Outcomes of Adolescent and Young Adults Receiving High Ligation and Mesh Repairs: A 16-Year Experience

Abstract

Introduction:

Interestingly, the pediatric and adult surgeons perform vastly different operations in similar patient populations. Little is known about long-term recurrence and quality of life (QOL) in adolescents and young adults undergoing inguinal hernia repair. We evaluated long-term patient-centered outcomes in this population to determine the optimal operative approach.

Methods:

The medical records of patients 12–25 years old at the time of a primary inguinal hernia repair at our institution from 2000 to 2016 were retrospectively reviewed. Patients then completed a phone survey of their postoperative courses and QOL. Outcomes of high ligation performed by pediatric surgeons were compared to those of mesh repairs by adult general surgeons. The primary outcome was recurrence. Secondary outcomes included time to recurrence, postoperative complications, and patient-centered outcomes. A Cox regression analysis was used to determine associations for recurrence.

Results:

Of 213 patients identified, 143 (67.1%) were repaired by adult surgeons and 70 (32.9%) repaired by pediatric surgeons. Overall recurrence rate for the entire cohort was 5.7% with a median time to recurrence of 3.5 years (interquartile range 120–2155 days). High ligation and mesh repairs had similar rates of recurrence (6.3 versus 5.8, P = .57) and postoperative complications (17% versus 16%, P = .45). 101/213 (47%) patients completed the phone survey. Of those surveyed, 20% reported postoperative pain, 10% had residual numbness and tingling, and 10% of patients complained of intermittent bulging. Overall, a survey comparison showed no differences among subgroups.

Conclusions:

In adolescents and young adults, the long-term recurrence rate after inguinal hernia repair is ∼6% with time to recurrence approaching 4 years. Outcomes of high ligation and mesh repair are similar, highlighting the need for individualized approaches for this unique population.

Background

As one of the most commonly performed operations by both pediatric and adult general surgeons, the inguinal hernia repair remains a highly researched and debated topic.^1–3 Interestingly, the pediatric and adult surgeons perform vastly different operations in similar patient populations. A recent study by Bruns et al. highlighted this disparity, showing that the marked difference in operative choice between these two specialties were likely attributable to experience and comfort.⁴ This emphasizes the likelihood that the operative approach is driven by surgeon preference, not necessarily the disease process or patient outcomes.

Comparing outcomes of inguinal hernia repair techniques is challenging, as they are generally successful operations with low postoperative complications and high patient satisfaction.^5,6 There are many large-scale studies evaluating outcomes in both adult and pediatric populations. The use of mesh in the adult population has demonstrated a significant decrease in recurrence rates.⁷ On the other hand, the implementation of a prosthetic reinforcement in the pediatric population is contraindicated due to concern for infertility, contracture, chronic pain, and inability to grow with the child.^8,9 Classically, the pediatric hernia is caused by a patent processus vaginalis, making a high ligation of the sac and closure of the internal ring the most commonly performed operation, regardless of age of the patient.¹⁰ It is entirely possible that 2 adolescent patients only days apart in age could receive drastically different operations based on referral to either a pediatric or adult general surgeon. Most current studies either focus on older adults or young pediatric patients, with a paucity of data evaluating true outcomes in the adolescent and early adult years.¹¹

Our goal was to examine the long-term outcomes of primary inguinal hernia repair in adolescent and young adult patients. We compared outcomes of mesh repairs to a high ligation repair, focusing on recurrence and postoperative quality of life (QOL).

Methods

This study was approved by the University of Michigan Institutional Review Board. We retrospectively reviewed the charts of patients 12–25 years old who underwent elective primary inguinal hernia repairs at our institution from 2000 to 2016. Patients were excluded if they were not available for follow-up at least 1 week from their original operation.

Demographic data included age, gender, body mass index (BMI), comorbidities, previous abdominal operations, and smoking. Hernia and operative characteristics included laterality (right/left/bilateral/simultaneous and subsequent), operative length (minutes), operative approach (open versus laparoscopic), utilization of mesh, concomitant operations, and surgeon specialty (adult/pediatric). Patients were also subcategorized into adolescents receiving high ligation and young adults receiving mesh repairs.

