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ABSTRACT: OBJECTIVES: Abdominal aortic aneurysm disease has been hypothesized as associated with the development of abdominal wall hernia. We evaluated the risk factors for incisional hernia repair after open elective aortic reconstructive surgery for aortoiliac occlusive disease and abdominal aortic aneurysm. METHODS: A retrospective analysis of prospectively recorded data in nationwide databases was carried out, with merged data from the Danish Vascular Registry (January 2006-January 2012), the Danish Ventral Hernia Database (January 2007-January 2012), and the Danish National Patient Register (January 2007-January 2012) to obtain 100% follow-up for incisional hernia repair in patients undergoing open elective aortic reconstructive surgery. The predefined risk factors of age, sex, American Association of Anesthesiologists score, body mass index, smoking status, type of aortic surgery, and type of incision were tested in a multivariate Cox regression model for the risk of incisional hernia repair. RESULTS: We identified 2597 patients, of whom 838 and 1759 underwent open elective surgery for an aortoiliac occlusive disease and abdominal aortic aneurysm, respectively. The median follow-up was 28.9 months (range, 0-71.6 months), and the cumulative risk of hernia repair after aortic reconstructive surgery was 10.4% after 6 years of follow-up. Body mass index >25.0 kg/m(2) (adjusted hazard ratio, 1.74; 95% confidence interval, 1.21-2.46) and abdominal aortic aneurysm repair (adjusted hazard ratio, 1.58; 95% confidence interval, 1.06-2.35) were significantly associated with incisional hernia repair. CONCLUSIONS: High body mass index and abdominal aortic aneurysm repair were independent risk factors for a subsequent incisional hernia surgery in patients undergoing aortic reconstructive surgery.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 03/2013; · 3.52 Impact Factor
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ABSTRACT: BACKGROUND: Preliminary studies have indicated clinical advantages of mesh fixation using fibrin glue in transabdominal preperitoneal groin hernia repair (TAPP) compared with tack fixation. The aim of this randomized double-blinded, controlled, clinical trial is to compare fibrin glue with tacks fixation of mesh during TAPP. METHODS: One hundred and twelve men with unilateral inguinal hernia were enrolled. Primary outcome was pain during coughing on postoperative day 1. Secondary outcomes were postoperative scores of pain at rest, discomfort, and fatigue (day 1 and cumulated day 0-3), incidence of moderate/severe nausea and/or vomiting, foreign-body sensation, and recurrence after 6 months. Outcome measures were assessed by visual analogue scale (VAS, 0-100 mm), verbal rating scale (no, light, moderate or severe) and numerical rating scales (NRS, 1-10). RESULTS: One hundred patients were available for analysis. The fibrin group (n = 50) had significantly less pain during coughing on day 1 compared with the tacks group (n = 50) [median 23 (range 0-80) vs 35 (2-100) mm] (p = 0.020). Moreover, day 1 scores and all cumulated scores of pain during rest, discomfort, and fatigue were significantly lower in the fibrin group compared with the tacks group (all p-values ≤ 0.02). There was no significant difference in the incidence of nausea and/or vomiting (p > 0.05) or recurrence (fibrin glue n = 2, tacks n = 0, p = 0.241). Incidence of foreign-body sensation was significantly lower in the fibrin group at 1 month (p = 0.006). CONCLUSIONS: Fibrin glue compared with tacks fixation improved the early postoperative outcome after TAPP. The trial was registered at clinicaltrials.gov NCT01000116.
Surgical Endoscopy 01/2013; · 4.01 Impact Factor
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ABSTRACT: Groin hernia repair is a commonly performed surgical procedure in the western world but large-scaled epidemiologic data are sparse. Large-scale data on the occurrence of groin hernia repair may provide further understanding to the pathophysiology of groin hernia development. This study was undertaken to investigate the age and gender dependent prevalence of groin hernia repair.
