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Background. Laparoscopic skills training and evaluation outside the operating room is important for all surgeons learning new skills. To study feasibility, a video box trainer tracking 4-dimensional (4D) metrics was evaluated as a laparoscopic training tool. Method. Simball Box is a video box trainer with authentic surgical instruments and camera with video recording, equipped with 4D motion analysis registered through trocars using machine vision technology. Residents attending a 3-day laparoscopy course were evaluated performing a laparoscopic surgical knot at start, middle, and end. Metrics were obtained. Feedback data were presented in reference to expert/tutorial performance. Results. Ten right-handed residents were included. Median time (range) to finish the task was 359 (253-418), 129 (95-166), and 95 (52-156) seconds; 655%, 236%, and 174% of tutorial performance, with significance pre-/midcourse ( P < .0001), pre-/postcourse ( P < .0001), and mid-/postcourse ( P = .0050). Combined median total instrument motion decreased pre-/midcourse from 1208 (845-1751) to 522 cm (411-810 cm); P = .042 to 405 cm (246-864 cm) postcourse; pre-/postcourse P < .0001; 673%, 291%, 225% of tutorial performance. Total angular distance in radians (range) was 150 (87-251), 65 (42-116), and 50 (33-136) with significance pre-/midcourse ( P = .022) and pre-/postcourse ( P = .0002). Right-handed average speed (cm/s) increased: 1.94 (1.11-2.27) pre-, 2.39 (1.56-2.83) mid-, 2.60 (1.67-3.19) postcourse with significance pre-/midcourse ( P = .022) and pre-/postcourse ( P = .002). Average acceleration (mm/s2) and motion smoothness (µm/s3) failed to show any difference. Conclusion. For laparoscopic training and as a promising evaluation device, Simball Box obtained metrics mirroring progression well.

Chronic groin postherniorrhaphy pain (CGPP) is common and sometimes so severe that surgical treatment is necessary. The aim of this study was to identify risk factors for being reoperated due to CGPP.All 195,707 repairs registered in the Swedish Hernia Register between 1999 and 2011 were included in the study. Out of these, 28,947 repairs were excluded since they were registered as procedures on the same patient after a previous repair. Age, gender, hernia anatomy (indirect reference), method of repair (anterior sutured repair reference) and postoperative complications were included in a multivariate Cox analysis with reoperation due to CGPP as endpoint.Of the patients included in the study cohort, 218 (0.13%) later underwent reoperation due to CGPP, including 31 (14%) women. Median age at the primary repair was 61.5 years. Risk factors for being reoperated were agemedian [hazard ratio (HR) 3.03, 95% confidence interval (CI) 2.22-4.12], female gender (HR 2.13, CI 1.41-3.21), direct hernia (HR 1.35, CI 1.003-1.81), other hernia (HR 6.03, CI 3.08-11.79), Lichtenstein repair (HR 2.22, CI 1.16-4.25), plug repair (HR 3.93, CI 1.96-7.89), other repair (HR 2.58, CI 1.08-6.19), bilateral repair (HR 2.58, CI 1.43-4.66) and postoperative complication (HR 4.40, CI 3.25-5.96).Risk factors for being reoperated due to CGPP in this cohort included low age, female gender, a direct hernia, a previous Lichtenstein or plug repair, bilateral repair and postoperative complications. Further research on how to avoid CGPP and explore the effectiveness of surgery for CGPP is necessary.

