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A steep increase of small papillary thyroid cancers (sPTCs) has been observed globally. A major risk factor for developing PTC is ionizing radiation. The aim of this study is to investigate whether geological differences in the prevalence of sPTCs in Sweden are correlated to the deposit of Caecium-137, Thorium-232 (Th-232), Uranium-238 (U-238) or Potassium-40 (K-40) using different Geographical Information System (GIS) methods. Datasets of 812 sPTC patients were combined with the datasets of the total population in Sweden and were layered with the gamma radionuclide deposits. The prevalence of metastatic sPTC was associated with significantly higher levels of Gamma radiation from Th-232, U-238 and K-40. The observed results clearly indicate that sPTC has causative factors that are neither evenly distributed among the population, nor geographically, calling for further studies with bigger cohorts where environmental factors are believed to play a major role in the pathogenesis of the disease.

The COVID-19 pandemic posed a significant threat to healthcare systems worldwide. Efforts to contain the pandemic, including lock-down and cancellation of elective surgery, increased barriers to healthcare. Its impact on the access to surgical care of children in less resourced contexts is not known. This study investigated how paediatric surgical services was affected during the pandemic in the Teso sub-region in Eastern Uganda. Data were collected from theatre logbooks about surgical activity before and during the pandemic (2019–2021). Data about health workers’ and parents’ experience of how access to surgical service for children was affected during the Covid-19 pandemic were collected through interviews. Total surgical procedures for children increased by 24% between 2019 (n = 1407) and 2021 (n = 1751). Procedures performed for pregnancy-related conditions increased most (58.3% increment). 12 parents and 25 health workers participated in the interviews. Using reflexive thematic analysis, two themes emerged. A reduction of surgical service delivery was expected as barriers to surgical care increased in several ways. However, the number of surgical procedures performed increased compared to before the pandemic. Many lessons were learned, and health care system was reinforced. This is an important momentum for building a resilient health care system for future challenges.

The aim of this study was to evaluate chronic pain 1 year after surgery, and risk factors for chronic pain after groin hernia repair in women.Groin hernia surgery in women is less frequently studied than in men. Chronic pain is common after groin hernia surgery and remains an important area with room for improvement. Previous studies are small or inconclusive. Guidelines recommend timely repair of all female groin hernias.From the Swedish Hernia Register 4021 female and 37,542 male patients operated between September 1, 2012 and August 30, 2017 responded to a patient-reported outcome questionnaire (response rate 70.0%) 1 year after primary groin hernia surgery. Multivariable analysis was performed to compare chronic postoperative pain in women with men as a control group, and to evaluate risk factors for chronic pain in women.Among women operated for groin hernia, 18% suffered chronic postoperative pain. The risk for chronic pain was significantly higher for women [odds ratio 1.3 (95% confidence interval 1.16-1.46). Three risk factors for chronic pain in women were found: high body mass index, high American Society of Anesthesiologists classification, and femoral hernia. No differences in chronic pain in women were seen when comparing surgical methods or emergency versus elective surgery.Almost one-fifth of women suffered of chronic pain affecting daily activity after groin hernia repair. Chronic pain was more common for women than men. In view of the high-rate chronic postoperative pain, further research on management strategies in female groin hernia is warranted.

Background The organization of healthcare could have an impact on the outcome of patients treated for acute cholecystitis (AC). The aim of this study was to analyze the way in which patients with AC are managed relative to the level of care by the treating hospital. Methods Data were collected from the Swedish Register for Gallstone Surgery and ERCP (GallRiks). Cholecystectomies between 2010 and 2019 were included. The inclusion criterion was acute cholecystectomy in patients with AC operated at either tertiary referral centers (TRCs) or regional hospitals. Results A total of 24,194 cholecystectomies with AC met the inclusion criterion. The time between admission and acute surgery was significantly elongated at TRCs compared with regional hospitals (2.2 ± 1.7 days vs. 1.6 ± 1.4 days, mean ± SD; p p p Surprisingly, an increased number of hospital beds correlated slightly with an increased number of days between admission and surgery (R2 = 0.132; p = 0.0075). Conclusion Compared with regional hospitals, patients with AC had to wait longer at TRCs before surgery. A history of AC significantly increased the risk of adverse events. These findings indicate that logistic and organizational aspects of hospital care may affect the management of patients with AC. However, whether these findings can be generalized to healthcare organizations outside Sweden requires further investigation.

The role of surgery in global health has gained greater attention in recent years. Approximately 1.8 billion children below 15 years live in low- and middle-income countries (LMIC). Many surgical conditions affect children. Therefore, paediatric surgery requires specific emphasis. Left unattended, the consequences can be dire. Despite this, there is a paucity of data regarding prevalence of surgical conditions in children in LMIC. The present objective was to investigate the prevalence of paediatric surgical conditions in children in a defined geographical area in Eastern Uganda.A cross-sectional study was carried out in the Iganga-Mayuge Health and Demographic Surveillance Site located in Eastern Uganda. Through a two-stage, cluster-based sampling process, 490 households from 49 villages were randomly selected, generating a study population of 1581 children. The children's caregivers were interviewed, and the children were physically examined by two medical doctors to identify any surgical conditions.The interview was performed with 1581 children, and 1054 were physically examined. Among these, the overall prevalence of any surgical condition was 16.0 per cent (n = 169). Of these, 39 per cent had an unmet surgical need (66 of 169). This is equivalent to a 6.3 per cent prevalence of current unmet surgical need. The most common groups of surgical condition were congenital anomalies and trauma-related conditions.Surgical conditions in children are common in eastern Uganda. The unmet need for surgery is high. With a growing population, the need for paediatric surgical capacity will increase even further. The health care system must be reinforced to provide services for children with surgical conditions if United Nations Sustainability Development Goal 3 is to be achieved by 2030.

Objectives: To estimate the incidence of men seeking specialized care and receiving treatment for hydro or spermatocele complaints. Also, to determine the risk of complications of treatment.Materia...

