Efficiency in inguinal hernia repair

Abstract

In the past few decades the quality of inguinal hernia surgery has improved drastically. Recurrence rates have fallen below 5% after the introduction of mesh repair and post-operative pain rates have dropped since laparoscopy was introduced. Now that technical improvements appear to have reached a plateau and post-operative pain and recurrence rates are at acceptably low levels, the interest concerning inguinal hernia repair appears to have shifted towards efficiency. Therefore, doctors are not only held responsible for improving quality of care, they are also obliged to pursue improvement of efficiency and eradicate waste. This can be achieved by simplifying care and administration, reducing errors and complications and avoiding redundant or low-value medical practice (e.g. operations in patients without complaints or unnecessary medical imaging). Concerning the question of how health care systems can further ensure efficiency in inguinal hernia surgery, it would be wrong to pretend there is one answer. ‘Efficiency’ is a dynamic concept that will continue to evolve. However, the work presented in this thesis is a modest step towards (evaluating) efficiency in the current practice of inguinal hernia repair. The following conclusions may be drawn from the studies presented in this thesis: Single-visit endoscopic TEP inguinal hernia repair is cost-effective compared to regular TEP procedures from both a hospital and a societal perspective, of which the reduction in societal costs is the most contributory. Ultrasound diagnostics in patients with clinically apparent inguinal hernias is redundantly requested in primary care. The probability of wrongly attributing groin complaints to an incidental inguinal hernia, diagnosed on ultrasound, is considerable. Reducing recurrence rates can be achieved by mesh fixation in bilateral, large and direct defects and by thoroughly searching for, and subsequently removing, preperitoneal lipomas. Ultrasound does not need to be incorporated in the diagnostic workup of an apparent recurrent inguinal hernia. Young adults (18–30 years) do not experience more CPIP after TEP hernia repair compared to older adults (≥31 years). In the majority of European countries, administration of antibiotic prophylaxis in open inguinal hernia repair can be considered overtreatment.