ArticlesQuality assessment of 26 304 herniorrhaphies in Denmark: a prospective nationwide study
Introduction
The number of groin herniorrhaphies done worldwide every year exceeds 20 million, because this procedure is one of the most common. Outcomes of hernia surgery usually focus on recurrence rate, acute and chronic pain, convalescence, outpatient surgery, type of anaesthesia, risk of complications, and cost issues. Although groin herniorrhaphies have been done for more than 100 years, new techniques are continuously being developed, which shows that no procedure is optimum, and hernia specialists continue to strive for excellence. However, the effectiveness of the various groin herniorrhaphy procedures remains largely unclarified.1 Although there have been previous reports of hernia audit in regional populations,1, 2 nationwide studies in hernia surgery are scarce.
Traditionally, recurrence rate has been the primary outcome measure, but there is a discrepancy between the low rates (<5%) reported in most studies of inguinal hernia3, 4 and the proportion of operations done for recurrence (about 20%).1, 2, 5 Although many hernia trials have been done, there is no consensus about optimum surgical procedure. Other aspects of quality of care include use of local anaesthesia, which may be the safest and most costeffective anaesthetic technique, but such anaesthesia is rarely used outside hernia centres;1,3,4,6·8 striking variation in recommendations for and duration of convalescence;9, 10 inconvenience and social consequences of acute and chronic postoperative pain;11, 12 and variation in and organisation of procedures on an outpatient basis.1, 2 Thus, despite being a simple operation, groin herniorrhaphy is an example of the challenges that arise in surgery at a time when new technology could change practice and when cost constraints call for documentation of quality of care and costeffectiveness. Although quality of care within hernia surgery may have improved, most information comes from specialist centres or from surgeons with an interest in hernia surgery, and nationwide data are not readily available.
To monitor the outcomes of surgery for groin hernia and to establish a scientific basis for improvement, a Danish nationwide database has been established to prospectively record all surgical procedures for groin hernia. We report data obtained in the first 30 months.
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Methods Data collection
The database was established in 1997 and registration began on Jan 1, 1998. Immediately after operation, the surgeon records on a simple form data for all inguinal and femoral hernia repairs in patients older than 18 years of age.13 The forms are posted to a central secretariat, where data are entered into the database by optical scanning and character recognition. Registration is based on patients' unique social security number, which matches each operation to a specific patient and allows the
Results
Between Jan 1, 1998, and June 30, 2000, 26 304 operations (24 192 patients) were recorded in the database, with a median observation time of 15·5 months (range 7·4-21·7), corresponding to 93% of all herniorrhaphies done in Denmark during that time.
Almost 4500 operations were for recurrent hernia and over 500 reoperations were done in patients who had their first operation after Jan 1, 1998 (table 1). 4% of all operations were for femoral hernias, 32% of which were seen in acute operations. A
Discussion
Our results show the importance of a nationwide database for groin hernia surgery, since several issues that require improvement have been defined (number of outpatient procedures, choice of surgical and anaesthetic technique). The value of continuous monitoring is supported by the rapid increase in use of improved surgical techniques (mesh repairs), which resulted in reduced reoperation rates. The national database collaboration has provided a basis for large-scale collaborative studies within
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