Page 119 - International guidelines for groin hernia management

Hernia

Training and learning curve registry? Future research might find objective data to
It is frequently stated that laparo-endoscopic inguinal her- answer these questions.
nia repair requires a longer learning curve when compared A novel strategy is to use health quality registries as
to open techniques, and endoscopic longer that laparo- platforms for randomization, so-called Registry-based
scopic. Learning curves are commonly expressed in num- Randomised Clinical Trials (RRCT). By including a ran-
bers of surgeries performed. However, endoscopic domization module in a population based clinical registry
competence of a resident prior to training is left out of the with high coverage and unselected consecutive enrolment,
equation. Gradually it is believed that competence based the advantages of a RCT can be combined with the
training and learning is a much more viable model. strengths of a large-scale registry. The advantages will be
Therefore, we recommend achieving consensus or guide- adequate power with unselected patients, facilitated follow-
lines on all aspects and surgical steps on groin hernia up, better control of confounding factors, and a powerful
training. Subsequently, outcomes can be analyzed with tool for conducting studies efficiently and cost-effectively.
regards to the surgeon’s competences and secondly to the
surgeon’s caseload. Outcomes and quality assessment
A groin hernia operation is considered a success, not only
Specialized centers and hernia specialists in absence of complications, such as recurrence and
Hernia surgery is commonly performed by general sur- chronic pain, but also if the patient is satisfied with all
geons in general hospitals. However, specialized hernia aspects of the repair. Patient Reported Outcome Measures
centers are emerging, focusing solely on hernia manage- (PROMs) assess how patients experience their illness and
ment. The additional value of these centers needs to be health after treatment. It is foreseen that in the future
evaluated. Are the outcomes after hernia surgery in a PROMs will have a growing significant meaning in the
specialized hernia center better compared to hernia surgery treatment of any condition or disease. The linkage of
performed by a general surgeon in a general hospital? And PROMs to national registries, yields opportunities to ana-
if so, where should hernia surgery be performed? Which lyze numerous of variables in hernia surgery and their
minimal conditions need to be fulfilled to perform hernia weight in quality outcomes. It is necessary to develop
surgery in a non-specialized center? Additionally, which quality indicators that are well defined and feasible given
requirements are to be met, to call a center a Hernia center the time and resources it needs to collect and analyze them.
in terms of caseload, diagnostics, techniques performed,
registry and scientific research participation? And equally, Implementation
what would be the requirements to call oneself a hernia These current guidelines are an initiative of many surgical
specialist? hernia societies. It would be interesting to conduct a survey
in the future to evaluate surgeons’ adherence to these
Costs guidelines. Guideline adherence is a tool to measure the
value and implementation of the guidelines.
The hernia literature needs standardized ways to report cost
so that techniques may be equally compared. This would Inguinal hernia surgery in low resource settings
start with a review of the reported different cost models and In low resource settings these current guidelines are less
then propose a standard model. Direct and indirect costs applicable. Mesh is not always available, and subsequent
need to be taken into account, respecting international and non-mesh techniques are the best surgical option. Question
cultural differences. remains, whether it is feasible to implement a safe and
cost-effective method of groin hernia mesh repair under
Registries local anesthesia in low income settings? Aspects of train-
ing, standardizing hernia care and financial aspects should
The use of registries has increased the last couple of years. be addressed.
Large sets of data have shown to be contributive in fields in
which randomized controlled trials are lacking. It still Proposed trials
needs to be determined whether national hernia registries Apart from the trials mentioned in the previous text, we
improve outcomes of hernia treatment? And if so, should stimulate researchers to initiate the following specific
registration be internationally encouraged? What is the trials:
value of a registry compared to randomized controlled
• A randomized controlled trial including young male
trials? And is data generated by registries valid? Can data
from national registries be pooled to an international adults (18–25-years-old) with an inguinal hernia com-
paring SAC resection only with a Shouldice repair and

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