Potential benefit in information providing and influence on patient anxiety and satisfaction by means of preoperative explanatory videos in total extraperitoneal inguinal hernioplasty: study protocol of a multicentre, double-blinded, randomised parallel-group controlled trial

INTRODUCTION

The use of electronic media in informed consent giving has become increasingly important in recent years. Due to the easy access to information via electronical media, patients are primed in a heterogeneous manner concerning expectations and wishes regarding surgical interventions. Inherent to its nature elective interventions are critically questioned as there is time for information gathering and reflection. In this study, we set out to investigate the effect of an educational video as a supporting element in the process of informed consent giving for one the most frequently performed interventions in general surgery, namely inguinal hernia repair.

METHODS AND ANALYSIS

In a multicentre setup, eligible patients for primary inguinal hernia repair will be randomly assigned to one of three groups. All three groups will have a preoperative informed consent discussion with a physician in which they will eventually sign the informed consent sheet if participation is desired. Eventually, all three groups will get an online link. For two groups, the link will lead to a video with audiovisual information (an inguinal hernia video for the intervention group and a mock video for the control group). The intervention video provides basic principles of endoscopic extraperitoneal hernia repair. The second video is similar in length and design and displays general aspects of day surgery in the two study centres. All the three study groups will be provided with a copy of the informed consent form as it is standard by now. The third group's link will lead to the digital version of the informed consent brochure. Primary outcomes will consist of (1) score in a multiple choice test assessing gain of knowledge regarding hernia repair, (2) difference in the State-Trait Anxiety Inventory and (3) patient satisfaction questionnaire Individual Clinician Feedback (ICF, Picker Institute, Germany) as assessed 1-2 days after the first consultation. The study design guarantees double blinding, there will be no unblinding at any point. All patients will receive the same, quality and number of medical consultations as well as in the same surgical treatment. (Minor differences in the total extraperitoneal technique of the surgical treatment due to anatomical or pathophysiological differences are independent of the group allocation). Except for the additional videos, there will be no difference in in the information provided and the treatment prior, during or after the hernia repair.

ETHICS AND DISSEMINATION

We plan to publish the study in a peer-reviewed journal. The proposed research project has been reviewed by the Cantonal Ethics Committee (BASEC-No 2020-01548). In accordance with national legal regulations in Switzerland stated by the Human Research Act, the proposed project was declared exempt from approval requirement.

TRIAL REGISTRATION NUMBER

NCT04494087; Pre-results.

Patients want to be seen: The top 3 information needs of patients with inguinal hernia

Background

Good patient information has shown to improve surgical outcomes. In this study we explore what kind of pre-surgical information patients need and if the provision of a 360˚ video of a surgical procedure can be of added value to the information provided by the hospital.

Methods

An explorative qualitative study using semi-structured interviews on information needs was conducted among 17 inguinal hernia patients to gain more insight in the patients’ present surgical information needs. Patients either were planned to receive or already had received a surgical procedure. Questions were asked about the current information provision and, after being shown a 360˚ video of the surgery, whether this would be of added value.

Results

Of the total group of 17 patients (mean age 56, interquartile range 45–64) 16 were male and one was female. Most had no previous experience with virtual reality (14/17), already had undergone a surgical procedure (11/17). Patient information needs were all about “seeing” which can be viewed from three different perspectives [1] being seen as a unique person in the treatment process, [2] being seen as a partner, and [3] seeing is understanding. Patients wanted the contact with the doctor to be more personal, with the possibility to see the anesthetist in person, the surgeon to see their wound in the recovery phase, and to receive personal answers to questions about their specific situation. Patients found the 360-video not fearsome, and believed that visual content could be beneficial as it appeals more to their imagination than written or oral information and increases their understanding. It also provided them with a better understanding of their treatment options, their pre-, peri-, and post-surgical procedures and identification of the cause of post-operative side effects.

Conclusion

To address patients’ information needs, complementary tools or services are needed that increase personal contact as well as tailor it to individual patient’s needs. Even though video-apps are a partial alternative, hospitals should still offer patients the possibility of having face-to-face meetings with physicians as this is highly valued by patients and leads to increased trust in physicians’ performance.