Elective caesarean delivery is increasing rapidly in many countries, and one of the reasons might be that caesarean delivery is widely believed to protect against pelvic floor disorders, including anal incontinence. Previous studies on this issue have been small and with conflicting results. The aim of present study was to compare the risk of developing anal incontinence in women who had a caesarean delivery, in those who had a vaginal delivery, and in two age-matched control groups (nulliparous women and men).In this observational population-based study, we included all women in the Swedish Medical Birth Register who gave birth by caesarean delivery or vaginal delivery during 1973-2015 in Sweden and were diagnosed with anal incontinence according to ICD 8-10 in the Swedish National Patient Register during 2001-15. Exclusion criteria were multiple birth delivery, mixed vaginal and caesarean delivery, and four or more deliveries. We compared the diagnosis of anal incontinence between women previously delivered solely by caesarean delivery and those who solely had delivered vaginally. We also compared it with two age-matched control groups of nulliparous women and men from the Swedish Total Population Register. Finally, we analysed risk factors for anal incontinence in the caesarean delivery and vaginal delivery groups.3 755 110 individuals were included in the study. Between 1973 and 2015, 185 219 women had a caesarean delivery only and 1 400 935 delivered vaginally only. 416 (0·22 %) of the 185 219 women in the caesarean delivery group were diagnosed with anal incontinence compared with 5171 (0·37%) of 1 400 935 women in the vaginal delivery group. The odds ratio (OR) for being diagnosed with anal incontinence after vaginal delivery compared with caesarean delivery was 1·65 (95% CI 1·49-1·82; p0·0001). When the combination vaginal delivery and caesarean delivery was compared with the nulliparous control group, the OR of being diagnosed with anal incontinence was 2·05 (1·92-2·19; p0·0001). For the nulliparous women compared with men, the OR for anal incontinence was 1·89 (1·75-2·05; p0·0001). The strongest risk factors for anal incontinence after vaginal delivery were high maternal age, high birthweight of the child, and instrumental delivery. The only risk factor for anal incontinence after caesarean delivery was maternal age.The risk of developing anal incontinence increases after pregnancy and delivery. Women with known risk factors for anal incontinence should perhaps be offered a more qualified post-partum examination to enable early intervention in case of injury. Further knowledge for optimal management are needed.County Council of Jämtland.

Background: The lack of studies showing benefit from surgery in patients with symptoms of gallstone disease has led to a divergence in local practices and standards of care. This study aimed to explore regional differences in management and complications in Sweden. Furthermore, to study whether population density had an impact on management. Methods: Data were collected from the Swedish National Register for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks). Cholecystectomies undertaken for gallstone disease between January 2006 and December 2017 were included. Age, sex, American Society of Anesthesiologists (ASA) classification, intra- and post-operative complications, and the proportion of patients with acute cholecystitis who underwent surgery within 2 days of hospital admission were analyzed. The 21 different geographical regions in Sweden were compared, and each variable was analyzed according to population density. Results: A total of 139,444 cholecystectomies cases were included in this study. There were large differences between regions regarding indications for surgery and intra- and post-operative complications. In the analyses, there were greater divergences than would be expected by chance for most of the variables analyzed. Age of the cholecystectomized patients correlated with population density of the regions (R2 = 0.310; p = 0.0088). Conclusions: There are major differences between the different regions in Sweden in terms of the treatment of gallstone disease and outcome, but these did not correlate to population density, suggesting that local routines are more likely to have an impact on treatment strategies rather than demographic factors. These differences need further investigation to reveal the underlying causes.

Background and aims A high body mass index (BMI) is considered a risk factor for ventral abdominal wall hernias but protective for the development of groin hernias. The reason for this is unclear. The surrounding abdominal fat in obesity might “protect” and limit the passage through the inguinal canal. The aim was to compare two different methods used for obesity registration in groin hernia patients and to investigate the hypothesis of high BMI/low groin hernia risk phenomenon. Methods This was a population-based observational study comparing BMI to waist circumference (WC) as well as their correlations to the quantity of groin hernia repair performed in either sex. Two national registers were crosslinked to a large regional register including information on WC. Results A larger WC and a higher BMI were associated with a lower risk of having groin hernia repair in both sexes. There was no difference using either WC or BMI as a risk factor for groin hernia repair in either sex. There was no advantage to using body composition based on WC rather than BMI for surgery indication. Conclusions Overweight patients, both men and women, have a lower risk of undergoing groin hernia repair regardless of fat distribution. BMI is a well-established method for obesity registration and is recommended in the evaluation of hernia patients.

Introduction: Rates of cesarean section are rising in both developed and developing countries and while pregnancy and cesarean section are established as risk factors for thromboembolism and stroke, large population-based investigations focusing on all types of cardiovascular complication after delivery is missing. The aim was to analyze the risk of severe cardiovascular complications in the post-partum period following delivery by cesarean section. We also had a control group of vaginal deliveries and a reference group with nulliparas. Materials and Methods: This Swedish population-based study used three national registers between 2005 and 2017 and comprised a total of 1 165 684 individuals. Unselected register data was cross-linked and cardiovascular adverse events were identified by ICD diagnosis codes. 140 128 women (209 391 deliveries) were included in the cesarean group and 614 355 women (973 429 deliveries) in the vaginal control group. The reference group comprised 411 201 age-matched nulliparous women. The primary analysis was the risk of severe cardiovascular complications within 42 days of cesarean section or vaginal delivery. The secondary analysis evaluated risk factors for cardiovascular complications. Results: In the cesarean section group, 410 (0.20%) had a serious cardiovascular event within 42 days after delivery, and in the vaginal control group the number was 857 (0.09%). The risk of having an adverse cardiovascular event was significantly greater in the cesarean group (OR 2.23, CI 1.98 to 2.51) for all types of cardiovascular events. Risk factors were high BMI, preeclampsia, greater maternal age, tobacco use and acute cesarean delivery. Conclusions: The absolute numbers on severe maternal morbidity after delivery are low. However, since almost half of the world’s population are affected and the frequency of elective cesarean section continues to rise, a doubling of the risk for a severe cardiovascular event within 42 days of delivery is important to consider globally.

ObjectiveThis study investigated the surgical services for children at the highest levels of the public healthcare sector in Uganda. The aim was to determine volumes and types of procedure performed and the patients and the human resource involved.DesignThe study was a facility-based, record review.SettingThe study was carried out at the National Referral Hospital, all 14 regional referral hospitals and 14 general hospitals in Uganda, representing the highest levels of hospital in the public healthcare sector.ParticipantsThe subjects were children ResultsThe study hospitals contribute with an average annual rate of paediatric surgery at 22.0 per 100 000 paediatric population. This is a fraction of the estimated need. Most of the procedures were performed for congenital anomalies (n=3111, 39.4%), inflammation and infection (n=2264, 28.7%) and trauma (n=1210, 15.3%). Specialist surgeons performed 60.3% (n=4758) of the procedures, and anaesthesia was administered by specialist physician anaesthetists in 11.6% (n=917) of the cases.ConclusionsA variety of paediatric surgical procedures are performed in a relatively decentralised system throughout Uganda. Task shifting and task sharing of surgery and anaesthesia are widespread: a large proportion of surgical procedures was carried out by non-specialist physicians, with anaesthesia mostly delivered by non-physician anaesthetists. Reinforcing the capacity and promoting the expansion of the health facilities studied, in particular the general hospitals and regional referral hospitals, could help reduce the immense unmet need for surgical services for children in Uganda.

