A herniorrafia inguinal por via convencional é uma das intervenções cirúrgicas mais freqüentes em crianças, exibindo altos índices de sucesso e baixos índices de complicações. Porém o tratamento cirúrgico ainda tem controvérsias: a exploração do lado contralateral assintomático, a incidência de complicações relacionadas às lesões dos vasos espermáticos e ducto deferente e complicações relacionadas à técnica cirúrgica, como as recidivas da hérnia ou criptorquia iatrogênica. A questão sobre qual é a melhor maneira de detectar patência de um processo peritônio- vaginal contralateral em crianças com hérnia inguinal unilateral tem sido debatida por mais de 50 anos. O ideal seria eliminar a desnecessária exploração inguinal e um futuro reparo cirúrgico contralateral. Com o advento da videocirurgia e suas alternativas terapêuticas, objetivou este estudo analisar os resultados do tratamento das hérnias inguinais por videolaparoscopia em meninos acima de 6 meses de idade, avaliando a efetividade da técnica empregada, a presença de hérnia contralateral, a correlação do espessamento do cordão espermático com os achados videolaparoscópicos e a análise da ocorrência de complicações pós-operatórias. Foram incluídos em um estudo prospectivo não randomizado 51 pacientes masculinos com hérnia inguinal não recidivada, tendo sido efetuadas 68 herniorrafias inguinais. Concluiu-se que a técnica empregada neste estudo mostrou-se efetiva, segura e com baixa incidência de complicações, apresentando-se como um excelente método para avaliação diagnóstica do lado contralateral da hérnia e como um método mais eficaz para detectar a presença de hérnia inguinal ou patência peritônio-vaginal contralateral assintomática, quando comparado com o sinal clínico de espessamento do cordão espermático. O presente estudo evidenciou recidiva de 2 hérnias. Não houve alterações do tamanho dos testículos nem criptorquia iatrogênica. / The conventional inguinal herniorrhaphy represents one of the most frequent surgical interventions in children, presenting high success rates and low rates of complications. However, controversies regarding the treatment of inguinal hernia still remain: the exploration of the assintomatic contralateral side, the incidence of complications related to injury of spermatic vessels and vas deferens, and complications related to the surgical technique such as the hernia recurrence or iatrogenic cryptorchidism. What is the best way to detect a contralateral patent processus vaginalis in a child presenting a unilateral inguinal hernia is an issue that has been debated for over 50 years. The ideal tool would be the one that eliminated the unnecessary inguinal exploration and future contralateral surgical repair.The advent of videosurgery and its therapeutic alternatives motivated this study to analyze the results of the treatment of inguinal hernias through videolaparoscopy in boys over six months of age, assessing the effectiveness of the technique, the presence of contralateral hernia, the correlation of the spermatic cord thickening with the videolaparoscopic findings and the analysis of the occurrence of post-surgical complications. Fifty one male patients with non recurrent inguinal hernia were included in a prospective study and sixty eight herniorrhaphy were performed. The conclusion was that the technique used in this study was effective and safe with a low incidence of complications, being an excellent method for diagnostic assessment of the contralateral side of the hernia and as a better and more efficient method to detect the presence of an inguinal hernia or an assintomatic contralateral patent processus vaginalis as compared to the clinical sign of spermatic cord thickening. The present study has shown the recurrence of two hernias. There were no alterations in the size of the testicles or iatrogenic cryptorchidism.

