Showing papers in "Hernia in 1998"

Long-term result and current status of the Lichtenstein open tension-free hernioplasty

Abstract: The tension-free hernioplasty project began in 1984 at the Lichtenstein Hernia Institute. The method consists of complete reinforcement of the inguinal floor with a large sheet of mesh, with adequate mesh tissue interface beyond the boundary of the inguinal floor and creation of a new internal ring made of prosthesis. The preliminary report of this operation was published in 1989, with no recurrence at that point in time. Shortly after the submission of the report, several recurrences were encountered. Based on the lesson learned from those recurrences, the operation was slightly modified and reported in 1991 [Amid 1993]. Since then, the Lichtenstein technique has gained world-wide popularity. Outcome measures identical to ours and other authors have been achieved by even those surgeons who have no special interest or expertise in herniology. The purpose of this article is to report the current state of the open tension-free hernioplasty for the repair of primary and recurrent inguinal hernias.

Incisional hernias in midline incisions: An eight-year follow up

Abstract: The aim of this study was to report the incidence of incisional hernias following midline laparotomy incisions after 12 months and after 8 years. 374 patients who underwent midline laparotomy between August 1989 and December 1990 were included. The wounds were closed with a continuous suture and the technique was monitored by the suture length to wound length ratio. The incidence of incisional hernia, defined as a palpable defect in the fascia or a protrusion beyond this level, was monitored at 12 months and after 8 years. Early wound dehiscence occurred in 3 patients (1%) and wound infection in 32 (9%). At the 12-month examination 58 (20%) incisional hernias were detected in 292 patients. After 8 years 142 patients were examined and 5 (3%) hernias were found. All hernias that caused inconvenience or required surgical repair were detected at 12 months follow-up. Most hernias appearing later have probably been overlooked at the first examination.

The healing of laparotomies: review of the literature

Abstract: Closure of laparotomy incisions continues to be followed by complications such as infection, granuloma and fistula formation, and most particularly burst abdomen and incisional hernia. In spite of technological progress in the matter of suture materials, the incidence of burst abdomen remains unchanged. This study has the object of examining in the first place the physiological and pathological processes of scar tissue formation, in order to establish what are the best means of opening and closing the abdomen, as well as giving some guidelines as to the best suture materials. Normal healing is a complex process which comprises three phases which are fundamentally the same for all tissues. However, the speed with which they develop depends on the regenerative potential and repair of the damaged tissue. Healing of a wound may be considered to be complete when it has succeeded in re-establishing the function of the tissue which was injured. Aponeuroses, the function of which is mechanical, have weak powers of regeneration, and take a long time to repair. The abdominal wall only regains its preoperative resistance and strength at the fourth post operative month. Several general and local factors may interfere with the normal healing process of a laparotomy.

Groin hernia repair via a grid-iron incision: an alternative technique for preperitoneal mesh insertion

Abstract: Covering the myopectineal orifice of Fruchaud with a non-absorbable prosthesis in the preperitoneal space is a well established method for the repair of (recurrent) groin hernias. The laparoscopic extraperitoneal approach is widely used, but is a difficult technique which carries the disadvantages of high costs and the need for general anesthesia. An alternative method of placing a prosthesis of equal size in the preperitoneal space is described.

Abdominal wall compliance after Marlex® mesh implantation for incisional hernia repair

Abstract: In view of the poor results of suturing techniques, incisional hernias are often best repaired with biomaterials. Their use brings the recurrence rate to below 10%, but patients sometimes complain of discomfort and restricted abdominal mobility. We report our experience with 41 patients after implantation of a Marlex®-mesh in a preperitoneal, retromuscular position (mean follow-up period 16.7 months). The effect of implanted meshes on abdominal wall mobility was measured noninvasively with the aid of three dimensional stereography and compared with a non-operated healthy control group (n = 21). The commonest early postoperative complication was seroma in 32% of cases, usually relieved by aspiration. Infection and hematoma were less frequent at 4.9% and 12.2% respectively. Three patients developed a recurrent hernia. During follow-up 7.3% experienced pain during heavy activities, 29.3% during daily activities and 4.9% at rest. Three dimensional stereography showed a highly significant (p < 0.001) decrease in abdominal wall mobility following mesh implantation, compared to a non-operated control group. Improved composition of the mesh material involving a smaller proportion of polypropylene and greater elasticity, should be considered for the future, in order to reduce patient discomfort.

