Evolution of an inguinal hernia surgery practice.
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BACKGROUND: Inguinal hernia surgery has undergone numerous advances in the last few years. This study analysed the changes in the practice of one surgeon in a district general hospital over a seven year interval. The effect of changing from Bassini to Lichtenstein repair in 1994 was evaluated. METHODS: The study involved two parts: first a search of a computerised database of inguinal hernia procedures, and second, postal audits of men who had an inguinal hernia repair in 1993 and 1994 with outpatient follow up for those with a possible recurrence. RESULTS: A total of 1037 hernias were repaired over the seven years. There was an increase in the proportion of day cases from 18% to 70% and the number of operations performed under local anaesthetic rose from 1% to 45%. The postal audits had response rates of 79% (1993) and 66% (1994). Some 5/98 (5%) recurrent hernias were identified from the 1993 (Bassini) patients compared with 1/67 (1.5%) from the 1994 (Lichtenstein) cohort. CONCLUSION: Lichtenstein hernia repair can be performed safely as a day case using local anaesthetic in the majority of patients and appears to have a lower recurrence rate than Bassini repair. (+info)
Retroperitoneal liposarcoma presenting a indirect inguinal hernia.
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A 60-year-old man was admitted to our hospital with a right inguinal swelling that had been growing in size without any pain for 7 months. We diagnosed the growth as a right inguinal hernia and operated on him. The growth, however, was found to be a tumor it situated along the spermatic cord and testicular vessels. We diagnosed it as a lipoma. The tumor was resected near part of the internal inguinal ring. Histopathological diagnosis showed well-differentiated liposarcoma of the sclerosing type. Postoperative computed tomography (CT) revealed a large residual tumor in the retroperitoneum. We believed that the tumor was a retroperitoneal liposarcoma and that it developed in the inguinal region. The residue of the liposarcoma was resected onto the right inguinal tract. A periodic follow up has been performed and no evidence of recurrence or metastasis has been seen in the 4 years and 9 months since the second surgery. No adjuvant therapy was performed. Inguinal liposarcomas are relatively rare and in most cases these tumors are thought to originate in the spermatic cord. The origin of the tumor is believed to be the retroperitoneum. (+info)
Unexplained groin pain: safety and reliability of herniography for the diagnosis of occult hernias.
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A retrospective study of our initial experience of herniography in a district general hospital is presented. A total of 43 herniograms were performed in 41 patients (median age 57, range 16-77, 27 males, 14 females) over a two year period. Four herniograms were unsuccessful due to failed intraperitoneal contrast injection, of which two were repeated (success rate 90.5%). A total of 25 groin hernias were identified radiologically (two on the asymptomatic side). Twenty one patients underwent surgery and a hernia was confirmed in 19 (true positive rate 90.5%). Sixteen herniograms were considered negative and after a median follow up of 28 months (range 16-42 months), none of these patients have developed a hernia. There were no major complications. It is concluded that herniography is a safe and reliable method of determining or excluding the presence of an occult groin hernia. (+info)
Occult inguinal hernia in the female.
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Inguinal hernioplasty was performed in a series of 14 female patients with occult inguinal hernias over a period of five years. During this time 194 herniorrhaphies were performed and thus the incidence of repair for occult hernia was 8%. These patients represent a definite syndrome which has not been sufficiently documented in the surgical literature. The condition is defined and the anatomic pathology documented photographically. The mean age in this series was 20 years with a range of 15-45 years. Thirteen of the 14 cases were followed a mean of 10 months postoperatively. Ten of these were considered excellent results and were symptom-free. The remaining three cases were judged as good results but objective evaluation was less conclusive. There have been no recurrences. The anatomic basis for this syndrome has been documented by others. The absence of an impulse on clinical examination is explained on the basis of size of the hernias and the difference in the anatomy between males and females. Occult inguinal hernia in the female is clinically recognizable on the basis of intermittency, character, and localization of pain and after the exclusion of other pathologic conditions. This syndrome should be entertained in the differential diagnosis of lower abdominal pain in the female. Hernioplasty is safe and effective therapy and returns the patient to normal activity. (+info)
Statistical assessment of the learning curves of health technologies.