In a nationwide register-based study, using data from the Civil Registration System covering all Danish citizens, we established a population-based cohort of all people living in Denmark on December 31(st), 2010. Within this population all groin hernia repairs during the past 5 years were identified using data from the ICD 10(th) edition in the Danish National Hospital Register.
The study population covered n = 5,639,885 persons. During the five years study period 46,717 groin hernia repairs were performed (88.6% males, 11.4% females). Inguinal hernias comprised 97% of groin hernia repairs (90.2% males, 9.8% females) and femoral hernias 3% of groin hernia repairs (29.8% males, 70.2% females). Patients between 0-5 years and 75-80 years constituted the two dominant groups for inguinal hernia repair. In contrast, the age-specific prevalence of femoral hernia repair increased steadily throughout life peaking at age 80-90 years in both men and women.
The age distribution of inguinal hernia repair is bimodal peaking at early childhood and old age, whereas the prevalence of femoral hernia repair increased steadily throughout life. This information can be used to formulate new hypotheses regarding disease etiology with regard to age and gender specifications.
PLoS ONE 01/2013; 8(1):e54367. · 4.09 Impact Factor
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ABSTRACT: BACKGROUND: Incisional hernia repair is a frequent surgical procedure, but perioperative risk factors and outcomes have not been prospectively assessed in large-scale studies. The aim of this nationwide study was to analyze surgical risk factors for early and late outcomes after incisional hernia repair. STUDY DESIGN: We conducted a prospective nationwide study on all elective incisional hernia repairs registered in the Danish Ventral Hernia Database between January 1, 2007 and December 31, 2010. Main outcomes measures were surgical risk factors for 30-day readmission, reoperation (excluding recurrence), and mortality after incisional hernia repair. Late outcomes included reoperation for recurrence during the follow-up period. Follow-up was obtained by merging the Danish Ventral Hernia Database with the Danish National Patient Register. Results were evaluated by multivariate analyses. RESULT: The study included 3,258 incisional hernia repairs. Median follow-up was 21 months (interquartile range 10 to 35 months). The 30-day readmission, reoperation, and mortality rates were 13.3%, 2.2%, and 0.5%, respectively. Advanced age, open repair, large hernia defect, and vertical incision at the primary laparotomy were significant independent risk factors for poor early outcomes (p < 0.05). The cumulated risk of recurrence repair after open and laparoscopic repair was 21.1% and 15.5%, respectively (p = 0.03). Younger age, open repair, hernia defects >7 cm, and onlay or intraperitoneal mesh positioning in open repair were significant risk factors for poor late outcomes (p < 0.05). CONCLUSIONS: Elective incisional hernia repair were beset with high rates of readmission and reoperation for recurrence. Readmission and reoperation for recurrence were most pronounced after open repair and repair for hernia defects up to 20 cm. Additionally, sublay mesh position reduced the risk of reoperation for recurrence after open repairs.
Journal of the American College of Surgeons 12/2012; · 4.55 Impact Factor
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Ugeskrift for laeger 12/2012; 174(49):3069.
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ABSTRACT: OBJECTIVE:: To compare the clinical recurrence rate with reoperation rate for recurrence after ventral hernia repair. BACKGROUND:: Reoperation is often used as an outcome measure after ventral hernia repair, but it is unknown whether reoperation rate reflects the overall clinical risk for recurrence. METHODS:: The study cohort was recruited from the Danish Ventral Hernia Database and the Danish National Patient Registry during January 1, 2007, to December 31, 2007. Inclusion criteria were primary umbilical/epigastric (umb/epi) or incisional hernia repair from a regional area of 2 million inhabitants. A prospective clinical follow-up was conducted in January 2011 using a validated questionnaire on reoperation and possible recurrence. Suspicion of recurrence was the criterion for clinical examination. A telephone interview and/or patients' hospital files confirmed reoperation. RESULTS:: A total of 945 patients were eligible, and 902 patients responded to the questionnaire (response rate 95%) with a median postoperative follow-up of 41 months (range 0-48 months). The analysis comprised 646 patients with umb/epi and 256 patients with incisional hernia repair. Clinical examination was required in 241 patients. After umb/epi and incisional hernia repair, the cumulative risks of reoperation and overall recurrence (reoperation + clinical) were 4% and 15% (fourfold underestimation), and 8% and 37% (fivefold underestimation) (P < 0.001), respectively. CONCLUSIONS:: Reoperation rate for recurrence 41 months after primary umbilical/epigastric or incisional hernia repair underestimated overall risk of recurrence by four- to fivefolds. This study was registered in www.clinicaltrials.gov (NCT01325246).
