The impact of the Covid-19 pandemic on hernia surgery in the University Hospital in the Czech Republic

Hernia is one of the most common elective surgical procedures [1]. In March 2020, the global pandemic COVID-19 spread to Europe. This had a significant effect on health care systems all over the world, including the Czech Republic. In most countries, elective operations were temporarily cancelled or reduced to a minimum [2]. With the speed of onset of the pandemic, the guidance produced by countries and learned societies was an ever-changing affair [2,3]. The European Hernia Society (EHS) published guidance on hernia surgery in May 2020, which provided some clarity as to the management of such patients with an abdominal wall hernia [4]. The aim of this study was to review the hernia surgery workload in a large university teaching hospital department, in Prague, Czech Republic, from the onset of restrictions regarding people movement and hospital clinical activity in 2020 compared to a similar time period from the preceding year.

PATIENTS AND METHODS

A prospectively gathered computerised Hospital database was used to identify all patients undergoing a hernia repair at 3rd Department of Surgery, Motol University Hospital, Prague. Patients were identified by the type of operation performed. Two study periods were compared, March 1 to November 30 in 2020 and 2019. It was the period of the first and second waves of the COVID-19 pandemic.

The number of operations, type of hernia repair and elective or emergency surgery was retrieved from the database.

RESULTS

194 elective hernias were repaired in 2020, compared to 285 in the same time periods in 2019. Tab. 1 shows the elective hernia repair by hernia type for the two study periods. The biggest reduction in hernia workload between 2019 and 2020 was in the incisional hernia repair group, with the inguinal hernia repair numbers showing the smallest reduction. The num bers in the emergency group are small, (Tab. 2) but the effect of COVID-19 was seen to a similar degree across the hernia types.

DISCUSSION

This study identified that at the 3rd Department of Surgery at Motol University Hospital, the effect of the COVID-19 pandemic reduced elective hernia surgery by a third, and emergency hernia surgery by half. Most notable, was the reduction in elective incisional hernia surgery in 2020 to 41 % of the 2019 value. In contrast, inguinal hernia surgery only reduced to 80 %. Incisional hernia surgery is often a bigger operation, with an associated greater surgical physiological insult to the patient. The risk of suffering from COVID-19 around the time of surgery, with its increased risk of death [5,6] is likely to have been one of the greatest reasons for minimising this type of surgery.

While there was a reduction in elective hernia repairs at our surgery department, this does not appear to have been as marked as the decrease observed in Germany [7] and the South East of Scotland. The reasons of this are likely to be multifactorial. The time period of this study also included not only the lockdown period but a period of time where healthcare was able to function before the onset of the second wave of infections. Furthermore, the Czech Republic initiated strong early lockdown measures and patient testing that appeared to minimise the number of the population that were infected in the first wave, which allowed health care services to function without too much interruption. Nevertheless, cancellation of surgery, reduced theatre capacity, and bigger delays in theatre utilisation all had an effect, including the availability of staff to work at the wards and theatres due to COVID exposure and self-isolating rules [2,8].

One of the interesting findings of this study, was the greater reduction in emergency hernia surgery compared with elective surgery. This is a finding that has been observed in other countries as well [7,8]. It would not be unreasonable to assume that as elective hernia surgery decreases, this would reflect an increasing emergency workload. However, it is likely that as the time period of this study is relatively short, the number of expected acute hernia events in this enforced waiting group, will be less than 1 % [4]. It is possible that reduced heavy labour during the lockdown had an effect on the number of incarcerating hernias. Furthermore, it is possible that conservative methods of management were used more often [4] during these times as was suggested in the EHS guidelines [9]. It is however also possible that not all ‘incarcerated’ hernias actually needed an operation as they are not truly incarcerated [4]. It remains to be seen if the changes in hernia surgery activity as a result of COVID-19 will lead to a rise in emergency hernia surgery in the near future. Patients should be thoroughly informed about risks and symptoms of incarceration and also of the reason for postponing their surgery [3].

Forward planning needs to be undertaken seriously to match the increased numbers of patients requiring surgery against the availability of hospital resources as the world eventually emerges from this pandemic. Although this is not the subject of our study, changes to hospital design and patient flow, testing of patients and staff may help minimise the effects of future waves of COVID-19 and other pandemics.

CONCLUSION

The SARS –CoV- 2 pandemic has had a significant impact on both elective and emergency hernia surgery. It remains to be seen if the reduction in hernia activity will result in a greater emergency hernia workload in the near future.

MUDr. Barbora Jisova

3rd Department of Surgery

Motol University Hospital in Prague

e-mail: bara.jisova@seznam.cz

ORCID: 0000-0002-1169-2765