Erik Axman,1,2 Pär Nordin,3 Marina Modin,4 Hanna de la Croix1,2 1Sahlgrenska University Hospital/Östra Hospital, Department of Surgery, Gothenburg, Sweden; 2Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; 3Department of Surgery and Perioperative Sciences, Umeå University, Umeå, Sweden; 4Department of Research, Development, Education and Innovation, Skaraborg Hospital, Skövde, SwedenCorrespondence: Erik AxmanSahlgrenska University Hospital/Östra Hospital, Department of Surgery, Gothenburg, 416 85, SwedenTel +46313435474Email erik.axman@vgregion.seAim: To assess the validity and cover rate of the Swedish hernia register.Material and Methods: Since the start of the Swedish Hernia register an annual review of randomly selected hospitals has been carried out, and since 2013 in a more standardized form to allow a systematic data collection and evaluation. 10% of all clinics were randomly selected each year in a specific region of Sweden, ensuring a systematic validation of all regions from north to south. Data from 2013 to 2018 were analyzed regarding data quality and from 2014 to 2018 regarding cover rate. All operations registered at the validated clinics were compared with the Swedish Hernia Register to assess cover rate. Fifty operations were randomly selected at each clinic and data in the Swedish Hernia register were compared with the medical records to evaluate data quality.Results: Fifty-five clinics was evaluated and a total of 73,764 variables were compared with the medical records. Cover rate between 2014 and 2018 was 97%. The proportion of correct variables was 98% between 2013 and 2018. Most frequent errors were ASA score, date at which the patient was put on the waiting list and postoperative complications.Conclusion: This unique validation of a national hernia register shows a high cover rate and good quality of data. Efforts to maintain and improve national registers are of great importance. Research with data from the Swedish hernia register should be evaluated on the basis of the results presented in this study.Keywords: hernia, validity, cover rate, Swedish hernia register, data quality, national registers

Background Laparoscopy is common in abdominal surgery. Trocar site hernia (TSH) is a most likely underestimated complication. Among risk factors, obesity, the use of larger trocars and the umbilical trocar site has been described. In a previous study, CT scan in the prone position was found to be a reliable method for the detection of TSH following gastric bypass (LRYGB). In the present study, our aim was to examine the incidence of TSH after gastric sleeve, and further to investigate the proportion of symptomatic trocar site hernias. Methods Seventy-nine patients subjected to laparoscopic gastric sleeve in 2011–2016 were examined using CT in the prone position upon a ring. Symptoms of TSH were assessed using a digital survey. Results The incidence of trocar site hernia was 17 out of 79 (21.5%), all at the umbilical trocar site. The mean follow-up time was 37 months. There was no significant correlation between patient symptoms and a TSH. Conclusions The incidence of TSH is high after laparoscopic gastric sleeve, a finding in line with several recent studies as well as with our first trial on trocar site hernia after LRYGB. Up to follow-up, none of the patients had been subjected to hernia repair. Although the consequence of a trocar site hernia can be serious, the proportion of symptomatic TSH needs to be more clarified.

Background There is a shortage of high-quality studies regarding choice of mesh in open anterior inguinal hernia repair in relation to long-term chronic pain. The authors hypothesized that heavyweight compared with lightweight mesh causes increased postoperative pain. Methods An RCT was undertaken between 2007 and 2009 at two sites in Sweden. Men aged 25 years or older with an inguinal hernia evaluated in the outpatient clinic were randomized in an unblinded fashion to heavyweight or lightweight mesh for open anterior inguinal hernia repair. Data on pain affecting daily activities, as measured by the Short-Form Inguinal Pain Questionnaire 9–12 years after surgery, were collected as the primary outcome. Differences between groups were evaluated by generalized odds and numbers needed to treat. Results A total of 412 patients were randomized; 363 were analysed with 320 questionnaires sent out. A total of 271 questionnaires (84.7 per cent) were returned; of these, 121 and 150 patients were in the heavyweight and lightweight mesh groups respectively. Pain affecting daily activities was more pronounced in patients randomized to heavyweight versus lightweight mesh (generalized odds 1.33, 95 per cent c.i. 1.10 to 1.61). This translated into a number needed to treat of 7.06 (95 per cent c.i. 4.28 to 21.44). Two reoperations for recurrence were noted in the heavyweight mesh group, and one in the lightweight mesh group. Conclusion A large-pore lightweight mesh causes significantly less pain affecting daily activities a decade after open anterior inguinal hernia repair. Registration number: NCT00451893 (http://www.clinicaltrials.gov).

Background Groin hernia is a major public health problem with over 200 million people affected. The unmet need for surgery is greatest in Sub-Saharan Africa where specialist surgeons are few. This study was carried out in Uganda to investigate caseloads and practices of groin hernia surgery at publicly funded hospitals. Methods The study employed mixed methods covering 29 hospitals: the National Referral Hospital (NRH), 14 Regional Referral Hospitals (RRH) and 14 General Hospitals (GH). In part one of the study, surgeons and medical doctors performing hernia repair were interviewed about their practices and experiences of groin hernia surgery. In part two, operating theater records from 2013 to 2014 from the participating hospitals were reviewed and information about groin hernia operations collected. Results All respondents reported that sutured repair was the first-choice method. A total of 5518 groin hernia repairs were performed at the participating hospitals, i.e., an annual hernia repair rate of 7/100 000 population. Of the patients operated, almost 16% were women and 24% were children. Local anesthesia (LA) was used in 40% of the cases, and non-surgeon physicians performed 70.3% of the groin hernia repairs. Conclusion Groin hernia repair outputs need to increase along with the training of surgical providers in modern hernia repair methods. Methods and outcomes for hernia repair in women and children should be investigated to improve the quality of care.

Background and Aims: The Swedish National Patient Insurance Company (LÖF) can compensate patients who believe they have been exposed to an avoidable injury or malpractice in healthcare. Its register covers 95% of Swedish healthcare providers. Material and Methods: Data on patients operated for primary or incisional ventral hernia in Sweden between 2010 and 2015 and who had filed a claim, were retrieved from LÖF. A total of 290 cases were identified and included. Files include a copy of records, relevant imaging, and an expert advisor’s opinion. Results: Inadvertent enterotomy occurred during 25 repairs and in these cases, laparoscopic repair was clearly overrepresented ( p Conclusion: Inadvertent enterotomy is overrepresented, and the probability that a claim filed for an avoidable injury leads to high reimbursement is greater if laparoscopic repair is performed rather than open ventral hernia repair. The high amount of injuries related to general anesthesia during umbilical hernia repair may be reduced with an increased proportion executed in local anesthesia.