Annals of surgery 05/2012; · 7.90 Impact Factor
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ABSTRACT: Only limited data are available on subtotal laparoscopic colectomy (STC) in patients with in inflammatory bowel disease. We present the first Danish experiences with intended laparoscopic STC for inflammatory bowel disease (IBD). The primary outcome was 30-day morbidity.
The present study is a retrospective single-centre study with consecutive enrolment of patients undergoing intended STC for IBD from 1 January 2005 to 31 July 2009. The results were analysed as either emergency or elective operations. Only the most severe complication was noted for each patient. Data on medical treatment, blood tests and complications and death within 30 days were registered.
A total of 32 patients underwent surgery (15 elective and 17 emergency procedures). Patients in the emergency group had significantly more severe disease activity than elective patients. Severe complications were recorded in 47% and 20% of the patients undergoing emergency and elective STC, respectively (p = 0.15). The overall morbidity was 72%. One emergency patient died. Five of eight emergency patients and one of three elective patients underwent conversion and experienced a major complication (p = 0.55). The overall conversion rate was 32% (p = 0.15).
We found high morbidity and conversion rates in patients undergoing SLC for IBD. A prospective national Danish survey on early postoperative outcome is suggested.
not relevant.
not relevant.
Danish medical bulletin 12/2011; 58(12):A4326. · 0.75 Impact Factor
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ABSTRACT: Evidence-based recommendations for the expected duration of convalescence after laparoscopic groin hernia repair are not available, and objective reasons for prolonged convalescence are not clear. Our main aim was to establish the expected duration of convalescence using preoperative recommendations to the patient and to identify the limiting factors for early (postoperative) resumption of normal activities after laparoscopic transabdominal preperitoneal inguinal herniorraphy (TAPP).
This was a single-center prospective study. The intervention (the recommendation to the patient) was 1 day for convalescence. Several predefined factors were investigated for their influence on the duration of convalescence and the risk of early postoperative pain. Predefined, clinically justified reasons for not resuming normal activities within the first 3 postoperative days were also registered.
Between August 2009 and August 2010, 185 consecutive male patients with groin hernia were enrolled prospectively, and 162 patients were available for analysis. Convalescences from work and leisure activities were a median of 5 days (range, 1-40) and 3 days (range, 1-49), respectively (P = .34). Preoperative expectations of convalescence from work (the number of days) was the only factor to explain prolonged convalescence from work (P < .001). Postoperative, self-registered planned sick leave, and complaints of pain and fatigue were the dominant reasons for not resuming normal activities within the first 3 days after operation. Younger age was the only factor found to explain the intensity of postoperative pain (P < .001).
Postoperative convalescence (return to work or normal activities) was between 3 and 5 days after TAPP in patients who were counseled about a 1-day expected convalescence. The expectation of convalescence from work was an important reason for delayed convalescence beyond 1 day.
Surgery 10/2011; 151(4):556-63. · 3.10 Impact Factor
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ABSTRACT: Early outcome after elective ventral hernia repair is unsatisfactory, but detailed analyses are lacking. The aim of this study was to describe the aetiology of prolonged hospital stay (LOS), readmission and death < 30 days after elective ventral hernia repair.
