Open mesh repairs in primary inguinal hernia

Clinical and cost-effectiveness of open-mesh repairs in adults presenting with a clinically diagnosed unilateral, primary inguinal hernia who are operated on in an elective setting

Inguinal hernia repair is the most common surgical procedure in the UK, consuming substantial healthcare resources. A variety of surgical techniques and approaches are available, the most common in current practice being tension-free mesh repairs, which can be placed through open surgery (Lichtenstein method or open preperitoneal repair) or laparoscopic (keyhole) surgery. Lichtenstein is the gold standard among open repairs. The project synthesised evidence on the clinical and cost-effectiveness of open preperitoneal mesh repairs in comparison to Lichtenstein repair. Recurrence rates for these procedures are low. Key clinical outcomes were recurrence, chronic pain, complications and quality of life after inguinal hernia repair.

For the assessment of cost-effectiveness evidence, comprehensive literature searches were carried out to identify appropriate trial based or decision model economic evaluations of the relevant comparators. A fully probabilistic de novo Markov cohort economic decision analysis model was developed. Modelled health states included initial surgery, chronic pain, post-operative complications, numbness, recurrence and death. The perspective of the analysis was that of the UK NHS and results of the economic modelling were presented in terms of incremental cost per QALY gained. Comprehensive sensitivity analyses were used to describe the uncertainty in our results.

Outcome and Translation

Open preperitoneal mesh repair was £256 less costly, and improved health outcomes by 0.041 QALYs compared with Lichtenstein mesh repair. The open preperitoneal procedure was the most efficient and dominant treatment strategy with a high (> 98%) probability of being cost-effective for the NHS at a willingness-to-pay of £20,000 for a QALY. Results were robust to a range of sensitivity analyses.

Open preperitoneal mesh repair appears to be a safe and efficacious alternative to Lichtenstein mesh repair, with the potential to save substantial NHS resources. Further research should definitively determine the long-term clinical effectiveness as well as the most efficient type of open preperitoneal repair.

The project provided evidence to NHS decision makers regarding the efficient allocation of scarce funding resources to the surgical management of primary unilateral inguinal hernia repairs. A comprehensive monograph was prepared and presented to the NIHR funders and further academic papers are being drafted.

HERU researchers involved in this research project: Dwayne Boyers and Rodolfo Hernández

External collaborators: M Brazelli, P Sharma, M Cruikshank, C Fraser, L Kemp, C Ramsay (HSRU, University of Aberdeen); N Scott (Population Health, University of Aberdeen); I Ahmed (NHS Grampian); L Vale (Newcastle University)

Publications

Sharma, P., Boyers, D., Scott, N., Hernández, R., Fraser, C., Cruickshank, M., Ahmed, I., Ramsay, C. and Brazelli, M. (2015) ‘The clinical effectiveness and cost-effectiveness of open mesh repairs in adults presenting with a clinically diagnosed primary unilateral inguinal hernia who are operated in an elective setting: systematic review and economic evaluation', Health Technology Assessment, 19(92).

Presentations

Boyers, D., Hernández, R., Sharma, P., Scott, N., Fraser, C., Cruickshank, M., Ahmed, I., Ramsay, C. and Brazzelli, M. (2016) 'Cost-effectiveness of open mesh surgery for primary unilateral inguinal hernia', [poster] NHS Research Scotland Conference, Queen Elizabeth University Hospital Campus, Glasgow, 26 October 2016.

Jacobsen, E. and Boyers, D. (2017) 'Advancing research in hernia repair: a value of information analysis', Health Technology Assessment international (HTAi) Annual Meeting, Rome, Italy, 17-21 June 2017.