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Local, regional, or general anaesthesia in groin hernia repair: multicentre randomised trial
Department of Surgery, Östersund Hospital, Östersund, Sweden.
Department of Anaesthetics, Östersund Hospital, Östersund, Sweden.
Department of Surgery, Mora Hospital, University of Uppsala, Sweden.
Department of Surgery, Motala Hospital, Motala, Sweden.
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]


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.


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.


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.


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.

Place, publisher, year, edition, pages
2003. Vol. 362, no 9387, 853-858 p.
National Category
Medical and Health Sciences
URN: urn:nbn:se:liu:diva-84504DOI: 10.1016/S0140-6736(03)14339-5OAI: diva2:559834
Available from: 2012-10-10 Created: 2012-10-10 Last updated: 2012-10-10Bibliographically approved
In thesis
1. Groin hernia surgery: studies on anaesthesia and surgical technique
Open this publication in new window or tab >>Groin hernia surgery: studies on anaesthesia and surgical technique
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.
Linköping University Medical Dissertations, ISSN 0345-0082 ; 797
National Category
Medical and Health Sciences
urn:nbn:se:liu:diva-25695 (URN)10071 (Local ID)91-7373-487-X (ISBN)10071 (Archive number)10071 (OAI)
Public defence
2003-06-03, Elsa Brändström aulan, Hälsouniversitet, Linköping, 09:00 (Swedish)
Available from: 2009-10-08 Created: 2009-10-08 Last updated: 2012-10-10Bibliographically approved

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