The present study was a nationwide case-control study based on prospective results from elective ventral hernia repairs (incisional, umbilical/epigastric, parastomal and other rare ventral hernia repairs) performed in Denmark during 2008. The exclusion criteria were emergency operation and ventral hernia repair in addition to another surgical procedure. The study group were patients with poor outcome (a LOS ≥ 5 days and/or readmission and/or death ≤ 30 days) and the control group were patients without a poor outcome. Major complications were defined as severe and potentially fatal complications.
The cohort included 2,258 patients (a study group counting 258 patients (259 repairs) and a control group comprising 2,000 patients (2,016 repairs)). Patients in the study group underwent repair significantly more often for incisional (76% versus 28%, p < 0.001), parastomal (3% versus 1%, p = 0.001) and recurrent hernia (21% versus 12%, p < 0.001). Furthermore, hernia defects were significantly larger (median 8 cm versus 2 cm, p < 0.001) in the study group than in the control group. Prolonged LOS was mainly due to pain (27%), major complications (19%), and seroma formation (9%). Readmissions were primarily caused by wound infections and pain.
Readmissions and prolonged hospital stay after ventral hernia repair were mainly due to pain, major complications, wound infections and seroma formation.
The foundation of Engineer Johs. E. Ormstrup and wife Grete Ormstrup and Region Zealand"s foundation for health-care research provided funding for this study.
The study was registered with the Danish Data Protection Agency (ref. no. 2008-58-0020) and www.clinicaltrials.gov (ref. no. NCT01388634).
Danish medical bulletin 10/2011; 58(10):A4322. · 0.75 Impact Factor
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ABSTRACT: Previous studies have shown different pain characteristics in different types of laparoscopic operations, but pain pattern has not been studied in detail after laparoscopic inguinal hernia repair. To optimise preoperative patient information and postoperative analgesic treatment the present study investigated postoperative pain in terms of time course, pain intensity and individual pain components during the first 4 days after transabdominal preperitoneal hernia repair (TAPP).
The study was a single-centre prospective trial including 50 consecutive male patients with primary or recurrent inguinal and/or femoral hernia undergoing elective repair. Several pain components (visceral pain, incisional pain and shoulder pain) were studied as well as pain at the three different trocar incisions. Pain was recorded before operation and on a daily basis during the first four postoperative days using a visual analogue and a verbal rating scale. We used 1 × 12 and 2 × 5 mm trocars for TAPP.
A total of 46 patients were available for analyses (age median 58 years, range 27-69 years). Visceral pain dominated significantly compared with incisional pain (P < 0.01), which again dominated over shoulder pain intensity and incidence (P < 0.01). Pain intensity did not significantly differ between different trocar incisions (5 and 12 mm) (P > 0.05). The overall pain intensity (a conglomerate of the different pain components) was most intense 3 h after TAPP and declined to preoperative levels on day 3 (P > 0.5).
Pain was most intense 3 h after the operation and declined to low levels within the first 3 days. Visceral pain was by far the dominating pain component compared with incisional and shoulder pain.
Surgical Endoscopy 06/2011; 25(12):3859-64. · 4.01 Impact Factor
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ABSTRACT: The risk of trocar site hernia (TSH) may be 0-22%, but no large scaled data with long-term follow-up are available. The purpose of this study was to estimate the long-term risk of TSH repair.
All patients in Denmark who underwent a laparoscopic procedure in 1997 were identified using the Danish National Patient Register and followed during a 12-year period. Hospital records for patients with an incisional or umbilical hernia repair were tracked and manually analyzed for possible relationship between reoperation and the initial laparoscopy.
We included 7,626 patients. During follow-up, we identified 95 patients with TSH repair with a cumulative risk of 1.3% being lowest after minor gynecological procedures and appendectomy and highest after fundoplication, cholecystectomy, and oophorectomy. The TSH was mainly at the umbilicus site (n = 63, 66%), and 15 (16%) of the TSH repairs were performed as an emergency procedure.
