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 Table of Contents  
Year : 2017  |  Volume : 50  |  Issue : 3  |  Page : 89-96

Bilateral primary inguinal hernia repair in Taiwanese adults: A nationwide database analysis

1 Department of General Surgery, E-Da Hospital, Kaohsiung; Department of Colorectal Surgery, Dalin Tzu Chi Hospital, The Buddist Tzuchi Medical Foundation, Chia-Yi, Taiwan
2 Department of General Surgery, Dalin Tzu Chi Hospital, The Buddist Tzuchi Medical Foundation, Chia-Yi; School of Medicine, I-Shou University, Kaohsiung, Taiwan
3 School of Medicine, I-Shou University, Kaohsiung; School of Medicine, Tzu Chi University, Hualien, Taiwan

Date of Submission04-May-2016
Date of Decision31-Jul-2016
Date of Acceptance05-Oct-2016
Date of Web Publication29-May-2017

Correspondence Address:
Cheng-Hung Lee
General Surgery, Dalin Tzu Chi Hospital, The Buddist Tzuchi Medical Foundation, No.2, Minsheng Road, Dalin Township, Chiayi County 622
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/fjs.fjs_33_17

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Objective: The objective of this study was to identify the long-term rates of and treatment options for recurrence of bilateral primary inguinal hernias following various hernia repair methods, namely, open inguinal hernia repair (OIHR) without mesh, OIHR with mesh (OIHR-M), and laparoscopic inguinal hernia repair (LIHR).
Materials and Methods: Data in this retrospective study were retrieved from the Taiwan's National Health Insurance Research Database. All adult patients who underwent primary bilateral inguinal hernia repair were selected from this database using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedure codes.
Results: From 2000 to 2010, 13,636 adult patients underwent elective bilateral inguinal hernia repair, with a median follow-up of 63.95 months. The risk of recurrence was significantly lower in the LIHR group than in the OIHR group (hazard ratio [HR] =0.691,P = 0.003) and was similar to that in the OIHR-M group (HR = 1.187,P = 0.184). The median recurrence-free period was 28.93 months. After recurrence, 52.6% of patients underwent repair at the same hospital, and 35.5% of patients were operated on by the same surgeons. The LIHR group had a significantly shorter median recurrent period than did the other groups (OIHR, OIHR-M, and LIHR: 33.83, 23.33, 16.56 months, respectively;P < 0.001). Moreover, recurrence occurred in a significantly higher proportion of patients who were treated by the same surgeon (OIHR vs. OIHR-M vs. LIHR = 31.8% vs. 40.1% vs. 48.6%,P < 0.001).
Conclusions: In this large cohort study, the recurrence risk was significantly lower in the LIHR group than in the OIHR group and was similar to that in the OIHR-M group, for primary bilateral hernia repair. In addition, the LIHR group experienced similar mortality as the other groups but lower readmission rates. Moreover, the proportion of LIHR patients treated by the same doctor was significantly higher than that of traditional hernia repair patients. In short, LIHR is a reliable procedure and may offer an improved surgical experience for bilateral primary inguinal hernia repair.

Keywords: Bilateral inguinal hernia repair, healthcare-seeking behaviors, hernia recurrence, laparoscopic inguinal hernia repair, laparoscopy, National Health Insurance Research Database

How to cite this article:
Chen JH, Wu JC, Yin WY, Lee CH. Bilateral primary inguinal hernia repair in Taiwanese adults: A nationwide database analysis. Formos J Surg 2017;50:89-96

How to cite this URL:
Chen JH, Wu JC, Yin WY, Lee CH. Bilateral primary inguinal hernia repair in Taiwanese adults: A nationwide database analysis. Formos J Surg [serial online] 2017 [cited 2021 Jun 22];50:89-96. Available from: https://www.e-fjs.org/text.asp?2017/50/3/89/207179

