Is the annual hospital volume associated with recurrence and chronic postoperative inguinal pain (CPIP) syndrome after inguinal hernia repair in laparo-endoscopic or open mesh technique (Lichtenstein)?

Abstract

Background: In major surgery, several studies have shown a correlation between high annual hospital volume (hospital caseload) and better outcome. Therefore, centralization is recommended. However, in inguinal hernia surgery the data are limited.

Methods: The study is based on a retrospective analysis of prospective data from the German Herniamed Registry collected between 2009 and 2018. Out of the total of 731,982 patients operated on in 737 institutions, patients who had undergone inguinal hernia repair in Lichtenstein or in laparo-endoscopic (TAPP/TEP) technique were included. Hospitals were divided into three annual caseload categories: Low volume: ≤ 75 cases; middle volume: 76-199 cases; high volume: ≥ 200 cases. The relationship between hospital volume and the outcome parameters was analyzed using multivariable binary logistic models.

Results: 222,487 patients were enrolled in analysis, with 70.4% hernias operated on in laparo-endoscopic technique and 29.6% cases in open mesh technique. Overall, the outcome after laparo-endoscopic repair was significantly favorable except for the intraoperative complications (worse) and recurrence rate (no significant difference). Descriptive and multivariable analysis identified a long operating time as the main factor associated with an unfavorable outcome. In low-volume hospitals the risk was higher for intraoperative complications as well as for postoperative complications in both techniques. There was a significantly favorable association between the recurrence rate and hospital volume but only after laparo-endoscopic repair. Patients who were operated on in a low-volume center experienced significantly less pain across all three pain categories, independently of the technique used.

Conclusions: While hospital volume has a favorable association with most outcome parameters, this varied in accordance with the operative technique used. In contrast to open surgery, laparo-endoscopic surgery in a low-volume hospital (≤ 75) has the disadvantage of a higher recurrence rate. Long operating time is the most detrimental factor, proving that surgeon proficiency is of paramount importance. However, chronic postoperative inguinal pain (CPIP) syndrome is significantly less frequent in patients operated on in low-volume hospitals; this result is difficult to explain but may be due to a closer patient-surgeon relationship in these institutions.