A national center for persistent severe pain after groin hernia repair: Five-year prospective data

Severe persistent pain after groin hernia repair impairs quality-of-life. Prospective, consecutive cohort study including patients with pain-related impairment of physical and social life. Relevant surgical records were obtained, and examinations were by standardized clinical and neurophysiological tests. Patients demonstrating pain sensitivity to pressure algometry in the operated groin underwent re-surgery, while patients with neuropathic pain received pharmacotherapy. Questionnaires at baseline (Q0) and at the 5-year time point (Q5Y) were used in outcome analyses of pain intensity (numeric rating scale [NRS] 0-10) and pain-related effect on the activity-of-daily-living (Activities Assessment Scale [AAS]). Data are mean (95% CI).Analyses were made in 172/204 (84%) eligible patients. In 54/172 (31%) patients re-surgery (meshectomy/selective neurectomy) was performed, while the remaining 118/172 (69%) patients received pharmacotherapy. In the re-surgery group, activity-related, and average NRS-scores at Q0 were 6.6 (5.6-7.9) and 5.9 (5.6-5.9), respectively. Correspondingly, NRS-scores at Q5Y was 4.1 (3.3-5.1) and 3.1 (2.3-4.0; Q0 vs. Q5Y: P < .0005), respectively. Although both groups experienced a significant improvement in AAS-scores comparing Q0 vs. Q5Y (re-surgery group: 28% (4-43%; P < .0001); pharmacotherapy group: 5% (0-11%; P = .005)) the improvement was significantly larger in the re-surgery group (P = .02).This 5-year cohort study in patients with severe persistent pain after groin hernia repair signals that selection to re-surgery or pharmacotherapy, based on examination of pain sensitivity, is associated with significant improvement in outcome. Analyzing composite endpoints, combining pain and physical function, are novel in exploring interventional effects.ClinicalTrials.gov Identifier NCT03713047.

Psychiatric morbidity after surgery for inflammatory bowel disease: A systematic review

AIM

To examine the evidence about psychiatric morbidity after inflammatory bowel disease (IBD)-related surgery.

METHODS

PRISMA guidelines were followed and a protocol was published at PROSPERO (CRD42016037600). Inclusion criteria were studies describing patients with inflammatory bowel disease undergoing surgery and their risk of developing psychiatric disorder.

RESULTS

Twelve studies (including 4340 patients) were eligible. All studies were non-randomized and most had high risk of bias. Patients operated for inflammatory bowel disease had an increased risk of developing depression, compared with surgical patients with diverticulitis or inguinal hernia, but not cancer. In addition, patients with Crohn’s disease had higher risk of depression after surgery compared with non-surgical patients. Patients with ulcerative colitis had higher risk of anxiety after surgery compared with surgical colorectal cancer patients. Charlson comorbidity score more than three and female gender were independent predictors for depression and anxiety following surgery.

CONCLUSION

The review cannot give any clear answer to the risks of psychiatric morbidity after surgery for IBD studies with the lowest risk of bias indicated an increased risk of depression among surgical patients with Crohn’s disease and increased risk of anxiety among patients with ulcerative colitis.

Tacks, staples, or suture: method of peritoneal closure in laparoscopic transabdominal preperitoneal inguinal hernia repair effects early quality of life

INTRODUCTION

TAPP inguinal hernia repair (IHR) entails the development of a peritoneal flap (PF) in order to reduce the hernia sac and create a preperitoneal space in which to place mesh. Many methods for closure of the PF exist including sutures, tacks, and staples. We hypothesized that patients who had PF closure with suture would have better short-term QOL outcomes.

METHODS AND PROCEDURES

A prospective institutional hernia-specific database was queried for all adult, TAPP IHRs from July 2012 to August 2013. Unilateral and bilateral patients were included and each hernia was analyzed separately. The main outcome of interest was quality of life (QOL) at two- and four-week follow-up, as measured by the Carolinas Comfort Scale.

RESULTS

There were 227 patients who underwent TAPP, with 99 bilateral and 128 unilateral IHR, for a total of 326 IHR. PF closure was performed using tacks in 45.1%, suture in 19.0%, and staples in 35.9%. Patient characteristics were statistically similar between the tack, suture, and staple group. There were 32.9% direct, 46.5% indirect, and 20.6% pantaloon hernias, which were not significantly different when compared by PF closure method. Post-operative complications and length of stay were same for the three groups. There were no hernia recurrences. Post-operative activity limitation at two weeks was significantly better in the suture group when compared to the stapled group (p = 0.005). Additionally, sutured PF closure had less early post-operative pain when compared to the tack group (p = 0.038).

CONCLUSIONS

Following TAPP IHR, suture closure of the PF significantly improves 2-week post-operative movement limitation compared to stapled and tacked PF closure. Continued randomized studies are needed to determine the best surgical hernia repair methods for ideal post-op QOL.

Assessing the performance of the EQ-VAS in the NHS PROMs programme

Objectives

The study aims to increase knowledge about the performance of the EuroQol-visual analogue scales (EQ-VAS) in the UK NHS patient-reported outcome measures (PROMs) programme, which covers groin hernia, hip and knee replacement and varicose vein surgery, and make suggestions for improved collection, coding and analysis of data.

Methods

Four hundred scanned images of matched before-and-after EQ-VAS PROMs responses were selected at random. These were classified according to the different ways in which they were completed. Patient-level PROMs programme data linked to Hospital Episode Statistics for all patients from April 2009 to February 2011 were used to analyse the relationship between the EQ-VAS and the EQ-5D profile, index-weighted profile and condition-specific instruments. The linked PROMs and HES data comprise 331,951 anonymised patient records.