All hernia repair techniques were included in this study. A majority of pediatric surgeons performed a primary repair with high ligation of the hernia sac, with few instances of laparoscopic repairs with mesh utilization primarily later in the study period. Adult surgeons performed open and laparoscopic repairs throughout the study period. With changes in practice patterns, adult repairs that, early in the study period, were mainly performed without mesh (i.e., Bassini) gave way to use of mesh reinforcement in more recent years, and the predominance of laparoscopic repairs, specifically, a total extraperitoneal repair with mesh.

Outcome data were collected at follow-up, which included the most up-to-date encounter with a surgical service, whether it was in clinic, hospital admission, or emergency department (ED). To obtain the most current follow-up information, attempts were made to contact all included patients with a telephone or e-mail survey adapted from previously reported postoperative surveys, focusing on QOL, physical symptoms, and information on care elsewhere.

The primary outcome was recurrence, confirmed by imaging, physical examination, or reoperation. Secondary outcomes included time to recurrence, postoperative complications, and patient-reported outcomes obtained by survey. Postoperative complications were defined as reoperation/reintervention, surgical site infection (at any point), symptomatic hematoma, symptomatic hydrocele, postoperative pain requiring ED visit or pain management referral, or recurrence. The 30-day surgical site infections were diagnosed by CDC criteria.¹² After patients were subcategorized, a comparison of all outcomes was made between patients repaired by high ligation to those repaired with a mesh.

Repair techniques were compared using chi-square or Fisher's exact tests for categorical variables and independent t-test and Mann–Whitney tests for continuous variables. Predictors of recurrence were examined by single factor Kaplan-Meier curves and log-rank tests for categorical predictors and single factor Cox regression analysis for continuous predictors. These predictors included operative approach, laterality variables, mesh utilization, age, BMI, and operative time. All analyses were performed using STATA 13.¹³ A P value <.05 was considered statistically significant.

Results

A total of 213 patients met inclusion criteria, including 70 (32.9%) repaired by pediatric surgeons and 143 (67.1%) repaired by adult surgeons. Demographics, operative data, and hernia characteristics are reported in Table 1. Overall, 198 (93%) patients were male with a mean age of 19.8 ± 0.25 years and a mean BMI of 23.5 ± 3.9. Thirteen (6%) patients who had major comorbidities, 37 (17%) had a previous abdominal operation, and 19 (5%) were reported smokers.

Table 1.

Outcomes of Adolescents and Young Adults

	Entire cohort (n = 213)	Young adult mesh (n = 103)	Adolescent high ligation (n = 64)	P
Demographics
Age (mean ± SD), years	19.8 ± 0.25	21.9 ± 3	15.5 ± 2	<.001
Gender, male	193 (91%)	101 (98%)	60 (94%)	.06
BMI (mean ± SD)	23.5 ± 3.9	24.5 ± 3.7	21.3 ± 3.0	<.001
Major comorbidities	13 (6%)	6 (6%)	4 (6%)	.57
Previous abdominal surgeries	37 (18%)	14 (14%)	12 (19%)	.25
Smoking	19 (9%)	14 (13%)	1 (2%)	.005
Operative characteristics
Hernia laterality
Right	106 (48%)	46 (45%)	32 (50%)	.66
Left	75 (35%)	39 (38%)	22 (34%)
Bilateral (simultaneous)	24 (11%)	17 (17%)	7 (11%)
Bilateral (subsequent)	8 (4%)	3 (3%)	3 (5%)
Length of operation (mean ± SD), minutes	61.9 ± 32	69 ± 36	51 ± 23	.004
Operative approach
Open	161 (76%)	54 (52%)	63 (98%)	<.001
Laparoscopic	52 (24%)	49 (48%)	1 (2%)	<.001
Concomitant operation	8 (4%)	1 (1%)	4 (6%)	.07
Utilization of mesh	109 (51%)	103 (100%)	0 (0%)
Follow-up (median, interquartile range), days	365 (20–2263)	784 (30–2360)	1164 (89–2553)	.008
Mean, days	1288	1007	1627
Postoperative outcomes
Recurrence	12 (5.7%)	6 (5.8%)	4 (6.3%)	.57
Time to recurrence (median, interquartile range), days	1286 (120–2155)	208 (90–1637)	1580 (380–2233)	.22
Mean, days	1696	784	1453
Postoperative complications	31 (15%)	16 (16%)	11 (17%)	.45
30-day surgical site infection	6 (3%)	4 (4%)	2 (3%)	.6
Survey performed	101 (47%)	45 (43%)	39 (61%)	.017

The values are n (%) or otherwise stated.

