Inguinal hernia repair: anaesthesia, pain and convalescence

Elective surgical repair of an inguinal or femoral hernia is one of the most common surgical procedures. The treatment, however, presents several challenges regarding anaesthesia for the procedure, the postoperative analgesic therapy and convalescence, as well as planning of the procedure. Local, general, and regional anaesthesia are all used for hernia repair, but to different degrees, primarily depending on traditions and whether the institution has specific interest in hernia surgery. Thus, the use of local anaesthesia varies from a few percent in Sweden, 18% in Denmark and up to almost 100% in specialised institutions, dedicated to hernia surgery. The feasibility of local anaesthesia is high, as judged by the rate of conversion to general anaesthesia (< 1%), although intraoperative pain is quite common. The generally low rate of serious complications does not allow firm conclusions, but the rate of less serious complications is lower by local anaesthesia, compared to other anaesthetic techniques. Of special interest is, that the rate of urinary retention can be eliminated by the use of local anaesthesia. Local anaesthesia results, in comparative studies, in a higher degree of patient satisfaction than other anaesthetic techniques. Local anaesthesia also facilitates faster mobilisation and earlier discharge/fulfilment of discharge criteria from post anaesthetic care units than other anaesthetic techniques. Pain after hernia repair is more pronounced at mobilisation or coughing than during rest, and younger patients seem to have more pain than older patients. The pain ceases over time, and it is most pronounced the day after surgery, where two thirds have moderate or severe pain during activity, while one third still have moderate or severe pain after one week, and approximately 10% after 4 weeks. Pain after laparoscopic surgery is less pronounced than after open surgery, while different open repair techniques do not exhibit significant differences. Postoperative pain is best treated with a combination of local analgesia and peripherally acting agents (paracetamol, NSAID or their combination), while opioids should be avoided due to side effects, primarily nausea and sedation. Moderate or severe pain one year postoperatively is seen in 5-12% of patients. There seem to be no difference between different surgical or anaesthetic techniques, but the following factors have been related to a higher rate of chronic pain: previous or subsequent hernia surgery on the same side, young age, pain before surgery, high pain scores in the immediate postoperative period, and postoperative complications and prolonged convalescence. Patients should be informed about the risk of chronic pain, particularly if the hernia is asymptomatic. The duration of convalescence after hernia repair varies considerably, primarily due to variation in recommendations. No documentation is available to support that a prolonged convalescence reduces the risk of recurrence of the hernia, and most specialised institutions recommend immediate return to all usual activities. Pain seems to be the most important cause of prolonged convalescence. From all published consecutive materials with recommendations of short convalescence the mean or median duration is 6-8 days, in contrast to the two to four weeks often seen in randomised comparisons of different surgical techniques. Patients should be informed, that they can immediately resume all activity if pain permits, but also to expect that pain may limit function of activities of daily living during the first postoperative week. Hernia surgery, including treatment of recurrent hernias, can and ought to be performed as day case surgery, irrespective of the chosen anaesthetic technique, as there are no medical or surgical contraindications to this. Social causes may indicate, that overnight stay may be advisable or desirable, preferably in a patient hotel facility. Despite this, the fraction of patients operated in a day-case surgical set-up varies from 6% in France to 83% in US, and in Denmark 60% of patients have their hernia repair as a day-case procedure. A day-case hernia surgery service should be organised with standardised patient records, including descriptions of surgery performed as well as letters of discharge for the general practitioner. If clinical data are stored electronically, the basis is created for valuable clinical databases like the one behind the present thesis, and they can be used both for scientific purposes and for quality control and improvement.

Assessing the costs and consequences of laparoscopic vs. open methods of groin hernia repair: a systematic review

BACKGROUND

We aimed to provide unbiased estimates of cost-effectiveness by systematically reviewing published cost and cost-effectiveness data derived from studies with rigorous designs that compared laparoscopic with open groin hernia repair.

METHODS

Studies reporting costs and outcomes were identified as part of a systematic review of randomized controlled trials comparing laparoscopic with open repair. The quality of the included studies was assessed against a standard checklist. Cost per recurrence avoided and cost per additional day at usual activities were estimated.

RESULTS

Fourteen studies were identified. Laparoscopic repair was less efficient than open mesh repair in terms of avoiding recurrences, avoided but it had a modest cost per additional day back at usual activities. Laparoscopic repair is more likely to be efficient when compared with open nonmesh repair.

CONCLUSION

The type of open repair with which laparoscopic repair is compared influences its cost-effectiveness. The earlier return to usual activities provided by laparoscopic repair may make it worthwhile in some circumstances.