  Introduction Top

The incidence of bilateral inguinal hernias, which were reported to have a higher risk of recurrence following open inguinal hernia repair (OIHR),[1] is between 8% and 30%. The treatment of bilateral hernias has been debatable. Laparoscopic inguinal hernia repair (LIHR), which has recently been suggested for bilateral and recurrent inguinal hernias by the National Institute for Health and Care Excellence (NICE) and the European Hernia Society guidelines,[2],[3] is a valuable option for patients. Specifically, LIHR has similar rates of mortality and lower rates of morbidity than does OIHR [4],[5],[6] and typically involves a shorter hospital stay, reduced postoperative pain, faster return to normal activity, and less long-term chronic pain and numbness.[7],[8],[9],[10] Most studies have reported equal or lower recurrence rates following LIHR than after OIHR.[6],[11] However, one meta-analysis reported that LIHR may have a higher recurrence rate than OIHR after more than 3 years of follow-up.[12] Thus, long-term outcomes of the varying recurrence rates after OIHR and LIHR remain highly unclear, largely because comprehensive long-term follow-up is difficult. Studies have reported follow-up rates between 30% and 60%, which were determined through clinical investigations, phone calls, letters, or E-mails;[13],[14] loss of follow-up was a consistent problem in these retrospective studies.

The National Health Insurance Research Database (NHIRD) is a nationwide resource that is maintained by the Taiwan's National Health Research Institutes. Health care in Taiwan is financed by the unique National Health Insurance (NHI) program, which enrolls 97% of the country's medical providers and approximately 99% of the population.[15] However, without gatekeeper systems or referral requirements, the insureds can consult any physician in any clinics or hospital. Otherwise, a low copayment scheme of the NHI program encourages patients to conduct hospital and doctor “shopping.”[16] If patients lose the confidence in the previous surgeons because of the recurrence of illness, it would be very easy for them to consult other doctors for treatment. The NHIRD records all medical behaviors in Taiwan, including the data of patients who were admitted to health-care facilities and underwent any hernia repair. We considered this database a comprehensive and reliable data source for the present study.

The present large cohort study was conducted using data from the NHIRD and estimated the long-term outcomes of adult patients with bilateral inguinal hernias following treatment with OIHR, OIHR with mesh (OIHR-M) placement, or LIHR. We primarily sought to determine the recurrence of any inguinal hernia repair. In addition, we explored patients' 30-day postoperative mortality, reoperation, and readmission rates as well as healthcare-seeking behaviors after recurrence.

  Materials and Methods Top


The NHIRD records all claims data from Taiwan's NHI program (Registered Number NHIRD-103-246). This study was fully reviewed and approved by the Institutional Review Board of Buddhist Dalin Tzu Chi Hospital (B10304006). Deidentified secondary data from the NHIRD, which had been released to the public for research purposes, were used, and the inpatient expenditures by admissions were analyzed. All NHIRD inpatient data from January 1, 1996, to December 31, 2012, were retrieved.

Identification of hernia repair

Adult patients (≥18-year-old) who were newly hospitalized for hernias (identified by the International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 550.xx–553.xx) between January 1, 2000, and December 31, 2010, were analyzed. The patients who were discharged with the surgical procedure code for bilateral inguinal hernia repair (ICD-9-CM 53.1x) were collected. Patients who were discharged with the surgical procedure codes for bilateral inguinal hernia repair (ICD-9-CM 53.10-53.13) were considered to have undergone OIHR, and those with the surgical procedure codes for bilateral inguinal hernia repair with graft or prosthesis (ICD-9-CM 53.14-53.17) were considered to have undergone OIHR-M, and the patients who were discharged with the surgical procedure code for bilateral inguinal hernia repair (ICD-9-CM 53.1x) and laparoscopic surgery (ICD-9-CM 54.21) were considered to have undergone LIHR. The patients with recurrent inguinal hernia codes (550.01, 550.03, 550.11, 550.13, 550.91, or 550.93) and complicated inguinal hernia codes (550.0x, 550.1x, 551.x, or 552.x)[17] were excluded. The patients who underwent concurrent operations during the same hospitalization were also excluded because we could not clearly identify the surgical complications of inguinal hernia repair or other procedures. The admission date was designated as the date of hernia repair, the index date, and all patients who underwent hernia repair were followed until withdrawal from the study because of death, absence, or living abroad for more than 6 months or the end of the study period (December 31, 2012). [Figure 1] illustrates the patient selection algorithm.
Figure 1: Study flowchart

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The primary endpoint was recurrence after the index date. The recurrence was defined as receiving any inguinal hernia repair more than 30 days after a previous bilateral inguinal repair. Reoperations within 30 days of the first surgery, by contrast, were defined as a complication of the index operation. Secondary endpoints, including the length of hospital stay, insurance cost, 30-day mortality, and 30-day readmission by any cause, were also collected and analyzed. The mortality was defined as withdrawal from the NHI program.[18]

Adjustment for covariates

Several covariates reported as recurrence risk factors, including age, sex, and hernia type,[19],[20],[21] were identified. The hernia type was identified by the surgical procedure codes (bilateral direct type: 53.11 and 53.14; bilateral indirect type: 53.12 and 53.15; one direct and one indirect type: 53.13 and 53.16; and unspecified: 53.10 and 53.17).