Purpose There is a paucity of high-quality evidence concerning mesh choice in open inguinal hernia repair. Using an expertise-based randomized clinical trial design, we aimed to evaluate the postoperative impact of two different mesh types on pain and discomfort, quality of life and sex life. Methods In two regional hospitals, male patients with primary inguinal hernia were randomized to one of two groups of surgeons that performed the Lichtenstein operation. One group of surgeons used a heavyweight polypropylene mesh (90 g/m2, Bard™ Flatmesh, Davol) while the second group employed a lightweight mesh (28 g/m2, ULTRAPRO™, Ethicon). Follow-up data were collected by questionnaires and outpatient visits in the range of 1–3 years after surgery. Results Some 412 patients were randomized and 363 patients were analysed. There was no difference in pain between groups after surgery but a statistically significant difference concerning awareness of a groin lump and groin discomfort, favouring the lightweight group 1 year after surgery. No differences in quality of life between groups could be detected but both groups had a substantially better quality of life postoperatively, as compared to before surgery. In the analysis of impact on sex life, no differences between mesh groups were found. Conclusion The Lichtenstein operation performed for primary inguinal hernia improves quality of life for most of the male patients, independently of the type of mesh used. The lightweight mesh group experienced less awareness of a groin lump and groin discomfort 1 year postoperatively. ClinicalTrials.gov Identifier: NCT00451893.

Background The rate of caesarean section without medical indication is rising but the risk for surgical complications has not been fully explored. Methods Altogether 79 052 women from the Swedish Medical Birth Register who delivered by caesarean section only from 2005 through 2016 were identified and compared with a control group of women delivering vaginally only from the same register and the same period of time. By cross-linking data with the National Patient Register the risks for bowel obstruction, incisional hernia and abdominal pain were analysed, as well as risk factors for these complications. We also analysed acute complications, uterine rupture, and placenta praevia. Findings Caesarean section is associated with an increased risk for bowel obstruction (OR 2.92; CI 2.55–3.34), surgery for bowel obstruction (OR 2.12; CI 1.70–2.65), incisional hernia (OR 2.71; CI 2.46–3.00), surgery for incisional hernia (OR 3.35; CI 2.68–4.18), and abdominal pain (OR 1.41; CI 1.38–1.44). Smoking, obesity, and more than one section delivery added significantly to the risk for these complications. Interpretation Caesarean section is considered a safe procedure, but awareness of the risk for serious complications is important when deciding on mode of delivery. In this study, more than one section, obesity and smoking significantly increased the risk for complications after caesarean section. Prevention of smoking and obesity among fertile women worldwide must continue to be a high priority.

BackgroundThe effectiveness of different procedures in routine surgical practice for hernia repair with respect to chronic postoperative pain and reoperation rates is not clear.MethodsThis was prospective cohort study based on a unique combination of patient-reported outcomes and national registry data. Virtually all patients with a groin hernia repair in Sweden between September 2012 and April 2015 were sent a questionnaire 1 year after surgery. Persistent pain, defined as at least ‘pain present, cannot be ignored, and interferes with concentration on everyday activities’ in the past week was the primary outcome. Reoperation for recurrence recorded in the register was the secondary outcome.ResultsIn total, 22 917 patients (response rate 75·5 per cent) who had an elective unilateral groin hernia repair were analysed. Persistent pain present 1 year after hernia repair was reported by 15·2 per cent of patients. The risk was least for endoscopic total extraperitoneal (TEP) repair (adjusted odds ratio (OR) 0·84, 95 per cent c.i. 0·74 to 0·96), compared with open anterior mesh repair. TEP repair had an increased risk of reoperation for recurrence (adjusted OR 2·14, 1·52 to 2·98), as did open preperitoneal mesh repair (adjusted OR 2·34, 1·42 to 3·71) at 2·5-year follow-up. No other methods of repair differed significantly from open anterior mesh repair.ConclusionThe risk of significant pain 1 year after groin hernia repair in routine surgical practice was 15·2 per cent. This figure was lower in patients who had surgery by an endoscopic technique, but at the price of a significantly higher risk of reoperation for recurrence.

Background Over 200 million people worldwide live with groin hernia and 20 million are operated on each year. In resource-scarce settings, the superior surgical technique using a synthetic mesh is not affordable. A low-cost alternative is needed. The objective of this study was to calculate and compare costs and cost-effectiveness of inguinal hernia mesh repair using a low-cost versus a commercial mesh in a rural setting in Uganda. Methods This is a cost-effectiveness analysis of a double-blinded RCT comparing outcomes from groin hernia mesh repair using a low-cost mesh and a commercially available mesh. Cost-effectiveness was expressed in US dollars (with euros in parentheses, exchange rate 30 December 2016) per disability-adjusted life-year (DALY) averted and quality-adjusted life-year (QALY) gained. Results The cost difference resulting from the choice of mesh was $124·7 (€118·1). In the low-cost mesh group, the cost per DALY averted and QALY gained were $16·8 (€15·9) and $7·6 (€7·2) respectively. The corresponding costs were $58·2 (€55·1) and $33·3 (€31·5) in the commercial mesh group. A sensitivity analysis was undertaken including cost variations and different health outcome scenarios. The maximum costs per DALY averted and QALY gained were $148·4 (€140·5) and $84·7 (€80·2) respectively. Conclusion Repair using both meshes was highly cost-effective in the study setting. A potential cost reduction of over $120 (nearly €120) per operation with use of the low-cost mesh is important if the mesh technique is to be made available to the many millions of patients in countries with limited resources. Trial registration number: ISRCTN20596933 (http://www.controlled-trials.com).

