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Gender discrimination in endoscopic groin hernia repair. Minimal invasive groin hernia repair is offered less often to female patients compared to male patients
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Journal of Visceral Surgery (2019) xxx, xxx—xxx
Available online at
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ORIGINAL ARTICLE
Gender discrimination in endoscopic groin hernia repair. Minimal invasive groin hernia repair is offered less often to female patients compared to male patients M. Stodolski a, H. Zirngibl a, P.C. Ambe a,b,∗ a
Department of Surgery, Helios Universitätsklinikum Wuppertal, Witten/Herdecke University, Wuppertal, Germany b Department of General, Visceral and Transplantation Surgery, University Hospital Münster Albert-Schweitzer-Campus 1, Gebäude W1 Waldeyerstraße 1, 48149 Münster, Germany
KEYWORDS Groin hernia; Inguinal hernia; Endoscopic hernia repair
Summary Background: Groin hernia repair constitutes a very common procedure in general surgery. Minimal invasive closure of groin hernia has evolved to become the standard means of closure. However, there seems to be a gender-associated discrimination with regard to endoscopic groin hernia repair. We investigated the rate of endoscopic closure in female patients undergoing groin hernia closure. Materials and methods: A retrospective analysis of the data of patients undergoing elective groin hernia repair within a four-year period from 2013 to 2016 was performed. The rate of endoscopic hernia repair was calculated for both genders. Results: Eight hundred and forty-six patients including 94 females and 752 males were included for analysis. The female group was significantly older compared to the male group (68.0 vs. 61.0 yrs, P = 0.02). The rate of endoscopic groin hernia repair was significantly lower in the female group compared to in the male cohort (30% vs. 60%, P = 0.001). The overall duration of surgery was 74.0 min in the female cohort and 93.0 min in the male group, P = 0.001. However, there was no statistically significant difference amongst both groups with regard to the duration of surgery for endoscopic repair: 78.0 min in the female group and 89.0 min in the male group, P = 0.67. Conclusion: Findings from this retrospective collective suggests that, there might be some degree of sex discrimination with regard to endoscopic groin hernia repair in favor of the male population. © 2019 Published by Elsevier Masson SAS.
∗ Corresponding author at: Department of General, Visceral and Transplantation Surgery, University Hospital Münster Albert-SchweitzerCampus 1, Gebäude W1 Waldeyerstraße 1, 48149 Münster, Germany E-mail address: [email protected] (P.C. Ambe).
https://doi.org/10.1016/j.jviscsurg.2019.12.006 1878-7886/© 2019 Published by Elsevier Masson SAS.
Please cite this article in press as: Stodolski M, et al. Gender discrimination in endoscopic groin hernia repair. Minimal invasive groin hernia repair is offered less often to female patients compared to male patients. Journal of Visceral Surgery (2019), https://doi.org/10.1016/j.jviscsurg.2019.12.006
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Introduction Groin hernia repair constitutes a significant portion of surgical workload [1,2]. Mesh associated closure represents the gold standard of treatment [3]. Mesh implantation can be performed using both open and minimally invasive techniques [4,5]. Endoscopic repair has been shown to be associated with less pain, early return to work and better cosmeses compared to open repair [6,7]. Over the last decade endoscopic hernia repair has evolved to be the preferred technique for addressing groin hernia [8,9]. The transabdominal pre-peritoneal plastic (TAPP) and the total extraperitoneal plastic (TEP) represent the most commonly used techniques while the anterior repair with a mesh represents the current standard for open closure [1,10—13]. Our clinical observation suggests a gender-dependent discrimination in patients undergoing endoscopic management of groin hernia in favor of male patients. The aim of this work was to investigate the rate of endoscopic groin hernia repair amongst male and female patients undergoing elective hernia surgery in a university hospital.
Materials and methods A written consent was received from all patients included in the study. Study approval was received from the institutional review board at the Witten/Herdecke University, Germany. A retrospective analysis of data of patients managed at a university hospital within a four-year period from January 2013 to December 2016 was performed. The charts of all consecutive patients undergoing elective groin hernia repair were assessed for relevant information. Demographic parameters like age, sex and body mass index (BMI) were extracted. Medical data including the diagnosis, concomitant medical conditions defined by the American Society of Anesthesiologist score (ASA) were documented. Only patients undergoing elective groin hernia repair were included for analysis. Preoperative work-up included a nasal micro-bacterial swab for methicillin-resistant Staphylococcus aureus (MRSA). Patients with positive MRSA swabs were decolonized using a 1:1 diluted octenidine dihydrochloride preparation for the skin and mupirocin for the nose for five days as reported elsewhere [14]. Patients undergoing emergency surgery and those undergoing repair following hernia recurrence were excluded from the study. Surgery was performed as in-patient procedure under general anesthesia. A single shot antibiotic, usually cefuroxim® was given prior to incision. Surgery began with the placement of a 10 mm port just above the umbilicus via mini-laparotomy followed by pneumoperitoneum with the maximum intraabdominal pressure set a 12 mmHg. Two further ports; 12 mm in the right and 5 mm in the left mid abdomen slightly below the umbilicus were placed under visual control. The patient was brought in to the Trendelenburg position after which the diagnosis was confirmed. The parietal peritoneum covering the inguinal region was incised followed by a dissection of the pre-peritoneal space while preserving relevant structure like the spermatic duct and vessels. A 10 × 15 cm polypropylene mesh was used in all cases. The mesh was inserted via the 12 mm port and attached to the os pubis and anterior abdominal wall using titanium tackers. The peritoneal incision was closed using a running 3-0 vicryl suture. No drains were placed. Postoperative care included oral pain killers as need. Patients were routinely discharged on postoperative day two.