Results

A large majority (95 %) of EQ-VAS responses were completed in an unambiguous way, but only a minority (45 %) conformed strictly to the instructions given, posing challenges for data coding. The EQ-VAS data have a predictable and consistent relationship with the EQ-5D profile, although the correlations between the EQ-VAS and other measures of patient-reported health, both before and after surgery and in the change between them, are weak.

Conclusions

EQ-VAS data might be improved by providing better guidance on collection and coding. It is argued that the observed differences in results from EQ-VAS and other measures of health reflect the fact that it measures a broader underlying construct of health, arguably providing a means of summarising overall health that is closer to the patient’s perspective.

Bilateral giant inguinoscrotal Hernia: psychosocial issues and a new classification

BACKGROUND

Bilateral giant inguinoscrotal hernias pose challenging psychosocial problems to the patient. The engulfed phallus and hernia size are socially embarrassing and may make penetration during coitus increasingly difficult and uncomfortable. This paper presents a classification and the psychosocial aspects of bilateral giant inguinoscrotal hernias.

METHODS

A prospective study of patients with bilateral giant inguinoscrotal hernia in which the phallus was completely engulfed by the swelling, managed by this author between 2002 and 2011 in both urban and rural practice in Nigeria and Sierra Leone was reviewed and analyzed using a simple frequency distribution.

RESULTS

Eleven patients with bilateral giant inguinoscrotal hernias were reviewed. Age range 63-86 years. Mean age 73.73 (± 6.96SD) years. The reason for delayed presentation was financial constraint. Six patients (54.55%) presented due to continuous refusal of coitus by their partners. Sexual satisfaction was poor in all the patients (100.00%). All the patients (100.00%) had poor self-esteem and poor socialization habits as a result of continuous ridicule from peers and colleagues.

CONCLUSION

To improve quality of life of the elderly, there is the need for early awareness campaigns and provision of improved access to free surgical health care services particularly in rural African communities.

Informed consent for inguinal herniorrhaphy and cholecystectomy: describing how patients make decisions to have surgery

BACKGROUND

We describe how patients perceive the process of informed consent and its influence on decision making for elective surgery.

METHODS

A cohort of 38 patients documented consent for cholecystectomy or inguinal herniorrhaphy using the Veterans Affair's computer-based tool for documenting informed consent for clinical treatment. Participants completed semistructured telephone interviews exploring their attitudes about informed consent, iMed, and the decision-making process. We used qualitative methods to code and analyze the data.

RESULTS

Sixty-nine percent of patients decided to have surgery before meeting their surgeon, and 47% stated that the surgeon did not influence their decision. Although the surgeon was an important source of information for most patients (81%), patients frequently described using information gathered before meeting the surgeon, such as other health care providers (81%) or family members (58%). Most (68%) patients perceived iMed as a legal formality with little influence on decision making.

CONCLUSIONS

Future research should examine whether patient decision making regarding elective surgery becomes better informed if nonsurgeon clinicians connect patients to educational resources such as iMed closer to the time of initial diagnosis and before meeting the surgeon.

Elective inguinal hernia repair: a unified informed consent, or who wants to know what?

Informed consent is increasingly being standardized. We sought to evaluate variability in the amount and quality of information desired by patients in choosing whether to undergo elective surgical hernia repair, a prototypical low- to moderate-risk common procedure. Consecutive stable outpatients were asked to assume that they were considering hernia repair and interviewed with a standard questionnaire that asked them to rate their interest in learning about the natural history, pathology, and management of inguinal hernia as well as herniorrhaphy complications and postoperative recovery. Ninety-eight consecutive patients exhibited substantial interpersonal variability in their level of interest in receiving information. Although interest in some types of information tended to correlate with interest in other types of information, patients' degree of interest in receiving information about anesthesia during the procedure was independent of other variables. Education and previous exposure to individuals with hernias also affected interest in receiving potentially important information before deciding whether to consent to hernia surgery. Patients may vary with regard to the information they want to receive when deciding whether to consent to an invasive procedure. It may be preferable to individualize the consent process to patients' preferences rather than adhering to standardized content.

Intra-operative natural sound decreases salivary amylase activity of patients undergoing inguinal hernia repair under epidural anesthesia

BACKGROUND

The perioperative period is psychologically as well as physically stressful for patients. Although music and sound are known to reduce patients' psychological stress, a few previous studies showed an objective outcome of music. The aim of the present study was to evaluate the relaxing effect of music during epidural anesthesia, using patients' salivary amylase activity.

METHODS

Thirty-two American Society of Anesthesiologists (ASA) I or II patients presenting for inguinal hernia repair under epidural anesthesia were randomly assigned to listen to sounds of a soft wind and a twitter (S group) or to have no sounds (N group). Patients' salivary amylase activity was evaluated on arrival to the operating room and at wound closure.

