The ANZ hernia repair practices study: low consensus on inguinal and small ventral hernia management and infrequent long‐term follow‐up

摘要

There are some concerns among professional bodies and health insurers that variations in groin hernia repair approaches in Australia and New Zealand (ANZ) may be contributing to low-value surgical care.1 In Australia alone, Medicare spent $7.9 million on groin hernia repairs in 2021, and 61% of this expenditure was for minimally invasive surgery approaches.2 There is ongoing debate about whether an open, laparoscopic (or robotic) approach for primary or recurrent groin hernias is best,3 and international data are often hard to interpret and difficult to implement into local practice.4 Hernia treatment choices in ANZ are largely driven by a surgeon's level of knowledge, experience, and preferences. The ANZ Hernia Repair Practices Study (ANZ HRPS) collected over 200 anonymous reports about inguinal and ventral hernia repair approaches from a representative sample of surgeon and trainee members of General Surgeons Australia (GSA) and the New Zealand Association of General Surgeons (NZAGS). It is the first comprehensive bi-national study of hernia surgery practices including the choice of repair technique, mesh and fixation materials, surgeon attitudes towards same-day surgery, the impact of COVID-19 restrictions,5 and the timing of postoperative follow-up consultations. This is the first of a series of articles reporting findings for the management of inguinal and small (<2 cm) ventral hernias. A cross-sectional anonymous survey of members of the GSA (n = 1580) and the NZAGS (n = 224) was conducted in July 2021. The survey hyperlink was distributed via an email invitation letter (endorsed by the senior author) and an information sheet describing the study objectives and contact information. All respondents indicated their consent by submitting the survey. The survey development process is provided in Appendix A. Data were collected and managed using REDCap hosted at The University of Sydney.6, 7 Approval for this study was provided by The University of Sydney Human Research Ethics Committee (2020/748). Respondents completed multiple choice and 4- or 5-point Likert-scale questions on whether and how often they disagreed or agreed with statements. Optional free-text boxes were also provided. The questionnaire is available from the authors on request. Descriptive analysis was performed using IBM SPSS Statistics for Macintosh, Version 28.0 (Armonk, NY: IBM Corp). A total of 244 respondents returned the survey (14% response rate). Data from those who discontinued the survey (n = 14) and one with outlying responses were excluded. The final sample included 229 pre- and post-fellowship surgeons (mean ± SD, standard deviation 13 ± 13 years post-fellowship) from Australia (93%; 214/229) and New Zealand (7%; 15/229). Most respondents operated in both the private and public sectors (62%, 142/229), and most in urban settings only (76%, 175/229). Over a third of respondents (37%; 66/229) stated that they did not perform any hernia surgery as the primary operator at all, and so presumably their opinions were based on either prior experience or their observations of others in practice (Table 1). Totally extraperitoneal (TEP) repair was the most preferred technique for both primary unilateral (47%; 107/229) and primary bilateral inguinal hernias (61%; 139/229). Most respondents stated that they performed an anterior ‘open’ repair for recurrent hernias after a previous TEP (69%; 159/229) or transabdominal preperitoneal (TAPP) repair (67%; 154/229). By contrast, they preferred a posterior ‘minimally invasive’ approach after a previous open repair (TEP: 60%; 138/229 versus TAPP: 8%; 19/229). One in ten (11%; 26/229) of the surgeons surveyed used an open approach after a failed open repair, and three-quarters (74%; 170/229) used an MIS approach after a failed MIS repair. Two-thirds (66%; 150/229) of the surgeons chose a monolayer synthetic mesh (e.g., polypropylene, polyester) for the repair of an inguinal hernia, 16% (36/229) used a composite mesh (