A prospective study of 1000 hernias: results of the Plymouth Hernia Service.
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BACKGROUND: A hernia service within a general hospital was prospectively evaluated to establish whether evidence-based protocols could deliver results comparable to those reported from specialist hernia clinics. METHODS: Protocols were devised according to established models. With the support of a nurse specialist, 1015 patients with inguinal hernia were treated. Quality-of-life analysis was undertaken using the Short Form 36. RESULTS: Patients ranged in age from 16-98 years (median, 56 years). Ambulatory day-case surgery was achieved in 820 patients (81%), with local anaesthesia in 891 (88%). Wound infection occurred in 10 patients (0.98%). Wound haematoma requiring surgical intervention occurred in three patients. Two patients formed wound seromas that settled spontaneously. One patient developed ischaemic orchitis resulting in testicular atrophy. At 5 days after operation, 91% of patients had returned to normal activity. At 1 year, 7 patients (0.7%) had pain sufficient to limit normal activity or employment. There were 8 recurrences (0.78%) at a median follow-up of 2.5 years. Quality-of-life was enhanced at 1 year postoperatively. CONCLUSION: A protocol-driven hernia service within a general hospital can provide patient outcomes comparable to specialist hernia clinics. (+info)
Quantitative analysis of collagen and elastic fibers in the transversalis fascia in direct and indirect inguinal hernia.
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PURPOSE: Our previous studies demonstrated structural and quantitative age-related changes of the elastic fibers in transversalis fascia, which may play a role in inguinal hernia formation. To verify whether there were differences in the extracellular matrix between direct and indirect inguinal hernia, we studied the amount of collagen and elastic fibers in the transversalis fascia of 36 male patients with indirect inguinal hernia and 21 with direct inguinal hernia. MATERIAL AND METHODS: Transversalis fascia fragments were obtained during surgical intervention and underwent histological quantitative analysis of collagen by colorimetry and analysis of elastic fibers by histomorphometry. RESULTS: We demonstrated significantly lower amounts of collagen and higher amounts of elastic fibers in transversalis fascia from patients with direct inguinal hernia compared to indirect inguinal hernia patients. The transversalis fascia from direct inguinal hernia patients showed structural changes of the mature and elaunin elastic fibers, which are responsible for elasticity, and lower density of oxytalan elastic fibers, which are responsible for resistance. These changes promoted loss of resiliency of the transversalis fascia. CONCLUSION: These results improve our understanding of the participation of the extracellular matrix in the genesis of direct inguinal hernia, suggesting a relationship with genetic defects of the elastic fiber and collagen synthesis. (+info)
The effects of the critical pathway for inguinal hernia repair.
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This study was conducted to develop a case management program using the critical pathway (CP) as an intervention method for patients with an inguinal hernia for a herniorrhaphy, and to determine the effects of the CP on the period of hospitalization, medical costs, the rates of postoperative complaints, patient satisfaction and the nurses' job satisfaction. One hundred patients (60 in the experimental group, 40 in the control group) who were admitted to a general hospital in Seoul for inguinal herniorrhaphy were enrolled in this study. The results showed that the period of hospitalization and the postoperative hospital stay were significantly reduced in the CP group. In addition, the total medical cost, was lowered significantly by use of the CP for patients undergoing an inguinal herniorrhaphy. The rates of postoperative complaints, patients' satisfaction and the information on the treatment were enhanced after implementing the CP. These results suggests that the CP may be a useful tool for enhancing the health care outcome by decreasing the period of hospitalization, overall medical costs and by improving the quality of care, all of which can benefit the patients, the patients' family, caregivers and the hospital. (+info)
Local or general anesthesia for open hernia repair: a randomized trial.
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OBJECTIVE: To compare patient outcome following repair of a primary groin hernia under local (LA) or general anesthesia (GA) in a randomized clinical trial. SUMMARY BACKGROUND DATA: LA hernia repair is thought to be safer for patients, causes less postoperative pain, cost less, and is associated with a more rapid recovery when compared with the same operation performed under GA. METHODS: All patients presenting to three surgeons during the study period with a primary groin hernia were considered eligible. Outcome parameters measured including tests of vigilance, divided attention, sustained attention, memory, cognitive function, pain, return to normal activity, and costs. RESULTS: Two hundred seventy-nine patients were randomized to LA or GA hernia repair; 276 of these had an operation, with 138 participants in each group. At 6, 24, and 72 hours postoperatively there were no differences in vigilance or divided attention between the groups. Similarly, memory, sustained attention, and cognitive function were not impaired in either group. Although physical activity was significantly impaired at 24 hours, this and return to usual social activities were similar in both groups. While patients in the LA group had significantly less pain on moving, at 6 hours they were less likely to recommend the same operation to someone else. GA hernia repair cost 4% more than the same operation under LA. CONCLUSIONS: There are no major differences in patient recovery after LA or GA hernia repair. Patients should be offered a choice of anesthesia, LA or GA, for repair of their groin hernia. (+info)
Routine pathological evaluation of tissue from inguinal hernias in children is unnecessary.
