Incidence of tissue-based inguinal hernia repair in Belgium: a web-based national survey

Inguinal hernia repair is one of the most commonly performed procedures worldwide. Several different methods for repair exist, where the preferred surgical procedure for a non-complicated unilateral inguinal hernia is still up for debate. Originally described as a tissue repair, the introduction of prostheses have led many surgeons to move away from this type of repairs. However, recently updated guidelines still recommend non-mesh treatment, in a subgroup of patients, with a preference for the Shouldice technique. Therefore, we set out to map the incidence and knowledge about tissue-based repair of a primary inguinal hernia in Belgium.

We designed a voluntary, open web-based survey for both surgeons and trainees asking about their knowledge, experience and indication for tissue-based suture repair, using a Google-forms document. The survey included level of experience and surgical preference, practice of tissue-based inguinal repair, indications for tissue-based repair, and technique and knowledge about tissue-based repair. Data was collected between 1st of December 2023 and 31st of January 2024 and analyzed using Microsoft Excel (version 16.77.01).

A total of 122 respondents filled out the questionnaire, 47 trainees and 75 surgeons, of which 4 were discarded due to inaccurate data. Only 15 out of 71 surgical respondents still performed a non-mesh based repair in an elective setting, where the Shouldice repair was the preferred technique (n = 12, 80%). Knowledge about tissue-based mesh was rated mainly moderate (43.7%) and a non-mesh based repair was still considered an option when faced with fecal contamination (54.9%). Upon patient's request, 67.7% respondents would convince patients of mesh superiority. Among surgical trainees eighteen respondents (38.3%) had never seen a tissue based repair before and 36.1% respondents said tissue-based repair was not taught in their current or previous hospital(s). Most surgical trainees (48.9%) had basic knowledge and know a single technique. Considering indications for primary tissue repair, 57.4% mentioned a contaminated field as a valid indication. Comparable to the surgeon's response, 66% of surgical trainees would convince the patient of mesh superiority when asked for a pure tissue-based repair.

Our survey confirms the declining rate of tissue based repairs, with only 7% of surgical respondents performing sufficient procedures to allow for equivocal result compared to mesh-based repairs. Centralizing these procedures into specific hernia centers might allow for an increased case-load and dedicated training pathways giving trainees and future surgeons proper training.