The key independent variable for comorbidities was identified using the Charlson comorbidity index (CCI), which is a widely accepted measure for risk adjustment in administrative claims datasets.[22],[23] The CCI is a weighted measure that incorporates age and 19 medical categories, each of which is weighted according to its effects on mortality [Table 1]. The final score was calculated for each patient by considering all comorbidities. On the basis of inpatient codes, the comorbidities recorded in all admissions from 12 months before the first bilateral inguinal hernia repair were noted and analyzed [Table 1]. In our study, the CCI was divided into four groups: 0, 1, 2, and ≥3.[22],[24]
Table 1: Translation of Charlson comorbidity index components into International Classification of Diseases, Ninth Revision, Clinical Modification codes

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Statistical analysis

All descriptive statistics and contingency tables were analyzed using MedCalc for Windows, version 14.12 (MedCalc Software, Ostend, Belgium). In addition, analysis of variance was performed to analyze continuous variables, Chi-square tests were used to compare categorical variables, and a Kaplan–Meier analysis was used to identify the differences in recurrence among the three groups. Finally, a backward stepwise Cox proportional hazards model was used to evaluate the risk factors for the recurrence after adjusting for the potential confounders of age, sex, hernia type, and CCI group. Statistical significance was set at P < 0.05.

  Results Top

According to the NHIRD, a total of 15,740 patients underwent primary bilateral hernia repair between January 1, 2000, and December 31, 2010. We excluded 690 patients who had complicated hernias and 1414 patients who underwent hernia repair combined with other operations during the same admission. Finally, a total of 13,636 adult patients who underwent primary bilateral inguinal hernia repair alone were included in the present study; the median follow-up period was 63.9 months.

The patients were separated into one of three groups on the basis of their repair surgeries, namely, OIHR (6250, 45.8%), OIHR-M (6132, 44.9%), or LIHR (1253, 9.3%). [Table 2] presents a list of the characteristics of the study population. On average, the OIHR, OIHR-M, and LIHR groups required 3.05, 3.49, and 2.43 days of hospital stay, respectively, which were not significantly different (P = 0.112). Eleven patients (0.2%) in the OIHR group, nine (0.1%) in the OIHR-M group, and two (0.2%) in the LIHR group died within 30 days postoperation, with no significant difference (P = 0.921). The 30-day reoperation rate among the three groups was also not significantly different (P = 0.162) although 223 patients (3.6%) in the OIHR group, 207 (3.4%) in the OIHR-M group, and 22 (1.8%) in the LIHR group were readmitted within that time period [Table 2]. Notably, the LIHR group showed a significantly lower 30-day readmission rate than did the other groups (P = 0.002).
Table 2: Clinical characteristics of 13,636 patients who received primary bilateral inguinal hernia repair

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Incidence of long-term recurrence of bilateral inguinal hernias

During the follow-up period, recurrent hernias occurred in 1190 patients (8.7%). Specifically, we observed 741 (11.9%) recurrences in the OIHR group, 377 (6.1%) in the OIHR-M group, and 72 (5.7%) in the LIHR group. At the end of 3 years, 52.4% (389/741) of the recurrences had occurred in the OIHR group, 63.6% (240/377) had occurred in the OIHR-M group, and 79% (57/72) had occurred in the LIHR group (P < 0.001). [Figure 2] illustrates the cumulative incidences of bilateral inguinal hernia recurrence following the various hernia repair methods.
Figure 2: Cumulative incidences of bilateral inguinal hernia recurrence following various hernia repairs

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After Cox regression analysis and adjusting for age, sex, hernia type, and CCI group, the LIHR group was determined to have a significantly lower recurrence risk than the OIHR group (hazard ratio [HR] = 0.691, 95% confidence interval [CI] =0.542–0.882, P = 0.003). However, the recurrence risk was similar in both LIHR and OIHR-M groups (HR = 1.187, 95% CI = 0.922–1.530, P = 0.184).