RESULTS

Intra-operative music significantly decreased salivary amylase activity at wound closure in the S group and the activity at wound closure of the S group was significantly smaller than that of the N group.

CONCLUSION

Intra-operative natural sound significantly decreased salivary amylase activity of patients undergoing inguinal hernia repair under epidural anesthesia.

Waiting for elective general surgery: impact on health related quality of life and psychosocial consequences

Background

Long waiting times for elective surgical treatment threaten timely care provision in several countries. The purpose of this study was to assess the impact of waiting for elective general surgery on the quality of life and psychosocial health of patients.

Methods

A cross-sectional questionnaire study with postoperative follow-up was performed among patients on waiting lists for surgical treatment of varicose veins (n = 176), inguinal hernia (n = 201), and gallstones (n = 128) in 27 hospitals.

Results

In each group the waiting period involved worse general health perceptions (GHPQ), more problems in quality of life (EuroQoL), and raised levels of anxiety (STAI) as compared to after surgery (all differences: p < 0.05). Quality of life was not affected in 19–36% of patients.

Emotional reactions to waiting were most negative among patients with gallstones. Prior information about the duration of the wait reduced the negativity of these reactions (p < 0.05).

Social activities were affected in 39% to 48% of the patients and 18%-23% of employed patients reported problems with work during the wait.

Having waited a longer time was associated with worse quality of life among patients with inguinal hernia. Longer waited times also engendered more negative reactions to waiting among patients with inguinal hernia and gallstones (multilevel regression analysis, p < 0.01).

Conclusion

Waiting for general surgery mainly involves a prolonged period of decreased health and an affected psychological and social life of the patient in waiting. Variation in the severity of these consequences across patients indicates that the prioritisation of patients could reduce the overall burden of waiting. Early information about the duration of the delay could further promote a patient's acceptance of waiting.

Discomfort five years after laparoscopic and Shouldice inguinal hernia repair: a randomised trial with 867 patients. A report from the SMIL study group

BACKGROUND

In recent years long-term discomfort after inguinal hernia surgery has become an issue of great concern to hernia surgeons. Long-term results on discomfort from large randomised studies are sparse.

METHODS

One-thousand one-hundred and eighty-three patients were randomised in a multicentre trial with the primary aim of comparing recurrence rates after laparoscopic TAPP and Shouldice repair. Evaluating late discomfort and its possible risk factors were secondary objectives, and are reported here. The patients were clinically examined after 1 and 5 years, and answered questionnaires 2 and 3 years postoperation.

RESULTS

Of 1,068 operated patients, 867 were eligible for analysis after 5 years (81.2%). The percentage of patients experiencing discomfort of any kind were 8.5% in the TAPP group and 11.4% (p = 0.156) in the Shouldice group. Although discomfort was usually mild it was severe for 0.2 and 0.7%, respectively. Severe pain the first postoperative week was a risk factor for late discomfort in the Shouldice group (OR 2.25, P = 0.022) but not in the TAPP group. No other risk factor for late discomfort was found.

CONCLUSION

There was no difference between late discomfort at five-year follow-up after laparoscopic TAPP and Shouldice repair. Discomfort was mostly mild and pain during the first postoperative week was a prognostic variable for late discomfort in Shouldice patients.

Does an informative video before inguinal hernia surgical repair influence postoperative quality of life? Results of a prospective randomized study

PURPOSE

Patients undergoing surgery can be impaired in several health-related quality of life areas. As a result, a modern and effective presentation of medical information before elective surgery is of great importance. Thorough preoperative education of the patient could possibly lead to an improvement of postoperative quality of life.

MATERIALS AND METHODS

In a prospective randomized study we examined the influence of a preoperative informative video on the postoperative quality of life of patients undergoing elective surgery for inguinal hernia. Quality of life was assessed with a short form questionnaire (SF-36) preoperatively, on the first postoperative day and 3, 6, and 12 months after surgery.

RESULTS

From January 2004 until January 2005, 100 patients were included in the study (video group n = 50 patients, control group n = 50 patients). Quality of life was measured higher in the video group soon after surgery and until 3 months afterwards. In the same group other aspects evaluated such as "global health" and "social role" showed higher values postoperatively and resumption of preoperative activities took place earlier. No difference was detectable 6 months after surgery.

CONCLUSION

Informative video presents a modern and cost-effective method for the justified and detailed education of the patient about the several pre-, intra-, and postoperative steps of an elective groin hernia operation. The higher information level and the better conditions of surgical care, as the patients perceive these, lead to a better postoperative quality of life.