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INTRODUCTION: Because unexpected disease is rare in a child's inguinal hernia sac we decided to investigate the cost of routine pathological evaluation of inguinal hernial sacs in children and the incidence of clinically significant pathological findings. METHODS: We searched the health records at the University Hospital, Saskatoon, for patients under 20 years of age who had inguinal hernia repair between 1988 and 1997. For records noting pathology findings of duct-like structures, the operative reports and histology slides were reviewed. Specimens were immunostained for muscle-specific actin. The cost of pathological evaluation was estimated using a provincial physician-billing schedule. RESULTS: During the study period, there were 488 inguinal hernia repairs in 371 patients under 20 years of age. Of these, 456 (93.4%) specimens were evaluated microscopically. There were 4 (0.88%) cases with unexpected findings diagnosed as epididymis at a cost of Can dollar 6988/case. CONCLUSION: The routine histologic evaluation of inguinal hernia sacs in children is an unnecessary expense and should be reserved for select cases at the discretion of the surgeon. (+info)
Surgical physiology of inguinal hernia repair--a study of 200 cases.
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BACKGROUND: Current inguinal hernia operations are generally based on anatomical considerations. Failures of such operations are due to lack of consideration of physiological aspects. Many patients with inguinal hernia are cured as a result of current techniques of operation, though factors that are said to prevent hernia formation are not restored. Therefore, the surgical physiology of inguinal canal needs to be reconsidered. METHODS: A retrospective study is describer of 200 patients operated on for inguinal hernia under local anaesthesia by the author's technique of inguinal hernia repair. RESULTS: The posterior wall of the inguinal canal was weak and without dynamic movement in all patients. Strong aponeurotic extensions were absent in the posterior wall. The muscle arch movement was lost or diminished in all patients. The movement of the muscle arch improved after it was sutured to the upper border of a strip of the external oblique aponeurosis (EOA). The newly formed posterior wall was kept physiologically dynamic by the additional muscle strength provided by external oblique muscle to the weakened muscles of the muscle arch. CONCLUSIONS: A physiologically dynamic and strong posterior inguinal wall, and the shielding and compression action of the muscles and aponeuroses around the inguinal canal are important factors that prevent hernia formation or hernia recurrence after repair. In addition, the squeezing and plugging action of the cremasteric muscle and binding effect of the strong cremasteric fascia, also play an important role in the prevention of hernia. (+info)
Propofol sparing effect of remifentanil using closed-loop anaesthesia.
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BACKGROUND: General anaesthesia is a balance between hypnosis and analgesia. We investigated whether an increase in remifentanil blood concentration would reduce the amount of propofol required to maintain a comparable level of anaesthesia in 60 patients undergoing ambulatory surgery. METHODS: Patients were allocated randomly to receive remifentanil to a target blood concentration of 2 ng ml(-1) (low), 4 ng ml(-1) (medium), or 8 ng ml(-1) (high), administered by target-controlled infusion (TCI). After equilibration, propofol TCI was commenced in closed-loop control, with auditory evoked potentials (AEPex) as the input signal, aiming for an AEPex of 35. This was to ensure a comparable and unbiased level of anaesthesia in all patients. RESULTS: We found a dose-dependent decrease in propofol requirements with increasing remifentanil concentrations. The mean (95% CI) propofol target blood concentration during adequate anaesthesia was 4.96 (3.85-6.01) micro g ml(-1) in the low, 3.46 (2.96-3.96) micro g ml(-1) in the medium, and 3.01 (2.20-3.38) micro g ml(-1) in the high group. There was no significant difference when recovery end points were achieved between the groups. Cardiovascular changes were moderate, but most pronounced in the high concentration group, with a decrease in heart rate of 21% compared with baseline. The mean calculated effect site propofol concentration at loss of consciousness was 2.08 (1.85-2.32) micro g ml(-1), and at recovery of consciousness was 1.85 (1.68-2.00) micro g ml(-1). CONCLUSIONS: This study confirms a synergistic interaction between remifentanil and propofol during surgery, whereas the contribution of remifentanil in the absence of stimulation seems limited. In addition, our results suggest that the propofol effect site concentration provides a guide to the value at which the patient recovers consciousness. (+info)
Pneumomediastinum as a complication of preperitoneal laparoscopic herniorrhaphy.
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BACKGROUND: As new approaches to herniorrhaphy are popularized, new complications are being encountered. Pneumomediastinum is one such complication. METHODS: We present a patient who developed pneumomediastinum after an elective bilateral preperitoneal laparoscopic hernia repair. RESULTS: The patient was observed and discharged 24 hours later with no permanent sequelae. CONCLUSION: Pneumomediastinum is a rare complication of laparoscopic hernia repair. (+info)