A herniorrafia inguinal por via convencional é uma das intervenções cirúrgicas mais freqüentes em crianças, exibindo altos índices de sucesso e baixos índices de complicações. Porém o tratamento cirúrgico ainda tem controvérsias: a exploração do lado contralateral assintomático, a incidência de complicações relacionadas às lesões dos vasos espermáticos e ducto deferente e complicações relacionadas à técnica cirúrgica, como as recidivas da hérnia ou criptorquia iatrogênica. A questão sobre qual é a melhor maneira de detectar patência de um processo peritônio- vaginal contralateral em crianças com hérnia inguinal unilateral tem sido debatida por mais de 50 anos. O ideal seria eliminar a desnecessária exploração inguinal e um futuro reparo cirúrgico contralateral. Com o advento da videocirurgia e suas alternativas terapêuticas, objetivou este estudo analisar os resultados do tratamento das hérnias inguinais por videolaparoscopia em meninos acima de 6 meses de idade, avaliando a efetividade da técnica empregada, a presença de hérnia contralateral, a correlação do espessamento do cordão espermático com os achados videolaparoscópicos e a análise da ocorrência de complicações pós-operatórias. Foram incluídos em um estudo prospectivo não randomizado 51 pacientes masculinos com hérnia inguinal não recidivada, tendo sido efetuadas 68 herniorrafias inguinais. Concluiu-se que a técnica empregada neste estudo mostrou-se efetiva, segura e com baixa incidência de complicações, apresentando-se como um excelente método para avaliação diagnóstica do lado contralateral da hérnia e como um método mais eficaz para detectar a presença de hérnia inguinal ou patência peritônio-vaginal contralateral assintomática, quando comparado com o sinal clínico de espessamento do cordão espermático. O presente estudo evidenciou recidiva de 2 hérnias. Não houve alterações do tamanho dos testículos nem criptorquia iatrogênica. / The conventional inguinal herniorrhaphy represents one of the most frequent surgical interventions in children, presenting high success rates and low rates of complications. However, controversies regarding the treatment of inguinal hernia still remain: the exploration of the assintomatic contralateral side, the incidence of complications related to injury of spermatic vessels and vas deferens, and complications related to the surgical technique such as the hernia recurrence or iatrogenic cryptorchidism. What is the best way to detect a contralateral patent processus vaginalis in a child presenting a unilateral inguinal hernia is an issue that has been debated for over 50 years. The ideal tool would be the one that eliminated the unnecessary inguinal exploration and future contralateral surgical repair.The advent of videosurgery and its therapeutic alternatives motivated this study to analyze the results of the treatment of inguinal hernias through videolaparoscopy in boys over six months of age, assessing the effectiveness of the technique, the presence of contralateral hernia, the correlation of the spermatic cord thickening with the videolaparoscopic findings and the analysis of the occurrence of post-surgical complications. Fifty one male patients with non recurrent inguinal hernia were included in a prospective study and sixty eight herniorrhaphy were performed. The conclusion was that the technique used in this study was effective and safe with a low incidence of complications, being an excellent method for diagnostic assessment of the contralateral side of the hernia and as a better and more efficient method to detect the presence of an inguinal hernia or an assintomatic contralateral patent processus vaginalis as compared to the clinical sign of spermatic cord thickening. The present study has shown the recurrence of two hernias. There were no alterations in the size of the testicles or iatrogenic cryptorchidism.

A herniorrafia inguinal por via convencional é uma das intervenções cirúrgicas mais freqüentes em crianças, exibindo altos índices de sucesso e baixos índices de complicações. Porém o tratamento cirúrgico ainda tem controvérsias: a exploração do lado contralateral assintomático, a incidência de complicações relacionadas às lesões dos vasos espermáticos e ducto deferente e complicações relacionadas à técnica cirúrgica, como as recidivas da hérnia ou criptorquia iatrogênica. A questão sobre qual é a melhor maneira de detectar patência de um processo peritônio- vaginal contralateral em crianças com hérnia inguinal unilateral tem sido debatida por mais de 50 anos. O ideal seria eliminar a desnecessária exploração inguinal e um futuro reparo cirúrgico contralateral. Com o advento da videocirurgia e suas alternativas terapêuticas, objetivou este estudo analisar os resultados do tratamento das hérnias inguinais por videolaparoscopia em meninos acima de 6 meses de idade, avaliando a efetividade da técnica empregada, a presença de hérnia contralateral, a correlação do espessamento do cordão espermático com os achados videolaparoscópicos e a análise da ocorrência de complicações pós-operatórias. Foram incluídos em um estudo prospectivo não randomizado 51 pacientes masculinos com hérnia inguinal não recidivada, tendo sido efetuadas 68 herniorrafias inguinais. Concluiu-se que a técnica empregada neste estudo mostrou-se efetiva, segura e com baixa incidência de complicações, apresentando-se como um excelente método para avaliação diagnóstica do lado contralateral da hérnia e como um método mais eficaz para detectar a presença de hérnia inguinal ou patência peritônio-vaginal contralateral assintomática, quando comparado com o sinal clínico de espessamento do cordão espermático. O