Leistenhernienreparation – Wo wird wie operiert?^[*]

Zusammenfassung

Hintergrund: In den Guidelines der European Hernia Society (EHS) gibt es klare Stellungnahmen, wo und wie der Leistenbruch operiert werden soll. Für ASA-I- und -II-Patienten lautet die Empfehlung, die Operation ambulant durchzuführen. Über 30-jährige männliche Patienten sollten möglichst immer mit Netzverfahren versorgt werden. Sind die Empfehlungen im klinischen Alltag angekommen und sind diese Vorgaben der Guidelines alleiniger Schlüssel zum Erfolg? Anhand der Daten zweier Register, der Daten der Einzelpraxis des Erstautors und einer Literaturanalyse soll dies analysiert werden. Material und Methode: Es erfolgt die Auswertung der prospektiv erhobenen Daten zweier deutscher Register und einer auf die Hernienchirurgie spezialisierten Einzelpraxis. Die Ergebnisse werden durch eine Literaturanalyse ergänzt. Ergebnisse: Hinsichtlich der ambulanten Operationen unterscheiden sich die 3 Gruppen wie folgt: Herniamed-Register 22,3 %, QS-Leistenhernie-Register 62,7 % und in der Einzelpraxis 80,5 % ambulante Operationen. Der Anteil ASA-I- und -II-Patienten unterschied sich in den 3 Gruppen nur marginal (Herniamed 83,4 %, QS-Leistenhernie 89,5 % und Einzelpraxis 88,3 %). Die Rezidivraten betrugen nach 12 Monaten in QS-Leistenhernie 0,6 % und in der Einzelpraxis 0,7 %. In der Einzelpraxis wurden in 30 % Nahtverfahren angewandt. Schlussfolgerung: Ein hoher Anteil ambulanter Operationen ist bei ASA-I- und -II-Patienten ohne Qualitätsverlust machbar. Das nationale Register Herniamed zeigt einen im internationalen Vergleich deutlich niedrigeren Anteil ambulanter Operationen und einen überproportional höheren Anteil endoskopischer Verfahren. Hinsichtlich der Vergütungssituation sind im internationalen Vergleich ambulante Operationen in Deutschland deutlich schlechter gestellt. Ein weiterer Fakt ist, dass Deutschland über ca. ein Drittel mehr Krankenhausbetten verfügt als der Durchschnitt der OECD-Staaten.

Abstract

Background: Within the Guidelines of the European Hernia Society (EHS), there are disctinct statements about where and how inguinal hernia has to be surgically approached. In ASA-I and -II patients, it is recommended to perform the operation in an outpatient clinic setting. Male patients older than 30 years of age should undergo preferably surgical intervention using a mesh. In this context, there are two basic questions: “Are these recommendations already implemented in daily surgical practice (?)” and “Are these guidelines the road to success (?)”, which are to be commented based on i) data from two registries, ii) data obtained in the surgical practice of the first author and iii) a selective literature search. Material and Methods: An analysis was made of prospectively obtained data from two German registries (Herniamed registry [H-med]; Quality Assurance Inguinal Hernia Registry [QIHR]) and a consecutive and representative patient cohort of a single surgical practice [Surg-Pract] specialised in hernia surgery. Main results and concluding remarks are discussed in light of data reported in the literature. Results: Proportions of hernia repair in an outpatient clinic setting were substantially different among the 3 groups (as follows): H-med (22.3 %), QIHR (62.7 %), Surg-Pract (80.5 %) whereas the percentages of ASA-I and -II patients differed only slightly: H-med (83.4 %), QIHR (89.5 %) and Surg-Pract (88.3 %). Recurrency rates after 12 months were 0.6 % (QIHR) and 0.7 % (Surg-Pract), respectively. In Surg-Pract, for 30 % of hernia repairs, “only” suturing for reconstruction was used. Conclusion: In ASA-I and -II patients, a substantial proportion of individuals can be surgically treated in an outpatient clinic setting with no disadvantages regarding high surgical quality and favourable outcome. Data from the national H-med indicated a much lower percentage of such patients than internationally reported and, in addition, a disproportionately high rate of endoscopic procedures. Moreover, reimbursement for hernia repair in an outpatient clinic setting is much worse in Germany compared with international standards, and, interestingly, there is by a factor of 1/3 an above average number of hospital beds in Germany compared with the OECD countries.

Schlüsselwörter

Leistenbruch - ambulante Chirurgie - Operationstechnik - Ökonomie - „Tailored approach“

Key words

inguinal hernia - surgery in an outpatient clinic setting - surgical technique - economy - tailored approach

^* Prof. Dr. Dr. H. Lippert gewidmet

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