A qualitative study of groin hernia management in adolescents

Choosing a management strategy for groin hernias in adolescents can be challenging. Physical growth varies considerably between adolescents, and they can grow rapidly in a short amount of time. Well-established and regularly updated international guidelines on groin hernia management are available for adults [1]; but for adolescents, no international consensus or guidelines exist. Compared with young children and adults, groin hernia repairs in adolescents are rare [2, 3]. Today, in most modern surgical settings worldwide, children under ten years are operated with a non-mesh approach [4, 5] and adults aged 18 years or more with a mesh approach [1]. Meanwhile, uncertainty remains as to how patients aged 10-17 years should be managed. A watchful waiting strategy may safely be used for asymptomatic inguinal hernias in adults [6] but not in young children [7], and most surgeons would repair asymptomatic inguinal hernias in adolescents within a few months [8].

In an area with sparse pre-existing evidence and to guide future research, individual interviews may provide an intuitive approach to obtaining an in-depth understanding and uncover the current practice and considerations of surgeons with experience in groin hernia repair in adolescents. Therefore, the aim of this study was to explore surgeons’ considerations on the management of groin hernias in adolescents aged 10-17 years.

METHODS

This was a qualitative study exploring participants’ experiences with and considerations of the management of groin hernias in adolescents. The study was reported according to the Consolidated Criteria for Reporting Qualitative Research guideline [9]. Approval for this study was granted by the Danish Data Protection Agency (P-2022-861). Approval from the local ethics committee was not required under Danish law [10]. Participants provided informed consent and the study was conducted in compliance with the Declaration of Helsinki [11].

Participants were surgical specialists from public and private hospitals across Denmark with experience in groin hernia surgery in adolescents aged 10-17 years. Purposive sampling was used to select participants [12]. A list of eligible surgeons was drawn up in collaboration with board members of the Danish Hernia Database. Eligible participants were contacted directly by email, and interviewed participants recommended other eligible surgeons who were then approached for participation (snowball sampling). Sample size was determined by conducting interviews until achieving code saturation. A semi-structured, open-ended interview guide [13] was developed by the first author and critically revised by the author group until a consensus was reached. All interviews were conducted one-to-one by phone by the first author (a male, medical doctor and PhD student of the subject), whom none of the participants knew beforehand. One interview was held with each participant in a setting of their choice (work, home or while commuting). The interview guide was pilot tested on an experienced hernia surgeon. Recordings were taped and transcribed verbatim. Data were analysed using content analysis [14]. Both manifest and latent content was analysed [15]. Data were analysed in a cyclic process, repeatedly returning to the data during the process of analysis. Full quotes from transcripts were condensed into short sentences containing only the essential content of the text. These short sentences were further condensed into codes, labelling the quote. Codes were then sorted into categories and categorised data were interpreted for their essential meaning. The interpretation of what these data meant was then formulated into themes. Data were analysed by the first author. The analyses were rigorously and critically revised by the second author and discussed until a consensus had been reached.

Trial registration: not relevant.

RESULTS

In total, 35 surgical specialists were approached for potential inclusion in this study. Among these, 25 (71%) responded. Nine reported that they had no experience in operating adolescents, and none refused to participate. The remaining 16 surgeons were all included, see Table 1 for their characteristics. Among these, 69% had operated 20 or fewer groin hernias in adolescents. The median duration of the interviews was 26 minutes (range: 15-51 minutes). Analysis produced four themes: 1) mesh-related concerns, 2) watchful waiting, 3) growth and 4) lack of evidence and guidelines.

Mesh-related concerns

The decision on whether to use a mesh or a non-mesh approach was often described as challenging by the surgeons. All surgeons performed open repairs in adolescents with non-mesh techniques, whereas a laparoscopic approach was used for all mesh repairs. Placing a mesh in the groin of adolescents who were not fully grown worried surgeons due to the lack of adaptability of the mesh to the surrounding growing tissue (Table 2, surgeon (S)11). The fear of postoperative chronic pain was often the main reason for reluctance to use mesh. Also, despite using mesh, some were concerned about the risk of recurrence due to mesh displacement. The suspected aetiology of chronic pain was often mechanical (Table 2, S16), with one surgeon mentioning the lack of evidence behind that reasoning (Table 2, S8). Consequently, most surgeons would never use a mesh in adolescents who were not fully grown (Table 2, S7). Also, even though adolescents were regarded as fully grown, some chose a non-mesh approach for fear of mesh-related complications (Table 2, S2).

Watchful waiting

Some surgeons described that they would apply a watchful waiting strategy in selected adolescents with asymptomatic hernias. In contrast, others argued for early repair. Arguments among surgeons in favour of watchful waiting varied. Some surgeons were worried about the risk of recurrence after non-mesh repairs and, therefore, postponed surgery to perform a mesh repair when adolescents were fully grown (Table 2, S15). Others argued for a conservative strategy due to the stress associated with going through surgery at a young age (Table 2, S11). Also, several surgeons applied a conservative strategy when either parents or parents and patients were unable to agree if the hernia should be repaired (Table 2, S6). Among those arguing for early repair, one surgeon distinguished between young and old adolescents and believed that young adolescents should have their hernia repaired without delay due to the risk of incarceration (Table 2, S3). Another surgeon also argued for early repair as the surgeon had experienced that the risk of recurrence and chronic pain was low in adolescents (Table 2, S4).