presente estudo evidenciou recidiva de 2 hérnias. Não houve alterações do tamanho dos testículos nem criptorquia iatrogênica. / The conventional inguinal herniorrhaphy represents one of the most frequent surgical interventions in children, presenting high success rates and low rates of complications. However, controversies regarding the treatment of inguinal hernia still remain: the exploration of the assintomatic contralateral side, the incidence of complications related to injury of spermatic vessels and vas deferens, and complications related to the surgical technique such as the hernia recurrence or iatrogenic cryptorchidism. What is the best way to detect a contralateral patent processus vaginalis in a child presenting a unilateral inguinal hernia is an issue that has been debated for over 50 years. The ideal tool would be the one that eliminated the unnecessary inguinal exploration and future contralateral surgical repair.The advent of videosurgery and its therapeutic alternatives motivated this study to analyze the results of the treatment of inguinal hernias through videolaparoscopy in boys over six months of age, assessing the effectiveness of the technique, the presence of contralateral hernia, the correlation of the spermatic cord thickening with the videolaparoscopic findings and the analysis of the occurrence of post-surgical complications. Fifty one male patients with non recurrent inguinal hernia were included in a prospective study and sixty eight herniorrhaphy were performed. The conclusion was that the technique used in this study was effective and safe with a low incidence of complications, being an excellent method for diagnostic assessment of the contralateral side of the hernia and as a better and more efficient method to detect the presence of an inguinal hernia or an assintomatic contralateral patent processus vaginalis as compared to the clinical sign of spermatic cord thickening. The present study has shown the recurrence of two hernias. There were no alterations in the size of the testicles or iatrogenic cryptorchidism.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24472号 / 医博第4914号 / 新制||医||1062(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 今中 雄一, 教授 山本 洋介, 教授 小濱 和貴 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

La disposición anatómica de las estructuras que conforman la región inguinal es uno de los factores etiológicos en la formación de las hernias inguinales. Existen diferencias entre los autores cuando se refieren al área débil susceptible a la formación de las hernias inguinales y su relación con los diámetros de la pelvis mayor.En nuestro estudio nos hemos propuesto identificar dicha área, describir las estructuras anatómicas que participan en su delimitación, determinar su extensión, identificar la relación existente entre el área y la configuración ósea de la pelvis mayor e identificar el patrón de variación de estos parámetros en función de los sexos y de las razas estudiadas.Para ello hemos utilizado 63 regiones inguinales pertenecientes a 17 cadáveres humanos adultos de raza blanca y a 15 de raza negra, siendo 21 regiones del sexo femenino y 42 del sexo masculino.El área presentó siempre una forma ovoidea, y no triangular, quedando limitada por las fibras inferiores del músculo oblicuo interno y por el ligamento inguinal, los cuáles alcanzaban medialmente el tubérculo del pubis. Hemos propuesto la denominación de "espacio inguinal" para esta región y no hemos observado que su extensión variara en función del sexo o de la raza.Hemos también identificado una zona aun más débil de la región inguinal, de morfología triangular, que quedaba limitada por el ligamento inguinal, por el borde inferior del músculo oblicuo interno y por los vasos epigástricos inferiores. En ella se localizaba la abertura del anillo inguinal superficial, a cuyo nivel su pared estaba formada tan sólo por la fascia transversalis. Hemos propuesto el término de "triángulo de herniación" para denominar a esta región. El ángulo ínfero-interno, que corresponde a la zona que resiste mayor presión en la postura bípeda, no cambiaba en función del sexo ni de la raza.El anillo inguinal superficial presentó una morfologia irregularmente ovalada y se localizó en el tercio medial del "espacio inguinal", por delante del "triángulo de herniación". Nuestros resultados han determinado que dicho anillo es más vertical en la raza negra que en la raza blanca [p-valor <0,0001], pero sin diferencia estadísticamente significativa en lo que respecta al valor medio de su eje transversal máximo. Comparando los sexos, se presentó una mayor longitud de su eje transversal máximo [ p-valor <0,0001] y una disposición más vertical [ p-valor <0,0001] en el sexo masculino.Las fibras inferiores de los músculos oblicuo interno y transverso se originaron en el ligamento inguinal y terminaron en el tubérculo del pubis, describiendo un trayecto arqueado. El borde caudal del músculo oblicuo interno fue de constitución muscular y sobrepasaba caudalmente al músculo transverso, que fue músculo-aponeurótico. No hemos observado ningún caso de unión parcial o total de las fibras inferiores de ambos músculos.El ligamento inguinal presentó un trayecto arqueado y su longitud media fue de 111 milímetros. El ligamento interfoveolar de Hesselbach fue observado en 14% de los casos y en ellos reforzaba parte de la pared del "espacio inguinal" y del "triángulo de herniación". El anillo inguinal profundo presentó forma de U. Su vértice se localizaba en el espacio inguinal y sus dos pilares en relación con las fibras aponeuróticas (el medial) y musculares (el lateral) del músculo transverso. Las