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Groin hernia surgery: studies on anaesthesia and surgical technique
Linköping University, Department of Biomedicine and Surgery, Surgery. Linköping University, Faculty of Health Sciences.
2003 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The modem era of groin hernia surgery began with Eduardo Bassini who in the late 19th century, developed the first modem anatomically based hernia repair. Surgical technique, anaesthesia, suture and biomaterials have been matters of discussion ever since.

In recent decades new techniques using a mesh prosthesis as adjunct have, to a large extent, replaced sutured repairs in groin hernia surgery. The advantages and disadvantages of new methods and devices are not easy to establish. Excellent results from specialised hernia centres have frequently been presented in the form of retrospective series. However, hernia surgery is usually considered an area within general surgery and, therefore, often performed by non-specialised surgeons and trainees.

The Swedish Hernia Register (SHR), initiated in 1992 has today become nationwide and covers some 90 % of all Swedish units where hernia surgery is performed. Register data may be used for local audit, follow-up studies, and as background for RCTs. Register data reflect the results obtained by general surgeons with varying background and experience of hernia surgery. The present thesis comprises flve studies (I-V), three RCTs and two analyses of SHR data.

Paper I: The aim of this RCT trial was to compare the Shouldice procedure with the Lichtenstein repair with respect to recurrence rate, technical difficulty, convalescence and chronic pain. A further aim was to determine to what extent general surgeons in routine surgical practice are able to reproduce the excellent results reported from specialised hernia centres. The Lichtenstein repair resulted in fewer recurrences took less time to perform and was easier to learn. It seemed possible to achieve excellent results with this technique even in non-specialised general surgical units.

Paper II: Although mesh techniques are used with increasing frequency sutured repairs will continue to have a place in groin hernia surgery. Between 1992 and 2000 detailed information on 18,057 repairs with open sutured non-mesh methods was recorded in the SHR. The purpose of this study was to analyse the relative risk for reoperation with early absorbable, late absorbable, and nonabsorbable sutures, and to compare the relative risk of reoperation using the Shouldice technique with that of other sutured repairs. The relative risk for reoperation with early absorbable sutures was significantly higher than with other sutures. Among sutured repairs the Shouldice technique carried a lower risk for reoperation than other sutured repairs.

Paper III: Data from 59,823 hernia operations recorded in SHR from 1992 through 2001 were used to estimate the relative risk of reoperation for recurrence (or chronic pain) when using general anaesthesia (GA), regional anaesthesia (RA), and local anaesthesia (LA). Time trends for anaesthetic and operative methods and other variables affecting risk for reoperation were also analysed. LA was associated with an enhanced risk for reoperation in primary but not recurrent repair. The Lichtenstein technique carried a significantly lower risk of reoperation compared to other methods.

Paper IV: Within a three-armed multicentre RCT (n=616), perform by ten units all aligned to the SHR, surgical outcomes using the three anaesthetic alternatives were compared. LA was found to have considerable advantages over RA and GA. General surgeons in routine surgical practice could to a great extent, reproduce the favourable results obtained using LA in specialised hernia centres.

Paper V: As part of Study IV patient satisfaction and quality of life following hernia surgery under GA,RA, and LA was compared in an RCT (n= 138) using a specially designed questionnaire. With the exception of slight intraoperative pain, LA was found to be well tolerated and associated with significant advantages when compared with GA and RA.

Quality assessment of hernia surgery is essential. RCTs enable us to compare new surgical and anaesthetic alternatives. Register studies reflecting outcome in routine clinical practice can give this assessment a new dimension.

Place, publisher, year, edition, pages
Linköping: Linköpings universitet , 2003. , 65 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 797
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-25695Local ID: 10071ISBN: 91-7373-487-X (print)OAI: oai:DiVA.org:liu-25695DiVA: diva2:246243
Public defence
2003-06-03, Elsa Brändström aulan, Hälsouniversitet, Linköping, 09:00 (Swedish)
Opponent
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-10-10Bibliographically approved
List of papers
1. Randomized trial of Lichtenstein versus Shouldice hernia repair in general surgical practice
Open this publication in new window or tab >>Randomized trial of Lichtenstein versus Shouldice hernia repair in general surgical practice
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2002 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 89, no 1, 45-49 p.Article in journal (Refereed) Published
Abstract [en]

Background:

The aim of the present randomized trial was to compare the Shouldice procedure and the Lichtenstein hernia repair with respect to recurrence rate, technical difficulty, convalescence and chronic pain. A further aim was to determine to what extent general surgeons in routine surgical practice were able to reproduce the excellent results reported from specialist hernia centres.