Routine pathological evaluation of tissue from inguinal hernias in children is unnecessary

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.

An illustration of the modelling of cost and efficacy data from a clinical trial

Health care providers, purchasers and policy makers need to make informed decisions regarding the provision of cost-effective care. When a new health care intervention is to be compared with the current standard, an economic evaluation alongside an evaluation of health benefits provides useful information for the decision making process. We consider the information on cost-effectiveness which arises from an individual clinical trial comparing the two interventions. Recent methods for conducting a cost-effectiveness analysis for a clinical trial have focused on the net benefit parameter. The net benefit parameter, a function of costs and health benefits, is positive if the new intervention is cost-effective compared with the standard. In this paper we describe frequentist and Bayesian approaches to cost-effectiveness analysis which have been suggested in the literature and apply them to data from a clinical trial comparing laparoscopic surgery with open mesh surgery for the repair of inguinal hernias. We extend the Bayesian model to allow the total cost to be divided into a number of different components. The advantages and disadvantages of the different approaches are discussed. In January 2001, NICE issued guidance on the type of surgery to be used for inguinal hernia repair. We discuss our example in the light of this information.

A cost--utility analysis of treatment options for inguinal hernia in 1,513,008 adult patients

BACKGROUND

The controversial issue of the cost-effectiveness of laparoscopic inguinal hernia repair is examined, employing a decision analytic method.

MATERIALS AND METHODS

The NSAS, NHDS (National Center for Health Statistics), HCUP-NIS (Agency for Healthcare Research and Quality) databases and 51 randomized controlled trials were analyzed. The study group constituted of a total of 1,513,008 hernia repairs. Projection of the clinical, economic, and quality-of-life outcomes expected from the different treatment options was done by using a Markov Monte Carlo decision model. Two logistic regression models were used to predict the probability of hospital admission after an ambulatory procedure and the probability of death after inguinal hernia repair. Four treatment strategies were modeled: (1) laparoscopic repair (LR), (2) open mesh (OM), (3) open non-mesh (ONM), and (4) expectant management. Costs were expressed in US dollars and effectiveness in quality-adjusted life years (QALYs). The main outcome measures were the average and the incremental cost-effectiveness (ICER) ratios.

RESULTS

Compared to the expectant management, the incremental cost per QALY gained was 605 dollars (4086 dollars, 9.04 QALYs) for LR, 697 dollars (4290 dollars, 8.975 QALYs) for OM, and 1711 dollars (6200 dollars, 8.546 QALYs) for ONM. In sensitivity analysis the two major components that affect the cost-effectiveness ratio of the different types of repair were the ambulatory facility cost and the recurrence rate. At a LR ambulatory facility cost of 5526 dollars the ICER of LR compared to OM surpasses the threshold of 50,000 dollars/QALY.

CONCLUSIONS

On the basis of our assumptions this mathematical model shows that from a societal perspective laparoscopic approach can be a cost-effective treatment option for inguinal hernia repair.

Cost–utility analysis of open versus laparoscopic groin hernia repair: results from a multicentre randomized clinical trial

Background

This study was a pragmatic economic evaluation carried out alongside a multicentre randomized controlled trial comparing laparoscopic with open groin hernia repair. The primary economic evaluation framework employed was a cost–utility analysis.

Methods

At 26 hospitals in the UK and Ireland, 928 patients with a groin hernia were assigned randomly to laparoscopic or open repair. Cost data were identified and measured both within and outwith the trial. Cost data were combined with quality-adjusted life years (QALYs) from the EQ-5D questionnaire to obtain cost-per-QALY ratios.

Results

The mean cost of laparoscopic hernia repair was £1112·64, compared with £788·79 for the open operation. The extra cost of £323·85 in the laparoscopic group was mainly due to additional theatre time and increased equipment and sterilization costs. The estimated incremental cost per QALY of the laparoscopic over the open method was £55 548·00 (95 per cent confidence interval £47 216·00–£63 885·00).

Conclusion

While the results show that a high cost was incurred to produce an additional QALY by using laparoscopic over open hernia repair, sensitivity analyses show that there are specific situations in which laparoscopic repair may be a viable alternative, such as when reusable equipment is employed.

[Management of groin hernias: long term results]

The Authors report their experience in the treatment of groin hernias. Over the years, hospital stay and anaesthetic procedure were modified without compromising the quality of results. The Authors conclude that groin hernia may be treated in a outpatient or day surgery regimen saving money.