fibras inferiores del músculo oblicuo interno se encontraban por delante del anillo inguinal profundo, cubriendo los 2/3 o _ superiores del mismo. Su longitud transversal máxima fue de 15 milímetros en el sexo masculino y de 10 milímetros en el sexo femenino [p-valor <0,0001]. El estudio comparativo entre las razas no determinó diferencias estadísticamente significativas. El parámetro arco púbico (longitud que separa el tubérculo del pubis de una línea interespinosa) se mostró como el parámetro más fiable de la pelvimetria externa. Su longitud aumentó con el aumento de la longitud del ligamento inguinal [p-valor < 0,0001] y con la disminución de la longitud de la línea interespinosa [p-valor < 0,0001]. Fue mayor en el sexo femenino y en la raza blanca [ p-valor de 0,001]. Cuando el arco púbico era bajo (&#8805; 75 mm) el área del espacio inguinal fue mayor [p-valor = 0,004] y el eje transversal del anillo inguinal profundo también mayor [p-valor = 0,024]. Consecuentemente existe una mayor predisposición para la formación de hernias inguinales. El arco púbico no variaba en función de la longitud de los ejes transversal [p-valor de 0,106] y longitudinal [p-valor de 0,468] del anillo inguinal superficial, y tampoco variaba con el ángulo de inclinación del mismo respecto al plano horizontal trazado a nivel de los tubérculos del pubis [p-valor de 0,546]. / The anatomical disposition of the structures that conform the inguinal region is one of the main factors noted in the etiology of the inguinal hernia.There are differences in the authors' opinions regarding the assignment of the most susceptible area for the formation of inguinal hernias and their relation to the diametres of the major pelvis.In the present study we want to identify the aforementioned area, describe the anatomical structures that participate in its delimitation, determine its area, identify the relation between that area and the bone configuration of the major pelvis and finally to identify the different variations of these parameters concerning genders and races.Therefore we studied 63 inguinal regions corresponding to 17 white human adults cadavers and to 15 black ones, 21 of the regions were female and 42 male.The area was always ovoidal and not triangular. It was limited by the inferior fibres of the internal oblique muscle and the inguinal ligament. Therefore we have proposed the term "inguinal space". According to our observations its extension does not change according to different sexes and races.We have also identified an even weaker zone of triangular morphology in the inguinal region which is delimited by the inguinal ligament, the inferior border of the internal oblique muscle and the inferior epigastric vessels. In this zone we observe the opening of the superficial inguinal ring and the transversalis fascia. We have proposed the term "herniation triangle" to call this zone. Regarding to this herniation triangle, we have showed that its internal and inferior angle, which corresponds to a zone that must resist a major pressure, does not change according to different sexes and races.The superficial inguinal ring, with an irregularly oval form, is located in the medial third of the "inguinal space" in front to the "herniation triangle". Its disposition with regard to these two spaces allows us to observe that the broader and the more vertical the ring, the larger is the unprotected area of the inguinal space. According to our results the superficial inguinal ring of black people is more vertical than the one of white people [p<0,0001], but there are no significant statistic differences with regard to the average value of the maximum transversal axis. Comparing the two different sexes, we find a longer maximum transversal axis [p<0,0001] and a more vertical disposition [p<0,0001] in males.The inferior fibres of the internal oblique and transversal muscles originated in the inguinal ligament and inserted on the pubic tubercle. Its inferior border was muscular and surpassed the transversus that was muscle-aponeurotic. In any case could we find a partial or total union of inferior fibres of both muscles.The inguinal ligament is the inferior and external border of the "inguinal space". Its average length was 111 milimeters.The interfoveolar ligament of Hesselbach was observed in 14% of cases and it reinforced the walls of the "inguinal space" and "herniation triangle".The deep inguinal ring was an U-shaped form. Its vertex was located inside the "inguinal space", and its inner crus was attached to the transversus aponeurosis fibres and its outer crus to the transversus muscle fibres and two thirds or three quarters of its area were covered by inferior fibres of the internal oblique muscle. Its maximum transversal length was 15 mm in male and 10 mm in female [p<0001]. We couldn´t find any statistical differences between black and white people. The pubic arc (length between the pubic tubercle and the interespinuous line) was revealed to be a more reliable parameter of external pelvimetry. Its length increase with the increase of the inguinal ligament length [p<0,0001] and with the decrease of the interespinal line length [p< 0,0001]. The pubic arc was major on female and white persons [ p= 0,001]. When the pubic arc is low (&#8805; 75 mm) the "inguinal space" area is larger [ p = 0,004] and the maximum transversal length of deep inguinal ring is also major [p = 0,024]. As a consequence it is easier to develop inguinal hernia. The pubic arc does not vary according to the transversal axis length [p = 0,106], the longitudinal axis [p = 0,468] and the angle of the superficial inguinal ring [ p = 0,546].