Metabolic factors contributing to herniation A review

Abstract: Modern herniology began during the golden century of anatomy (1750–1850), the underlying assumption being that the tissues lining the various abdominal defects were normal and would stay so. Even though Harrison [1922], Keith [1923] and Andrews [1924] questioned this dictum, it was not until 1964 that the possibility of connective tissue abnormalities was suggested. Thirty years ago, I noticed attenuation of the rectus sheath, and therefore, transversalis fascia in veterans undergoing preperitoneal repair. Evidence was accumulated suggesting leakage of proteases from the lungs of these heavy smokers as the mechanism (metastatic emphysema). A similar phenomenon was cited to explain the development of aortic aneurysm in this population. The evidence to support these concepts is reviewed and the mechanism has been extended to incisional herniation. Recently, studies primarily in non-smokers have shown that the genetic expression of collagen type I and III synthesis can be influenced by mutation. These data indicate that more than one factor can cause a systemic metabolic disease of collagen leading to abdominal herniation.

The mesh plug repair of groin hernias: A three year experience

Abstract: The first results of 140 mesh plug repairs for groin hernias are reported retrospectively. The procedures were performed by 4 surgeons who were totally free to choose mesh plug repair in every individual case. From January 1995 to October 1997 the choice of this operation increased from 20% to 54%. The operation was performed with slight modifications of the original technique as described by Rutkow and Robbins. 84% of the patients were available to follow-up (median 34 months, extremes 3 to 58). Results can be considered as good concerning the recurrence rate (0.9%) but tolerance of the material remains questionable: 7 patients (6.3%) experienced long-lasting pain in the groin leading to plug removal in 2 cases. These data must be considered and need further evaluation.

Laparoscopic inguinal anatomy

Abstract: Irrespective of the merits of laparoscopic herniorrhaphy, the anatomy of this surgical approach is poorly understood by most surgeons. To describe and document the normal analtomy and its variations, the inguinal region was dissected from peritoneum outward by the open method in 70 cadaveric sides and by the closed laparoscopic method in 28 cadaveric sides. In our results we describe the various layers, fossae, spaces and their contents. The data presented include variations of nerves in the inguinal area and measurements of bony landmarks from important neurovascular elements. In 74%, the distance from anterior superior iliac spine (ASIS) to pubic tubercle (PT) was 11 cm (10.0–14.0); in 56% ASIS to external iliac vessels was 6 cm (4.5–7.5 cm); ASIS to femoral nerve in 64% was 5 cm (3.0–7.5). The lateral femoral cutaneous nerve was found 1–4.5 cm medial to ASIS in 15%, increasing the possibility of nerve injury. In 25.5% the ilioinguinal nerve ran through the iliac fossa, in some cases passing through the iliopubic tract. In 18% the lateral femoral cutaneous and ilioinguinal nerves were combined, and in 7.7% the ilioinguinal and genitofemoral nerves were combined. It is critical for laparoscopic surgeons to be aware of the normal inguinal anatomy and its variants to avoid unnecessary injury and pain. It is important to remember that in approximately 30% of cases, the laparoscopic anatomy of one side will not be a mirror image of the other side.

