Our study showed that quality of life after elective surgery for incisional hernia was significantly better than preoperative status regardless of which surgical technique was used.
We used two generic health questionnaires, SF-36 Short Form Health Survey and EQ-5D. As prior studies showed that a disease-specific questionnaire is more useful than a general questionnaire in the evaluation of the changes in quality of life, we also used two specific hernia-related QoL questionnaires, HRQLes and EuraHS QoL, and one scale that measures the patient satisfaction following hernia repair. To the best of our knowledge, this paper is one of the few in which several QoL questionnaires have been applied [17], especially to compare the quality of life after the application of two different surgical techniques.
When we compare the preoperative and postoperative quality of life using the SF-36 questionnaire, it may be noted that all daily activities were significantly improved after hernia repair, excluding mental health. The role of incisional hernia surgery in improving the quality of life mostly can be observed in the physical subscales of the SF-36 instrument, additionally summarized in the PCS. Although the preoperative physical activity was worse in patients who underwent the CST technique, postoperative improvement in this domain was observed in both groups, without significant differences between them. Only item "mental health" showed a non-significant decrease after the operation. Nevertheless, the overall MCS score showed a significant improvement in postoperative function in both study groups, and our respondents indicated improvement in general health. It seems that physical, social functioning, and emotional aspect had a greater impact on participants´ well-being in both groups, which were observed in other studies [18]. Moreover, we observed an increase in the VAS scale from 41.5 to 72.4 on the scale of a maximum of 100, regardless of applied surgical technique. This score is a widely used health assessment method [29] because it is sensitive and easy to use. The improvement in general health also was revealed by the EQ-5D tool. In the prospective, multicenter, COBRA study, conducted in 9 centers in the USA and the Netherlands [20], it was found the significant improvement in health at 6 months onto 24-months postoperatively compared to preoperative baseline values at EQ-5D index and EQ-5D VAS scale.
HerQLes questionnaire, as an abdominal wall hernia-specific tool, allows patients to score their own physical and emotional status. The main advantage of this questionnaire is the ability to compare the quality of life after incisional hernia repair with different techniques and especially to compare techniques that use prosthetic mash vs. those without mash [15]. In our study, this tool showed that the quality of life 6 months after surgery was significantly better, regardless of which of the two surgical techniques was applied.
In line with previous scores, the EuraHS Qol questionnaire also showed improvement after surgery in the overall score and in all three elemental components of quality of life (pain, restriction of activities, and cosmetic discomfort) in our study, which already had been proved as the most important health assessment after hernia repair [16]. Preoperative pain is considered a risk factor for postoperative chronic pain [5]. In our study, the CST and Rives-Stoppa groups did not differ in the pain domain nor the other EuraHS Qol questionnaire domains before surgery. However, six months after hernia repair, patients who underwent surgery by the Rives-stop technique had a worse pain domain in the EuraHS Qol questionnaire. Although the Rives-Stoppa sublay technique is very popular, with low recurrence rates and minimal complications, the main disadvantage is the possibility of chronic abdominal pain, which explains the poorer values of the pain domain in this group of patients [21]. The specific questionnaire for hernia repair could find the differences in two types of surgery as it was the case regarding pain in the Rivers stopa group, which was not possible with a generic questionnaire.
The CCS is a widely accepted QoL questionnaire that is primarily used to assess QoL after hernia repair and validated in all hernia types undergoing mesh repair [22]. Also, perhaps most importantly, it is well accepted by patients. It is shown that patients prefer the CCS by a 3 to 1 ratio over the SF-36 survey because of its specificity and ease to use [23]. We found that at six months point after hernia repair there was no statistically significant difference in pain and movement score as well as in Carolinas total score between CST and Rives-Stoppa group. However, the mesh sensation score was worse in patients with Rives-Stoppa hernia repair. The sensation score for component separation was at the same level as in a study conducted by Klima et al [24], while Forester et al. Reported a slightly higher sensation score for open incisional hernia repair with mesh than it was revealed in our study [25]. The difference between these two groups in sensation may be due to the difference in the technique of these two types of operations. Namely, the component separation technique is based on subcutaneous lateral dissection, fasciotomy lateral to the rectus abdominis muscle, and dissection on the plane between external and internal oblique muscles with medial advancement of the block that includes the rectus muscle and its fascia [10]. What is essential is that the tissue used to cover the defect remains innervated, which is not the case with the Rives-Stop technique with sublay mesh position where lack of innervated tissue may lead to increased mesh sensation [24].
It is suggested that both uses of generic and hernia-specific QoL questionnaires represent the gold standard [22]. However, we already found that specific hernia-related questionnaires have shown greater sensitivity in detecting differences between patients operated with different techniques.
The limitation of this study was the assessment only 6-month after surgery. Most studies that used different HoL tools revealed an initial drop in the quality of life one month after surgery and an increase in further periods [20]. Second, we did not conduct a total blind study. However, the type of surgery was explained to the patients immediately before the operation. The advantage of this study was the fact that the patients were operated on by two surgeons with similar experiences. This avoids secession bias, ie the operation of less complex patients by a less experienced surgeon. Third, although it was shown in the literature reviews that complete assessment of the quality of life after hernia surgery is best achieved using a general scale with a specific scale and a validated pain scale [26], we did not use a specific pain score. We assessed pain using items in the SF-36 questionnaire, EuraHS QoL questionnaire, and CCS.