The long-term risk of TSH repair is low, but the risk of an emergency operation for TSH is relatively high, which suggests that all patients with a TSH should be offered elective repair.
Surgical Endoscopy 06/2011; 25(11):3678-82. · 4.01 Impact Factor
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Ugeskrift for laeger 02/2011; 173(9):635.
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ABSTRACT: The nationwide Danish Hernia Database, recording more than 10,000 inguinal and 400 femoral hernia repairs annually, provides a unique opportunity to present valid recommendations in the management of Danish patients with groin hernia. The cumulated data have been discussed at biannual meetings and guidelines have been approved by the Danish Surgical Society. Diagnosis of groin hernia is based on clinical examination. Ultrasonography, CT or MRI are rarely needed, while herniography is not recommended. In patients with indicative symptoms of hernia, but no detectable hernia, diagnostic laparoscopy may be an option. Once diagnosed, hernia repair is recommended in the presence of symptoms affecting daily life. In male patients with minimal or absent symptoms watchful waiting is recommended. In females, however, repair is recommended also in asymptomatic patients. In male patients with primary unilateral or bilateral groin hernia the preferred method is mesh repair, either at open surgery (Lichtenstein) or laparoscopically, irrespective of age. Conventional tension-producing methods like Bassini, McVay or Shouldice are no longer recommended in a routine elective setting. Whether repair should be done by open or laparoscopic technique, depends on local expertise, economical considerations and patient preference. Compared to the Lichtenstein operation laparoscopic repair is associated with less acute pain and faster recovery. Furthermore, available data suggest less chronic long-term pain after laparoscopic repair. In female patients laparoscopic repair is the recommended method. In patients with recurrent hernia laparoscopic repair is preferred in patients with a previous open repair, while patients with recurrence after laparoscopic repair should undergo open mesh repair. In open repair it is recommended to use a mesh secured with a nonabsorbable monofilament suture. In laparoscopic repair a mesh without a slit and with a minimum size of 15 by 10 cm is used. For mesh fixation absorbable or nonabsorbable tacks or glue can be used. Elective surgery for groin hernia should be performed in an outpatient setting, using cost-effective local anaesthesia in open mesh repair and general anaesthesia for laparoscopic repair. Spinal anaesthesia is not recommended. Routine prophylactic antibiotics are not indicated. In the early convalescence period there are no physical restrictions. These guidelines will also be available at the website for the Danish Hernia Database (www.herniedatabasen.dk). The guidelines will be updated when new substantial evidence becomes available.
Danish medical bulletin 02/2011; 58(2):C4243. · 0.75 Impact Factor
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Ugeskrift for laeger 12/2010; 172(50):3467.
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ABSTRACT: Objective structured clinical examination (OSCE) is a new and professionally acknowledged examination used in the evaluation of medical students. Students have criticized OSCE for being unnecessarily stressful. This study examines the effects of OSCE on students, examiners and examination supervisors' general well-being.
A controlled prospective, non-blinded, single centre-study. Before and after OSCE all subjects filled in a structured questionnaire concerning nervousness, discomfort, fatigue, nausea, and pain.
A total of 119 students and 22 examiners and examination supervisors participated in the study. The students were overrepresented by women and were younger and healthier than the group of examiners/examination supervisors. The students experienced significantly more nervousness, discomfort, fatigue, and nausea before OSCE than the examiners/examination supervisors. After OSCE the students experienced a significant reduction of the symptoms while the examiners/examination supervisors reported a non-significant increase of nausea and pain. The students experienced significantly larger fluctuations (before and after values) in symptoms than the examiners/examination supervisors.
We found that OSCE made the students feel significantly better while examiners/examination supervisors felt only slightly worse. The effects of OSCE on examiners/examination supervisors have not been studied previously. There are most likely multiple factors to explain our findings in the present study.