The column titled “Adolescent high ligation” pertains to patients who were repaired by pediatric surgeons and received a high ligation repair only. The column titled “Young adult mesh” pertains to patients who were repaired by adult surgeons and received a mesh reinforcement repair.

BMI, body mass index; SD, standard deviation.

There were 106 (48%) right-sided hernias, 75 (35%) left-sided hernias, 24 (11%) performed simultaneous bilaterally, and 8 (4%) subsequent bilateral repairs. The mean operative time overall was 62 ± 32 minutes. There were 161 (76%) open repairs and 52 (24%) laparoscopic repairs with most laparoscopic repairs performed by adult surgeons (94%). Eight (4%) operations were performed concomitantly with another procedure. Mesh was placed in 109 (51%) patients, primarily by adult surgeons (98%). The mean hospital length of stay was less than 1 day, with the overwhelming majority of these procedures performed on an outpatient basis.

Survey results obtained from 101 patients (47%) are summarized in Table 2. Mean follow-up time was 1288 days (range 9–5893), or ∼3.5 years, with a median of 1 year (interquartile range [IQR] 20–2263 days). The overall recurrence rate was 5.7%, with a mean time to recurrence of 1696 days (range 23–4284 days), or ∼4.5 years, and median of 3.5 years (IQR 120–2155 days). Postoperative complications were noted in 31 (14.6%) patients, with a 30-day surgical site infection rate of 3% (Table 1).

Table 2.

Quality-of-Life Survey Results

Survey questionnaire (answer “Yes”)	Whole cohort (n = 101)	Mesh (n = 46)	No mesh (n = 55)	P	Adolescent high ligation (n = 45)	Young adult mesh (n = 44)	P	Open (n = 85)	Laparoscopic (n = 16)	P
Was your hernia repair successful?	90 (90)	41 (89)	49 (90)	.5	40 (89)	40 (91)	.42	77 (91)	13 (81)	.2
Do you have any pain associated with your hernia repair	20 (20)	11 (24)	9 (16)	.45	5 (11)	11 (25)	.14	17 (20)	3 (19)	.59
Do you feel your hernia came back?	7 (7)	5 (11)	2 (4)	.31	4 (8)	2 (5)	.28	2 (2)	5 (30)	.31
Did you have any interventions related to your repair?	7 (7)	3 (7)	4 (7)	.61	4 (8)	3 (7)	.43	4 (5)	3 (19)	.08
Do you have any numbness or tingling in the area of your hernia repair?	10 (10)	6(13)	4 (7)	.26	1 (2)	6 (14)	.08	4 (5)	3 (19)	.08
Can you perform your day-to-day activities after your repair?	88 (88)	34 (74)	55 (100)	.001	38 (84)	33 (75)	.003	4 (5)	3 (19)	.08
Did you have additional operations related to your hernia?	13 (13)	9 (20)	4 (7)	.06	4 (8)	9 (20)	.166	4 (5)	3 (19)	.08
Do you feel any abnormal bulging at your incision site?	10 (10)	3(7)	7 (13)	.25	3 (6)	3 (7)	.6	9 (11)	1 (6)	.5

Values are shown in n (%). Survey results for patients responding to telephone survey.

“Mesh” column consists of all patients receiving mesh repairs. “No Mesh” consists of patients of all ages with no mesh utilized. “Adolescent High Ligation” entails all adolescent patients receiving a high ligation technique performed by a pediatric surgeon. “Young Adult Mesh” pertains to young adult patients who received a mesh repair by adult surgeons. “Open” group consisted of any open repair, and “Laparoscopic” group consisted of any patient receiving a laparoscopic repair.

Overall, 90% of patients agreed that their hernia repair was a success (Table 2), although 20 (20%) still had complaints of pain in the region of their repair. Seven (7%) patients believed their hernia had returned at some point. Ten (10%) patients were currently complaining of a bulge at their incision site, and 10 (10%) complained of numbness or tingling in the region of their repair. Overall, 88% of patients were still able to perform their day-to-day activities both at work and play.

Patients repaired through high ligation in the pediatric population were compared to patients repaired with mesh by adult surgeons (Table 1). Patients in the mesh group were older (21.9 versus 15.5, P < .001), included more smokers (13% versus 2%, P = .005), and had a slightly higher BMI (24.5 versus 21.3, P = <.001). Major comorbidities (6% versus 6%, P = .57), concomitant operation (1% versus 6%, P = .07), and hernia laterality (P = .66) were similar. Patient in the mesh group were far more likely to undergo a laparoscopic repair (48% versus 2%, P < .001). Operative times (69 minutes versus 51 minutes, P = .004) were higher in the mesh group. Recurrence rates (5.8% versus 6.2%, P = .57), postoperative complications (16% versus 17%, P = .45), and survey results (Table 2) were similar between groups.