Methods:

Three hundred patients with primary inguinal hernia were randomized to either a Shouldice repair or to a tension-free Lichtenstein repair. In a pretrial training programme the five participating general surgeons were taught to perform the two techniques in a standard manner. Follow-up was performed after 8 weeks, 1 year and 3 years. The last examination was performed by an independent blinded assessor.

Results:

There was a significant difference in operating time in favour of the Lichtenstein technique. After a follow-up of 36–77 months seven recurrences were found in the Shouldice group (95 per cent confidence interval (c.i.) 1·3 to 8·1) and one in the mesh group (95 per cent c.i. 0·0 to 2·0). Chronic groin pain was reported by 4·2 and 5·6 per cent in the Shouldice and Lichtenstein groups respectively. It was characterized as mild or moderate in all except two patients who had the Shouldice operation.

Conclusion: 

Lichtenstein hernia repair was easier to learn, took less time and resulted in fewer recurrences. It was possible to achieve excellent results with this technique in a general surgical unit. © 2002 British Journal of Surgery Society Ltd

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-84501 (URN)10.1046/j.0007-1323.2001.01960.x (DOI)
Available from: 2012-10-10 Created: 2012-10-10 Last updated: 2017-12-07Bibliographically approved
2. Sutures and surgical techniques in herniorrhaphy: an analysis of 18 057 sutured non-mesh repairs
Open this publication in new window or tab >>Sutures and surgical techniques in herniorrhaphy: an analysis of 18 057 sutured non-mesh repairs
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background: Although mesh techniques are used with increasing frequency sutured repairs will continue to have a place in groin hemia surgery. Studies relating suture material to recurrence rate have yielded conflicting results. The aim of the present study was to analyse the influence of suture material and sutured non-mesh techniques on risk for reoperation in open groin hernia repair using data from the Swedish Hernia Register (SHR).

Methods: The relative risk for reoperation after sutured repairs using nonabsorbable, late absorbable and early absorbable sutures were compared in multivariate analyses taking into account known confounding factors.

Results: During 1992 -2000, 46,745 hernia repairs were recorded in the SHR. Of these 18,057 repairs were performed with open non-mesh methods and included in the analysis. With nonabsorbable suture as reference the relative risk for reoperation of early absorbable suture and of late absorbable suture was 1.50 (95% CI 1.22-1.83) and 1.03 (95% CI 0.83-1.28), respectively. Using the Shouldice repair as reference, other sutured repairs were associated with a significantly higher relative risk for reoperation 1.22 (95% CI 1.03-1.44).

Conclusion: For open non-mesh groin hernia repairs a nonabsorbable or a late absorbable suture is recommended. The Shouldice technique was found superior to other open methods.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-84502 (URN)
Available from: 2012-10-10 Created: 2012-10-10 Last updated: 2012-10-10Bibliographically approved
3. Choice of anesthesia and risk of reooperation for recurrence in groin hernia repair
Open this publication in new window or tab >>Choice of anesthesia and risk of reooperation for recurrence in groin hernia repair
2004 (English)In: Annals of Surgery, ISSN 0003-4932, E-ISSN 1528-1140, Vol. 240, no 1, 187-192 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To analyze the relative risk of reoperation for recurrence using 3 anesthetic alternatives, general anesthesia (GA), regional (spinal-, epidural-) anesthesia (RA), and local anesthesia (LA), and to study time trends for various anesthetic and operative methods, as well as other risk factors regarding reoperation for recurrence.

Background: The method of anesthesia used for hernia repair is generally assumed not to affect the long-term outcome. The few studies on the topic have rendered conflicting results.

Methods: Data from the Swedish Hernia Register was used. Relative risk was first estimated using univariate analysis for assumed risk variables and then selecting variables with the highest or lowest univariate risk for multivariate analysis.

Results: From 1992 through 2001, 59,823 hernia repairs were recorded. Despite the fact that univariate analysis showed a somewhat lower risk for reoperation in the LA group, the multivariate analysis showed that LA was associated with a significantly increased risk for reoperation in primary but not in recurrent hernia repair. The Lichtenstein technique carried a significantly lower reoperation risk than any other method of operation.