Background Improved recurrence rates after groin hernia surgery have led to chronic pain becoming the most troublesome postoperative complication. Self-gripping mesh was developed to decrease the risk for development of chronic pain. The aim of this nationwide cohort study was to compare recurrence rate and chronic pain 1 year after an open, anterior mesh repair of inguinal hernias with either a self-gripping mesh or other lightweight mesh. Method All operations registered as open anterior mesh repair (Lichtenstein) in the Swedish Hernia Registry between September 2012 and October 2016 were selected. At 1 year after repair, patients were sent a pain questionnaire assessing chronic pain. We compared the prevalence of chronic pain and reoperation for recurrence using lightweight, sutured mesh or self-gripping mesh. Results We analyzed the 1,803 repairs using self-gripping mesh and 16,567 repairs using lightweight mesh. We found no difference in the prevalence of chronic pain 1 year after the hernia repair between self-gripping mesh and sutured lightweight mesh (OR 0.92, CI 95% 0.80–1.06, P = .257). There was no increase in reoperation for recurrence when using self-gripping mesh (HR 0.71, CI 95% 0.45–1.14, P = .156). Mean operation time was considerably less when using self-gripping mesh (43 vs 70 minutes; P > .001). Conclusion The use of self-gripping mesh does not decrease the incidence of chronic pain and reoperation for recurrence compared with lightweight, sutured mesh for open anterior mesh repair of inguinal hernias. Furthermore, the use of self-gripping mesh is associated with a clinically important, lesser operation time.

To analyze severe complications after groin hernia repair with respect to age, ASA score, hernia anatomy, method of repair and method of anesthesia, using nationwide registers. The annual rate of 20 million groin hernia operations throughout the world renders severe complications, although rare, important both for the patient, the clinician, and the health economist.Two nationwide registers, the Swedish Hernia Register and the National Swedish Patient Register were linked to find intraoperative complications, severe cardiovascular events and severe surgical adverse events within 30 days of groin hernia surgery.143,042 patients, 8 % women and 92 % men, were registered between 2002 and 2011. Intraoperative complications occurred in 801 repair, 592 patients suffered from cardiovascular events and 284 patients from a severe surgical event within 30 days of groin hernia surgery. Emergency operation was a risk factor for both cardiovascular and severe surgical adverse events with odds ratios for cardiovascular events of 3.1 (2.5-4.0) for men and 2.8 (1.4-5.5) for women. Regional anesthesia was associated with an increase in cardiovascular morbidity compared with local anesthesia, odds ratio 1.4 (1.1-1.9). In men, bilateral hernia and sliding hernia approximately doubled the risk for severe surgical events; odds ratio 1.9 (1.1-3.5) and 2.2 (1.6-3.0), respectively. Methods other than open anterior mesh repair increased the risk for surgical complications.Awareness of the increased risk for cardiovascular or surgical complications associated with emergency surgery, bilateral hernia, sliding hernia, and regional anesthesia may enable the surgeon to further reduce their incidence.

Introduction: Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery. Methods: An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group’s first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as “strong” (recommendations) or “weak” (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term “should” refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. Results and summary: The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with “watchful waiting” since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon’s expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10–12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation “Hernia Center”. From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients. Conclusions: The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Chronic pain is common after groin hernia surgery, affecting approximately 10% of patients. The type of anesthesia has been shown to affect short term pain (within 30 days) where Local Anesthesia ( ...

The aim of this study was to investigate reoperation for recurrence in men and women with respect to method of repair, hernia anatomy and year of operation.Since 1992, groin hernia repairs performed in Sweden are prospectively registered in the Swedish Hernia Register, (SHR). Reoperations are noted, regardless of where the reoperation is performed. Risk of reoperation for recurrence is calculated for men and women with respect of method of repair, hernia anatomy and year of operation.Out of 221 108 eligible operations registered between 1992-2013, 17 545 (8%) were performed on women. The risk of being operated for recurrence after laparoscopic surgery was lowered in women, RR 0,4(95%CI 0.3-0.7) and increased in men, RR 2.3(95% CI 2.0-2.7), compared to the Lichtenstein technique.The reoperation for recurrence rate differed significantly between men and women. As regards the technique used for primary repair, laparoscopic groin hernia repair lowered the risk of reoperation for recurrence in women whereas it doubled the risk in men.

Purpose The pathogenesis of groin hernia is not fully understood and some suggested risk factors are debatable. This population-based study evaluates the association between groin hernia repair and tobacco use. Method An observational study based on register linkage between the Swedish Hernia Register and the Vasterbotten Intervention Program (VIP). All primary groin hernia repairs performed from 2001 to 2013 in the county of Vasterbotten, Sweden, were included. Results VIP provided data on the use of tobacco in 102,857 individuals. Neither smoking nor the use of snus, increased the risk for requiring a groin hernia repair. On the contrary, heavy smoking decreased the risk for men, HR 0.75 (95% CI 0.58-0.96), as did having a BMI over 30 kg/m 2 HR (men) 0.33 (95% CI 0.27-0.40). Conclusion Tobacco use is not a risk factor for requiring a groin hernia repair, whereas having a low BMI significantly increases the risk.

Purpose Surgical repair of groin hernia should be carried out with minimal complication rates, and it is important to have regular quality control and accurate means of assessment. The Swedish healthcare system has a mutual insurance company (LÖF) that receives claims from patients who have suffered healthcare-related damage or malpractice. The Swedish Hernia Register (SHR) currently covers around 98% of all Swedish groin hernia operations. The aim of this study was to analyse damage claims following groin hernia repair surgery and link these with entries in the SHR, in order to identify risk factors and causes of injuries and malpractice associated with hernia repair. Methods Data on all 48,574 groin hernia operations registered in the SHR between 2008 and 2010 were compared and linked with data on claims made to the Swedish National Patient Injury Insurance (LÖF). Results Of the 130 damage claims received by LÖF, 26 dealt with bleeding, 20 with testicular injury and 7 with intestinal lesions. Eighty (62%) of the complications were considered malpractice according to the Swedish Patient Injury Act. Acute and recurrent surgery, sutured repair and general anaesthesia were associated with a significantly increased risk for a damage claim independently the patients were compensated or not. Females filed claims in greater proportion than males. There was no significant difference in background factors between claims accepted by LÖF and compensated and those who were rejected compensation. Conclusion Risk factors for filing a damage claim included acute surgery, operation for recurrence, sutured repair and general anaesthesia, whereas local anaesthesia reduced the risk.

The aim of the present study was to assess the outcome results after reoperation for persistent pain after hernia surgery in a population-based setting.All patients who had undergone surgery for persistent pain after previous groin hernia surgery 1999-2006 were identified in the Swedish Hernia Register (n = 237). Data on the surgical technique used were abstracted from the medical records. The patients were asked to answer a set of questions including SF-36 to evaluate the prevalence of pain after reoperation.The study group consisted of 95 males and 16 females, mean age 53 years. In 27 % of cases an intervention aimed at suspected ilioinguinal neuralgia was performed. The mesh was removed completely in 28% and partially in 13%. A suture at the pubic tubercle was removed in 13% of cases. Decrease in pain after the most recent reoperation was reported by 69 patients (62%), no change in pain by 21 patients (19%) and increase in pain in 21 patients (19%). There was no significant difference in outcome between mesh removal, removal of sutures at the tubercle or interventions aimed at the ilioinguinal nerve. All subscales of SF-36 were significantly reduced when compared to the age- and gender-matched general population (p0.05).Patients reoperated for persistent pain after hernia surgery often report a reduction in pain, but the natural course of persistent pain, the relatively low response rate and selection of patients make it difficult to draw definite conclusions.

