Leistenhernienreparation – Wo wird wie operiert?^[*]

Zusammenfassung

Hintergrund: In den Guidelines der European Hernia Society (EHS) gibt es klare Stellungnahmen, wo und wie der Leistenbruch operiert werden soll. Für ASA-I- und -II-Patienten lautet die Empfehlung, die Operation ambulant durchzuführen. Über 30-jährige männliche Patienten sollten möglichst immer mit Netzverfahren versorgt werden. Sind die Empfehlungen im klinischen Alltag angekommen und sind diese Vorgaben der Guidelines alleiniger Schlüssel zum Erfolg? Anhand der Daten zweier Register, der Daten der Einzelpraxis des Erstautors und einer Literaturanalyse soll dies analysiert werden. Material und Methode: Es erfolgt die Auswertung der prospektiv erhobenen Daten zweier deutscher Register und einer auf die Hernienchirurgie spezialisierten Einzelpraxis. Die Ergebnisse werden durch eine Literaturanalyse ergänzt. Ergebnisse: Hinsichtlich der ambulanten Operationen unterscheiden sich die 3 Gruppen wie folgt: Herniamed-Register 22,3 %, QS-Leistenhernie-Register 62,7 % und in der Einzelpraxis 80,5 % ambulante Operationen. Der Anteil ASA-I- und -II-Patienten unterschied sich in den 3 Gruppen nur marginal (Herniamed 83,4 %, QS-Leistenhernie 89,5 % und Einzelpraxis 88,3 %). Die Rezidivraten betrugen nach 12 Monaten in QS-Leistenhernie 0,6 % und in der Einzelpraxis 0,7 %. In der Einzelpraxis wurden in 30 % Nahtverfahren angewandt. Schlussfolgerung: Ein hoher Anteil ambulanter Operationen ist bei ASA-I- und -II-Patienten ohne Qualitätsverlust machbar. Das nationale Register Herniamed zeigt einen im internationalen Vergleich deutlich niedrigeren Anteil ambulanter Operationen und einen überproportional höheren Anteil endoskopischer Verfahren. Hinsichtlich der Vergütungssituation sind im internationalen Vergleich ambulante Operationen in Deutschland deutlich schlechter gestellt. Ein weiterer Fakt ist, dass Deutschland über ca. ein Drittel mehr Krankenhausbetten verfügt als der Durchschnitt der OECD-Staaten.

Abstract

Background: Within the Guidelines of the European Hernia Society (EHS), there are disctinct statements about where and how inguinal hernia has to be surgically approached. In ASA-I and -II patients, it is recommended to perform the operation in an outpatient clinic setting. Male patients older than 30 years of age should undergo preferably surgical intervention using a mesh. In this context, there are two basic questions: “Are these recommendations already implemented in daily surgical practice (?)” and “Are these guidelines the road to success (?)”, which are to be commented based on i) data from two registries, ii) data obtained in the surgical practice of the first author and iii) a selective literature search. Material and Methods: An analysis was made of prospectively obtained data from two German registries (Herniamed registry [H-med]; Quality Assurance Inguinal Hernia Registry [QIHR]) and a consecutive and representative patient cohort of a single surgical practice [Surg-Pract] specialised in hernia surgery. Main results and concluding remarks are discussed in light of data reported in the literature. Results: Proportions of hernia repair in an outpatient clinic setting were substantially different among the 3 groups (as follows): H-med (22.3 %), QIHR (62.7 %), Surg-Pract (80.5 %) whereas the percentages of ASA-I and -II patients differed only slightly: H-med (83.4 %), QIHR (89.5 %) and Surg-Pract (88.3 %). Recurrency rates after 12 months were 0.6 % (QIHR) and 0.7 % (Surg-Pract), respectively. In Surg-Pract, for 30 % of hernia repairs, “only” suturing for reconstruction was used. Conclusion: In ASA-I and -II patients, a substantial proportion of individuals can be surgically treated in an outpatient clinic setting with no disadvantages regarding high surgical quality and favourable outcome. Data from the national H-med indicated a much lower percentage of such patients than internationally reported and, in addition, a disproportionately high rate of endoscopic procedures. Moreover, reimbursement for hernia repair in an outpatient clinic setting is much worse in Germany compared with international standards, and, interestingly, there is by a factor of 1/3 an above average number of hospital beds in Germany compared with the OECD countries.