Bilateral hernia repair was performed at the discretion of the senior surgeon intraoperatively. Since this practice was not standardized only the information on the leading unilateral hernia, which was usually the indication of surgery were included in the study. Redo hernia repairs were excluded from the study. To achieve our goal, all cases managed using open techniques e.g. Lichtenstein, Shouldice, and Moschkowitz (the Cooper’s ligament is sutured to the inguinal ligament for the femoral hernia repair followed by an inguinal hernioplasty) were characterized as ‘‘open procedure’’. This group was compared to the endoscopic group. Our primary endpoint was the sex-dependent rate of endoscopic hernia repair. Secondary outcomes included the duration of surgery and the length of hospital stay. Other outcome measures were not examined in this study. The data collected was analyzed using the statistical package for social sciences (SPSS) version 24 (IMB Corp, Armonk, NY, USA). The study population was described using absolute numbers and percentages. Because continuous variables were not normally distributed, central tendencies were reported using median values with the corresponding ranges where necessary. The Mann—Withney—U - test or Chi2 tests were used for analytic statistics where necessary. The level of significance was set at P < 0.05.
Results Eight hundred and forty-six consecutive patients including 94 females and 752 males underwent elective surgical hernia repair in the groin region within the four years of investigation (Fig. 1). The female cohort was significantly older in comparison to the male cohort. Both groups were comparable in terms of concomitant medical conditions per ASA scores. The demographic and clinical features of the study population are presented in Table 1, while Table 2 presents a summary of diagnoses reached during surgery. Endoscopic hernia closure was performed in 502 (59.3%) cases in the entire study. Endoscopic repair was performed in 31 (33.0%) cases in the female cohort, while open hernia closure was performed in 63 (67.0%) cases. The open procedures included 21 (22.3%) cases with Lichtenstein repair, 17 (18.1%) cases with Shouldice repair, and 25 (26.6%) cases managed with Moschkowitz procedure. Endoscopic repair was performed in 471 (62.6%) cases in the male cohort while open hernia closure was performed in 281 (37.4%) cases. In this group, Lichtenstein repair was performed in 190 (25.3%) cases, Shouldice repair was done in 89 (11.9%) and Moschkowitz repair was performed in two (0.3%) cases. Endoscopic repair was performed significantly more often in the male cohort (P = 0.001, Fig. 2). The median duration of surgery in the general collective was 74.0 min (range: 29—248 min) in the female cohort and 93.0 min (range: 14—294 min) in the male group. Surgery lasted significantly longer in the male cohort compared to the female group (P = 0.001, Fig. 3). However, there was no statistically significant difference in the duration of surgery for endoscopic hernia repair amongst both groups (Fig. 4). The median LOS of stay was 3.0 d (range: 2—14 d) in the female cohort and 2.0 d (range: 2—14 d) in the male cohort. There was no significant difference (P = 0.57) amongst both groups with regard to postoperative LOS.
Please cite this article in press as: Stodolski M, et al. Gender discrimination in endoscopic groin hernia repair. Minimal invasive groin hernia repair is offered less often to female patients compared to male patients. Journal of Visceral Surgery (2019), https://doi.org/10.1016/j.jviscsurg.2019.12.006
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Gender discrimination in endoscopic groin hernia repair
Figure 1.
Table 1
3
Distribution of the study population.
Summary of the baseline features of the study population.
Characteristics
Female cohort
Male cohort
P-values
Median age(Range) Median BMI(Range) ASA scores 1—2 >2
68.0 yrs (16—88 yrs) 24.0 kg/m2 16.4—47.2 kg/m2
61.0 yrs (15—94 yrs) 25.8 kg/m2 17.2—42.9 kg/m2
0.021 0.001
77 (81.9%) 17 (18.1%)
657 (87.4%) 95 (12.6%)
0.141
ASA: American Society of Anesthesiologist; BMI: body mass index; yrs: years.
Table 2 Intraoperative hernia location. Combined inguinal hernia: presence of both lateral and medial hernia on the same side. Intraoperative diagnosis Medial inguinal hernia Lateral inguinal hernia Combined inguinal hernia Femoral herniaa a
Female group 24 39 4 27
(25.5%) (41.5%) (4.3%) (28.7%)
Male group 285 355 109 3
(37.9%) (47.2%) (14.5%) (0.4%)
Four cases with coexisting femoral and inguinal hernias were seen in the female group.