The female patients had a significantly lower recurrence risk than did the male patients (HR = 0.196, 95% CI = 0.121–0.317, P < 0.001). In addition, the patients with bilateral direct hernias (HR = 1.868, 95% CI = 1.585–2.201, P < 0.001) and those with direct hernias on one side and indirect hernias on the other side (HR = 1.280, 95% CI = 1.056–1.551, P = 0.012) presented with a significantly higher recurrence risk than did those with bilateral indirect hernias.

During the follow-up period, the median period from the index date to recurrence was 28.93 months among all the patients with a recurrent hernia. However, the LIHR group had a significantly shorter median recurrent period than did the other groups [OIHR, OIHR-M, and LIHR: 33.83, 23.33, and 16.56 months, respectively; P < 0.001; [Table 2]. After the median recurrence time, 413 residual recurrences occurred in the OIHR group (413/741, 55.73%), 163 occurred in the OIHR-M group (163/377, 43.23%), and 18 occurred in the LIHR group (18/72, 25%).

Healthcare-seeking behaviors after recurrence

Among all the patients with recurrences, 626 (57.6%) underwent a second inguinal treatment in the same hospital; of these patients, only 422 (35.6%) were operated on by the same surgeon. Notably, patients in LIHR group have significantly higher proportion repair the recurrence in the same hospital (OIHR: 46%, OIHR-M: 61.3%, and LIHR: 75%, P < 0.001) and were operated by same doctor (OIHR: 46%, OIHR-M: 61.3%, and LIHR: 75%, P < 0.001) when compared to the other two groups [Table 3].
Table 3: Health-care-seeking behaviors following hernia recurrence

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  Discussion Top

In this study, we identified several outcomes following different surgical treatments for hernias. First, the LIHR group had significantly smaller recurrence rate than the OIHR group but a similar recurrence rate compared with the OIHR-M group. Second, the LIHR group had a similar mortality rate compared with the other groups but a significantly lower readmission rate. Third, the LIHR group had a significantly shorter median recurrent period than did the other groups. Finally, a significantly higher proportion of patients in the LIHR group underwent recurrent treatment in the same hospital and by the same surgeon.

The NICE and European Hernia Society guidelines suggest LIHR for treating bilateral inguinal hernias and recurrent hernias.[2],[3] Moreover, several studies have reported a lower recurrence rate and more favorable outcomes following LIHR than those following other treatment options for bilateral inguinal hernias.[11],[25],[26] The present findings revealed that the recurrence rate of bilateral hernias following LIHR as the primary repair surgery was similar to that following OIHR-M but significantly lower than that following OIHR. In addition, the overall follow-up period of the patients in the LIHR group was significantly shorter than that in the other groups, which may have led to bias in the recurrent rate in the LIHR group. However, we considered that any bias would be relatively small because only 21% of recurrences were identified more than 3 years, the minimum follow-up period in our study, after bilateral inguinal hernia repair. Thus, this study confirmed the favorability of suing LIHR to treat bilateral inguinal hernia as reported previously.[3],[11] According to prior research, LIHR is an efficient approach for inguinal hernia repair because of the shorter recovery time before returning to normal activity, less postoperative pain,[27] and reduced long-term persistent pain and numbness [7],[8],[9],[28],[29] However, these data are not recorded in the NHI database, and thus, we could not analyze these crucial factors. Instead, we measured these factors by the patients' healthcare-seeking behaviors after hernia recurrence. As discussed previously, the NHI program has facilitated consultations between patients and other doctors to treat their recurrences because of a loss of confidence in their previous surgeons or otherwise poor surgical experience. However, in the present study, we found that recurrence was treated by the same doctor in a significantly higher proportion of patients who underwent LIHR as the primary repair for bilateral inguinal hernia. This may indicate that the patients' experience of LIHR as the primary repair may be more favorable than that of the other methods.

In addition, the period from the index date to LIHR recurrence was shorter in the LIHR group than in the remaining groups, which is consistent with the results reported by other studies.[11],[30] This may be related to the technical failure of LIHR. Specifically, recurrence in the LIHR group primarily resulted from technical mistakes, including missed hernias, incomplete dissection, a small mesh, and migration or incorrect positioning of the mesh.[31] Several studies have reported that surgeon experience is also significantly related to patient outcomes. An experienced LIHR surgeon has been defined as having performed between 10 and 250 laparoscopic hernia repairs,[3],[27],[29],[32],[33] with the first 30–50 being the most critical.[3] Moreover, El-Dhuwaib et al.[30] noted a strong correlation between reoperation and the consultant's caseload; these findings suggest that LIHR is technically more demanding than traditional hernia repair.