Schlüsselwörter

Leistenbruch - ambulante Chirurgie - Operationstechnik - Ökonomie - „Tailored approach“

Key words

inguinal hernia - surgery in an outpatient clinic setting - surgical technique - economy - tailored approach

^* Prof. Dr. Dr. H. Lippert gewidmet

• Literatur

• 1 Bittner R, Arregui ME, Bisgaard T et al. Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)]. Surg Endosc 2011; 25: 2773-2843
• 2 Stechemesser B, Jacob DA, Schug-Paß C et al. Herniamed: an internet-based registry for outcome research in hernia surgery. Hernia 2012; 16: 269-276
• 3 Heniford BT, Walters AL, Lincourt AE et al. Comparison of generic versus specific quality-of-life scales for mesh hernia repairs. J Am Coll Surg 2008; 206: 638-644
• 4 David G, Neumann MD. The changing geography of outpatient procedures. LDI Issue Brief 2011; 16: 1-4
• 5 Brökelmann J, Mayr R. Quality Assurance and Benchmarking in Ambulatory Surgery. Amb Surg 2007; 13: 61-62
• 6 Brökelmann J. Zahl der Operations-Fälle 2006 – Es fehlen exakte Daten. ambulant operieren 2008; 3: 141-145
• 7 Gesundheitsberichterstattung des Bundes Im Internet: http://www.gbe-bund.de Stand: 20.05.2013
• 8 Toftgaard C. Day surgery activities 2009 international survey on ambulatory surgery conducted 2011. Amb Surg 2012; 17: 53-63
• 9 Simons MP, Aufenacker T, Bay-Nielsen M et al. European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2009; 13: 343-403
• 10 Mattila K, Vironen J, Eklund A et al. Randomized clinical trial comparing ambulatory and inpatient care after inguinal hernia repair in patients aged 65 years or older. Am J Surg 2011; 201: 179-185
• 11 Majholm B, Engbaek J, Bartholdy J et al. Is day surgery safe? A Danish multicentre study of morbidity after 57,709 day surgery procedures. Acta Anaesthesiol Scand 2012; 56: 323-331
• 12 Kurzer M, Kark A, Hussain ST. Day-case inguinal hernia repair in the elderly: a surgical priority. Hernia 2009; 13: 131-136
• 13 Acevedo A, Leon J. Ambulatory hernia surgery under local anaestesia is feasable and safe in obese patients. Hernia 2010; 14: 57-62
• 14 Sanjay P, Leaver H, Shaikh I et al. Lichtenstein hernia repair under different anaesthetic techniques with special emphasis on outcomes in older people. Australas J Ageing 2011; 30: 93-97
• 15 Ngo P, Pélissier E, Levard H et al. Ambulatory groin and ventral hernia repair. J Visc Surg 2010; 147: e325-e328
• 16 Brökelmann J. Comparison of hospital- and office-based ambulatory surgery in Germany: surgery in small free standing units offers many advantages. Amb Surg 2012; 17: 83-85
• 17 Weyhe D, Winnemöller C, Hellwig A et al. Das Aus für die minimal-invasive Leistenhernienversorgung durch § 115 bSGBV. Eine Analyse zu Patientenoutcome und Ökonomie. Chirurg 2006; 77: 844-855
• 18 OECD. Health Data 2009. Im Internet: http://www.oecd.org Stand: 21.05.2013)
• 19 Nordin P, van der Linden W. Volume of procedures and risk of recurrence after repair of groin hernia: national register study. BMJ 2008; 336: 934-937
• 20 Kehlet H, Bay-Nielsen M. Danish Hernia Database Collaboration. Hernia 2008; 12: 1-7
• 21 Simons MP, Kleijnen J, van Geldere D et al. Role of the Shouldice technique in inguinal hernia repair: a systematic review of controlled trials and a meta-analysis. Br J Surg 1996; 83: 734-738
• 22 Amato B, Moja L, Panico S et al. Shouldice technique versus other open techniques for inguinal hernia repair. Cochrane Database Syst Rev 2012; (4) CD001543