Discussion Endoscopic hernia repair was performed twice more often in male patients compared to female patients. Surgery lasted significantly longer in the male cohort compared to the female group in entire collective. However, there was no statistically significant difference amongst both groups with regard to the duration of endoscopic repair. There was no significant difference amongst both groups with regard to the length of hospital stay. The incidence of femoral hernia was higher in the female cohort, while a combination of lateral and medial inguinal hernias was seen more frequently in the male cohort. The female cohort was older at the time of surgery compared to the male groups. Both groups were however comparable in terms of concomitant medical conditions. The advantages of minimally invasive surgery including less pain, early ambulation, early return to work and better
cosmesis are well known. Thus, minimal invasive procedures now represent the standard of care for most surgical procedures. Groin hernia repair represents a large portion of a surgeon’s workload. Minimal invasive groin hernia repair now represents the standard procedure for groin hernia repair, which has been endorsed by international guidelines [15]. Our clinical experience suggests that minimal invasive groin hernia repair might not be readily offered to female patients. This clinical impression was investigated in this work. The charts of all consecutive patients undergoing elective groin hernia repair were reviewed. This four-year review confirmed our clinical impression. Endoscopic groin hernia repair was offered twice more often to male patients than to female patients. This finding is in accordance with the observation reported by Thiels et al. based on data from a large multicenter study [16]. Female patients constituted just about 10% of the study population. This data is in line with the expected gender
Please cite this article in press as: Stodolski M, et al. Gender discrimination in endoscopic groin hernia repair. Minimal invasive groin hernia repair is offered less often to female patients compared to male patients. Journal of Visceral Surgery (2019), https://doi.org/10.1016/j.jviscsurg.2019.12.006
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Figure 2. Summary of endoscopic and open repair. Endoscopic repair was performed significantly more often in the male population compared to the female population, P = 0.001.
Figure 3. Duration of surgery in the entire study population. Surgery lasted significantly longer in the male group (93.0 min: range: 14—294 min) compared to the female group (74.0 min: range: 29—248 min), P = 0.001.
specific prevalence of groin hernia in the female population [17]. Equally, the significantly higher incidence of femoral hernia in the female cohort in this study was in accordance with existing literature [18]. Also, the female group was significantly older compared to the male group at the time of surgery. This finding is equally in accordance with existing literature [19]. Thus, the female population in this series is a good representation of the general situation based on current medical literature. The results of our analysis confirm our clinical suspicion regarding a gender discrimination in terms of endoscopic groin hernia repair. Only about 30% of female patients in this study were managed endoscopically compared to over 60% of the male population. This finding is alarming considering the fact that endoscopic repair should be considered as the treatment of choice for selected patients irrespective of sex [20]. More so, the European Hernia Society recommends that women should undergo laparoscopic repair in order to rule
out the presence of femoral hernia [21,22]. The importance of this recommendation lies in the fact that femoral hernia is often missed during clinical assessment and may not be readily discovered during an open procedure for inguinal hernia. In a Swedish publication by Koch et al. femoral hernia was found 41.6% of women compared to just 4.6% of men during reoperation following open closure of a direct or indirect inguinal hernia [23]. More recent data from the same Swedish register with over 221,108 patients published in 2017 by Nilsson et al. indicated that laparoscopic groin hernia repair lowered the risk of reoperation for recurrence compared to Lichtenstein’s procedure. In their study women had a ten-fold greater risk of having a femoral hernia during a reoperation for groin hernia compared to men [24]. This trend was confirmed in a recently published meta-analysis by Schmidt et al. [25]. According to Kockerling et al. a concomitant femoral hernia is easily missed during open inguinal hernia repair due to
Please cite this article in press as: Stodolski M, et al. Gender discrimination in endoscopic groin hernia repair. Minimal invasive groin hernia repair is offered less often to female patients compared to male patients. Journal of Visceral Surgery (2019), https://doi.org/10.1016/j.jviscsurg.2019.12.006
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Figure 4. Duration of surgery for endoscopic repair. The median duration of surgery for endoscopic repair was 78.0 min (range: 48—248 min) for the female group and 89.0 (range: 29—294 min) for the male group, P = 0.67.
the fact that the transversalis fascia is not routinely opened [26]. This, on one hand must be seen as an advantage for endoscopic groin hernia repair compared to the open repair. On the other hand, the risk of missing a concomitant femoral hernia during open inguinal hernia repair must be kept in mind. Thus, hernia surgeons performing open inguinal hernia repair should be encouraged to systematically search for and rule out a femoral hernia during open inguinal hernia repair. The reasons for this gender discrimination are difficult to understand. The female population did not differ from the male cohort with regard to concomitant medical conditions per ASA grading. Thus, this trend cannot be blamed on medical condition. Although the female group was significantly older compared to the male group at the time of surgery, this single factor cannot be the sole reason for the gender discrimination identified in this study. This is especially true following the fact that all patients included in this study were managed under general anesthesia. More so, 30% of female population underwent endoscopic closure despite the age difference. Thus, age alone cannot be the reason for this gender-dependent trend. All procedures were performed by surgeons with experience in both laparoscopic and open hernia repair. Therefore, surgeon’s experience does not seem to explain this disparity. Reasonable explanations for this trend must therefore blamed on institutional standards and surgeon’s preference. The findings of this retrospective study have led to a change in our departmental standards. Endoscopic groin hernia repair now represents the standard procedure in our department irrespective of sex in accordance with current practice. This is also true in the emergency setting. The results presented in this study represent findings from a single center and therefore cannot be readily projected on other institutions. Besides, the trend shown in this series might simple be due to institutional standards and/or surgeons preference and therefore cannot be generalized. Although patients were consecutively included in this study the retrospective study design must be stated as a further limitation. It would be interesting to investigate this topic in a prospective setting. Despite this limitation, the findings
from this study suggest a gender-dependent discrimination with regard to minimally invasive groin hernia repair.