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OBJECTIVES: (1) To describe systematically studies that directly assessed the learning curve effect of health technologies. (2) Systematically to identify 'novel' statistical techniques applied to learning curve data in other fields, such as psychology and manufacturing. (3) To test these statistical techniques in data sets from studies of varying designs to assess health technologies in which learning curve effects are known to exist. METHODS - STUDY SELECTION (HEALTH TECHNOLOGY ASSESSMENT LITERATURE REVIEW): For a study to be included, it had to include a formal analysis of the learning curve of a health technology using a graphical, tabular or statistical technique. METHODS - STUDY SELECTION (NON-HEALTH TECHNOLOGY ASSESSMENT LITERATURE SEARCH): For a study to be included, it had to include a formal assessment of a learning curve using a statistical technique that had not been identified in the previous search. METHODS - DATA SOURCES: Six clinical and 16 non-clinical biomedical databases were searched. A limited amount of handsearching and scanning of reference lists was also undertaken. METHODS - DATA EXTRACTION (HEALTH TECHNOLOGY ASSESSMENT LITERATURE REVIEW): A number of study characteristics were abstracted from the papers such as study design, study size, number of operators and the statistical method used. METHODS - DATA EXTRACTION (NON-HEALTH TECHNOLOGY ASSESSMENT LITERATURE SEARCH): The new statistical techniques identified were categorised into four subgroups of increasing complexity: exploratory data analysis; simple series data analysis; complex data structure analysis, generic techniques. METHODS - TESTING OF STATISTICAL METHODS: Some of the statistical methods identified in the systematic searches for single (simple) operator series data and for multiple (complex) operator series data were illustrated and explored using three data sets. The first was a case series of 190 consecutive laparoscopic fundoplication procedures performed by a single surgeon; the second was a case series of consecutive laparoscopic cholecystectomy procedures performed by ten surgeons; the third was randomised trial data derived from the laparoscopic procedure arm of a multicentre trial of groin hernia repair, supplemented by data from non-randomised operations performed during the trial. RESULTS - HEALTH TECHNOLOGY ASSESSMENT LITERATURE REVIEW: Of 4571 abstracts identified, 272 (6%) were later included in the study after review of the full paper. Some 51% of studies assessed a surgical minimal access technique and 95% were case series. The statistical method used most often (60%) was splitting the data into consecutive parts (such as halves or thirds), with only 14% attempting a more formal statistical analysis. The reporting of the studies was poor, with 31% giving no details of data collection methods. RESULTS - NON-HEALTH TECHNOLOGY ASSESSMENT LITERATURE SEARCH: Of 9431 abstracts assessed, 115 (1%) were deemed appropriate for further investigation and, of these, 18 were included in the study. All of the methods for complex data sets were identified in the non-clinical literature. These were discriminant analysis, two-stage estimation of learning rates, generalised estimating equations, multilevel models, latent curve models, time series models and stochastic parameter models. In addition, eight new shapes of learning curves were identified. RESULTS - TESTING OF STATISTICAL METHODS: No one particular shape of learning curve performed significantly better than another. The performance of 'operation time' as a proxy for learning differed between the three procedures. Multilevel modelling using the laparoscopic cholecystectomy data demonstrated and measured surgeon-specific and confounding effects. The inclusion of non-randomised cases, despite the possible limitations of the method, enhanced the interpretation of learning effects. CONCLUSIONS - HEALTH TECHNOLOGY ASSESSMENT LITERATURE REVIEW: The statistical methods used for assessing learning effects in health technology assessment have been crude and the reporting of studies poor. CONCLUSIONS - NON-HEALTH TECHNOLOGY ASSESSMENT LITERATURE SEARCH: A number of statistical methods for assessing learning effects were identified that had not hitherto been used in health technology assessment. There was a hierarchy of methods for the identification and measurement of learning, and the more sophisticated methods for both have had little if any use in health technology assessment. This demonstrated the value of considering fields outside clinical research when addressing methodological issues in health technology assessment. CONCLUSIONS - TESTING OF STATISTICAL METHODS: It has been demonstrated that the portfolio of techniques identified can enhance investigations of learning curve effects. (ABSTRACT TRUNCATED) (+info)
Laparoscopic hernia repair and bladder injury.