Chronic pain and physical disability are well-known problems after primary groin hernia surgery, but the outcome after recurrent hernia surgery is much less known. To study the impact of anterior mesh repair (AMR) and posterior mesh repair (PMR) on chronic pain and disability after first recurrent groin hernia surgery in a population-based cohort derived from the Swedish Hernia Register. Consecutive unilateral, first and second recurrent hernia repairs, registered between 1998 and 2007, were included. Follow-up was performed in 2009 based on the Inguinal Pain Questionnaire (IPQ) and selective clinical examination, comparing prevalence of pain between AMR, endoscopic (E-PMR) and open posterior mesh repairs (O-PMR) after first recurrent repair. Chronic pain after a second recurrent repair was analysed. Altogether 671 first recurrent repairs were analysed: 329 AMRs, 161 E-PMRs and 181 O-PMRs. IPQ response rate was 70.6 %. If the index repair was anterior, the E-PMR was associated with a lower risk of chronic pain and disability compared to AMR [OR 0.54 (CI 0.30–0.97), p = 0.039]. The risk of chronic pain increased after a second recurrent repair. A surgeon’s annual volume >5 O-PMRs was related to a lower risk compared to ≤5 [OR 0.42 (CI 0.19–0.94), p = 0.034]. Endoscopic repair for first recurrent groin hernia surgery, after an index anterior repair, was associated with less chronic pain, discomfort and disability compared to anterior approach. Chronic pain increased after a second recurrent repair. A high surgeon’s volume reduced the risk of chronic pain after open posterior mesh repair.

OBJECTIVE:: To describe the characteristics of patients undergoing multiple groin hernia repairs and to identify strategies that prevent further recurrence. SUMMARY BACKGROUND DATA:: Although relatively infrequent, recurrent groin hernias where several repairs have previously been undertaken constitutes a major problem in hernia surgery. Low numbers and heterogeneity have made it difficult to perform large prospective studies on this group. METHODS:: The study was designed as an observational population-based register study. All repairs for recurrent hernia recorded in the Swedish Hernia Register (SHR) 1992-2006 were identified. Risk for reoperation by number of previous repairs, with adjustment for gender and age, and risk for reoperation by unit responsible for previous repair were determined using Cox proportional hazard analysis. RESULTS:: There were 12,104 cases of hernia repaired once, 2 repairs in 4199 cases, 3 repairs in 310 cases, 4 repairs in 32 cases, and 5 repairs in 3 cases. The risk for further reoperation increased with the number of previous repairs (P < 0.001). The hazard ratios for reoperation following open preperitoneal mesh repair and laparoscopic repair decreased; whereas, the hazard ratio for sutured repair increased with the number of previous repairs. The difference between Lichtenstein repair and laparoscopic repair was significant for the first 2 repairs (P < 0.05). CONCLUSION:: Laparoscopic preperitoneal repair provides the best surgical outcome in repeated groin hernia recurrence.

OBJECTIVE:: The aim of the trial was to compare laparoscopic technique with open technique regarding short-term pain, quality of life (QoL), recovery, and complications. BACKGROUND:: Laparoscopic and open techniques for incisional hernia repair are recognized treatment options with pros and cons. METHODS:: Patients from 7 centers with a midline incisional hernia of a maximum width of 10 cm were randomized to either laparoscopic (LR) or open sublay (OR) mesh repair. Primary end point was pain at 3 weeks, measured as the bodily pain subscale of Short Form-36 (SF-36). Secondary end points were complications registered by type and severity (the Clavien-Dindo classification), movement restrictions, fatigue, time to full recovery, and QoL up to 8 weeks. RESULTS:: Patients were recruited between October 2005 and November 2009. Of 157 randomized patients, 133 received intervention: 64 LR and 69 OR. Measurements of pain did not differ, nor did movement restriction and postoperative fatigue. SF-36 subscales favored the LR group: physical function (P < 0.001), role physical (P < 0.012), mental health (P < 0.022), and physical composite score (P < 0.009). Surgical site infections were 17 in the OR group compared with 1 in the LR group (P < 0.001). The severity of complications did not differ between the groups (P < 0.213). CONCLUSIONS:: Postoperative pain or recovery at 3 weeks after repair of midline incisional hernias does not differ between LR and OR, but the LR results in better physical function and less surgical site infections than the OR does. (ClinicalTrials.gov Identifier: NCT00472537). (Less)