Ambulatory total extraperitoneal inguinal hernia repair: feasibility and impact on quality of life

BACKGROUND AND OBJECTIVES

Feasibility of ambulatory laparoscopic inguinal hernia repair in developing countries is not known due to lack of dedicated outpatient centers. This study prospectively evaluated the feasibility of outpatient discharge after laparoscopic total extraperitoneal inguinal hernia repair done in combination with in-hospital services and its impact on quality of life.

METHODS

Forty patients were studied who had uncomplicated inguinal hernias and fulfilled the selection criteria. Quality of life was evaluated by using the SF-12 questionnaire.

RESULTS

Ninety percent of patients could be discharged as outpatients. Four patients required admission. No major complications or readmissions occurred. Physical components of quality of life deteriorated in the immediate postoperative period but improved to above preoperative levels within one month. A transient deterioration in subgroups of the mental health component was observed, which recovered to normal in less than a week. There was no significant alteration in the emotional component. There has been no recurrence at a median follow-up of 25 months.

CONCLUSION

It was feasible to safely perform outpatient TEP in combination with routine in-hospital services without increasing complications or causing any adverse impact on quality of life. This was possible subject to adherence to proper selection and discharge criteria.

QUALITY OF LIFE ASSESSMENT IN PATIENTS WITH INGUINAL HERNIA

BACKGROUND

The natural history of untreated inguinal hernia (IH) is poorly understood. Whether a delay in operative repair of IH leads to excessive physical suffering or significant psychosocial impairment is not known. This study attempts to quantify the morbidity of patients with IH by assessing their quality of life (QOL) while on a waiting list for IH surgery.

METHODS

QOL was measured in adult patients with IH who were on the waiting list using a standardized SF-36 questionnaire. Scores were compared with a sample of age-, sex- and comorbidity-matched controls.

RESULTS

A total of 143 patients were identified, of which 106 were included in the study. Patients with IH had significantly impaired QOL compared with comorbidity- and demographic-matched controls across all of the domains measured. Subgroup analysis showed an inverse relationship between the size of the IH and the QOL and patients employed in manual work tended to have lower QOL compared with those with sedentary vocations.

CONCLUSIONS

In conclusion, we showed that the SF-36 score is a good measure of QOL in this patient group. Those patients on the elective waiting list for repair of IH have a significantly impaired QOL compared with age-, sex- and comorbidity-matched controls.

Assessment of patient functional status after surgery

BACKGROUND

Improvement in day-to-day functioning is a valued outcome of surgical intervention. A new functional status assessment instrument, the Activities Assessment Scale (AAS), was designed for a randomized clinical trial evaluating laparoscopic versus open hernia repair procedures.

STUDY DESIGN

The study data set included 2,164 patients at baseline and 1,562 patients at 3-month followup. Only male patients were enrolled in the trial. The psychometric characteristics of the AAS were examined in statistical analyses of cross-sectional and longitudinal data from the trial. Correlational analyses, factor analyses, and t-tests were used to evaluate scale performance.

RESULTS

We found that the AAS was a reliable measure (Cronbach's Coefficient Alpha =0.85) in the patient population studied. Factor analyses identified three subscales (sedentary activities; ambulatory activities; work and exercise activities). Construct validity was demonstrated by a correlation of 0.65 between the AAS and the physical functioning (PF) dimension of the SF-36 (p < 0.001); comparisons between clinical subgroups further confirmed its validity (p < 0.001). Patients reporting improvement on the physical functioning dimension after surgery showed an effect size of 1.20 for preoperative-postoperative change in their AAS scores.

CONCLUSIONS

The AAS has been demonstrated to be a reliable, valid, and clinically responsive instrument that can be used to evaluate patient functioning after hernia surgery. It is easy to administer and requires less than 5 minutes of patient time to complete. This measurement system may prove useful in assessing surgical outcomes in both research and office practice settings.

Psychological evaluation of children with idiopathic constipation and their parents

BACKGROUND

Constipation is one of the most common problems in childhood. In idiopathic constipation it is not possible to identify primary cause in every case. Child behavioral problems and disturbances in parent-child relationships have been cited as causes of constipation. Constipation is a source of anxiety to the child and to the family. The purpose of the present study was to evaluate psychological characteristics of constipated children and their parents.

METHODS

Thirty-two otherwise healthy children with idiopathic constipation over 4 years old were prospectively evaluated between January 2002 and June 2003. The Child Behavior Checklist (CBCL) and Symptom Checklist-90 revised (SCL-90-R) were used to assess the psychological profiles of the children and the parents, respectively. Thirty children with inguinal hernia who had no constipation or other problems, and their parents were asked to complete the checklists as controls. The scores of the constipation group were compared statistically with those of the control group.

RESULTS

In the constipation group there were 19 boys and 13 girls with a mean age of 7.3 years (4-14 years). All the patients responded to medical treatment. Constipated children and their parents were not found to have more behavior problems than the control group (P > 0.05).

CONCLUSIONS

Children with idiopathic constipation and their parents do not show significant behavioral and emotional problems. Their psychological profiles are not different from the general population.

