ORIGINAL ARTICLE

Morten Bay-Nielsen Æ Henrik Kehlet

Inguinal herniorrhaphy in women

Received: 3 May 2005 / Accepted: 25 June 2005 / Published online: 25 August 2005� Springer-Verlag 2005

Abstract Inguinal hernias in women are relatively rare,and an outcome in this specific subgroup of hernias hasnot been documented in the literature. An analysis wasperformed using data from the prospective recording of3,696 female inguinal hernia repairs in the nationalDanish hernia database, in the 5.5 year period fromJanuary 1, 1998 to June 30, 2003, where observation timespecific reoperation rates were used as a proxy forrecurrence. In the 3,696 female inguinal herniorrhaphiesrecorded, the overall reoperation rate was 4.3%, which isslightly higher compared to male inguinal herniorrha-phies (3.1%) (P=0.001). The reoperation rate was inde-pendent of the type of surgical repair. In 41.5% of thereoperations a femoral hernia was found, compared to5.4% in males. Female inguinal herniorrhaphy is fol-lowed by a higher reoperation rate than in males, and isunrelated to the type of repair. The frequent finding of afemoral hernia at reoperation suggests the need for theexploration of the femoral canal at the primary operation.

Keywords Hernia Æ Inguinal Æ Femoral Æ Female ÆSurgery Æ Registries

Introduction

Groin hernias in females are relatively rare and mostpublished studies and all randomized trials describe

either exclusively or primarily the treatment of maleinguinal hernias. Consequently, there is only little or nopublished evidence on the choice of treatment of femaleinguinal hernias since outcomes of female inguinal her-niorrhaphy have not been documented. The differencesin the anatomy and structure of the inguinal regionmake the extrapolation of results from male or mixedsex studies to the treatment of female inguinal herniasquestionable.

The establishment of prospective registration oftreatment/outcome in national or regional databaseswith the inclusion of a large number of patients enablesthe description of comparatively rare entities, such asfemale inguinal hernia. The aim of this study hastherefore been to evaluate recurrence rates after inguinalherniorrhaphy in women, based upon the nation-widedata collection in the Danish hernia database fromJanuary 1, 1998 to June 30, 2003, including 59,792herniorrhaphies.

Methods

The establishment and function of the Danish herniadatabase has been reported elsewhere [1, 2]. In brief,the database is a prospective registration of more than98% of the inguinal and femoral herniorrhaphies per-formed in Denmark and is based on a scheme com-pleted by the surgeon after the operation and validatedagainst national registries on surgical procedures, withpatients identified by unique social security numbers.From the database all inguinal (non-femoral) herni-orrhaphies in women from the period January 1, 1998to June 30, 2003 (5.5 years) were extracted andanalyzed.

Reoperation rates for the type of operation andgender were calculated as Kaplan–Meier estimates(compensating for changes in the pattern of operativeprocedures performed) and compared using the log-ranktest, while frequencies and reoperation rates for agegroups were compared with the chi square-test. P<0.05was considered significant.

M. Bay-Nielsen (&)Department of Surgery, KAS Glostrup,Glostrup 2600, DenmarkE-mail: herniedatabasen@hh.hosp.dkTel.: +45-3632-3404Fax: +45-3632-3722

H. KehletSection of Surgical Pathophysiology,The Juliane Marie Centre, 4074, Rigshospitalet,Copenhagen 2100, Denmark

M. Bay-Nielsen Æ H. KehletDanish Hernia Database,Department of Surgical Gastroenterology,Hvidovre University Hospital,Hvidovre 2650, Denmark

Hernia (2006) 10: 30–33DOI 10.1007/s10029-005-0029-3

Results

In the 5.5-year period from January 1, 1998 to June 30,2003, 5,343 herniorrhaphies were performed for groinhernia (inguinal and femoral) in females (Fig. 1). Ofthese, 3,696 (69%) were for inguinal (not femoral) her-nia while 31% was for femoral or combined femoral/inguinal groin hernia. In the same period, 50,517inguinal herniorrhaphies were performed in males. Themedian age at the time of female inguinal herniorrhaphywas 60 years, compared to 57 years for all male inguinal

herniorrhaphies in the database. Emergency surgery foringuinal hernia was recorded more frequently in females(6.7%) compared to males (2.7%) (P=0.001).