Conclusion Findings from this retrospective collective suggest that, there might be some degree of sex discrimination with regard to endoscopic groin hernia repair in favor of the male population.
Funding None.
Authors’ contribution Study concept: PA, study design: PA, MS, HZ, data collection: MS. Statistical analysis: PA, MS. Interpreted the results: PA, HZ, MS. Drafted the manuscript: MS, PA. Critically reviewed and approved the manuscript: PA, HZ, MS.
Acknowledgement Not applicable.
Disclosure of interest The authors declare that they have no competing interest.
References [1] Jensen KK, Henriksen NA, Jorgensen LN. Inguinal hernia epidemiology. In: Textbook of hernia. Switzerland: Springer International Publishing; 2017. p. 23—7. [2] Burcharth J, Pedersen M, Bisgaard T, et al. Nationwide prevalence of groin hernia repair. PloS One 2013;8:e54367.
Please cite this article in press as: Stodolski M, et al. Gender discrimination in endoscopic groin hernia repair. Minimal invasive groin hernia repair is offered less often to female patients compared to male patients. Journal of Visceral Surgery (2019), https://doi.org/10.1016/j.jviscsurg.2019.12.006
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[3] Collaboration EHT. Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials. Ann Surg 2002;235:322. [4] Grant A. Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000;87:860—7. [5] Amid PK. Groin hernia repair: open techniques. World J Surg 2005;29:1046—51. [6] Bignell M, Partridge G, Mahon D, Rhodes M. Prospective randomized trial of laparoscopic (transabdominal preperitonealTAPP) versus open (mesh) repair for bilateral and recurrent inguinal hernia: incidence of chronic groin pain and impact on quality of life: results of 10 year follow-up. Hernia 2012;16:635—40. [7] Collaboration EUHT. Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000;87:860—7. [8] Chung R, Rowland D. Meta-analyses of randomized controlled trials of laparoscopic vs conventional inguinal hernia repairs. Surg Endosc 1999;13:689—94. [9] Memon M, Cooper N, Memon B, et al. Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair. Br J Surg 2003;90:1479—92. [10] McKernan JB, Laws HL. Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach. Surg Endosc 1993;7:26—8. [11] Wake BL, McCormack K, Fraser C, et al. Transabdominal preperitoneal (TAPP) vs totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair. The Cochrane Library; 2005. [12] Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. The tension-free hernioplasty. Am J Surg 1989;157:188—93. [13] Kuroiwa M. Direct inguinal hernia and femoral hernia. In: Operative general surgery in neonates and infants. Japan: Springer; 2016. p. 149—53. [14] Sloot N, Siebert J, Hoffler U. Eradication of MRSA from carriers by means of whole-body washing with an antiseptic in combination with mupirocin nasal ointment. Zentralbl Hyg Umweltmed 1999;202:513—23.
[15] Shaikh I, Olabi B, Wong VM, et al. NICE guidance and current practice of recurrent and bilateral groin hernia repair by Scottish surgeons. Hernia 2011;15:387—91. [16] Thiels CA, Holst KA, Ubl DS, et al. Gender disparities in the utilization of laparoscopic groin hernia repair. J Surg Res 2017;210:59—68. [17] Ashfaq A, McGhan LJ, Chapital AB, et al. Inguinal hernia repair in women: is the laparoscopic approach superior? Hernia 2014;18:369—73. [18] Waltz P, Luciano J, Peitzman A, Zuckerbraun BS. Femoral hernias in patients undergoing total extraperitoneal laparoscopic hernia repair: including routine evaluation of the femoral canal in approaches to inguinal hernia repair. JAMA Surg 2016;151:292—3. [19] Burcharth J, Andresen K, Pommergaard HC, et al. Direct inguinal hernias and anterior surgical approach are risk factors for female inguinal hernia recurrences. Langenbecks Arch Surg 2014;399:71—6. [20] Anon. Laparoscopic surgery for inguinal hernia repair. Technol Apprais Guid 2004;83:1—36. [21] Miserez M, Peeters E, Aufenacker T, et al. Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2014;18:151—63. [22] 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. [23] Koch A, Edwards A, Haapaniemi S, et al. Prospective evaluation of 6895 groin hernia repairs in women. Br J Surg 2005;92:1553—8. [24] Nilsson H, Holmberg H, Nordin P. Groin hernia repair in women — A nationwide register study. Am J Surg 2018;216:274—9. [25] Schmidt L, Oberg S, Andresen K, Rosenberg J. Recurrence rates after repair of inguinal hernia in women: a systematic review. JAMA Surg 2018;153:1135—42. [26] Kockerling F, Koch A, Lorenz R. Groin hernias in women — a review of the literature. Front Surg 2019;6:4.
