Long-term incidence of contralateral primary hernia repair following unilateral inguinal hernia repair in a cohort of 50,220 patients.

Richard Zheng, MD1, Jie Yang, PhD2, Hao Chen2, Maria S Altieri, MD2, Andrew T Bates, MD2, Aurora D Pryor, MD2, Mark Talamini, MD2, Dana A Telem, MD2. 1Jefferson University Hospital, 2Stony Brook University Hospital

Background: Occult or asymptomatic contralateral inguinal hernias are present in many patients at the time of initial inguinal hernia repair. While many may eventually necessitate repair, data on long-term follow-up are sparse. The purpose of this study was to assess long-term rates and risk factors for contralateral inguinal hernia repair following unilateral inguinal hernia repair.

Methods: Using New York Statewide Planning and Research Collaborative (SPARCS) administrative data, 50,220 adult patients who underwent non-recurrent inguinal herniorrhaphy during 2002-2003 in New York State were identified. Of these, 49,956 patients had open unilateral inguinal hernia repair. ICD-9 codes and CPT codes were used to identify patients. Patients were followed for 10-years subsequent to their operation to assess for contralateral repair. "Loss to follow-up" was defined patients without inpatient or outpatient files after 1/1/2007, which was the average timing of contralateral repair. Patient risk factors were assessed and compared using descriptive univariate statistics. Significant variables were then analyzed via multivariable regression models.

Results: For adult patients having primary unilateral herniorrhaphy, 3364 patients (6.73%) had contralateral repair during the follow-up period. After excluding "loss of follow-up" patients, the contralateral repair rate was 10.3%. Contralateral hernia repairs first occurred at a mean of 3.9 +/-3.5 years and a median of 2.5 years after the initial surgery. Risk factors included age>45 years (OR 1.7[1.4-2.0],p<0.001), male gender (OR 2.2 [1.9-2.6],p<0.0001) and white race (OR 1.6 [1.1-2.4],p<0.001). Factors associated with significantly decreased likelihood for repair included: congestive heart failure (OR 0.6 [0.4-0.9], p=0.01), diabetes (OR 0.7 [0.5-0.8],0.02), neurological disorders (OR 0.6 [0.4-0.9],p=0.02), obesity (OR 0.3 [0.1-0.8],p=0.01) and alcohol abuse (OR 0.2 [0.03-0.8],p=0.03). 

Conclusion: The ten-year probability of necessitating a contralateral inguinal hernia repair is significant. This study assessed incidence of hernia repair, not incidence of hernia diagnosis. As such, hernias that were not repaired could not be assessed. Patients more likely to require repair were those who were older, white and male. Those less likely to undergo repair had significant comorbid conditions including heart failure, diabetes, neurological disorders, obesity and alcohol abuse. One interpretation is that the decreased incidence of repair in this population is due to their underlying health status and suitability for operative intervention.  Data depicts the time period prior to adoption of laparoscopy and highlights a key benefit of this approach over open. Based on this data an argument for laparoscopy with routine contralateral inspection in higher risk patients can be made.  

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