To assess the incidence of groin hernia repair after radical prostatectomy for prostate cancer compared with the incidence in a control population without prostate cancer in a nationwide, population-based study.Recent reports indicate an increase in the incidence of groin hernia repair after radical prostatectomy. Inadequate knowledge of the incidence of groin hernia in the general population makes this information hard to interpret.Information was retrieved from the Prostate Cancer Database (PCBaSe) and Swedish Hernia Register for events between 1998 and 2010. The incidence of groin hernia surgery was calculated for a group of men treated with radical prostatectomy (open and minimally invasive) and for a group treated with radiation therapy, and these were compared with the incidence in a control cohort of men matched for age and county of residence. Multivariate analysis was used to assess the hazard ratio (HR) of groin hernia repair according to age, tumor risk category, and Charlson Comorbidity Index.A total of 28,608 cases and 105,422 controls were included in the study. Men treated with radical prostatectomy and radiation therapy had a significantly higher incidence of groin hernia repair than the control cohort: HR: 3.95 (95% confidence interval: 3.70-4.21) for retropubic prostatectomy, HR: 3.37 (95% confidence interval: 2.95-3.87) for minimally invasive prostatectomy, and HR: 1.84 (95% confidence interval: 1.66-2.04) for radiation therapy.An almost 4-fold increase in groin hernia repair was observed after radical prostatectomy compared with controls, and men who received radiation therapy had an almost 2-fold increase in incidence. As well as postoperative changes in the abdominal wall, increased vigilance for groin hernia seems to be important for the increased incidence of groin hernia repair seen after radical prostatectomy or radiation therapy for prostate cancer.

Purpose In 2009, the European Hernia Society published the EHS Guidelines for the Treatment of Inguinal Hernia in Adult Patients. The Guidelines contain recommendations for the treatment of inguinal hernia from diagnosis till aftercare. The guidelines expired January 1, 2012. To keep them updated, a revision of the guidelines was planned including new level 1 evidence.

Background Hernia repair is the most commonly performed general surgical procedure worldwide. The prevalence is poorly described in many areas, and access to surgery may not be met in low- and middle-income countries. The objectives of this study were to investigate the prevalence of groin hernia and the surgical repair rate in a defined sub-Saharan region of Africa. Methods A two-part study on hernia prevalence was carried out in eastern Uganda. The first was a population-based prevalence study with 900 randomly selected men in a Health and Demographic Surveillance Site. The second was a prospective facility-based study of all surgical procedures performed in the two hospitals providing surgical care in the region. Results The overall prevalence of groin hernia (current hernia or scar after groin hernia surgery) in men was 9·4 per cent. Less than one-third of men with a hernia had been operated on. More than half had no pain symptoms. The youngest age group had an overall prevalence of 2·4 per cent, which increased to 7·9 per cent in the age range 35–54 years, and to 37 per cent among those aged 55 years and above. The groin hernia surgery rate at the hospitals investigated was 17 per 100 000 population per year, which corresponds to a surgical correction rate of less than 1 per cent per year. Based on hospital records, a considerable number of patients having surgery for groin hernia were women (20 of 84 patients, 24 per cent). Conclusion Groin hernia is a common condition in men in this east Ugandan cohort and the annual surgical correction rate is low. Investment is needed to increase surgical capacity in this healthcare system.

Objective The aim of this study was to examine whether intraperitoneal robot-assisted surgery leads to small bowel obstruction (SBO), possibly caused by the formation of intra-abdominal adhesions. Materials and methods In total, 7256 men treated by intraperitoneal robot-assisted radical prostatectomy (RARP) and 9787 men treated by retropubic radical prostatectomy (RRP) in 2005-2012 were identified in the Prostate Cancer data Base Sweden (PCBaSe). Multivariable Cox proportional hazards models were used to calculate the risk of readmission for SBO, SBO-related surgery and admissions due to abdominal pain up to 5 years postoperatively. Results During the first postoperative year, the risk of readmission for SBO was higher after RARP than after RRP [hazard ratio (HR) 1.92, 95% confidence interval (CI) 1.14-3.25] but after 5 years there was no significant difference (HR 1.28, 95% CI 0.86-1.91), and there was no difference in the risk of SBO surgery during any period. The risk of admission for abdominal pain was significantly increased after RARP during the first year (HR 2.24, 95% CI 1.50-3.33) but not after 5 years (HR 1.23, 95% CI 0.92-1.63). Conclusion Intraperitoneal RARP had an increased risk of SBO and abdominal pain in the short term during the first year, but not in the long term, compared to RRP.

BACKGROUND: The most effective method for repair of a groin hernia involves the use of a syn-thetic mesh, but this type of mesh is unaffordable for many patients in low- and middle-income countries. Sterilized mosquito meshes have been used as a lower-cost alternative but have not been rigorously studied.METHODS: We performed a double-blind, randomized, controlled trial comparing low-cost mesh with commercial mesh (both lightweight) for the repair of a groin hernia in adult men in eastern Uganda who had primary, unilateral, reducible groin hernias. Surgery was performed by four qualified surgeons. The primary outcomes were hernia recurrence at 1 year and postoperative complications.RESULTS: A total of 302 patients were included in the study. The follow-up rate was 97.3% after 2 weeks and 95.6% after 1 year. Hernia recurred in 1 patient (0.7%) assigned to the low-cost mesh and in no patients assigned to the commercial mesh (abso-lute risk difference, 0.7 percentage points; 95% confidence interval [CI], −1.2 to 2.6; P = 1.0). Postoperative complications occurred in 44 patients (30.8%) assigned to the low-cost mesh and in 44 patients (29.7%) assigned to the commercial mesh (absolute risk difference, 1.0 percentage point; 95% CI, −9.5 to 11.6; P = 1.0).CONCLUSIONS: Rates of hernia recurrence and postoperative complications did not differ signifi-cantly between men undergoing hernia repair with low-cost mesh and those un-dergoing hernia repair with commercial mesh. Originally published in manuscript form with title "Low cost mesh in groin hernia repair - A double-blinded, randomized trial"

Lactate has been thoroughly studied and found useful for stratification of patients with sepsis, in the Intensive Care Unit, and trauma care. However, little is known about lactate as a risk-stratification marker in the Medical Emergency Team- (MET-) call setting. We aimed to determine whether the arterial blood lactate level at the time of a MET-call is associated with increased 30-day mortality. This is an observational study on a prospectively gathered cohort at a regional secondary referral hospital. All MET-calls during the two-year study period were eligible. Beside blood lactate, age and vital signs were registered at the call. Among the 211 calls included, there were 64 deaths (30.3%). Median lactate concentration at the time of the MET-call was 1.82 mmol/L (IQR 1.16–2.7). We found differences between survivors and nonsurvivors for lactate and oxygen saturation, a trend for age, but no significant correlations between mortality and systolic blood pressure, respiratory rate, and heart rate. As compared to normal lactate (p<0.0006) for lactate 2.44–5.0 mmol/L and 4.45 (p<0.0016) for lactate > 5.0 mmol/L. The present results support that immediate measurement of blood lactate in MET call patients is a useful tool in the judgment of illness severity.