Introducción:El uso del abdordage preperitoneal en la cirugía de la hernia inguinal es conocido des de hace tiempo. Wantz, siguiendo los principios de Stoppa introdujo la malla con la finalidad de encontrar la técnica ideal de la malla. Otro aspecto importante en la cirugía de la hernia inguinal es el seguimiento de los pacientes. El examen clínico en las consultas externas puede ser impracticable en hospitales terciarios con áreas de influencia sobre grandes grupos poblacionales.El objetivo del presente estudio es analizar los parámetros de la calidad a largo plazo de la cirugía de la hernia inguinal y la utilidad de un cuestionario postal con visita selectiva combinado con llamada telefónica en el seguimiento.Método:Se han incluido los pacientes intervenidos por una hernia inguinal mediante un abordaje preperitoneal y de forma ambulatoria en el Servicio de Cirugía General de un hospital terciario, entre el 1/1/1999 y el 31/12/2003.El cuestionario con seis preguntas con la opción de contestación si o no: ¿era la primera vez que le operaban la hernia?, ¿era del lado derecho, lado izquierdo o los dos a la vez?, ¿ha notado de nuevo un bulto en la zona operada?, ¿ha tenido dolor en la zona operada pasado un mes de la intervención?, ¿le continua doliendo en la actualidad la zona operada?, ¿esta satisfecho con la cirugía que se realizó?Resultados: Un total de 841 pacientes (72.9%) devolvieron el cuestionario después de tres envios (512 después del primero, 205 después del segundo y 124 después del tercero). El cuestionario con respuesta positiva se halló en 152 pacientes (18.1%) y con respuesta negativa en 689 pacientes (81.9%). De los 152 pacientes que respondieron "si" a alguna de las preguntas sobre dolor en la actualidad y/o recurrencia, 91 no quisieron ser visitados en consultas externas, 24 no se pudieron contactar por teléfono, y 37 quisieron ser visitados. De los 312 pacientes que no respondieron el cuestionario postal, 8 habían fallecido, 124 no quisieron ser visitados y 180 no se localizaron. La tasa de recurrencia hallada fue de 2.7% y la de dolor crónico de 5.9%.Conclusiones:1.La tasa de recidiva herniaria en nuestra serie puede oscilar entre el 4,3% y el 0,12% según como se tomen los criterios de recidiva y como se escoja la muestra de control.2.El dolor crónico postcirugía no se ha presentado y sólo se ha encontrado un 7,3% de parestesias y molestias inespecíficas en la región operada.3.El 95,2% de los pacientes que han respondido al cuestionario postal han manifestando estar satisfechos con la cirugía. Cuando se aplica el cuestionario SF-36, todos presentan unas puntuaciones medias superiores a 60 en cualquiera de sus dimensiones.4.El abordaje preperitoneal en régimen de Cirugía Mayor Ambulatoria es una buena técnica en nuestro ámbito.5.El uso de un cuestionario postal nos ha determinado una respuesta del 72,9%. Esto nos hace concluir que es una modalidad muy útil para la obtención de datos cuando se pretenden realizar estudios de calidad y de control del procedimiento.6.El uso del cuestionario postal con visita selectiva no ha aportado datos significativos para control sucesivo de un paciente.7.Una vez evaluada la calidad de la técnica y establecidos unos resultados a partir de un cuestionario postal, la utilización de un protocolo para el seguimiento no aporta ningún resultado añadido que lo justifique a menos que se modifique la técnica o el equipo.8.Al paciente intervenido consideramos que se le ha de proponer una única visita postoperatoria, donde a parte de hacer el control posquirúrgico pertinente, hay que informarle de que su hernia operada no necesita más controles. / Background:The open preperitoneal surgery for hernia repair is known since ages. Wantz, following Stoppa principles introduced the mesh trying to find, with this way, the ideal hernia repair technique. In the other hand, follow-up of the patient who have had a hernia repair is still an important problem nowadays for the general Surgeon. Classical follow-up with the patient are nearly impossible when the amount of patients is very high, and also, because of the low recurrence rate. This is the reason why we decided to evaluate the quality control parameters in hernia surgery (recurrence and pain) and also to assessed the usefulness of a short postal questionnaire and selective clinical examination combined with repeat mailing and telephone reminders for quality assessment in hernia surgery.Method: All patients (n = 1153) who underwent tension-free hernioplasty through an open preperitoneal approach between 1999 and 2003 received a 6-item questionnaire with a covering letter and a stamped addressed enveloped. Non-responders received two successive new questionnaires and a telephone call. Concerning to the questionnaire, we asked the patients to answer 6 questions: 1-Was it your first hernia surgery procedure? 