Optimizing Inguinal Hernia Surgery

Abstract

The aim of this thesis has not just been to expose problems, obstacles, or lacking consensus, but to provide pragmatic solutions and recommendations to optimize inguinal hernia surgery. This thesis focusses on three key-aspects of inguinal hernia surgery that remain controversial in the present-day treatment of inguinal hernia patients. What type of mesh should be used for open and laparo-endoscopic inguinal hernia surgery? Do specific patient populations benefit from patient-tailored surgery? And what is the purpose and necessity of follow-up after inguinal hernia surgery, and how should follow-up be organized?

This thesis has provided an end to the debate on the type of mesh, which has been ongoing for almost 2 decades. Open (Lichtenstein) inguinal hernia repairs can be optimized using a lightweight mesh. The use of lightweight mesh decreases the risk of developing chronic pain and foreign body feeling, while no difference in risk of recurrence was established. Laparo-endoscopic inguinal hernia repairs can be optimized using a heavyweight mesh for direct or large inguinal hernias. For indirect inguinal hernias, no difference was detected. Using lightweight mesh significantly increased, and more than doubled, the risk of developing a recurrence, especially in non-fixated lightweight mesh.

In this thesis the treatment strategy was optimized for three specific patient populations with inguinal complaints: young patients with an inguinal hernia, athletes that suffer from inguinal disruption, and inguinal hernia patients in the work-up for a radical prostatectomy. This thesis demonstrated that young adults (18-30 years) compared to older adults (≥31 years) do not experience more CPIP after TEP hernia repair in a high-volume hernia clinic. Moreover, athletes with inguinal disruption, selected through a multidisciplinary work-up, benefit from TEP repair. Furthermore, urological surgeons report technical surgical difficulties that can lead to aborted radical prostatectomies, additional interventions for mesh explantation or inguinal hernia recurrences, and increased healthcare costs. In particular, a less adequate pelvic lymph node dissection is undisputed and considered clinically most important since it can result in under-staging and under-treatment of prostate cancer patients.

Follow-up after inguinal hernia surgery is performed with a patient-related purpose, in research settings, and to register data for internal quality control and national or international benchmarking. In this thesis the efficiency and purpose of regular follow-up after TEP inguinal hernia repair was evaluated, and patient appreciation with follow-up was determined. It was determined that follow-up after TEP inguinal hernia surgery serves no clinical purpose. The purpose of follow-up is patient satisfaction and data registration for quality objectives. Additionally, the PINQ-PHONE was found to be a valuable tool in TEP repair follow-up by telephone to detect recurrences, and further optimized to have more patients refrain from visiting the outpatient clinic and still safely detect all recurrences. Finally, a study protocol was presented to determine the validity, relaibility and patient satisfaction with the Inguinal Hernia Application that can potentially substitute follow-up after inguinal hernia surgery by telephone or at the outpatient clinic.