To explore the prevalence of and to identify possible risk factors for chronic pain after surgery for femoral hernia.Chronic pain has become a very important outcome in quality assessment of inguinal hernia surgery. There are no studies on the risk for chronic pain after femoral hernia surgery.The Inguinal Pain Questionnaire was sent to 1967 patients who had had a repair for primary unilateral femoral hernia between January 1, 1997 and December 31, 2006. A follow-up period of at least 18 months was chosen. Answers from 1461 patients were matched with data recorded in the Swedish Hernia Register and analyzed.Some degree of pain during the previous week was reported by 24.2% (354) of patients. Pain interfered with daily activities in 5.5% (81) of patients. Emergency surgery (OR = 0.54; 95% CI = 0.40-0.74) and longer time since surgery (OR = 0.93; 95% CI = 0.89-0.98 for each year added) were associated with lower risk for chronic postoperative pain, whereas a high level of preoperative pain was associated with a higher risk for chronic pain (OR = 1.17; 95% CI = 1.10-1.25). Surgical technique was not found to influence the risk for chronic pain in multivariate logistic regression analysis.Chronic postoperative pain is as important a complication after femoral hernia surgery as it is after inguinal hernia surgery. In contrast to inguinal hernia surgery, no risk factor related to surgical technique was found. Further investigations into the role of preoperative pain are necessary.

BACKGROUND: Several animal studies have raised concern about the risk for obstructive azoospermia owing to vasal fibrosis caused by the use of alloplastic mesh prosthesis in inguinal hernia repair. The aim of this study was to determine the prevalence of male infertility after bilateral mesh repair. METHODS: In a prospective study, a questionnaire inquiring about involuntary childlessness, investigation for infertility and number of children was sent by mail to a group of 376 men aged 18-55 years, who had undergone bilateral mesh repair, identified in the Swedish Hernia Register (SHR). Questionnaires were also sent to 2 control groups, 1 consisting of 186 men from the SHR who had undergone bilateral repair without mesh, and 1 consisting of 383 men identified in the general population. The control group from the SHR was matched 2:1 for age and years elapsed since operation. The control group from the general population was matched 1:1 for age and marital status. RESULTS: The overall response rate was 525 of 945 (56%). Method of approach (anterior or posterior), type of mesh, and testicular status at the time of the repair had no significant impact on the answers to the questions. Nor did subgroup analysis of the men

Background There is no consensus on the best management of the indirect hernial sac in groin hernia surgery. The aim of this study was to investigate to what extent different management options are associated with reoperation for recurrence. Methods This study used data from the Swedish Hernia Register. Surgeons registered whether the indirect hernial sac was managed by division (leaving the distal part in place), excision or invagination. Results An indirect hernia was found in 48 433 operations; the sac was excised in 49·5 per cent, invaginated in 37·6 per cent and divided in 12·9 per cent of operations. The 5-year cumulative reoperation incidence was 1·7 per cent for hernial sac excision, 1·7 per cent for division and 2·7 per cent for invagination. For indirect hernia repair, the relative risk of reoperation for recurrence was 0·63 (95 per cent confidence interval 0·51 to 0·79) for excision of the sac and 0·72 (0·53 to 0·99) for division compared with invagination. Lichtenstein repair combined with hernial sac excision had a 5-year cumulative reoperation incidence of only 1·0 per cent. Conclusion Excision of the indirect hernial sac in inguinal hernia repair is associated with a lower risk of hernia recurrence than division or invagination.

Objectives: In most clinics, follow-up after inguinal hernia surgery is not a routine procedure and complications may pass unnoticed, thus impairing quality assessment. The aim of this study was to investigate the frequency, spectrum, and risk factors of short-term adverse events after groin hernia repair. Methods: All patients aged 15 years or older with a primary unilateral inguinal or femoral hernia repair recorded in the Swedish Hernia Register (SHR) between November 1 and December 31, 2002 were sent a questionnaire asking about complications within the first 30 postoperative days. Results: Of the 1643 recorded patients, 1448 (88.1%) responded: 1341 (92.6%) were men and 107 (7.4%) women, mean age 59 years. There were 195 (11.9%) nonresponders. Postoperative complications reported in the questionnaire were hematoma in 203 (14.0%) patients, severe pain in 168 (11.6%), testicular pain in 120 (8.3%), and infection in 105 (7.3%). Adverse events were reported in the questionnaire by 391 (23.8%) patients, whereas only 85 (5.2%) were affected according to the SHR. Risk factors for postoperative complications were age below the median (59 years) among the studied hernia patients (OR 1.36; 95% CI 1.06-1.74) and laparoscopic repair (OR 2.66; 95% CI 1.17-6.05). Conclusion: Questionnaires provide valuable additional information concerning postoperative complications. We recommend that they become an integrated part of routine postoperative assessment.

To analyze mortality following groin hernia operations.It is well known that the incidence of groin hernia in men exceeds the incidence in women by a factor of 10. However, gender differences in mortality following groin hernia surgery have not been explored in detail.The study comprises all patients 15 years or older who underwent groin hernia repair between January 1, 1992 and December 31, 2005 at units participating in the Swedish Hernia Register (SHR). Postoperative mortality was defined as standardized mortality ratio (SMR) within 30 days, ie, observed deaths of operated patients over expected deaths considering age and gender of the population in Sweden.A total of 107,838 groin hernia repairs (103,710 operations), were recorded prospectively. Of 104,911 inguinal hernias, 5280 (5.1%) were treated emergently, as compared with 1068 (36.5%) of 2927 femoral hernias. Femoral hernia operations comprised 1.1% of groin hernia operations on men and 22.4% of operations on women. After femoral hernia operation, the mortality risk was increased 7-fold for both men and women. Mortality risk was not raised above that of the background population for elective groin hernia repair, but it was increased 7-fold after emergency operations and 20-fold if bowel resection was undertaken. Overall SMR was 1.4 (95% confidence interval, 1.2-1.6) for men and 4.2 (95% confidence interval, 3.2-5.4) for women, in accordance with a greater proportion of emergency operations among women compared with men, 17.0%, versus 5.1%.Mortality risk following elective hernia repair is low, even at high age. An emergency operation for groin hernia carries a substantial mortality risk. After groin hernia repair, women have a higher mortality risk than men due to a greater risk for emergency procedure irrespective of hernia anatomy and a greater proportion of femoral hernia.