Please cite this article in press as: Stodolski M, et al. Gender discrimination in endoscopic groin hernia repair. Minimal invasive groin hernia repair is offered less often to female patients compared to male patients. Journal of Visceral Surgery (2019), https://doi.org/10.1016/j.jviscsurg.2019.12.006
ARTICLE IN PRESS
JVS-990; No. of Pages 6
Journal of Visceral Surgery (2019) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
ORIGINAL ARTICLE
Gender discrimination in endoscopic groin hernia repair. Minimal invasive groin hernia repair is offered less often to female patients compared to male patients M. Stodolski a, H. Zirngibl a, P.C. Ambe a,b,∗ a
Department of Surgery, Helios Universitätsklinikum Wuppertal, Witten/Herdecke University, Wuppertal, Germany b Department of General, Visceral and Transplantation Surgery, University Hospital Münster Albert-Schweitzer-Campus 1, Gebäude W1 Waldeyerstraße 1, 48149 Münster, Germany
KEYWORDS Groin hernia; Inguinal hernia; Endoscopic hernia repair
Summary Background: Groin hernia repair constitutes a very common procedure in general surgery. Minimal invasive closure of groin hernia has evolved to become the standard means of closure. However, there seems to be a gender-associated discrimination with regard to endoscopic groin hernia repair. We investigated the rate of endoscopic closure in female patients undergoing groin hernia closure. Materials and methods: A retrospective analysis of the data of patients undergoing elective groin hernia repair within a four-year period from 2013 to 2016 was performed. The rate of endoscopic hernia repair was calculated for both genders. Results: Eight hundred and forty-six patients including 94 females and 752 males were included for analysis. The female group was significantly older compared to the male group (68.0 vs. 61.0 yrs, P = 0.02). The rate of endoscopic groin hernia repair was significantly lower in the female group compared to in the male cohort (30% vs. 60%, P = 0.001). The overall duration of surgery was 74.0 min in the female cohort and 93.0 min in the male group, P = 0.001. However, there was no statistically significant difference amongst both groups with regard to the duration of surgery for endoscopic repair: 78.0 min in the female group and 89.0 min in the male group, P = 0.67. Conclusion: Findings from this retrospective collective suggests that, there might be some degree of sex discrimination with regard to endoscopic groin hernia repair in favor of the male population. © 2019 Published by Elsevier Masson SAS.
∗ Corresponding author at: Department of General, Visceral and Transplantation Surgery, University Hospital Münster Albert-SchweitzerCampus 1, Gebäude W1 Waldeyerstraße 1, 48149 Münster, Germany E-mail address: [email protected] (P.C. Ambe).
https://doi.org/10.1016/j.jviscsurg.2019.12.006 1878-7886/© 2019 Published by Elsevier Masson SAS.
Please cite this article in press as: Stodolski M, et al. Gender discrimination in endoscopic groin hernia repair. Minimal invasive groin hernia repair is offered less often to female patients compared to male patients. Journal of Visceral Surgery (2019), https://doi.org/10.1016/j.jviscsurg.2019.12.006
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Introduction Groin hernia repair constitutes a significant portion of surgical workload [1,2]. Mesh associated closure represents the gold standard of treatment [3]. Mesh implantation can be performed using both open and minimally invasive techniques [4,5]. Endoscopic repair has been shown to be associated with less pain, early return to work and better cosmeses compared to open repair [6,7]. Over the last decade endoscopic hernia repair has evolved to be the preferred technique for addressing groin hernia [8,9]. The transabdominal pre-peritoneal plastic (TAPP) and the total extraperitoneal plastic (TEP) represent the most commonly used techniques while the anterior repair with a mesh represents the current standard for open closure [1,10—13]. Our clinical observation suggests a gender-dependent discrimination in patients undergoing endoscopic management of groin hernia in favor of male patients. The aim of this work was to investigate the rate of endoscopic groin hernia repair amongst male and female patients undergoing elective hernia surgery in a university hospital.
Materials and methods A written consent was received from all patients included in the study. Study approval was received from the institutional review board at the Witten/Herdecke University, Germany. A retrospective analysis of data of patients managed at a university hospital within a four-year period from January 2013 to December 2016 was performed. The charts of all consecutive patients undergoing elective groin hernia repair were assessed for relevant information. Demographic parameters like age, sex and body mass index (BMI) were extracted. Medical data including the diagnosis, concomitant medical conditions defined by the American Society of Anesthesiologist score (ASA) were documented. Only patients undergoing elective groin hernia repair were included for analysis. Preoperative work-up included a nasal micro-bacterial swab for methicillin-resistant Staphylococcus aureus (MRSA). Patients with positive MRSA swabs were decolonized using a 1:1 diluted octenidine dihydrochloride preparation for the skin and mupirocin for the nose for five days as reported elsewhere [14]. Patients undergoing emergency surgery and those undergoing repair following hernia recurrence were excluded from the study. Surgery was performed as in-patient procedure under general anesthesia. A single shot antibiotic, usually cefuroxim® was given prior to incision. Surgery began with the placement of a 10 mm port just above the umbilicus via mini-laparotomy followed by pneumoperitoneum with the maximum intraabdominal pressure set a 12 mmHg. Two further ports; 12 mm in the right and 5 mm in the left mid abdomen slightly below the umbilicus were placed under visual control. The patient was brought in to the Trendelenburg position after which the diagnosis was confirmed. The parietal peritoneum covering the inguinal region was incised followed by a dissection of the pre-peritoneal space while preserving relevant structure like the spermatic duct and vessels. A 10 × 15 cm polypropylene mesh was used in all cases. The mesh was inserted via the 12 mm port and attached to the os pubis and anterior abdominal wall using titanium tackers. The peritoneal incision was closed using a running 3-0 vicryl suture. No drains were placed. Postoperative care included oral pain killers as need. Patients were routinely discharged on postoperative day two.