The parental perspective regarding the contralateral inguinal region in a child with a known unilateral inguinal hernia

PURPOSE

The management of the contralateral region in a child with a known inguinal hernia has been debated by surgeons for more than 50 years. However, the perspective of the child's parents has not been sought, and this study was designed to evaluate parental views on this topic.

METHODS

After IRB approval, all patients less than 10 years of age with a unilateral inguinal hernia seen by the senior surgeon were studied prospectively from November 2001 through February 2003. A study sheet was given to the parents about the nature of an inguinal hernia, the incidence of 20% to 40% of a contralateral patent processus vaginalis (CPPV), and the possible surgical options (perform repair of the unilateral inguinal hernia only, repair the unilateral inguinal hernia with contralateral exploration and repair if indicated, or unilateral inguinal hernia repair with laparoscopy through the ipsilateral hernia sac and repair of a CPPV if discovered). The parents of the last 113 patients requesting contralateral inspection were asked their motives (convenience or anesthesia concerns) regarding their decision.

RESULTS

One hundred sixty-seven patients comprise the study group. Twelve parents chose unilateral repair alone, 13 chose bilateral incisions with contralateral repair if a CPPV was found, and 142 chose unilateral hernia repair with laparoscopic contralateral inspection followed by repair if needed. Regarding their motives, 90 of the last 113 parents requesting contralateral inspection indicated that convenience was the primary motive. Surprisingly, only 21 exhibited concerns about their child undergoing a second anesthesia.

CONCLUSIONS

When presented options regarding management of a unilateral inguinal hernia, parents preferred laparoscopic inspection and repair of the contralateral region, if needed, more for convenience than for concerns about a second procedure and anesthesia.

Psychological stress impairs early wound repair following surgery

OBJECTIVE

Laboratory studies have demonstrated that psychological stress is associated with slower healing of small superficial wounds. The application of this finding to the clinical environment has not yet been undertaken. In order to do this, we investigated the relationship between psychological stress and wound repair in patients following routine surgery.

METHODS

Forty-seven adults with an inguinal hernia were given a standardized questionnaire assessing psychological stress and worry about the operation before undergoing open incision repair. Wound fluid was collected from 36 participants over the first 20-hour postoperative period. Wound healing was assessed by levels of interleukin-1, interleukin-6, and matrix metalloproteinase-9 in the fluid. Other outcome measures included patient self-reports of recovery, as well as cytokine response to lipopolysaccharide stimulation of peripheral blood.

RESULTS

Greater preoperative perceived stress significantly predicted lower levels of interleukin-1 in the wound fluid (beta = -0.44, p = 0.03). Greater worry about the operation predicted lower levels of matrix metalloproteinase-9 in the wound fluid (beta = -0.38, p = 0.03) as well as a more painful (beta = 0.51, p = 0.002), poorer (beta = -0.36, p = 0.04), and slower recovery (beta = 0.43, p = 0.01).

CONCLUSIONS

Psychological stress impairs the inflammatory response and matrix degradation processes in the wound immediately following surgery. This finding generalizes previous laboratory research to surgical patients and expands the known influence of stress to connective tissue matrix remodelling processes. These results suggest that in clinical practice, interventions to reduce the patient's psychological stress level may improve wound repair and recovery following surgery.

Dispositional pessimism predicts delayed return to normal activities after inguinal hernia operation

BACKGROUND

The traditional outcome measure to assess effectiveness of inguinal hernia operation was recurrence. Open mesh repair has reduced recurrence rates and attention is now turning to outcomes other than recurrence. The factors influencing the large variation in reported times of resumption of normal activities after inguinal hernia repair are many and diverse. The human factors influencing resumption of normal activity are rarely reported.

METHODS

We undertook a prospective study of 206 patients undergoing primary inguinal hernia repair in an ambulatory setting in a public hospital to ascertain whether dispositional outlook on life affected resumption of normal activity after hernia repair. Outlook on life was assessed using the life orientation test. An independent observer assessed the patients preoperatively and determined timing of resumption of normal activities.

RESULTS

Regression analysis showed a highly significant relationship between delayed return to normal activity and dispositional pessimism (P =.0004).

DISCUSSION

Dispositional pessimism correlates strongly with delayed return to normal activities. Further studies of this kind will help to elucidate the human factors that affect recovery after operation. Studies which use return to normal activities as a measure of the outcome of a surgical technique should include an assessment of the patient's preoperative outlook on life. Surgeons should consider the personality of the patient presenting for groin hernia repair and may wish to tailor their counseling accordingly.

Outcomes research: an interdisciplinary perspective

Outcomes achieved by healthcare providers are a function of patient clinical and demographic characteristics, baseline health status, delivered treatments and interventions, and setting characteristics. This article describes a prospective, interdisciplinary study of the outcomes of selected surgeries using both generic and condition-specific data collection instruments. The results of several different analyses are discussed, which illustrate the usefulness of such an effort for patients, nurses and physicians, the institution, and the respective disciplines in general.