Recurrences are summarized in Table 3. All occurred in male patients, aged 20 ± 3.3 years, mean BMI of 26 ± 4.7, with 75% repaired by an adult surgeon. Of these, 33% were initially repaired laparoscopically and 50% with mesh. The management of recurrences was mainly performed open (66%) with all recurrences repaired with mesh.

Table 3.

Analysis of Recurrences

Surgeon	Approach	Mesh	BMI	Age at surgery	Time to recurrence (days)	Approach to recurrence	Repaired with mesh	Mesh	Survey performed
Pediatric	Open		21.3	14	127	Open	Yes	Polypropylene	No
	Open		29.3	16	869	Laparoscopic	Yes	Polypropylene	Yes
	Open		20.9	18	1703	Open	Yes	Polypropylene	No
Adult	Open		21.7	20	4284	Open	Yes	Polypropylene	No
	Open		26.6	18	2059	Laparoscopic	Yes	n/a-OSH	Yes
	Open	Polypropylene	25.0	25	208	Open	Yes	Polypropylene	No
	Open		25.3	19	1861	Open	Yes	Polypropylene	Yes
	Laparoscopic	Polypropylene	27.1	20	101	Laparoscopic	Yes	Polypropylene	No
	Laparoscopic	Polypropylene	23.8	24	80	Laparoscopic	Yes	Polypropylene	No
	Open	Polypropylene	29.0	23	2445	Open	Yes	Polypropylene	Yes
	Laparoscopic	Polyester	37.8	22	23	Open	Yes	Polypropylene	No
	Laparoscopic	Polyester	23.7	19	1844	Open	Yes	n/a-OSH	Yes

This demonstrates the initial operation approach (“Approach”), the chosen method recurrence repair (“Approach to Recurrence”), and if a mesh was utilized (“Repaired with Mesh”).

BMI, body mass index; n/a-OSH, not available, performed at outside hospital; SSI, surgical site infection.

Single factor Kaplan-Meier curves for recurrence were performed for laparoscopic repairs (log-rank; P < .04), laterality (4) (log-rank; P < .001), and mesh (log-rank; P = .72). Other variables assessed were age (hazard ration = 1.0, P < .9), length of operation (hazard ratio = 1.0 P = .37), and BMI, which has the strongest association with recurrence (hazard ratio = 1.17, P < .015).

Discussion

In this study, we sought to investigate the interesting clinical scenario where pediatric and adult surgeons chose to repair inguinal hernias in similar patients. This study evaluated the long-term outcomes and QOL in an adolescent and young adult population. The minimum recurrence rate for the entire cohort was 5.7%, with an average time to recurrence of 4.5 years postrepair. In addition, outcomes were similar for mesh repairs and high ligations in a similar patient population. The risk factor for recurrence was increasing BMI, with age itself not effecting recurrence. Utilizing a follow-up survey, postoperative pain was found in 20% of patients, numbness and tingling in 10%, and bulging in 10%. While the details of each technique vary, this study is the first of its kind to compare mesh repair with high ligation of inguinal hernia in the adolescent/young adult population.

Well-established as one of the main outcome measures for hernia repair, low recurrence rates are accepted as an indicator of success. In adult hernia literature, studies report recurrence rates of 1%–5%, with a majority of studies focusing on patients aged 50–70 years.^14–16 On the other hand, inguinal hernia studies in pediatric literature demonstrate a recurrence rate of 0%–4% using the high ligation technique, with most patient cohorts being less than 5 years old.^2,17–21 There are few studies, however, focusing on the outcomes of adolescents and young adults. While traditional approaches to pediatric hernias focus on ligating the internal ring, adult surgeons generally perform both hernia sac reduction and mesh reinforcement.