Ugeskrift for laeger 12/2010; 172(50):3481-4.
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ABSTRACT: The number of procedures involving transabdominal preperitoneal laparoscopic surgery for inguinal hernia (TAPP) has increased in Denmark. Optimized perioperative regimens are needed.
This retrospective, single-institution study included consecutive patients during an eight-year period from 1 January 2002 to 31 December 2007 (period I) and from 1 January 2008 to 31 December 2009 (period II). In period II, perioperative indwelling catheter (Foley catheter) was not used routinely. Furthermore, the surgical technique was adjusted, a small team of dedicated TAPP surgeons was established, and two of the surgeons attended prearranged surgical training programmes. Additionally, period II patients were enrolled into structured patient protocols. The primary endpoint was complications within the first 30 days after surgery, and we also registered the rate of reoperation due to recurrence.
A total of 684 patients underwent TAPP surgery for 946 inguinal hernias. From period I to II, the number of TAPP surgeons was reduced to a third and two surgeons received TAPP training. During period I, minor urological complications were observed in 5% (confidence interval (CI) 3.1-6.9%) compared with 1% in period II (0.0-2.5%). The overall morbidity rate was 13%. Serious complications were observed in 3% (CI 3.1-6.9%) of the cases in period I and in 2% (0.0-2.5%) of the cases in period II. For the entire eight-year study period, the cumulative rate of re-operation due to recurrence was 2%.
TAPP without routine use of an indwelling catheter may reduce the risk of urological complications.
Danish medical bulletin 09/2010; 57(9):A4176. · 0.75 Impact Factor
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ABSTRACT: The evidence for choice of surgical technique in ventral hernia treatment is poor. The outcomes have so far been associated with high recurrence rates and significant morbidity. Data from the Danish Ventral Hernia Database show large variations in the surgical approach. On the basis of a consensus meeting, agreement on a national strategy for ventral hernia surgery in Denmark is proposed in order to facilitate future interpretation of the outcomes.
Ugeskrift for laeger 06/2010; 172(26):1987-9.
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Ugeskrift for laeger 05/2010; 172(20):1507.
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ABSTRACT: Lumbar hernia is a rare condition. Lumbar hernia should be considered a rare differential diagnosis to unexplained back pain. Symptoms are scarce and diffuse and can vary with the size and content of the hernia. As there is a 25% risk of incarceration, operation is indicated even in asymptomatic hernias. We report a case of lumbar hernia in a woman with a slow growing mass in the lumbar region. She presented with pain and a computed tomography confirmed the diagnosis. She underwent open surgery and fully recovered with recurrence within the first half year.
Ugeskrift for laeger 03/2010; 172(12):968-9.
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ABSTRACT: Spigelian hernia is a rare condition, which is frequently difficult to diagnose. This study describes our experience and we briefly discuss our findings in relation to the sparse literature.
Seven-year retrospective study (2000-2006) with prospective follow-up in a consecutive series of patients.
We identified a total of 12 patients with 13 spigelian hernias among 379 patients with ventral hernia (3.1%). Symptoms and clinical findings varied substantially between patients. Due to strangulation, four patients underwent acute operation and eight patients underwent elective operation (laparoscopic (n = 7); open (n = 1)). One patient was treated conservatively. After a median of 3.3 years (range 0.8 to 6.8 years) recurrence was found in one patient and one patient (without recurrence) had moderate pain at the former hernia site.
Due to the relatively high risk of strangulation, all patients with spigelian hernias should be offered surgery regardless of symptoms. Pain and perhaps bulging at the semilunar line indicates a spigelian hernia, but the diagnosis can be difficult to establish. When in doubt, we suggest the use of computed tomography and, subsequently, diagnostic laparoscopy and laparoscopic repair.
Ugeskrift for laeger 11/2009; 171(48):3518-22.
