Guidance on Assessing Recurrence After Hernia Repair

Assessing recurrence after abdominal wall hernia repair (including ventral and inguinal hernia) continues to be a challenging task.  This involves a complex interaction between a patient’s symptoms, clinical examination, and radiographic studies such as computed tomography, ultrasound, and magnetic resonance imaging.  Despite these obstacles, short and long-term hernia recurrence remains an important quality metric and practical outcome that can impact patients’ quality of life and health status.

The ACHQC has committed extensive resources to determine the optimal methods of assessing recurrence after hernia repair since the Collaborative was founded.  Additionally, the ACHQC has worked closely with patients, surgeons, hospitals, regulatory agencies, and device manufacturers to identify practical and effective ways for assessing recurrence.  

The ACHQC recognizes that different types of recurrence assessments are needed for different purposes and that these assessments may produce varying results.  The underlying data utilized to assess recurrence may include the medical record, registries, patient reported outcomes, and administrative databases.  These sources may be considered in a stand-alone fashion or combined (e.g., integration of clinical registries with administrative data). To clarify these complexities, the ACHQC has adopted this guidance for assessing recurrence after hernia repair.  

Defining recurrence – A recurrence after hernia repair is defined as a new hernia detected within 7cm of the original repair.

Defining long and short-term recurrence – Long-term hernia recurrence is defined as a hernia detected one year or greater after the date of repair.  Any recurrence less than one year after repair is defined as short-term recurrence.

Defining reoperation for recurrence – A reoperation for recurrence is defined as an operative procedure performed with the specific goal of repairing a recurrent hernia.

Defining pragmatic recurrence – Pragmatic recurrence is defined as recurrence based on any or all elements of patient-reported, clinical or radiographic recurrence.  If a combination of modalities are available, the algorithm published by Krpata et al utilizing a consensus definition of recurrence is utilized.

Recommended method for reporting hernia recurrence for regulatory purposes – The recommended method for reporting recurrence for regulatory purposes (e.g. post-market surveillance, expanded indications) is reoperation for recurrence.  

Recommended method for reporting hernia recurrence for non-regulatory purposes including clinical, research, and quality improvement – The recommended method for reporting recurrence for non-regulatory purposes including clinical, research, quality improvement, is pragmatic recurrence[HS1] [PB2] .  

As the intent of this document is to provide guidance, and not definitive statements, it is recognized that this is an evolving field with a maturing body of evidence.  Although recommendations have been made for specific scenarios (e.g. regulatory versus non-regulatory purposes), it is also recognized that any of these methods for reporting hernia recurrence can be used in a variety of circumstances.  The goal is to provide a meaningful assessment of recurrence while balancing the practicalities of obtaining the assessment data.

 

References:

1.         Poulose BK, Shelton J, Phillips S, et al. Epidemiology and cost of ventral hernia repair: making the case for hernia research. Hernia. 2012;16(2):179-183. doi:10.1007/s10029-011-0879-9

2.         Luijendijk RW, Hop WCJ, van den Tol MP, et al. A Comparison of Suture Repair with Mesh Repair for Incisional Hernia. N Engl J Med. 2000;343(6):392-398. doi:10.1056/NEJM200008103430603

3.         Baucom RB, Ousley J, Feurer ID, et al. Patient reported outcomes after incisional hernia repair—establishing the ventral hernia recurrence inventory. The American Journal of Surgery. 2016;212(1):81-88. doi:10.1016/j.amjsurg.2015.06.007

4.         Tastaldi L, Barros PHF, Krpata DM, et al. Hernia recurrence inventory: inguinal hernia recurrence can be accurately assessed using patient-reported outcomes. Hernia. Published online July 29, 2019. doi:10.1007/s10029-019-02000-z

5.         Krpata DM, Petro CC, Prabhu AS, et al. Effect of Hernia Mesh Weights on Postoperative Patient-Related and Clinical Outcomes After Open Ventral Hernia Repair. JAMA Surg. 2021;156(12):1-8. doi:10.1001/jamasurg.2021.4309