recurrences is an insufficient medial mesh fixation and overlap over the pubic tubercle. Avoidance of more than half of the recurrences after the Lichtenstein repair may be obtained by increased attention to this specific technical aspect of the operation.

Risk of recurrence 5 years or more after primary Lichtenstein mesh and sutured inguinal hernia repair

The risk of recurrence of inguinal hernia within 5 years of repair is lower after mesh than sutured repair in men, but no large‐scale studies have compared the risk of recurrence beyond 5 years.

Establishment of a national Danish hernia data base: preliminary report

SummaryDespite improvements in hernia surgery, there are still unsolved problems, especially when operations are performed outside dedicated hernia centres: reduction of recurrence rates, selection of the optimal anesthesia, reduction of length of stay and formulation of evidence based convalescence recommendations. Most of these problems can only be solved through collaboration and multicenter studies. By setting up a national clinical data base for hernia surgery, we aim to establish a scientific basis for the surgical practise in hernia surgery, based on two parallel strategies: 1) to collect nation wide information on the relation between the procedures performed and rates of operation for recurrence, choice of anesthesia and length of stay and 2) to use the data base collaboration to establish multicenter prospective clinical trials. A simple, inexpensive and functional data base was developed and started registration on 1. Jan 1998, with current participation of departments and outpatient clinics, performing approximately 95% of hernia repairs in Denmark. Presently, 3 prospective multicenter studies are under development. A national Danish hernia data base is in function and has the potential to monitor and improve current practise in hernia surgery.

Authors' reply: prospective nationwide analysis of laparoscopic versus Lichtenstein repair of inguinal hernia (Br J Surg 2005; 92: 1277-1281)

The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses can be sent electronically via the BJS website (www.bjs.co.uk) or by post. All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length. Letters submitted by post should be typed on A4-sized paper in double spacing and should be accompanied by a disk.

Authors' reply: Risk of recurrence 5 years or more after primary Lichtenstein mesh and sutured inguinal hernia repair (Br J Surg 2007; 94: 1038–1040)

1 Ravn H, Bergqvist D, Björck M. Nationwide study of the outcome of popliteal artery aneurysms treated surgically. Br J Surg 2007; 94: 970–977. 2 Ravn H, Björck M. Popliteal artery aneurysm with acute ischemia in 229 patients. Outcome after thrombolytic and surgical therapy. Eur J Vasc Endovasc Surg 2007; 33: 690–695. 3 Ravn H, Wanhainen A, Bjorck M. Surgical technique and long-term results after popliteal artery aneurysm repair: results from 717 legs. J Vasc Surg 2007; 46: 236–243. 4 Ravn H, Wanhainen A, Bjorck M. High risk to develop new aneurysms after surgery for popliteal artery aneurysm. A study based on 190 re-examined patients with a median follow-up of seven years. Submitted manuscript.