Bilateral hernia repair was performed at the discretion of the senior surgeon intraoperatively. Since this practice was not standardized only the information on the leading unilateral hernia, which was usually the indication of surgery were included in the study. Redo hernia repairs were excluded from the study. To achieve our goal, all cases managed using open techniques e.g. Lichtenstein, Shouldice, and Moschkowitz (the Cooper’s ligament is sutured to the inguinal ligament for the femoral hernia repair followed by an inguinal hernioplasty) were characterized as ‘‘open procedure’’. This group was compared to the endoscopic group. Our primary endpoint was the sex-dependent rate of endoscopic hernia repair. Secondary outcomes included the duration of surgery and the length of hospital stay. Other outcome measures were not examined in this study. The data collected was analyzed using the statistical package for social sciences (SPSS) version 24 (IMB Corp, Armonk, NY, USA). The study population was described using absolute numbers and percentages. Because continuous variables were not normally distributed, central tendencies were reported using median values with the corresponding ranges where necessary. The Mann—Withney—U - test or Chi2 tests were used for analytic statistics where necessary. The level of significance was set at P < 0.05.
Results Eight hundred and forty-six consecutive patients including 94 females and 752 males underwent elective surgical hernia repair in the groin region within the four years of investigation (Fig. 1). The female cohort was significantly older in comparison to the male cohort. Both groups were comparable in terms of concomitant medical conditions per ASA scores. The demographic and clinical features of the study population are presented in Table 1, while Table 2 presents a summary of diagnoses reached during surgery. Endoscopic hernia closure was performed in 502 (59.3%) cases in the entire study. Endoscopic repair was performed in 31 (33.0%) cases in the female cohort, while open hernia closure was performed in 63 (67.0%) cases. The open procedures included 21 (22.3%) cases with Lichtenstein repair, 17 (18.1%) cases with Shouldice repair, and 25 (26.6%) cases managed with Moschkowitz procedure. Endoscopic repair was performed in 471 (62.6%) cases in the male cohort while open hernia closure was performed in 281 (37.4%) cases. In this group, Lichtenstein repair was performed in 190 (25.3%) cases, Shouldice repair was done in 89 (11.9%) and Moschkowitz repair was performed in two (0.3%) cases. Endoscopic repair was performed significantly more often in the male cohort (P = 0.001, Fig. 2). The median duration of surgery in the general collective was 74.0 min (range: 29—248 min) in the female cohort and 93.0 min (range: 14—294 min) in the male group. Surgery lasted significantly longer in the male cohort compared to the female group (P = 0.001, Fig. 3). However, there was no statistically significant difference in the duration of surgery for endoscopic hernia repair amongst both groups (Fig. 4). The median LOS of stay was 3.0 d (range: 2—14 d) in the female cohort and 2.0 d (range: 2—14 d) in the male cohort. There was no significant difference (P = 0.57) amongst both groups with regard to postoperative LOS.
Please cite this article in press as: Stodolski M, et al. Gender discrimination in endoscopic groin hernia repair. Minimal invasive groin hernia repair is offered less often to female patients compared to male patients. Journal of Visceral Surgery (2019), https://doi.org/10.1016/j.jviscsurg.2019.12.006
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Gender discrimination in endoscopic groin hernia repair
Figure 1.
Table 1
3
Distribution of the study population.
Summary of the baseline features of the study population.
Characteristics
Female cohort
Male cohort
P-values
Median age(Range) Median BMI(Range) ASA scores 1—2 >2
68.0 yrs (16—88 yrs) 24.0 kg/m2 16.4—47.2 kg/m2
61.0 yrs (15—94 yrs) 25.8 kg/m2 17.2—42.9 kg/m2
0.021 0.001
77 (81.9%) 17 (18.1%)
657 (87.4%) 95 (12.6%)
0.141
ASA: American Society of Anesthesiologist; BMI: body mass index; yrs: years.
Table 2 Intraoperative hernia location. Combined inguinal hernia: presence of both lateral and medial hernia on the same side. Intraoperative diagnosis Medial inguinal hernia Lateral inguinal hernia Combined inguinal hernia Femoral herniaa a
Female group 24 39 4 27
(25.5%) (41.5%) (4.3%) (28.7%)
Male group 285 355 109 3
(37.9%) (47.2%) (14.5%) (0.4%)
Four cases with coexisting femoral and inguinal hernias were seen in the female group.