Background The reoperation rate after recurrent groin hernia surgery is more than twice that recorded for primary groin hernia procedures. The aim was to define the outcome from routine redo hernia surgery by analysing a large population-based cohort from a national hernia register. Methods All recurrent groin hernia operations registered in the Swedish Hernia Register from 1992 to 2008 were analysed using multivariable analysis with stratification for preceding repair. Results Altogether 174 527 hernia operations were recorded in the Swedish Hernia Register between 1992 and 2008, including 19 582 reoperations. The preceding repair was included in the register for 5565 of these recurrent repairs. With laparoscopic repair as reference standard, the hazard ratio for recurrence was 2·55 (95 per cent confidence interval 1·66 to 3·93) after sutured repair, 1·53 (1·20 to 1·95) after Lichtenstein repair, 2·31 (1·76 to 3·03) after plug repair, 1·36 (0·95 to 1·94) after open preperitoneal mesh and 3·08 (2·22 to 4·29) after other repairs. Laparoscopic and open preperitoneal repair were associated with a lower risk of reoperation following a preceding open repair (P < 0·001), but no technique differed significantly from the others following a preceding preperitoneal repair. Conclusion The laparoscopic and the open preperitoneal mesh methods of repair for recurrent groin hernias were associated with the lowest risk of reoperation. Although the method of repair in previous surgery must be considered, these techniques are the preferred methods for recurrent groin hernia surgery.

The aim of this study was to assess the impact of the degree of difficulty and quality of hernia repair, as perceived by the surgeon, and operative time on the reoperation rate. All hernia repairs performed during the period 1994-1995 at the Department of Surgery, University Hospital of Lund, Sweden, were recorded prospectively. The degree of difficulty and the degree of difficulty in relation to the preoperative expectation of the surgeon were graded on a three-degree scale, the final outcome graded as optimal or suboptimal, and the time required to perform the hernia repair was recorded. Recurrence repairs prior to 1998 were traced in a retrospective review of the patient notes. The Swedish Hernia Register was checked for reoperations from 1998 and later. Altogether, 184 hernia repairs were recorded during the study period, including 14 repairs on women. The mean age of the patients was 58 years and the standard deviation was 15 years. Subsequent reoperation for recurrence was identified in 21 (11.4%) of these patients. The operative time correlated significantly with the surgeon's perception of the degree of difficulty (P < 0.05). Operative time less than 20 min (n = 4) was significantly associated with increased risk for reoperation (P < 0.05). The degree of difficulty, the degree of difficulty in relation to preoperative expectation, and the assessment of the final outcome were not associated with the risk for reoperation. Although neither the grade of difficulty nor the surgeon's perception of the quality of repair significantly predicted the final outcome, the risk for reoperation increased if the repair was performed rapidly.

Objective: To audit the effect of changes in treatment of inguinal hernias on recurrence rate. Design: Retrospective analysis of consecutive patients operated on in 1990 and prospective analysis of consecutive patients operated on in 1996. Follow up with questionnaire followed by selective clinical examination. Setting: County hospital, Sweden. Subjects: 144 patients with 147 inguinal hernias operated on in 1990 and 154 patients with 165 inguinal hernias operated on in 1996. Interventions: In 1993, we changed many aspects of the treatment of inguinal hernia. We introduced new techniques such as Shouldice, Lichtenstein, and laparoscopic hernia repair. Non-absorbable polypropylene sutures replaced the braided absorbable sutures previously used. Inguinal herniorrhaphy went from a "low status" operation to a high status operation and became a primary teaching operation for surgical residents. Main outcome measures: Recurrence rate at 5 year follow up. Results: The 5 year recurrence rate decreased from 28% in 1990 to 3% in 1996 (p < 0.001). The median operating time increased from 35 minutes in 1990 to 78 minutes in 1996 (p < 0.001). Conclusion: Changing the strategy of inguinal hernia surgery by introducing uniform operating techniques and new materials dramatically improved the results and allowed us to achieve recurrence rates comparable to those seen in specialised hernia centres. (Less)