[Comparative study between laparoscopic "TEP" and "tension-free" repair of groin hernia]

The "Tension free" and TEP (total preperitoneal repair) of groin hernia gained more popularity in surgical practice in the last five years. The aim of the study was to reveal our experience with these two surgical techniques. The TEP procedure was done in 29 cases, till "Tension free" herniorraphy was performed at 32 cases. Postoperative complications in the group with TEP hernia repair were found in 1 case. Two complications were observed in the "Tension free" group. The follow up of the patients revealed I recurrence in the group of TEP herniorraphy and no recurrence in "Tension free" group. These two techniques for repair of groin hernias had several advantages and in spite of increased operating theater costs should be adopted on a routine basis in some cases than conventional techniques for repair of groin hernia.

Surgical outcome and hospital cost analyses of laparoscopic and open tension-free hernia repair

Surgeons who favor the laparoscopic repair of groin hernias must limit the additional costs associated with this technique, which is not universally acknowledged to be superior to other less expensive open tension-free repairs. This retrospective study compared outcome and costs between laparoscopic and open tension-free hernia repair in 320 patients with inguinal hernias. Patients underwent either (a) transabdominal preperitoneal procedure (TAPP; 60 patients, 72 procedures), (b) totally extraperitoneal procedure (TEP; 174 patients, 202 procedures), or (c) open tension-free procedure (86 patients, 105 procedures). Regarding important postoperative complications there were two (3.3%) recurrences in the TAPP group and one (0.6%) in the TEP group, and six (9.9%) transient neuralgias in the TAPP group and one (1.2%) in the tension-free group. There were no deaths, no testicular atrophies, and no wound or mesh infections. The mean hospital postoperative stay was the same in the three groups (1 day). Mean operating time was shorter in the tension-free group concerning the unilateral cases and shorter in the TEP group concerning the bilateral cases. Fewer patients required analgesia during the first 6 h after the operative procedure in the TEP group than in the other two groups. The mean total costs were 483.90 euros in the open tension-free repair, 763.20 euros in the TAPP repair, and 572.50 euros in the TEP repair. The open procedure was the cheaper for the hospital. Laparoscopic hernia repair and tension-free repair as described by Gilbert are comparable in postoperative complications. TEP hernia repair is associated with less postoperative pain and earlier return to normal activities, but it is more expensive and continues to be a difficult procedure. Open tension-free repair is the least expensive method and is easier to learn than the other two procedures.

Cost-effective, reliable laparoscopic hernia repair: a report on 500 consecutive repairs

BACKGROUND

A series of 500 consecutive laparoscopic hernia repairs, performed by one surgeon, was studied to evaluate the procedure for reliability, safety, and cost-effectiveness.

METHODS

Patients with routine, first-time, recurrent or multiply recurrent, inguinal hernias were operated using the technique described.

RESULTS

The recurrence rate was 0.2%. The complication rate was 0.6%. There were no deaths. Ninety-six percent of patients returned to work in 4-10 days.

CONCLUSIONS

Laparoscopic inguinal hernia repair is reliable, safe, and cost-effective.

Randomized clinical trial of non-mesh versus mesh repair of primary inguinal hernia

BACKGROUND

The optimum method for inguinal hernia repair has not yet been determined. The recurrence rate for non-mesh methods varies between 0.2 and 33 per cent. The value of tension-free repair with prosthetic mesh remains to be confirmed. The aim of this study was to compare mesh and non-mesh suture repair of primary inguinal hernias with respect to clinical outcome, quality of life and cost in a multicentre randomized trial in general hospitals.

METHODS

Between September 1993 and January 1996, all patients scheduled for repair of a unilateral primary inguinal hernia were randomized to non-mesh or mesh repair. The patients were followed up at 1 week and at 1, 6, 12, 18, 24 and 36 months. Clinical outcome, quality of life and costs were registered.

RESULTS

Three hundred patients were randomized of whom 11 were excluded. Three-year recurrence rates differed significantly: 7 per cent for non-mesh repair (n = 143) and 1 per cent for mesh repair (n = 146) (P = 0.009). There were no differences in clinical variables, quality of life and costs.

CONCLUSION

Mesh repair of primary inguinal hernia repair is superior to non-mesh repair with regard to hernia recurrence and is cost-effective. Postoperative complications, pain and quality of life did not differ between groups.