Conclusions: LA was associated with a higher risk of reoperation for recurrence after primary hernia repair. The use of mesh techniques has increased considerably, and among these the Lichtenstein repair was associated with a significantly lower risk for reoperation than any other repair.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-84503 (URN)10.1097/01.sla.0000130726.03886.93 (DOI)
Available from: 2012-10-10 Created: 2012-10-10 Last updated: 2017-12-07Bibliographically approved
4. Local, regional, or general anaesthesia in groin hernia repair: multicentre randomised trial
Open this publication in new window or tab >>Local, regional, or general anaesthesia in groin hernia repair: multicentre randomised trial
2003 (English)In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 362, no 9387, 853-858 p.Article in journal (Refereed) Published
Abstract [en]

Background

In specialised centres, local anaesthesia is almost always used in groin hernia surgery; whereas in routine surgical practice, regional or general anaesthesia are the methods of choice. In this three-arm multicentre randomised trial, we aimed to compare the three methods of anaesthesia and to determine the extent to which general surgeons can reproduce the excellent results obtained with local anaesthesia in specialised hernia centres.

Methods

Between January, 1999, and December, 2001, 616 patients at ten hospitals, were randomly assigned to have either local, regional, or general anaesthesia. Primary endpoints were early and late postoperative complications. Secondary endpoints were duration of surgery and anaesthesia, length of postoperative hospital stay, and time to normal activity. Analysis was by intention to treat.

Findings

Intraoperative tolerance for local anaesthesia was high. In the early postoperative period, local anaesthesia was superior to the other two types with respect to almost all endpoints. At 8 days' and 30 days' follow-up, there were no significant differences between the three groups. Although the mean duration of surgery was longer, the total anaesthesia time—ie, time from the start of anaesthesia until the patient left the operating room—was significantly shorter than it was for regional or general anaesthesia.

Interpretation

Local anaesthesia has substantial advantages compared with regional or general anaesthesia, such as shorter duration of admission, less postoperative pain, and fewer micturition difficulties. The favourable results obtained with local anaesthesia in specialised hernia centres can, to a great extent, be reproduced by general surgeons in routine surgical practice.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-84504 (URN)10.1016/S0140-6736(03)14339-5 (DOI)
Available from: 2012-10-10 Created: 2012-10-10 Last updated: 2017-12-07Bibliographically approved
5. Type of anaesthesia and patient acceptance in groin hernia repair: a multicentre randomised trial
Open this publication in new window or tab >>Type of anaesthesia and patient acceptance in groin hernia repair: a multicentre randomised trial
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2004 (English)In: Hernia, ISSN 1265-4906, E-ISSN 1248-9204, Vol. 8, no 3, 220-225 p.Article in journal (Refereed) Published
Abstract [en]

Background  Groin hernia repair can be performed under general (GA), regional (RA), or local (LA) anaesthesia. This multicentre randomised trial evaluates patient acceptance, satisfaction, and quality of life with these three anaesthetic alternatives in hernia surgery.

Methods  One hundred and thirty-eight patients at three hospitals were randomised to one of three groups, GA, RA, or LA. Upon discharge, they were asked to complete a specially designed questionnaire with items focusing on pain, discomfort, recovery, and overall satisfaction with the anaesthetic method used. The global quality-of-life instrument EuroQol was used for estimation of health perceived.

Results  Significantly more patients in the LA group than in the RA group felt pain during surgery (P<0.001). This pain was characterised as light or moderate and for the majority of LA patients was felt during infiltration of the anaesthetic agent. Postoperatively, patients in the LA group first felt pain significantly later than patients in the other two groups (P=0.012) and significantly fewer LA patients consumed analgesics more than three times during the first postoperative day (P=0.002). The results concerning nausea, vomiting, and time to first meal all favour LA. No difference was found among the three groups concerning overall satisfaction and quality of life.

Conclusion   In a general surgical setting, we found LA to be well tolerated and associated with significant advantages compared to GA and RA.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-24775 (URN)10.1007/s10029-004-0234-5 (DOI)7036 (Local ID)7036 (Archive number)7036 (OAI)
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13Bibliographically approved

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