There were two study arms investigating patients who underwent an open Lichtenstein hernia repair (LHR), under local anaesthesia and sedation with a mesh reinforcement.

The first was a large case series of patients (n=405) who underwent single, bilateral or recurrent hernia repair from 2006 to 2008, whose data was collected at the time of repair. Their postoperative analgesia requirements and time taken to return to work or normal actvities were recorded at review.

The second was a detailed prospective consecutive cohort, operated upon in mid 2010. Fifty-eight consecutively repaired hernias from 2010 were selected, with a follow-up rate of 93% (n=54). All patients with unilateral, bilateral or recurrent inguinal hernias were included. Patients were interviewed and examined at 1 and 4 weeks by the treating surgeon and interviewed at 2 and 3 months by telephone, to assess and determine the degree of recovery using a short-term questionnaire (STQ).

These two cohorts were then compared to see if there were any statistical correlations, and to assess the consistency of the results over several years, between a non-stratified and a stratified group.

There have been fewer questionnaires that have been developed to assess short-term pain and recovery following hernia repair, with most focussing on long-term outcomes⁵. This study adopted many already established methods of assessing recovery as proposed by Kehlet and Franneby, as well as investigating the following primary and secondary outcomes:

Time to return to normal activity

Analgesia requirements (required days of paracetamol 500mg and codeine phosphate 30mg tablets (2 tablets QID))

Complications

Pain at 1 and 4 weeks

Comparison to preoperative pain

Percentage of normal activities able to be carried out at 1 and 4 weeks

Comparison to preoperative pain

Satisfaction with surgery

Cohort 2’s normal activities and return to work were analysed, with patients stratified into four groups based on usual level of activity and/or occupation.

Office/Professional

Labourer

Retired active

Retired inactive and infirm

Other

A single surgeon with experience in over 8000 hernia operations performed all the repairs. This ensured consistency with technique.

Procedures were carried out using local anaesthetic infiltration and light intravenous sedation. No pre-medication was used. Commonly fentanyl or IV anti-inflammatories were used at the time of surgery, depending on anaesthetist preference.

A combination of 20ml of lignocaine 2% with adrenaline 1 in 200,000 was combined with Bupivacaine 0.5% plain 20ml. A combined total of 40ccs was within the recommended maximum range for safety. For bilateral hernias and larger patients this was diluted with 10ccs of normal saline. The nerves were usually identified and preserved.

The surgical technique has been well described⁶. Some important aspects of our technique and possible differences include:

No diathermy was used – the adrenaline kept the blood loss to a minimum,

The local anaesthetic technique required a gentle dissection method, facilitated by the local anaesthetic opening up the tissue planes between the sac and the cord,

For indirect hernias the sac was either excised or reduced (especially for sliding hernias),

For direct hernias the sac was reduced,

Many patients had an additional lipoma of the cord which was always excised,

A standard polypropolene mesh was generally used (Johnson & Johnson),

A standard skin stapler was used to fix the mesh.

Ethics approval was sought from the relevant local body, and all patients gave informed consent. All patients were also followed up in the clinic by the surgeon who performed the operation.

Figure 2

Figure 1: Days of post-operative analgesia requirement

Figure 3

Figure 2: Days to return to work or normal activities

In the first study arm of 405 patients, return to work was consistent, with a median of 5 to 6 days (Figure 1). Sevety-five per cent of patients were back to their normal activities and duties after 10 days. Interestingly, the results were skewed by a number of outliers. On closer examination, the vast majority of these patients were patients being treated under the Australian “WorkSafe” scheme, for injuries caused by work. Those outliers required the same amount of analgesia post-operatively as all other patients. The median analgesic requirement was 2 days (Figure 2).

Forty-one patients (75%) reported having preoperative pain. At the end of week 1, 28 (51%) had returned to their normal duties or work, with 24 (44%) stating that they felt that they were back to 100% at the end of week 4. The level of activity patients were able to complete at week 1 and week 4 are shown in table 2.

Figure 4

Table 2 Comparison of pain ratings, week 1 and week 4 after surgery. Values are number of patients, with percentages displayed in parentheses.

Figure 5

Figure 3: Days of post-operative analgesia requirements 2010

Figure 8

Table 4: Pre- and post-operative pain in patients from cohort 2 (n=54).

The median post-operative analgesia requirements for cohort 2 were 3 days, with 75% requiring analgesia for no more than six days. The median return to normal activities or work was seven days, with 75% returning before two weeks. These results are consistent with those from cohort 1.

Figure 7

Table 3: Return to work and analgesic requirements based on patient stratification in cohort 2. Patients who were retired and inactive and students were not included, as they do not form a large enough population to be statistically valuable.

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Patient Satisfaction with Surgery In the second arm, 94.4% of patients were satisfied with their repair, with three patients (5.6%) recording that they were “unsure”, and this was due to persisting pain following repair due to wound infection. One of these patients still had pain at 3 months.

Hospital stay

Pain has been previously treated as dichotomous entity. Throughout this study, it was noticed that adequately defining pain was incredibly difficult for some patients, and the line between true pain or discomfort was often blurred. The questionnaire proposed by Franneby⁵ for chronic pain had the advantage that it departed from the traditional model of analysing pain by a visual analogue score (VAS) or numeral rating system (NRS), and instead looked at important activity parameters after four weeks. To thoroughly investigate the early postoperative recovery, this study adopted components of Franneby’s questionnaire with other traditional modes of pain measurement, to determine true outcomes using all the established techniques.