Introduction

Inguinal hernia repair is the most frequent operation in general surgery (1). The most important criteria for the choice of surgical technique are safety, recurrence rate and satisfaction to the patient (2). Recurrence rates vary considerably for the various techniques: from less than 5% to 25% (3). Recurrences are important as many of these need repeated surgery (4). Repeated surgeries are difficult with predictable increased morbidity and overall costs. Improving the results would therefore have a useful medical and economic impact. Mesh techniques have been reported to have the lowest recurrence rates, with Lichtenstein as the prototype (5). In the recent past, a newer technique that combines the three principles of onlay, plug and underlay mesh placement has been developed. Such meshes include the prolene hernia system (PHS) or ultrapro hernia system (UHS). This bilayer mesh has shown promising results. Overall, there was a trend toward decreased complications, with a significant difference in the hematoma/seroma rates, and a significant decrease in the recurrence rate for the PHS mesh group (6,7). Inguinodynia is pain or discomfort lasting greater than 3 months after surgery (8). However, it is suggested that it may be due to entrapment of the ilioinguinal, iliohypogastric or genital branch of the genitofemoral nerve either in the sutures, mesh or scar tissue (9-11). The aim of this study was to document the recurrence and inguinodynia rates among patients undergoing mesh hernioplasty at KNH, a non-hernia specialist centre.

 

Methods

After study approval by institutional ethical board, data from eligible patients were abstracted from the patients’ records. All patients who had been operated for groin hernia using mesh technique at KNH since year 2006 were included in the study. Demographic and peri-operative information was collected. The files were further scrutinized for two outcomes of interest (hernia recurrence and pain/ discomfort). To increase completeness of the data, phone calls were made to the patients to inquire if hernia had recurred and if they had inguinodynia. Two trained final year medical students were utilized to make the calls and every tenth call was corroborated by the main author. The respondents were asked if a swelling similar to a previous one had recurred and if they had discomfort or pain in the groin that interfered with their activities of daily living.

 

Results

A total of 246 (250 herniae) patients met the eligibility criteria and were included in the study. The mean age was 44.1 years ( SD 17.7, range 16-85). The modal age group was 30-39 years. Male patients were the majority at 95.1% (n= 234). Majority of the hernias were right sided (n=160, 65.3%) with4 hernias being bilateral (1.6%). Only 101 (40%) of the hernia were classified with indirect (lateral) forming 71% of them. Majority (N=181, 73.6%) were operated using mesh technique utilizing Lichtenstein (73, 40.3%) and bilayer (104, 57.5%). Four of the mesh techniques were not defined. Micro-porous mesh (prolene type) was utilized in 126 (70%) of the cases, while macro-porous vypro in 44 (24.4%) and ultrapro in 3 cases. Of the 181 patients with mesh repair, 129 were traced via telephone for assessment of pain and recurrence. The follow up period ranged from 14 to 91 months with a median follow up period of 37 months (3 years 1 month). Six patients reported a recurrence representing 4.7% over the follow up period. Of these, 3 had a bilayer device inserted while the other 3 had a Lichtenstein repair. Thirty nine (30.2%) reported pain or discomfort in the groin over the same follow up period. Of these, 24 had a bilayer repair, while the other 15 had a Lichtenstein repair.

 

Discussion

Inguinal hernia is a common surgical condition that is highly prevalent among men (12). It is associated with risk of various complications including obstruction, strangulation and potential for death. Untreated, even when life threatening complications do not occur, it may enlarge and interfere with the individuals’ quality of life (13). When no contraindications exist, inguinal hernias have continued to be treated by surgery. However, it has continued to be dogged by multiple complications, amongst them being a high recurrence rate (3). Other complications include seroma, infection and persistent groin pain (inguinodynia). Pain can be quite debilitating and influence the choice of a treatment modality (14). The treatment of hernia has a large economic impact, given the high prevalence of the disease. The impact of treatment of a recurrence is higher. Surgery for recurrent disease is more difficult with potential for higher morbidity (15). In a meta-analysis recurrence rates reduced from 3.6% vs. 0.8% when Shouldice technique “the gold standard” was compared with mesh repair (16,17). These rates differ from specialist versus non specialist hernia centers. Our non-specialist centre had a recurrence rate of 4.7%. Burcharth in a review of the Danish hernia registry reported an overall inguinal hernia re-operation rate of 3.8%. He acknowledged re-operation rates underestimate recurrence rates (18). Other studies have reported rates that do not widely differ from ours (19).

​Post-surgical chronic pain represents a major, largely unrecognized clinical problem. High rates of pain have been reported. Several studies and randomized clinical trials indicate that up to 30% of patients report some form of pain 1 year after Lichtenstein hernia repair (20, 21). Our rate of inguinal pain or inguinal discomfort was similarly quite high at 30.2%. A recent meta-analysis suggested that use of pre-peritoneal approach and mesh placement may have less prevalence of pain due to reduced dissection that affects nerves in the inguinal canal (22).

 

Conclusion

The inguinal hernia recurrence rates reported are acceptable in a non-hernia specialist center. However, like other authors the pain and groin discomfort rates were high. We suggest that pain should be the new target of outcome measure given the low rates of recurrence.

 

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