Growth

For most surgeons, the stage of physical growth was the decisive factor when determining the preferred management strategy. Various methods for assessing growth were described. Generally, the expected height of the adolescent – often relative to the height of the parents – was the most frequently mentioned method to estimate growth (Table 2, S3, S4, S5 and S8). Surgeons would simply look at the height of the patient and parents while also asking questions about recent growth of the adolescent. Growth was a more important parameter than chronological age (Table 2, S8). No standardised tools were described for estimating growth, though some sought help from information via search engines on the internet (Table 2, S3). In girls, some also used the combination of age and debut of menstruation as an indication of the stage of growth (Table 2, S5). In one case, a surgeon described using both height and smoking status to determine the treatment approach (Table 2, S4). Another surgeon described evaluating the testis, growth of pubic hairs and groin anatomy (Table 2, S14).

Lack of evidence and guidelines

The lack of evidence and guidelines on this topic was frequently highlighted as an issue. One surgeon was used to follow guidelines strictly and described the challenge of not having available literature to support decision-making in adolescents (Table 2, S15). Surgeons also often showed an interest in the results of the interviews conducted for the present study, as they were curious about how other surgeons managed groin hernias in adolescents (Table 2, S10). Furthermore, one surgeon was curious if the surgeons’ answers were similar to other surgeons’ answers (Table 2, S14). Surgeons frequently mentioned that it was a problem that children and adolescents are not registered in the Danish Hernia Database as this would potentially provide valuable knowledge about these patients (Table 2, S5). One surgeon highlighted that the Danish Hernia Database could uncover specific outcomes in adolescents, such as recurrence, if they develop contralateral groin hernias and if they have chronic issues related to the operated groin later in life (Table 2, S3).

DISCUSSION

Four themes related to the management of groin hernias in adolescents were identified in this qualitative study. First, a general concern was recorded about long-term mesh-related complications and, hence, a reluctance to use mesh in growing adolescents. Second, some adopted a watchful waiting strategy as a bridge to perform mesh repair, while others argued for early repair. Third, physical growth was most frequently used when deciding on a management strategy, especially height, but the methods for assessing growth varied considerably and were not standardised. Fourth, surgeons highlighted the need for evidence and guidelines to assist them in their decision-making.

This study found that surgeons were challenged when presented with groin hernias in adolescents. Most surgeons would treat fully grown adolescents with a laparoscopic mesh repair to lower the risk of recurrence, whereas an open sutured repair was used in growing adolescents primarily due to concerns about chronic pain, but also because of concerns for recurrence due to mesh displacement. Concerns about chronic pain in young adults were also raised after a binational survey conducted in 2000 [16]. However, a recent network meta-analysis found no difference in chronic pain between non-mesh and mesh repairs in adults [17]. With respect to recurrence, a study based on prospectively collected data in the Danish Hernia Database suggested low reoperation rates after sutured repairs in young males [18], and use of non-mesh techniques for small hernias in young males has been suggested [1]. Concerns about a potentially increased risk of chronic pain after mesh repairs and indications of a low risk of recurrence after non-mesh repairs in young adult patients may indicate that a non-mesh approach is the most appropriate approach in selected adolescents regardless of their growth status. When feasible, many surgeons in this study also preferred a watchful waiting strategy to delay surgery until the completion of physical growth was certain, thereby enabling a mesh repair. A consideration not covered in this study or the existing literature is the patients’ perspectives and viewpoints, which may be important when determining a management strategy.

Estimating the stage of physical growth, especially growth spurts, during pubertal development was decisive for surgeons when deciding on a management strategy. Height was used by most surgeons, but methods varied considerably and no surgeons used recognised, standardised methods. Though still discussed, well-established methods to evaluate growth like growth curves and hand radiographs exist [19]. To our knowledge, no such methods have been implemented in groin hernia surgery, but it is evident that surgeons may potentially benefit from guidance in this area as they are already relying on various non-standardised estimates of physical growth in their decision-making.

This study has several strengths. The qualitative study approach produced an in-depth understanding of a sparsely studied topic told by those dealing with it first-hand. A pilot interview was performed to test the interview guide, and dedicated hernia specialists from both public and private hospitals nationwide were interviewed. Limitations include that interviews were conducted by phone, hence prohibiting the observation of body language and facial expressions. Furthermore, surgeons included in this study had performed a limited self-reported number of groin hernia repairs in adolescents, and detailed data on the surgeons’ preferred operative approach were not collected. Lastly, the findings in this study reflect the considerations of a relatively small number of surgeons and may not be applicable to other surgeons. However, this is a limitation of interview studies in general.

Surgeons frequently emphasised the lack of guidelines, and this study uncovered a lack of consensus and uniformity among surgeons on the management of adolescents. A survey found that general and paediatric surgeons differed significantly in their surgical approach to adolescents [20]. This further highlights the need for increased research efforts and ultimately evidence-based guidelines to assist surgeons, which is challenging based on current data. The Danish Hernia Database only includes patients aged 18 years and above, whereas the Swedish Hernia Register includes patients aged 15 years and above. Databases like these provide unique and valuable prospectively collected data, and registering children and adolescents in these databases would greatly increase our knowledge of the management of groin hernias in these patients. Considering the low occurrence of groin hernias in adolescents [2, 3], it may possibly be favourable to manage these patients in dedicated hernia centres to ensure a consistent and standardised treatment.

CONCLUSIONS

This qualitative study found a lack of consensus and uniformity between surgeons on the management of groin hernias in adolescents. Surgeons had concerns about the use of mesh, differing opinions on watchful waiting and used a variety of non-standardised methods for evaluating physical growth. Lastly, this study found a desire among surgeons for further research on the topic, ultimately producing guidelines to assist them in their decision-making.