Flat plug and mesh hernioplasty in the “Inguinal box”: description of the surgical technique

Abstract: A new anatomical terminology is used for a better understanding of the operation and for more accurate identification of the boundaries and spaces of the inguinal region. Inguinal mesh and plug hernioplasties are performed using prostheses of different sizes and shapes, either sutured or not, to the tissues. A tension-free, sutureless pre-shaped mesh inguinal hernioplasty, performed within the boundaries of the lateral and medial ≪inguinal box≫ has several advantages as compared with other mesh techniques. The sutureless implantation of a flat plug and a pre-shaped prosthesis can be performed in all primary inguinal hernioplasties.The aim of this article is to describe a surgical technique which has been used in 3,422 patients.

Laparoscopic and open abdominal wall reconstruction using Parietex® meshes Clinical results in 2700 hernias

Abstract: The authors report a series of 2445 inguinal hernias and 272 incisional hernias treated between 1993 and 1997 by the insertion of a Parietex mesh via either a laparoscopic (1595 procedures) or an open approach (578 procedures) Pain scores and time to return to normal activity were lower in the laparoscopic group than in the open surgery group (p < 0001) In all of the groups, the average incidence of the total reported events (complications) was around 10% with no statistical difference This ratio seemed to compare favourably to previously published reports Considering inguinal hernias in particular, chronic pain was extremely rare (06% in the laparoscopic group and 08% in the open surgery group) Whatever the approach, sepsis was also very rare (1/1526 laparoscopic procedures, 2/380 open operations) These findings illustrate the local tolerance of the mesh Recurrence rates were below 1% with no statistical difference between groups This retrospective study demonstrates the clinically apparent local tolerance of this type of mesh Prospective and long term clinical results will be necessary to show whether the short term tolerance of Parietex mesh influences the long term functional results

Some problems encountered at re-operation following repair of groin hernias with pre-peritoneal prostheses

Abstract: The easy performance and efficiency of these repairs is nonetheless accompanied by some drawbacks of which the surgeon should be aware. These may be discovered when reoperating on the bladder, prostate or iliac vessels. The difficulties are related to the extensive fibrosis involving the cave of Retzius and/or the space of Bogros. The authors report their intraoperative and anatomical findings. They propose the following solutions: 1. When cleavage of the cave of Retzius is impossible (in bladder or prostate surgery): a retropubic subperiosteal plane is developed, either isolated or combined with a transperitoneal approach. 2. When cleavage of the space of Bogros is impossible (in surgery on the iliac vessels): a transperitoneal approach is used. Prevention of fibrosis after the use of large prostheses can be achieved by preservation of the funicular sheath which protects the iliac vessels, providing no slit has been made in the mesh and by preservation of the umbilico-prevesical fascia.

Application of three-dimensional stereography to assess abdominal wall mobility

Abstract: Functional impairment of the abdominal wall can cause serious discomfort in patients, even during daily activity. We introduce a new method to describe and calculate abdominal wall mobility and its disturbances. The abdominal wall compliance can be measured non-invasively by three-dimensional stereography. Three-dimensional stereography is an optical method for measuring the topography of surfaces. The deformation of a light grid projected onto the abdominal wall is documented by video. After automatic digitisation of the pictures the computer calculates changes of the surface area. The abdominal wall mobility can then be measured by comparing the abdominal surface changes in minimum and maximum excursions. Measurement of defined geometric bodies proved the accuracy of our method with a variation under 5%. We found an abdominal wall mobility in normal persons (n=21) of 5.4 cm ± 1.9 for height difference, 2.6 1/100 cm ± 1.4 for the minimum curvature difference, 6.2 1/100 cm ± 1.8 for the maximum curvature (p<0.01), 110 cm ± 74 for the adjusted radius at minimum excursion and 41 cm ± 14 at maximum excursion (p<0.01). This method allows us to calculate abdominal wall compliance and its restriction. Comparison of pre- and postoperative data could help us to assess the success of operations concerning the abdominal wall.