Laparoscopic hernia repair in 2000. Update of the European Association for Endoscopic Surgery (EAES) Consensus Conference in Madrid, June 1994

The 1994 meeting of the European Association for Endoscopic Surgery (E.A.E.S.) in Madrid highlighted a consensus-developing conference on the then new laparoscopic procedure for hernia repair. The conference was chaired by A. Paul from Cologne, Germany, and A. Fingerhut, from Poissy, France. The other members of the jury were B. Millat (France), L. Nyhus (USA), J. Himpens (Belgium), J.-L. Dulucq (France), V. Schumpelick (Germany), E. Laporte Rosello (Spain), C. Klaiber (Switzerland), J. Mouiel (France), P. Go (Netherlands), and J.-H. Alexandre (France). At that time, there were, in all, only three randomized trials available for analysis. Today, there are more than 60 trials and more than 12,500 patients have been entered into them. An update, presented this year in Vienna, is summarized herein.

Randomized clinical trial comparing totally extraperitoneal inguinal hernia repair with the Shouldice technique

BACKGROUND

The optimal technique for inguinal hernia repair remains contentious. This study compared the Shouldice repair with the totally extraperitoneal endoscopic (TEP) method in a randomized clinical trial, with quality of life (QoL) and cost analysis.

METHODS

Two hundred patients were randomized to Shouldice or TEP repair. Patients were assessed after operation by questionnaire to determine operative outcomes, complications, QoL, and return to work and normal lifestyle.

RESULTS

There were 117 TEP and 115 Shouldice repairs. Median operating time was longer for TEP repair (70 versus 56 min; P = 0.0001), but patients were discharged earlier (68 versus 48 per cent within 1 day; P = 0.0065), and had a quicker return to work (14 versus 30 days; P = 0.0001) and normal lifestyle (21 versus 35 days; P = 0.0001). Open repair was nearly 40 per cent cheaper. Late follow-up in 171 patients (86 per cent) at a median of 1.3 years found that TEP repair led to fewer complications at 1 year (9 versus 21 per cent; P = 0.05) and was associated with significant improvement for the QoL components of work performance and satisfaction, physical symptoms and sense of well-being.

CONCLUSION

TEP repair results in fewer complications and an earlier return to work and normal lifestyle, but is more expensive and takes longer to perform.

[What should you tell your patient who has an inguinal hernia?]

Surgery of the inguinal hernia has undergone rapid progress in a decade. Evaluation of new techniques, prothetic and laparoscopic, are often confusing. Comparison with classical surgery may seem difficult to the non surgeon. Though, the general practitioner keeps an important place in caring for patients with this particular pathology. The importance of economical repercussion involved by hernia pathology and knowledge of the different techniques at disposition and their outcome should allow him to objectively guide his patient who is more and more informed through the media and the web.

Reimbursement policies, incentives and disincentives to perform laparoscopic surgery in Israel

The introduction of laparoscopic surgery was believed to bestow great advantages to patients and health services. Health services and societal costs may also be affected by changes in length of hospital stay, operating room costs and return to normal activity. The aim of this paper is to examine the influence of two different reimbursement methods (per diem and DRG) on the incentives and disincentives given to different role players in the Israeli health-care system regarding two common surgical procedures: appendectomy and inguinal hernia repair. Three different perspectives are discussed: society, the hospitals and the sick funds. From the hospital's perspective, laparoscopic surgery is usually more expensive compared to open procedures, mainly due to higher operating room costs. We suggest that as far as current reimbursement methods are preserved, hospitals have no economic incentive to adopt the laparoscopic technology as benefits occur only to society. In general, sick funds would encourage hospitals to perform laparoscopic appendectomy, where the payment is per diem and would be economically indifferent regarding laparoscopic inguinal hernia repair, where hospitals are compensated on a DRG basis. It has been suggested that economic advantages to society may arise from a faster return to work after laparoscopic appendectomy and laparoscopic inguinal hernia repair. In this case, new payment arrangements should be set to give proper incentives for the adoption of laparoscopic procedures.

Costs and benefits of laparoscopic surgery--a review of the literature

The purpose of this paper is to look at the cost-effectiveness of laparoscopic surgery in relation to conventional open surgery. It focuses both on the results and the methods, and aims to identify the need for further studies as well as the appropriate methods of economic evaluation. We searched the literature and identified studies in which "cost" or "cost-effectiveness" was mentioned in relation to open and laparoscopic surgery. Laparoscopic and open surgery were compared for gallbladder disease, inguinal hernia and gastro-oesophageal reflux disease (GORD). Finally, we reviewed studies that focused on cost comparisons of disposable compared with reusable instruments in laparoscopic surgery. We found that the evidence on whether laparoscopic surgery results in lower costs for the health care system than open operations is not conclusive. There are, however, indications that it results in savings in indirect costs from reduced periods of sick leave. There is also an indication that reusable instruments resulted in lower costs for each operation than disposable instruments. We conclude that a prospective, randomised study is the preferred study design in the early stage of the development of a new technique, when it is not fully obvious what the indications for the new technique are. This should be considered when doing economic evaluations of new indications for laparoscopic surgery, for example appendicectomy and non-inguinal hernia repair.