Return to work after inguinal hernia repair

BACKGROUND

There is much variation in the time when a patient returns to work after inguinal hernia repair. Most surgical research has focused on the type of operation performed, but other factors may be equally or more important. This study attempted to identify these factors.

METHODS

We prospectively studied the return to work after inguinal hernia repair in a convenience sample of 235 patients who were operated on by one surgical group. Ninety-three of these subjects, who were working and had complete data, were included in this analysis. Data were gathered through personal interviews, written surveys, and medical record reviews. The main outcome measures were actual and expected return to work.

RESULTS

Primary tissue repair was done in 94% of the patients. The mean age was 49 years; 90% were male. The expected return to work was 10 days; the actual mean return to work after operation was 12 days (median, 7 days; range, 2 to 60 days) and was unrelated to preoperative functional status. Bivariate analysis showed that age, educational level, income level, occupation, symptoms of depression, and the expected return to work accounted for 61% of the variation in actual return to work.

CONCLUSIONS

Factors other than operative technique, including patient expectations, are strongly associated with return to work after inguinal hernia repair. Depression significantly delayed return to work. More research is needed to understand how expectations are formed and how decisions are made regarding return to work, and whether these can and/or should be influenced by surgeons, employers, or others to promote earlier return to work.

Back to work more quickly after an inguinal hernia repair

Tension-free hernia repair plus recovery expectancy statements return personnel to work more quickly. On the day of primary inguinal hernia repair, patients were given statements about their likelihood of returning from convalescent leave after 7 days and performing nonstrenuous work. Similar statements were given to them by telephone at 72 hours postoperatively and at a 1-week follow-up appointments. Seventy-four percent of the 73 patients returned to nonstrenuous work within 7 days, and 90% returned to strenuous work within 30 days. In this small sample, 385 work days were saved from the Navy's recommended 14 days of convalescent leave. By combining recovery expectancy statements with an effective surgical procedure, it is possible to avoid prolonged convalescence, thereby enhancing military readiness.

[Effect of preoperative preoperative visualization therapy on postoperative outcome after inguinal hernia surgery and thyroid resection]

This randomized controlled trial aims to evaluate the influence of preoperative relaxation techniques on postoperative outcomes. From January 1997 to June 1998 208 patients were operated on for primary inguinal hernia or goiter. The patients were randomized into two groups: Group A (n = 103) underwent the surgical treatment with a preoperative visualization therapy. Group B (n = 105) underwent the surgical treatment without a preoperative therapy. Patients with age under 18 years, ASA-status IV-V, recurrent inguinal hernia or recurrent goiter and malignant neoplasms were excluded from the study. There were no differences in age, sex, duration of the operation, training of the surgeon, and preoperative blood parameters between the two groups.

RESULTS

During the postoperative follow-up we observed more hematomas (group A with visualization therapy: 30.3%, group B without visualization therapy: 44.4%) as well as more pain (group A: 4.2, group B: 5.2) and analgesic consumption (group A: 59.7 mg Tramadol HCL, group B: 72.5 mg Tramadol HCL) in group B (p < 0.05). There were no significant differences in infections, nausea, hypocalcemia, tetania, recurrent nerve palsy, fever.

CONCLUSIONS

Preoperative visualization therapy reduces significantly the number of postoperative hematomas after inguinal hernia repair. Furthermore a decrease of analgesic requirements after surgical treatment was observed.

Patient acceptance of outpatient treatment for inguinal hernia in Jos, Nigeria

BACKGROUND

Patient acceptability constitutes an important component of outpatient treatment for hernias. It is essential that patients are properly selected so that only those who need admission are admitted and cared for with the limited available resources. It is also equally important that those who qualify for outpatient care are adequately informed that there is no added risk attributable to outpatient treatment and that they are free to accept or reject such treatment.

OBJECTIVE

To determine the acceptability of day care treatment for inguinal hernia in our environment.

DESIGN

Prospective cross sectional study.

SETTING

Jos University Teaching Hospital.

SUBJECTS

121 selected patients were randomized to undergo elective inguinal hernia repair either as outpatients (61) or inpatients (60).

MAIN OUTCOME MEASURES

Six weeks after operation, an assessment of patients' opinion was made as to their preferred method.

RESULTS

52 of 61 day cases and 24 of 60 inpatients preferred outpatient treatment, while two daycare patients and 36 inpatients preferred hospital admission (p < 0.001). Altogether, acceptability rate for outpatient treatment was 68.6%.

CONCLUSION

in carefully selected and adequately informed patients, outpatient elective inguinal hernia repair is readily acceptable.