Discussion Endoscopic hernia repair was performed twice more often in male patients compared to female patients. Surgery lasted significantly longer in the male cohort compared to the female group in entire collective. However, there was no statistically significant difference amongst both groups with regard to the duration of endoscopic repair. There was no significant difference amongst both groups with regard to the length of hospital stay. The incidence of femoral hernia was higher in the female cohort, while a combination of lateral and medial inguinal hernias was seen more frequently in the male cohort. The female cohort was older at the time of surgery compared to the male groups. Both groups were however comparable in terms of concomitant medical conditions. The advantages of minimally invasive surgery including less pain, early ambulation, early return to work and better
cosmesis are well known. Thus, minimal invasive procedures now represent the standard of care for most surgical procedures. Groin hernia repair represents a large portion of a surgeon’s workload. Minimal invasive groin hernia repair now represents the standard procedure for groin hernia repair, which has been endorsed by international guidelines [15]. Our clinical experience suggests that minimal invasive groin hernia repair might not be readily offered to female patients. This clinical impression was investigated in this work. The charts of all consecutive patients undergoing elective groin hernia repair were reviewed. This four-year review confirmed our clinical impression. Endoscopic groin hernia repair was offered twice more often to male patients than to female patients. This finding is in accordance with the observation reported by Thiels et al. based on data from a large multicenter study [16]. Female patients constituted just about 10% of the study population. This data is in line with the expected gender
Please cite this article in press as: Stodolski M, et al. Gender discrimination in endoscopic groin hernia repair. Minimal invasive groin hernia repair is offered less often to female patients compared to male patients. Journal of Visceral Surgery (2019), https://doi.org/10.1016/j.jviscsurg.2019.12.006
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Figure 2. Summary of endoscopic and open repair. Endoscopic repair was performed significantly more often in the male population compared to the female population, P = 0.001.
Figure 3. Duration of surgery in the entire study population. Surgery lasted significantly longer in the male group (93.0 min: range: 14—294 min) compared to the female group (74.0 min: range: 29—248 min), P = 0.001.
specific prevalence of groin hernia in the female population [17]. Equally, the significantly higher incidence of femoral hernia in the female cohort in this study was in accordance with existing literature [18]. Also, the female group was significantly older compared to the male group at the time of surgery. This finding is equally in accordance with existing literature [19]. Thus, the female population in this series is a good representation of the general situation based on current medical literature. The results of our analysis confirm our clinical suspicion regarding a gender discrimination in terms of endoscopic groin hernia repair. Only about 30% of female patients in this study were managed endoscopically compared to over 60% of the male population. This finding is alarming considering the fact that endoscopic repair should be considered as the treatment of choice for selected patients irrespective of sex [20]. More so, the European Hernia Society recommends that women should undergo laparoscopic repair in order to rule
out the presence of femoral hernia [21,22]. The importance of this recommendation lies in the fact that femoral hernia is often missed during clinical assessment and may not be readily discovered during an open procedure for inguinal hernia. In a Swedish publication by Koch et al. femoral hernia was found 41.6% of women compared to just 4.6% of men during reoperation following open closure of a direct or indirect inguinal hernia [23]. More recent data from the same Swedish register with over 221,108 patients published in 2017 by Nilsson et al. indicated that laparoscopic groin hernia repair lowered the risk of reoperation for recurrence compared to Lichtenstein’s procedure. In their study women had a ten-fold greater risk of having a femoral hernia during a reoperation for groin hernia compared to men [24]. This trend was confirmed in a recently published meta-analysis by Schmidt et al. [25]. According to Kockerling et al. a concomitant femoral hernia is easily missed during open inguinal hernia repair due to
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Figure 4. Duration of surgery for endoscopic repair. The median duration of surgery for endoscopic repair was 78.0 min (range: 48—248 min) for the female group and 89.0 (range: 29—294 min) for the male group, P = 0.67.
the fact that the transversalis fascia is not routinely opened [26]. This, on one hand must be seen as an advantage for endoscopic groin hernia repair compared to the open repair. On the other hand, the risk of missing a concomitant femoral hernia during open inguinal hernia repair must be kept in mind. Thus, hernia surgeons performing open inguinal hernia repair should be encouraged to systematically search for and rule out a femoral hernia during open inguinal hernia repair. The reasons for this gender discrimination are difficult to understand. The female population did not differ from the male cohort with regard to concomitant medical conditions per ASA grading. Thus, this trend cannot be blamed on medical condition. Although the female group was significantly older compared to the male group at the time of surgery, this single factor cannot be the sole reason for the gender discrimination identified in this study. This is especially true following the fact that all patients included in this study were managed under general anesthesia. More so, 30% of female population underwent endoscopic closure despite the age difference. Thus, age alone cannot be the reason for this gender-dependent trend. All procedures were performed by surgeons with experience in both laparoscopic and open hernia repair. Therefore, surgeon’s experience does not seem to explain this disparity. Reasonable explanations for this trend must therefore blamed on institutional standards and surgeon’s preference. The findings of this retrospective study have led to a change in our departmental standards. Endoscopic groin hernia repair now represents the standard procedure in our department irrespective of sex in accordance with current practice. This is also true in the emergency setting. The results presented in this study represent findings from a single center and therefore cannot be readily projected on other institutions. Besides, the trend shown in this series might simple be due to institutional standards and/or surgeons preference and therefore cannot be generalized. Although patients were consecutively included in this study the retrospective study design must be stated as a further limitation. It would be interesting to investigate this topic in a prospective setting. Despite this limitation, the findings
from this study suggest a gender-dependent discrimination with regard to minimally invasive groin hernia repair.
