J K Ramjist1,2,3, F Dossa2,3,4,5, T A Stukel4,6, D R Urbach1,4,5,6,7, L Fu6, N N Baxter8,9,10,11,12,13. 1. Institute for Medical Sciences, University of Toronto, Toronto, ON, Canada. 2. Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada. 3. Division of General Surgery, Department of Surgery, St. Michael's Hospital, 040-16 Cardinal Carter Wing, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. 4. Institute of Health Policy, Management and Education, University of Toronto, Toronto, ON, Canada. 5. Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada. 6. Institute for Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada. 7. Department of Surgery, University Health Network, Toronto, ON, Canada. 8. Institute for Medical Sciences, University of Toronto, Toronto, ON, Canada. BaxterN@smh.ca. 9. Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada. BaxterN@smh.ca. 10. Division of General Surgery, Department of Surgery, St. Michael's Hospital, 040-16 Cardinal Carter Wing, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. BaxterN@smh.ca. 11. Institute of Health Policy, Management and Education, University of Toronto, Toronto, ON, Canada. BaxterN@smh.ca. 12. Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada. BaxterN@smh.ca. 13. Institute for Clinical Evaluative Sciences, Sunnybrook Research Institute, Toronto, ON, Canada. BaxterN@smh.ca.
Abstract
PURPOSE: Despite the frequency with which inguinal hernia repairs (IHR) are performed, the real-world comparative effectiveness of laparoscopic versus open repairs is not well established. We compared the rate of recurrent inguinal hernia after laparoscopic and open mesh procedures. METHODS: We designed a population-based retrospective cohort study using linked administrative databases including adult patients in Ontario, Canada, who underwent primary IHR from April 1, 2003 to December 31, 2012. Patients were followed to August 31, 2014. Our primary outcome was reoperation for recurrent IHR, with covariate adjustment using Cox proportional hazards modeling. We constructed separate models to evaluate the effect of surgeon caseload on recurrence rates. RESULTS: We identified 93,501 adults undergoing primary IHR (85.4% open with mesh and 14.6% laparoscopic) with a median follow-up of 5.5 years. The 5-year cumulative risk of recurrent IHR was 2.0% in the open group and 3.4% in the laparoscopic group. After adjusting for patient and surgeon factors, we found that patients who underwent laparoscopic repair had a higher risk of recurrent IHR than those who underwent open repair when annual surgeon volume in the preceding year was ≤25 technique-specific cases (HR 1.76; 95% CI 1.45-2.13) or 26-50 technique-specific cases (HR 1.78; 95% CI 1.08-2.93). Few high-volume laparoscopic surgeons (> 50 cases/year) could be identified. Laparoscopic IHR did not carry a higher risk of recurrence for patients whose surgeons had performed > 50 technique-specific cases in the preceding year (HR 1.21; 95% CI 0.45-3.26). CONCLUSION: Laparoscopic IHR is generally associated with a higher risk of recurrence than open IHR. Though high-volume surgeons may be able to achieve equivalent results with laparoscopic and open techniques, few surgeons in our study population met this volume criterion for laparoscopic repairs.
PURPOSE: Despite the frequency with which inguinal hernia repairs (IHR) are performed, the real-world comparative effectiveness of laparoscopic versus open repairs is not well established. We compared the rate of recurrent inguinal hernia after laparoscopic and open mesh procedures. METHODS: We designed a population-based retrospective cohort study using linked administrative databases including adult patients in Ontario, Canada, who underwent primary IHR from April 1, 2003 to December 31, 2012. Patients were followed to August 31, 2014. Our primary outcome was reoperation for recurrent IHR, with covariate adjustment using Cox proportional hazards modeling. We constructed separate models to evaluate the effect of surgeon caseload on recurrence rates. RESULTS: We identified 93,501 adults undergoing primary IHR (85.4% open with mesh and 14.6% laparoscopic) with a median follow-up of 5.5 years. The 5-year cumulative risk of recurrent IHR was 2.0% in the open group and 3.4% in the laparoscopic group. After adjusting for patient and surgeon factors, we found that patients who underwent laparoscopic repair had a higher risk of recurrent IHR than those who underwent open repair when annual surgeon volume in the preceding year was ≤25 technique-specific cases (HR 1.76; 95% CI 1.45-2.13) or 26-50 technique-specific cases (HR 1.78; 95% CI 1.08-2.93). Few high-volume laparoscopic surgeons (> 50 cases/year) could be identified. Laparoscopic IHR did not carry a higher risk of recurrence for patients whose surgeons had performed > 50 technique-specific cases in the preceding year (HR 1.21; 95% CI 0.45-3.26). CONCLUSION: Laparoscopic IHR is generally associated with a higher risk of recurrence than open IHR. Though high-volume surgeons may be able to achieve equivalent results with laparoscopic and open techniques, few surgeons in our study population met this volume criterion for laparoscopic repairs.
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