While no large studies exist, some groups have attempted to address this issue. van Kerckhoven et al. reported a recurrence rate of 4.7% in young adult patients aged 18–40 years after a non-mesh hernia repair, although no recurrences were reported in the 18–25 year old subgroup.²² This study demonstrated an alternative to the standard mesh repair performed in patients ≥18 years old and suggested that age affects recurrence risk in non-mesh repairs. Shen et al. randomized adolescents aged 13–18 to either high ligation or Lichtenstein repair with acellular mesh, with high ligation trending toward more recurrences (6% versus 0%), a rate similar to our reported subpopulation of adolescent patients undergoing high ligation (6.2%).^23,24 This study conspicuously did not include young adults older than 18 years. These studies, together with our data, highlight our assertion that patients aged 12–25 are unique and likely require an individualized operation.

Considering time to recurrence is important when evaluating recurrence rates,^25,26 with a mean time to recurrence of 4.5 years, our data suggest underreporting in current literature, likely due to inadequate follow-up.^27,28 While some studies recommend at least 2 years of follow-up, Zheng et al. found a mean time to recurrence of ∼4 years, consistent with our findings.^29,30 We acknowledge that obtaining this information is laborious. Hernias are mainly outpatient procedures, and many surgeons do not require any postoperative visit. This makes tracking of postoperative outcomes, including recurrences, difficult. In our study, patients were considered to have recurred only if they were subsequently repaired again or if recurrence was confirmed with imaging, not based on symptomatology. Despite these barriers, phone follow-up in our study was up to 15 years postoperatively, providing long-term data for analysis. Even so, the “lost to follow-up” obstacle is a challenge to all hernia studies and we acknowledge that this limitation cannot be overlooked.

Aside from recurrence, QOL represents a commonly studied outcome in inguinal hernia repair and was assessed by our postoperative survey. Our response rate of nearly 50% was similar to previously reported studies.^11,22 One of the most commonly reported measures of QOL is postoperative pain, with most long-term studies reporting rates of chronic pain from 1% to 20%, again corroborating our results.^6,31 Patients who received mesh had slightly higher rates of numbness, consistent with previous reports, but otherwise no differences in chronic pain existed between subgroups.^32,33 In addition, 10% of patients complained of bulging at their incision site. This complaint is commonly queried after hernia repair, and its utility in determining recurrence is heavily debated.^11,34,35 A recent study suggested that presence of symptoms as reported by questionnaire has a high negative predictive value and low positive predictive value for recurrence.³⁶ Thus, we chose to only include recurrences confirmed by operation or imaging. Finally, it is important to note that patients with a mesh repair were less likely to be able to perform their day-to-day activities compared to the patients with a non-mesh repair (74% versus 100%, P = .001). This is an important point, suggesting a potential QOL disadvantage to the use of mesh overall in this subpopulation.

Overall, the strongest association with recurrence in our study was BMI. Additional variables such as mesh and age were not strongly associated with recurrence. Data in adult literature suggests a lower recurrence rate with mesh placement, but this did not affect recurrence in our study.³⁷ Therefore, it appears that BMI, not age, should be the primary determinant of operation approach in this population. This challenges the current status where age itself determines the surgeon a patient visits, pediatric or adult.

There are multiple limitations in this study worth mentioning. This was a single institution, retrospective analysis, subjecting the data to selection bias. As such, gathering follow-up data was challenging and laborious. While some patients were contacted up to 15 years after their initial operation, many others could not be reached to complete the phone survey. Similarly, our stipulation that recurrence only be confirmed by repeat operation or imaging suggests that our recurrence rates represent a minimum. In addition, it is also possible that patients lost to follow-up failed to return to our institution if they had a poor outcome due to dissatisfaction. With this in mind, we reassert that our reported recurrence rates likely underestimate true recurrence, an issue frequently encountered in the inguinal hernia repair literature. Another criticism of the study is that the comparison between high ligation and mesh repairs, regardless of the technique, cannot be performed. This viewpoint is one of the reasons for pursuing the study, as some similar patients are receiving much different operations. Finally, to a certain degree, the inherent differences in these two populations, such as their smoking status, may influence their recurrence rate as well. Even so, it is quite possible that since most adolescent patients are accompanied by their parents, the smoking status may not be as accurate in this sample.

Despite these limitations, this study is the first of its kind to evaluate the entire cohort of inguinal hernia repairs spanning both the adolescent and young adult populations. Whether an adolescent patient with an inguinal hernia would be better served receiving the current standard approach with mesh or a traditional high ligation remains debatable, as our data suggest similar outcomes in this group. Our study suggests that an average time to recurrence approaches 5 years, with a recurrence rate higher than currently reported data.

Footnotes

Disclosure Statement

No competing financial interests exist.

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