The use of operative procedures changed in theobservation period, with a marked increase in the use ofLichtenstein repair from initially about 30% to nearly70% in 2003 (overall 50.8%). Conversely, there was lessuse of non-Lichtenstein mesh repairs (overall 11.9%)and open anterior (non mesh) repairs (overall 34.2%),while 3.1% was performed as a laparoscopic repair(Table 1 and Fig. 2).

n=59,792herniorraphies in database

n=5,343females

n=3,696inguinal (non-femoral) herniorraphy

n=159re-operation

n=54,499males

n=1,647femoral orcombined

n=3,537no reop.

n=50,517

inguinal(non-femoral)herniorraphy

n=1,584re-operation

n=59,792herniorraphies in database

n=5,343females

n=3,696inguinal (non-femoral) herniorraphy

n=159re-operation

n=54,499males

n=1,647femoral orcombined

n=3,537no reop.

n=50,517

inguinal(non-femoral)herniorraphy

n=1,584re-operation

Fig. 1 Number and types ofherniorrhaphies in database.Danish hernia database,January 1998–June 2003

Table 1 Patient management,type of anesthesia, age,operative technique andfindings at reoperation(percentages). n=54,213inguinal herniorrhaphies,Danish hernia database,January 1998–June 2003

Females Males

Number of operations 3,696 50,517Type of patients

Day cases 2,013 (54.5%) 31,138 (61.6%) P<0.0001Hospitalized 1,437 (38.9%) 18,025 (35.7%) P<0.0001Median/mean length of stay,hospitalized patients

2/2.4 days 2/2.6 days P<0.0001

Emergency surgery 246 (6.7%) 1,354 (2.7%) P<0.0001

Type of anesthesiaGeneral anesthesia 2,462 (66.6%) 32,996 (65.3%) P=0.1099Regional anesthesia 590 (16.0%) 8,961 (17.7%) P=0.0062Local infiltration anesthesia 644 (17.4%) 8,560 (16.9%) P=0.4536

AgeMedian 60 years 57 years P<0.0001Interquartile range 44–76 years 46–69

Operative techniqueLaparoscopic 113 (3.1%) 2,806 (5.6%) P<0.0001Lichtenstein 1,879 (50.8%) 31,250 (61.9%) P<0.0001Conventional open non-mesh repair 1,189 (32.2%) 8,088 (16.0%) P<0.0001Other anterior mesh repair 515 (13.9%) 8,373 (16.6%) P<0.0001

Reoperations 159 (4.3%) 1,584 (3.14%) P=0.0001Findings of reoperation

Inguinal hernia 86 (54.1%) 1,400 (88.4%) P<0.0001Femoral hernia 66 (41.5%) 86 (5.4%) P<0.0001Other/unspecified 7 (4.4%) 98 (6.2%) P=0.3675

Median time to reoperation (n=159)Inguinal hernia 12.6 months 14.1 months P=0.0147Femoral hernia 10.3 months 7.5 months P=0.1234Other/unspecified 8.4 months 14.8 months P=0.1673

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The overall reoperation rate was 4.3% (n=159), witha median observation time of 29 months. Kaplan–Meierestimates of reoperation rates in the four groups ofoperative techniques [Lichtenstein mesh repair, otheropen mesh repairs, conventional (non mesh) openrepairs and laparoscopic repair] showed no significantdifferences (Fig. 3). The overall reoperation rates in thefour groups of operative techniques are shown inTable 2. Kaplan–Meier estimates of the reoperation ratein females were slightly higher than the reoperation ratein males (Fig. 4) (P=0.001). The operative findings andmedian time to reoperation in the 159 operations for a

recurrent hernia are shown in Table 1. A femoral herniawas found at reoperation in 41.5%, compared with only5.4% in males.

There was no difference in the reoperation rate,comparing women older than 50 years of age (4.0%)with women below 50 years of age (4.9%) (P= 0.195).

Discussion

Female inguinal herniorrhaphy has not been studied inany detail previously in the literature, probably because

0%

20%

40%

60%

80%

Laparoscopicrepair

Lichtenstein

Other anteriormesh repair

Conventionalopen repair

1998 1999 2000 2001 2002 2003

0%

20%

40%

60%

80%

Laparoscopicrepair

Lichtenstein

Other anteriormesh repair

Conventionalopen repair

1998 1999 2000 2001 2002 2003

Fig. 2 Changes in use ofoperative techniques. n=3,696inguinal herniorrhaphies infemales, Danish herniadatabase, January 1998–June2003