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BACKGROUND: Bladder injury is a complication of laparoscopic surgery with a reported incidence in the general surgery literature of 0.5% and in the gynecology literature of 2%. We describe how to recognize and treat the injury and how to avoid the problem. CASE REPORTS: We report two cases of bladder injury repaired with a General Surgical Interventions (GSI) trocar and a balloon device used for laparoscopic extraperitoneal inguinal hernia repair. One patient had a prior appendectomy; the other had a prior midline incision from a suprapubic prostatectomy. We repaired the bladder injury, and the patients made a good recovery. CONCLUSION: When using the obturator and balloon device, it is important to stay anterior to the preperitoneal space and bladder. Prior lower abdominal surgery can be considered a relative contraindication to extraperitoneal laparoscopic hernia repair. Signs of gas in the Foley bag or hematuria should alert the surgeon to a bladder injury. A one- or two-layer repair of the bladder injury can be performed either laparoscopically or openly and is recommended for a visible injury. Mesh repair of the hernia can be completed provided no evidence exists of urinary tract infection. A Foley catheter is placed until healing occurs. (+info)
Reoperation after recurrent groin hernia repair.
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OBJECTIVE: To analyze reoperation rates for recurrent and primary groin hernia repair documented in the Swedish Hernia Register from 1996 to 1998, and to study variables associated with increased or decreased relative risks for reoperation after recurrent hernia. METHODS: Data were retrieved for all groin hernia repairs prospectively recorded in the Swedish Hernia register from 1996 to 1998. Actuarial analysis adjusted for patients' death was used for calculating the cumulative incidence of reoperation. Relative risk for reoperation was estimated using the Cox proportional hazards model. RESULTS: From 1996 to 1998, 17,985 groin hernia operations were recorded in the Swedish Hernia Register, 15% for recurrent hernia and 85% for primary hernia. At 24 months the risk for having had a reoperation was 4.6% after recurrent hernia repair and 1.7% after primary hernia repair. The relative risk for reoperation was significantly lower for laparoscopic methods and for anterior tension-free repair than for other techniques. Postoperative complications and direct hernia were associated with an increased relative risk for reoperation. Day-case surgery and local infiltration anesthesia were used less frequently for recurrent hernia than for primary hernia. CONCLUSIONS: Recurrent groin hernia still constitutes a significant quantitative problem for the surgical community. This study supports the use of mesh by laparoscopy or anterior tension-free repair for recurrent hernia operations. (+info)
Guidelines for inguinal hernia repair in everyday practice.
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BACKGROUND: The Royal College of Surgeons of England published clinical guidelines for the management of groin hernia in adults in July 1993. We compared our indications, techniques, complications and outcome with these guidelines. PATIENTS AND METHODS: A consecutive series of 440 patients who underwent a groin hernia repair from the 1 July 1994 to 30 July 1995 were studied retrospectively. Special consideration was given to the advantages and acceptance of day-case surgery. Confidential questionnaires were sent to all patients 6-12 months following surgery. RESULTS: The majority of elective primary inguinal hernias (83%) were repaired by the open tension-free Lichtenstein mesh technique. Our selection criteria for day-case surgery included ASA I, age (< 65 years) and social situation; 56% underwent an operation on a day-case basis. Including in-patients discharged within 24 h following operation, this proportion of 'day-cases' increased to 72.5%. Less complications occurred in the day-case group (P = 0.018). However, this difference may be caused by incomplete reporting of complications in the day-case group. There were no significant differences in patients' satisfaction, postoperative attendance for medical advice or time back to work between the day-case and in-patient group. CONCLUSIONS: The guidelines need to be reviewed. The Lichtenstein repair offers an excellent and simple technique for hernia repair as a day-case procedure. Our results suggest that the number of hernia repairs performed as a day-case could substantially be increased to more than the recommended 30%. Time off work is mainly influenced by the advice given by GPs and surgeons. Reducing time off work by giving more appropriate recommendations and increasing the number of day-case surgery cases could significantly reduce the costs of health-care. (+info)