2-You were operated of the right, left or both hernia? 3-After a month since surgery, have you had a lump in the groin? 4-After a month since surgery, have you had pain in the groin? 5-Do you still have pain in the groin? 6-Are you satisfied with the surgery?Results:A total of 841 (72.9%) patients returned questionnaires after three reminders (512 after the first mailing, 205 after the second, and 124 after the third). Positive questionnaire answers were documented for 152 (18.1%) repairs and negative answers for 689 (81.9%). Of the 152 patients who answered "yes" to either of the questions regarding recurrence and/or current pain, 91 declined clinical appointment, 24 could not be contacted by phone, and 37 underwent physical examination. Of the 312 patients who did not return the questionnaire, 8 had died, 124 were not willing to be visited, and 180 could not be localised. The recurrence rate was 2.7% and the chronic pain rate 5.9%.Conclusions:1. Recurrence is estimated to be between 4.3% and 0,12% depending recurrence criteria and patients selection.2. Chronic pain has not been reported and 7.3% of patient refer paresthesias and unspecific pain.3. In our study, patients are satisfied with surgery (95.2%), SF-36 shows good results and our surgery quality in terms of satisfaction and recurrence is acceptable.4. Low recurrence rate, no chronic pain and few paresthesias added to a high number of patients satisfied allows us to say that preperitoneal technique in Ambulatory Surgery is a good option in our area.5. The use of a postal questionnaire in our area could be a useful way to obtain information when a quality control of the surgery is done.6. The use of a postal questionnaire in our area with selective physical examination, has not added significant data for the control of patients.7. Once evaluated the quality of the technique and established some results about the postal questionnaire, unless the technique or the team changes, the use of a protocol is not required.8. The patient who underwent a surgery of inguinal hernia, has to be visited only once after operation and inform him that his hernia does not need more examinations.

published_or_final_version / abstract / toc / Surgery / Master / Master of Surgery

BACKGROUND: We compared hernia recurrence rates in patients undergoing primary elective inguinal hernia repair at general hospitals with the Shouldice Hospital in Ontario, Canada. METHODS: We conducted an administrative data analysis of persons who underwent inguinal hernia repair in Ontario, Canada from 1993-2007. Risk of recurrent hernia repair was estimated according to hospital type and volume, using Cox proportional-hazards regression models. RESULTS: Recurrence risk in the lowest volume quartile was 5.7%, compared to 3.9% at high volume general hospitals and 1.1% at the Shouldice hospital. Compared to persons who had surgery at the lowest volume hospitals, hernia recurrence among Shouldice Hospital patients was substantially lower after adjustment for confounding variables (hazard ratio 0.18, CI (0.16 to 0.19), P <0.001). CONCLUSIONS: Persons who had elective primary inguinal hernia repair at the Shouldice Hospital had a substantially lower risk of recurrence than those treated at general hospitals, including high volume general hospitals.

BACKGROUND: We compared hernia recurrence rates in patients undergoing primary elective inguinal hernia repair at general hospitals with the Shouldice Hospital in Ontario, Canada. METHODS: We conducted an administrative data analysis of persons who underwent inguinal hernia repair in Ontario, Canada from 1993-2007. Risk of recurrent hernia repair was estimated according to hospital type and volume, using Cox proportional-hazards regression models. RESULTS: Recurrence risk in the lowest volume quartile was 5.7%, compared to 3.9% at high volume general hospitals and 1.1% at the Shouldice hospital. Compared to persons who had surgery at the lowest volume hospitals, hernia recurrence among Shouldice Hospital patients was substantially lower after adjustment for confounding variables (hazard ratio 0.18, CI (0.16 to 0.19), P <0.001). CONCLUSIONS: Persons who had elective primary inguinal hernia repair at the Shouldice Hospital had a substantially lower risk of recurrence than those treated at general hospitals, including high volume general hospitals.

Thesis (M.S.)--University of Hong Kong, 2002. / Title from title frame. Includes bibliographical references (leaves 133-151).