One study has reported a higher complication rate in LIHR than in open procedures,[27] whereas more recent studies have indicated that LIHR had an equal [12],[26] or lower [11] complication rate than traditional hernia repair. However, because all complications in the NHIRD are recorded by ICD-9-CM codes, we could not clearly categorize the diagnostic codes into surgical complications or independent events in the present study. Therefore, we used 30-day mortality, reoperation, and readmission rates instead of overall surgical mortality and complication rates. After our analysis, the 30-day mortality and reoperation rates were determined to vary nonsignificantly. However, the LIHR group had a significantly lower 30-day readmission rate than did the other groups. Further analysis should be performed to obtain more accurate results for perioperative complications.

The universal coverage of the NHI program ensures unrestricted medical services from every doctor for every patient. However, as noted earlier, the insufficient referral system and a low co-payment scheme encourage patients to do hospital and doctor “shopping,”[16] resulting in Taiwan reporting the highest annual physician visits per person worldwide.[34] Once patients experience a recurrent hernia after repair, their confidence in their first surgeon often disappears, and they tend to seek out other doctors to treat the recurrence.

Our results corroborate this tendency. Notably, only 35.6% of the patients in the present study revisited their first surgeons and only 57.6% revisited the same hospital to treat their recurrent hernia. Under such conditions, it is difficult to conduct long-term follow-up analyses or identify patterns of recurrence in patients by one physician or even physicians of the same hospital. Therefore, we collected this study's data from the NHRID because the NHI program enrolls most of the country's medical providers and population. In brief, the study cohort herein comprised patients with any repeat hernia repair after an initial repair within the study period, except for those who lived abroad. We easily observed the long-term outcomes of different procedures in Taiwan, with only a limited loss to follow-up.


This study has some limitations. First, the NHIRD database is secondary and administrative, and the ICD-9-CM codes are not typically determined by surgeons. Instead, the surgeons always provided different codes according to health insurance surgical orders from Taiwan's NHI program, which is directly associated with surgeon revenues. Hence, the risk of miscoding exists. However, most ICD-9-CM codes during admissions were given by professional coders based on the records during admission. Moreover, the NHI Administration of the Ministry of Health and Welfare provided an official comparison table of these different codes. Therefore, we considered the miscoding of surgical procedures to be minimal.

Second, the number of laparoscopic hernia and mesh repairs may be underestimated because of the various operation fees for laparoscopic hernia repair and open procedures, for which the high-end mesh materials are paid for by the patients themselves and may be claimed as nonmesh repair. Third, we could not analyze each physician's notes in detail to clarify the specific operative methods, such as the placement of the transabdominal preperitoneal or fully extraperitoneal mesh, the placement of the Lichtenstein or mesh plug, use of the Bassini or Shouldice technique, the Nyhus classification of the hernia, the type of mesh placed, and the ways the mesh was fixed.

Fourth, we analyzed only the inpatient expenditures by admissions. No records about medication use during the follow-up period were retrieved, and we could not identify these unrecorded factors using the NHIRD database. Thus, we could not detect several reported advantages of specific surgical modalities, including faster return to normal activity, reduced postoperative pain, or less long-term chronic pain and numbness.[7],[8],[9],[27],[29],[35] Moreover, we could not identify the number of nonoperated recurrences through the NHIRD. Although the absolute number of recurrences may be higher than that observed in this study, we did not overestimate the true number of reoperations for recurrent inguinal hernias because we used data regarding reoperations and presented estimates that pragmatically reflect the rate of clinically significant hernia recurrence.

  Conclusions Top

In this large cohort study, LIHR was associated with a significantly lower rate of hernia recurrence than OIHR and a similar risk of primary bilateral inguinal hernia repair as OIHR-M, during the follow-up period. Moreover, LIHR and traditional hernia repair had similar 30-day mortality and lower readmission rates. We conclude that LIHR is a reliable procedure that may offer improved surgical experiences for patients requiring bilateral primary inguinal hernia repair.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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