Background Inguinal hernia repair is a common operation in general surgery and can be performed under local, regional or general anaesthesia. This multicentre randomized trial was undertaken to compare the costs of the three anaesthetic methods in general surgical practice. Methods Between January 1999 and December 2001, 616 patients at ten hospitals who underwent primary inguinal hernia repair were randomized to local, regional or general anaesthesia. The primary endpoints were direct costs. Secondary endpoints were indirect costs and recurrence rates. Results Total intraoperative, as well as total early postoperative, data showed local anaesthesia to have significant cost advantages over regional and general anaesthesia (P < 0·001). The advantage was also significant for total hospital and total healthcare costs (P < 0·001), whereas there was no significant difference between regional and general anaesthesia. Conclusion The use of local anaesthesia for inguinal hernia repair was significantly less expensive than regional or general anaesthesia.

Mesh fixation is used to prevent recurrence at the potential risk for chronic pain in TEP. The aim was to compare the impact of permanent fixation (PF) with no fixation (NF)/nonpermanent fixation (NPF) of mesh on chronic pain after TEP repair for primary inguinal hernia.Men, 30 to 75 years old, consecutively registered in the Swedish Hernia Register for a TEP primary repair in 2005 to 2009, were included in a mail survey using SF-36 and the Inguinal Pain Questionnaire (IPQ). Primary endpoint was IPQ question "Did you have pain during past week that could not be ignored." Risk factors for chronic pain and recurrent operations were analyzed.A total of 1110 patients were included (325 PF, 785 NF/NPF) with 7.7% reporting pain at median 33 months follow-up. No difference regarding primary endpoint pain (P0.462), IPQ and SF-36 subscales were seen. Recurrent operation was carried out in 1.4% during 7.5 years follow-up with no difference between PF- and NF-groups including subgroups of medial hernias. All SF-36 subscale-scores were equal to or better than the Swedish norm. A postoperative complication was a risk factor for chronic pain (OR 2.44, 95% CI 1.23-5.25, P0.023).The TEP procedure for primary inguinal hernia repair in men is associated with a low frequency of chronic pain and recurrent operations, with no difference between permanent fixation and no/nonpermanent fixation of mesh in a nationwide population-based study. TEP without fixation reduces costs and is safe for all patients.

Incisional hernia is a common problem after abdominal surgery. The complication and recurrence rates following the different repair techniques are a matter of great concern. Our aim was to study the results of incisional hernia repair in Sweden. A questionnaire was sent to all surgical departments in Sweden requesting data concerning incisional hernia repair performed during the year 2002. Eight hundred and sixty-nine incisional hernia repairs were reported from 40 hospitals. Specialist surgeons performed the repair in 782 (83.8%) patients. The incisional hernia was a recurrence in 148 (17.0%) patients. Thirty-three per cent of the hernias were subsequent to transverse, subcostal or muscle-splitting incisions or laparoscopic procedures. Suture repair was performed in 349 (40.2%) hernias. Onlay mesh repair was more common than a sublay technique. The rate of wound infection was 9.6% after suture repair and 8.1% after mesh repair. The recurrence rate was 29.1% with suture repair, 19.3% with onlay mesh repair, and 7.3% with sublay mesh repair. This survey revealed that there is room for improvement regarding the incisional hernia surgery in Sweden. Suture repair, with its unacceptable results, is common and mesh techniques employed may not be optimal. This study has led to the instigation of a national incisional hernia register.

Background Although 8 per cent of groin hernia repairs are performed in women, there is little published literature relating specifically to women. This study compared differences in outcome between women and men after groin hernia repair. Methods Data collected prospectively in the Swedish Hernia Register between 1992 and 2003 were analysed, including 6895 groin hernia repairs in women and 83 753 in men. Results A higher proportion of emergency operations was carried out in women (16·9 per cent) than men (5·0 per cent), leading to bowel resection in 16·6 and 5·6 per cent respectively. During reoperation femoral hernias were found in 41·6 per cent of the women who were diagnosed with a direct or indirect inguinal hernia at the primary operation. The corresponding proportion for men was 4·6 per cent. The hernia repair was not classified as a standard operation (e.g. Shouldice, Lichtenstein, Plug/Mesh, TAPP/TEP) in 38·2 per cent of women and 11·2 per cent of men. Women had a significantly higher risk of reoperation for recurrence than men, and techniques associated with the lowest risk for reoperation in men had the highest risk in women. Conclusion A greater proportion of women than men require emergency groin hernia repair, with consequently higher rates of bowel resection, complications and death. Surgical techniques developed for use in men may put women at unnecessary risk.

Background Chronic pain is common after herniorrhaphy, but the effect of surgical technique (mesh versus non-mesh repair) and the social consequences of the pain have not been established. The aim of this study was to analyse chronic postherniorrhaphy pain and its social consequences in young males operated on for an indirect inguinal hernia with a Lichtenstein mesh repair, Shouldice or Marcy (annulorrhaphy) repair. Methods This was a postal questionnaire study carried out within the Danish and Swedish Hernia Database Collaboration. Some 2612 patients responded (response rate 80·9 per cent), of whom 1250 had undergone a Lichtenstein, 630 a Shouldice and 732 a Marcy repair. Results Chronic pain had been experienced within the previous month by 22·9 per cent of the patients who responded. There was an overall decrease in pain with time, from 29·7 per cent at 6–12 months to 18·1 per cent at 37–48 months after surgery, with no overall differences between the three types of repair. Pain was more common in patients younger than 40 years of age. Some 3·9 per cent of patients described the pain as moderate to severe and as frequent or constant. Of all patients with pain, 10·7 per cent experienced it as worse after than before surgery, and 56·6 per cent stated that it interfered with social activities. Conclusion Chronic pain is common after primary inguinal hernia repair in young males, but there is no difference in the pain associated with open mesh and non-mesh repair.