Costing anaesthetic practice. An economic comparison of regional and general anaesthesia for varicose vein and inguinal hernia surgery

A computerised database of operating theatre activity was used to estimate the costs of regional and general anaesthesia for varicose vein and inguinal hernia surgery. Data retrieved for each procedure included the anaesthetic technique and drugs used, and the duration of anaesthesia, surgery and recovery. The costs of anaesthetic drugs and disposables, salary costs of the anaesthetic personnel and maintenance costs for anaesthetic equipment were considered. Drugs and disposables accounted for approximately 25% of the total cost of an anaesthetic. Anaesthetic times were 5 min longer for regional anaesthesia, but recovery times were 10 min shorter following regional anaesthesia for varicose vein surgery. Staff costs were dependent on the length of time each staff member spent with the patient. Although the number of cases was small, provision of a field block and sedation for inguinal hernia repair was considerably cheaper than other anaesthetic techniques.

[Day surgery for adult inguinal hernia]

The mesh plug technique for adult inguinal hernia repair is easy to perform and results in a good postoperative quality of life. It allows inguinal hernia surgery to be performed as day surgery, but some problems may occur. We performed day surgeries tp repair 110 adult inguinal hernias, and the results are reported here. The procedures are as follows. Under local anesthesia, the inguinal canal and hernial sac are freed. Then the internal ring and the weakness of the posterior wall are estimated. The plug is inserted and then the mesh is on layed. As a result, all of our cases were successful under local anesthesia. After surgery, 5 subcutaneous hematomas occurred. Six patients required subsequent hospitalization: one because of subcutaneous hematoma; and 5 for pain control. In summary, the mesh plug technique under local anesthesia for adult inguinal hernia repair is a useful method for day surgery, but some an on-call system after surgery is necessary and hospitalization for postoperative complications may be required.

Update: what is left for laparoscopic hernia repair?

The risks, benefits and costs of laparoscopic hernia repair are still being debated. According to a current survey on the situation of hernia surgery in Germany in 1996, laparoscopic hernioplasty was done in about 60% of the answering hospitals; about a quarter of all hernia repairs are done laparoscopically. Since April 1993, about 2, 700 laparoscopic hernia repairs were done at Marienhospital Stuttgart. The operating time was on the average 50 min. The rate of complications was about 3%. The postoperative period of disablement was a median of 20 days; included in this time was the postoperative hospital stay. The recurrence rate was about 1%. It is remarkable that laparoscopic hernia repair was equally efficient in repairing unilateral primary hernias, recurrent hernias or bilateral hernias. The cost analysis showed that the application of multipath articles will make the operation costs of laparoscopic hernia repair only about DM 100 higher than for a conventional operation.

[Experience with the laparoscopic repair of inguinofemoral hernias]

The authors have performed 110 inguinofemoral hernioplasties on 100 patients by transabdominal endoscopic method. There has been only one serious complication: a 50 years old man was reoperated on against a trocar-site bleeding and a postoperative adhesion-ileus. All patients recovered. The authors have got good experiences: postoperative pains are minimal, hospitality is short, ability to work comes back soon. Technics of the operation and cost-analysis are discussed here.

Laparoscopic hernia repairs. The importance of cost as an outcome measurement at the century's end

At the dawn of this new millennium, surgeons not only must be masters of their craft but also are responsible for identifying and learning new techniques that are being introduced at an ever-increasing rate. Surgeons must overcome the instinctual mistrust of "the new" and, at the same time, avoid over enthusiastic, uncritical adoption of unproven procedures. Today's surgeons must also carefully assess and select the procedures and technologies that they will have time to learn and that will complement their practices and interests. More new things are coming along than any single individual can learn and practice with expertise, which makes general surgery a specialty with relative, as opposed to specifically, defined boundaries. Surgeons also should participate in the process of measuring the outcomes effective and to offer some advantages over open repair, namely less pain and a more rapid recovery period. On the other hand, this surgery has been shown to be difficult to learn and more costly. In a situation such as this, one can delete the procedure from the individual or institutional repertoire or use the modern tools of medical management to attempt to address the "outlier" issues and preserve the good. Laparoscopic hernia repair is a good procedure that can be done in a cost-effective manner if cost-conscious practice guidelines are initiated. It is not yet, however, a technique for all surgeons because of its difficulty to learn and advanced skills needed to perform it well.