• 23 Liem MSL, van Duyn EB, van der Graaf Y et al. Coala Trial Group. Recurrences after conventional anterior and laparoscopic inguinal hernia repair: a randomized comparison. Ann Surg 2003; 237: 136-141
• 24 Bittner R, Sauerland S, Schmedt CG. Comparison of endoscopic techniques vs. Shouldice and other open nonmesh techniques for inguinal hernia repair: a meta-analysis of randomized controlled trials. Surg Endosc 2005; 19: 605-615
• 25 McGillicuddy JE. Prospective randomized comparison of the Shouldice and Lichtenstein hernia repair procedures. Arch Surg 1998; 133: 974-978
• 26 Nyhus LM. Invited Commentary. Arch Surg 1998; 133: 978
• 27 OʼReilly EA, Burke JP, OʼConnell PR. A meta-analysis of surgical morbidity and recurrence after laparoscopic and open repair of primary unilateral inguinal hernia. Ann Surg 2012; 255: 846-853
• 28 Lundström KJ, Sandblom G, Smedberg S et al. Risk factors for complications in groin hernia surgery: a national register study. Ann Surg 2012; 255: 784-788
• 29 Simons MP. . 2012; 156: A5223
• 30 Gass M, Banz VM, Rosella L et al. TAPP or TEP? Population-based analysis of prospective data on 4,552 patients undergoing endoscopic inguinal hernia repair. World J Surg 2012; 36: 2782-2786
• 31 Koning GG, Wetterslev J, van Laarhoven CJ et al. The totally extraperitoneal method versus Lichtensteinʼs technique for inguinal hernia repair: a systematic review with meta-analyses and trial sequential analyses of randomized clinical trials. PLoS One 2013; 8: e52599
• 32 Al-Momani H, Stephenson BM. Comparison of mesh-plug and Lichtenstein for inguinal hernia repair: a meta-analysis of randomized controlled trials. Li J, Ji Z, Li Y. Hernia 2013; 17: 151
• 33 Koning GG, de Vries J, Borm GF et al. Health status one year after TransInguinal PrePeritoneal inguinal hernia repair and Lichtensteinʼs method: an analysis alongside a randomized clinical study. Hernia 2013; 17: 299-306
• 34 Willaert W, De Bacquer D, Rogiers X et al. Open Preperitoneal Techniques versus Lichtenstein Repair for elective Inguinal Hernias. Cochrane Database Syst Rev 2012; (7) CD008034
• 35 Li J, Ji Z, Cheng T. Comparison of open preperitoneal and Lichtenstein repair for inguinal hernia repair: a meta-analysis of randomized controlled trials. Am J Surg 2012; 204: 769V778
• 36 Koning GG, Adang EM, Stalmeier PF et al. TIPP and Lichtenstein modalities for inguinal hernia repair: a cost minimisation analysis alongside a randomised trial. Eur J Health Econ 2012; Dec 28. [Epub ahead of print]
• 37 Zhao G, Gao P, Ma B et al. . 2009; 250: 35-42
• 38 Persson K, Rimback G, Dalenback J. The Lichtenstein Perfix Plug and Prolene Hernia System techniques for inguinal hernia repair – Long time follow up of a RCT. Hernia 2012; 16 (Suppl. 01) S143
• 39 Sanjay P, Watt DG, Ogston SA et al. Meta-analysis of Prolene Hernia System mesh versus Lichtenstein mesh in open inguinal hernia repair. Surgeon 2012; 10: 283-289
• 40 Scheidbach H, Wolff S, Lippert H. Prothetische Materialien in der Bauchwandchirurgie – ein Überblick. Zentralbl Chir 2011; 136: 568-574
• 41 Mantke R, Becker A. [Quality assurance with hospital routine data in general and visceral surgery: colon and hernia surgery]. Zentralbl Chir 2013; 138: 189-197
• 42 Negro P, DʼAmore L, Gossetti F. Mesh plug repair and surgeonʼs satisfaction. Hernia 2010; 14: 223-224