Incarcerated anterior abdominal wall hernias in a community hospital

Abstract: Abdominal wall hernias are among the most common problems encontered by surgeons. It is generally agreed that a hernia should be electively repaired to avoid the complication of incarceration and its attendant risk of strangulation. Nevertheless, many patients remain undiagnosed or are reluctant to have surgical correction of hernias, and as a result many emergency procedures are performed for complications of neglected hernias. We performed a retrospective analysis of incarcerated anterior abdominal wall hernias, and we used multivariate analysis to identify variables that were predictive of gangrenous bowel. There were a total of 1680 anterior abdominal wall hernias during the study period. Surgery was performed emergently for acute incarceration in 132 patients (7.9%), 25% of these were strangulated, and 57.6% of the strangulated cases progressed to gangrene. Femoral hernias had the highest incidence of incarceration and strangulation. Independent predictors of gangrenous bowel were a pulse rate > 100, ASA class four or greater, radiographic evidence of obstruction and the presence of a femoral hernia. The overall mortality rate was 4.5% for the patients with incarceration, and 15.8% for the patients with gangrenous sac contents. The mortality from incarcerated anterior wall hernias has decreased over time, but mortality is still appreciable. Hernias should be repaired electively to avoid the complication of incarceration. The presence of gangrenous bowel can be predicted by a pulse rate > 100, ASA class four or greater, radiographic evidence of obstruction and the presence of a femoral hernia.

Repair of femoral hernias with "plug" technique

Abstract: Femoral hernia is one of the less frequently encountered forms of groin hernia, but nonetheless produces a considerable amount of surgical concern. The repair of femoral hernia utilizing traditional sutured techniques is frequently associated with complications and a significant incidence of recurrence. A series of 24 cases repaired with the meshplug technique is presented with technical details of the operative procedure. All of these operations were performed on an ambulatory basis in an out-of-hospital, government-certified, ambulatory surgical environment. Not a single case of recurrence or other significant complication has been encountered. This retrospective study demonstrates the efficacy and reliability of plug repair of femoral hernia.

Traumatic rupture of the right diaphragm

Abstract: The diagnosis and management of diaphragmatic injuries still presents a problem. In a recently published series the proportion of these injuries which is initially overlooked remains at between 20 and 40%, and the post-operative mortality at 21%. Based on two personal cases of rupture of the right diaphragm and on an analysis of published series, we endeavour to lay down some guidelines for the diagnosis and treatment of this injury. Appropriate radiological investigations include chest x-ray (which should be repeated), abdominal ultrasound and thoraco-abdominal tomodensitometry. The treatment is surgical. The preferred route of access in the elective case is via the thorax, but in emergency, in the absence of a pre-operative diagnosis, an abdominal route may be indicated.

Reoperations for chronic infections following prosthetic hernia repair

Abstract: The growing popularity of prosthetic hernia repair has resulted in a larger number of complications such as a chronically discharging sinus; in such cases, the infected mesh may have to be removed. Five reoperations were performed in the past five years, all in male patients aged 52 to 73 years. A cylinder plug was removed in two cases, and in the other three a partial or complete removal of the mesh was required. Four of the prostheses were made of polypropylene and one of dacron. Recovery was satisfactory in all patients; infection recurred in one case six months later, and one patient developed a new hernia. Alloplasty was performed in 1,190 hernias: 16 wound infections occurred, although no meshes had to be removed due to the onset of a chronically discharging sinus. The importance of monitoring the patients' condition and offering early treatment to avoid complications is highlighted. In conclusion, inexperience in prosthetic surgery appears to be the main risk factor. Cylinder plugs are most at risk, especially the larger or tightly rolled up ones. Inguinal hernia mesh-plug repair (cone-shaped plugs) appears to be a safe and reliable operation when correctly performed and followed up.