Conclusion Findings from this retrospective collective suggest that, there might be some degree of sex discrimination with regard to endoscopic groin hernia repair in favor of the male population.
Funding None.
Authors’ contribution Study concept: PA, study design: PA, MS, HZ, data collection: MS. Statistical analysis: PA, MS. Interpreted the results: PA, HZ, MS. Drafted the manuscript: MS, PA. Critically reviewed and approved the manuscript: PA, HZ, MS.
Acknowledgement Not applicable.
Disclosure of interest The authors declare that they have no competing interest.
References [1] Jensen KK, Henriksen NA, Jorgensen LN. Inguinal hernia epidemiology. In: Textbook of hernia. Switzerland: Springer International Publishing; 2017. p. 23—7. [2] Burcharth J, Pedersen M, Bisgaard T, et al. Nationwide prevalence of groin hernia repair. PloS One 2013;8:e54367.
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M. Stodolski et al.
[3] Collaboration EHT. Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials. Ann Surg 2002;235:322. [4] Grant A. Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000;87:860—7. [5] Amid PK. Groin hernia repair: open techniques. World J Surg 2005;29:1046—51. [6] Bignell M, Partridge G, Mahon D, Rhodes M. Prospective randomized trial of laparoscopic (transabdominal preperitonealTAPP) versus open (mesh) repair for bilateral and recurrent inguinal hernia: incidence of chronic groin pain and impact on quality of life: results of 10 year follow-up. Hernia 2012;16:635—40. [7] Collaboration EUHT. Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000;87:860—7. [8] Chung R, Rowland D. Meta-analyses of randomized controlled trials of laparoscopic vs conventional inguinal hernia repairs. Surg Endosc 1999;13:689—94. [9] Memon M, Cooper N, Memon B, et al. Meta-analysis of randomized clinical trials comparing open and laparoscopic inguinal hernia repair. Br J Surg 2003;90:1479—92. [10] McKernan JB, Laws HL. Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach. Surg Endosc 1993;7:26—8. [11] Wake BL, McCormack K, Fraser C, et al. Transabdominal preperitoneal (TAPP) vs totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair. The Cochrane Library; 2005. [12] Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. The tension-free hernioplasty. Am J Surg 1989;157:188—93. [13] Kuroiwa M. Direct inguinal hernia and femoral hernia. In: Operative general surgery in neonates and infants. Japan: Springer; 2016. p. 149—53. [14] Sloot N, Siebert J, Hoffler U. Eradication of MRSA from carriers by means of whole-body washing with an antiseptic in combination with mupirocin nasal ointment. Zentralbl Hyg Umweltmed 1999;202:513—23.
[15] Shaikh I, Olabi B, Wong VM, et al. NICE guidance and current practice of recurrent and bilateral groin hernia repair by Scottish surgeons. Hernia 2011;15:387—91. [16] Thiels CA, Holst KA, Ubl DS, et al. Gender disparities in the utilization of laparoscopic groin hernia repair. J Surg Res 2017;210:59—68. [17] Ashfaq A, McGhan LJ, Chapital AB, et al. Inguinal hernia repair in women: is the laparoscopic approach superior? Hernia 2014;18:369—73. [18] Waltz P, Luciano J, Peitzman A, Zuckerbraun BS. Femoral hernias in patients undergoing total extraperitoneal laparoscopic hernia repair: including routine evaluation of the femoral canal in approaches to inguinal hernia repair. JAMA Surg 2016;151:292—3. [19] Burcharth J, Andresen K, Pommergaard HC, et al. Direct inguinal hernias and anterior surgical approach are risk factors for female inguinal hernia recurrences. Langenbecks Arch Surg 2014;399:71—6. [20] Anon. Laparoscopic surgery for inguinal hernia repair. Technol Apprais Guid 2004;83:1—36. [21] Miserez M, Peeters E, Aufenacker T, et al. Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2014;18:151—63. [22] 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. [23] Koch A, Edwards A, Haapaniemi S, et al. Prospective evaluation of 6895 groin hernia repairs in women. Br J Surg 2005;92:1553—8. [24] Nilsson H, Holmberg H, Nordin P. Groin hernia repair in women — A nationwide register study. Am J Surg 2018;216:274—9. [25] Schmidt L, Oberg S, Andresen K, Rosenberg J. Recurrence rates after repair of inguinal hernia in women: a systematic review. JAMA Surg 2018;153:1135—42. [26] Kockerling F, Koch A, Lorenz R. Groin hernias in women — a review of the literature. Front Surg 2019;6:4.
Please cite this article in press as: Stodolski M, et al. Gender discrimination in endoscopic groin hernia repair. Minimal invasive groin hernia repair is offered less often to female patients compared to male patients. Journal of Visceral Surgery (2019), https://doi.org/10.1016/j.jviscsurg.2019.12.006