Brief report: behavioral correlates of postoperative pain in toddlers and preschoolers

OBJECTIVE

To investigate the association between preoperative parent and child behaviors and postoperative pain in toddlers and preschoolers.

METHOD

Participants were 74 pediatric patients (59 boys, 15 girls), scheduled for inguinal hernia or hydrocele repair, and their parents. Children ranged in age from 12 to 64 months (M = 33.7 months, SD = 14.7 months). Child and parent behaviors were assessed 30 minutes prior to surgery using the Behavioral Observation Scale (BOS), a modified version of the Dyadic Prestressor Interaction Scale (Melamed & Bush, 1985. Postoperative pain was assessed using an observational measure, the Toddler-Preschooler Postoperative Pain Scale (TPPPS) (Tarbell, Cohen, & Marsh, 1992).

RESULTS

Postoperative pain was negatively related to parents' provision of surgery-relevant information during the preoperative observation period.

CONCLUSIONS

Preoperative interventions for young children should include information about the surgery experience.

Quality of life in patients undergoing inguinal hernia repair

Inguinal hernia repair is one of the most common surgical procedures undertaken in the NHS. Despite this, no previous work has examined quality of life in this patient group. This study examines quality of life preoperatively and at 3 and 6 months postoperatively in 140 patients undergoing inguinal hernia repair in the context of a randomised controlled trial of laparoscopic versus open hernia repair. Surgery was undertaken on a day case basis, and quality of life was assessed using the Short Form 36 (SF36). In the initial phase of the study, 57% of those screened for suitability met the study inclusion criteria and were randomised. No significant differences were found between laparoscopic and open hernia repair in terms of quality of life at 3 and 6 months postoperatively. No difference was found between 3 and 6 month scores, suggesting that patients had already made a good recovery by 3 months. A significant improvement was found between preoperative and postoperative scores, with the greatest change arising on dimensions assessing pain, physical function, and role limitation owing to physical restriction. After standardising for age, sex, and social class, a comparison of the hernia patients to population norms for the SF36 was consistent with improvement from preoperative to postoperative assessment. This study has demonstrated the improvement in quality of life in patients undergoing elective inguinal hernia repair by experienced surgeons on a day case basis. It has also demonstrated the feasibility of assessing quality of life using generic measures in this patient group. Further work in this area is required. Ultimately, the priority given to elective inguinal hernia repair will depend on how the demonstrated benefits compare with those derived from other elective surgical procedures.

[Patient information in surgery]

In a prospective study 50 patients undergoing a hernia repair were asked their opinion about an information sheet which was given to them preoperatively. For 94% this paper is of help; for 82% the written information has to be clarified by an additional personal talk with the doctor. Another possibility, especially good for visualisation, is the video. At the hospital of Davos there are at the moment 7 clips available to explain the treatment and the aftercare after an operation or conservative therapy in traumatology.

Who's afraid of informed consent?

OBJECTIVE

To test the assumption that patients will become unduly anxious if they are given detailed information about the risks of surgery in an attempt to obtain fully informed consent.

DESIGN

Preoperative anxiety assessed before and after patients were randomly allocated an information sheet containing either simple or detailed descriptions of possible postoperative complications.

SETTING

Four surgical wards at two Sheffield hospitals.

SUBJECTS

96 men undergoing elective inguinal hernia repair under general anaesthesia.

MAIN OUTCOME MEASURE

Change in anxiety level observed after receiving information about potential complications.

RESULTS

Detailed information did not increase patient anxiety (mean Spielberger score at baseline 33.7 (95% confidence interval 31.3 to 36.2), after information 34.8 (32.1 to 37.5); p = 0.20, paired t test). A simple explanation of the facts provided a statistically significant degree of reassurance (mean score at baseline 34.6 (31.5 to 37.6), after information 32.3 (29.8 to 34.9); p = 0.012), although this small effect is likely to be clinically important only in those whose baseline anxiety was high (r = 0.27, p = 0.05).

CONCLUSIONS

In men undergoing elective inguinal hernia repair a very detailed account of what might go wrong does not increase patient anxiety significantly and has the advantage of allowing patients a fully informed choice before they consent to surgery, thus reducing the potential for subsequent litigation.

[Information to patients following surgery for cancer]

Patients who are operated upon for cancer tumour are anxious about the postoperative information and the result of the surgical procedure. This investigation was undertaken to study the routines for postoperative information in a department of surgical oncology. Thirty two patients operated for abdominal cancer ("cancer patients") and 36 patients operated for inguinal hernia or gallstone disease ("hernia patients") answered a questionnaire with 16 questions. Sixty nine percent replied. The need for postoperative information about the result of the operation was higher for the cancer patients than for the hernia patients. The cancer patients were given more attention by the doctors postoperatively and were given more opportunities to ask about the operation than the hernia patients. However, there was lack of privacy in the information situation and both groups were informed on the ward in presence of other patients.