Laparoscopic

Lichtenstein

Other anterior mesh repairConventional open repair

Rate of reoperation

0%

2%

4%

6%

8%

10%

Months

0 6 12 18 24 30 36 42 48 54 60 66

Laparoscopic

Lichtenstein

Other anterior mesh repairConventional open repair

Rate of reoperation

0%

2%

4%

6%

8%

10%

Months

0 6 12 18 24 30 36 42 48 54 60 66

Fig. 3 Kaplan–Meier estimatesof reoperation rates and type ofrepair. n=3,696 inguinalherniorrhaphies in females,Danish hernia database,January 1998–June 2003

Table 2 Overall reoperationrates and type of repair.n=3,696 inguinalherniorrhaphies in females,Danish hernia database,January 1998–June 2003

Number ofoperations

Number ofreoperations

Reoperationrate (95% CI)

Laparoscopic repair 113 2 1.8% (0–6.4)Lichtenstein 1,879 82 4.4% (3.5–5.4)Open anterior mesh repair 515 22 4.3% (2.7–6.4)Conventional open non-mesh repair 1,189 53 4.5% (3.4–5.8)

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it has not been considered a clinical problem due to themore simple anatomy compared with males. Also,female herniorrhaphy only contributes to about 8% ofall groin hernia repairs (8.9% in the Danish herniadatabase). The main findings of our study, which is thelargest available, is a slightly higher and earlier reoper-ation rate in females compared with males (Fig. 4).Furthermore, the higher reoperation rate could not berelated to a particular technique of hernia repair, and thepreviously demonstrated better results after open meshrepairs, compared to open non-mesh repairs in studiespredominantly in males [2, 3], could not be found.Consequently, routine use of open mesh methods in fe-males cannot be recommended, due to economic con-siderations and the small risk of mesh-relatedcomplications.

Randomized trials to study the outcome after differ-ent techniques of female herniorrhaphy are probablyimpossible to carry out, due to the relatively low inci-dence, arguing for information from the present largepopulation studies.

The high frequency of femoral hernias found at re-operation may be explained by either the overlooking ofa femoral hernia at the primary operation or by an in-creased risk to develop a de novo femoral hernia as aresult of the primary herniorrhaphy.

The time course of the reoperations shows a tendencyto earlier reoperation in female inguinal herniorrhaphy,compared to male herniorrhaphy (Fig. 4), which sug-gests that some of the reoperations were due to over-looked femoral hernias, already existing at the time ofthe primary herniorrhaphy. In a previous study of the

risk of a femoral recurrence after inguinal herniorrhaphy[4], the much lower rates of reoperations for a femoralrecurrence in a mixed sex population did not lead torecommendations of routine exploration for a femoralhernia when performing an inguinal herniorrhaphy.However, the almost tenfold higher risk of overlookingor inducing a femoral hernia in females as suggested inthe present study may call for routine exploration for afemoral hernia.

In conclusion, female inguinal herniorrhaphy is fol-lowed by a higher reoperation rate than in males, and isunrelated to the type of repair. The frequent finding of afemoral hernia at reoperation suggests the need forexploration of the femoral canal at the primary operation.

Acknowledgements The study was supported by grants from: HSHospital Corporation, The Danish Research Council (22-01-0160),Center for Technology Assessment and Medical Evaluation at theDanish Health Board and Helsefonden.

References

1. Bay-Nielsen M, Kehlet H (1999) Steering committee of thedanish hernia data base. Establishment of a national Danishhernia data base: preliminary report. Hernia 3:81–83

2. Bay-Nielsen M, Kehlet H, Strand L, Malmstrom J, AndersenFH, Wara P, Juul P, Callesen T (2001) Quality assessment of26,304 herniorrhaphies in Denmark: a prospective nationwidestudy. Lancet 358:1124–1128

3. EU Hernia Trialists Collaboration (2000) Mesh compared withnon-mesh methods of open groin hernia repair: systematic re-view of randomized controlled trials. Br J Surg 87:854–859

4. Mikkelsen T, Bay-Nielsen M, Kehlet H (2002) Risk of femoralhernia after inguinal herniorrhaphy. Br J Surg 89:486–488

Rate of reoperation

0%

1%

2%

3%

4%

5%

6%

7%

Months

0 6 12 18 24 30 36 42 48 54 60 66

Femalesn=3,696

Malesn=50,517

p=0.0001

Rate of reoperation

0%

1%

2%

3%

4%

5%

6%

7%

Months

0 6 12 18 24 30 36 42 48 54 60 66

Femalesn=3,696

Malesn=50,517

p=0.0001

Fig. 4 Kaplan–Meier estimatesof reoperation rates after maleand female inguinalherniorrhaphy. n=54,213inguinal herniorrhaphies,Danish hernia database,January 1998–June 2003

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