Tissue response to polyester mesh for hernia repair: An ultramicroscopic study in man

Abstract: We studied by ultramicroscopy the tissue response after mesh hernia repair. 11 patients, bearing dacron mesh from 7 days to 9 years, were biopsied during later operations. There were two groups of patients: 6 with a normal tissue response and 5 with rejection of the mesh. We observed that mesh repair was characterised by development of a foreign-body giant cell layer around the fibres, the presence of macrophages in an intermediate layer and fibroblasts in the outer layer. Collagen fibres and bundles ran between the giant cells and the host tissues. When the mesh was rejected, there were no chronic inflammatory cells and collagen bundles were reabsorbed. In the peripheral areas where the mesh-integrated tissue still persisted, there was a considerable reduction in the numbers of the giant cells and there were red blood cells and acute inflammatory cells instead of macrophages and epithelioid cells. Collagen was reduced to fibrils. From our results, mesh-tissue repair seems to be a dynamic and unstable process characterised by chronic inflammation and continuous collagen maturation. During the development, the tissue response to the mesh, as with any inflammatory condition, makes colorisation by hematogenic bacteria easier. Infection can destroy the capsule around the mesh and causes its rejection.

Laparoscopic treatment of a strangulated obturator hernia

Abstract: The authors report a case of strangulated obturator hernia, presenting a non-specific clinical picture, where the diagnosis and treatment were made by laparoscopy. This mini-invasive approach, in a predominantly female population where precise preoperative diagnosis is rare, allowed both rapid diagnosis and repair of the hernia. Apart from emergencies, laparoscopy also appears to be the intra- or preperitoneal approach of choice in the treatment of obturator hernias.

Long-term foreign-body reaction to preperitoneal polypropylene mesh in the pig

Abstract: The aim of the study is to establish the long-term foreign-body reaction to a polypropylene mesh used for inguinal hernia repair in a pig model. Twenty-two Surpipro® meshes were implanted in 22 preperitoneal inguinal areas in 11 female 10-week-old Yorkshire and Dutch landway swine. The prosthetic mesh was implanted using a laparoscopic transperitoneal technique. At 1, 2, 3, 4, 6, 12 and 26 weeks, the animals were sacreificed and the number of foreign-body giant-cells at the mesh-tissue interface was counted. The mean numbers of giant-cells (SD) after 1, 2, 3, 4, 6, 12 and 26 weeks were: 0.9 (2.4), 7.3 (5.4), 19 (8.2), 15.2 (7.9), 15.9 (6.9), 14.1 (5.6), and 8.2 (4.7). The mean number of giant-cells at 12 weeks was significantly lower than at 3 weeks. The mean number of giant-cells at 26 weeks was significantly lower than at 3, 4, 6, and 12 weeks. We conclude that the foreign-body giant-cell reaction to polypropylene mesh increases until the third week after implantation. Thereafter, it gradually decreases, and at six months it persists at half the maximal level at 3 weeks.

Ventral herniorrhaphy: Treatment evolution in a hernia service

Abstract: Between 1980 and 1996 the author operated at a teaching academic center and in a private hospital on 230 patients harboring ventral hernias. Fifty hernias were primary and one hundred eighty were incisional. Utilized techniques included direct tissue approximation or overlapping (N=35, recurrence rate 42%), ePTFE or polypropylene prostheses sutured to aponeurotic edges (N=147, recurrence rate 4.7%) and preperitoneal polyester prostheses (N=48, recurrence rate 2%). Nine wound infections occurred: three in clean, three in clean contaminated, and three in infected wounds, producing an overall 3.9 % infection rate. Thirteen markedly obese patients (Quetelet Index 31.9%) with gigantic multiply recurrent hernias offered a serious challenge requiring repeated procedures for recurrence, wound infection and mesh fragmentation. The technical transition leading to preperitoneal approaches utilizing polyester meshes lowered the overall complication rate and has become our procedure of choice until new prostheses are created.

Late colocutaneous fistula after mesh repair of an inguinal hernia

Abstract: Tension free prosthetic mesh reinforcement has become the most popular type of inguinal hernia repair in the UK due to very low complication and recurrence rates [RCSE 1993, Amid 1995]. Polypropylene (Marlex) or nylon are the most commonly used prosthetic materials although metal meshes were used in years gone [Smith 1971, Preston 1973]. We report a patient who developed a colocutaneous fistula, presumably due to the intraperitoneal migration of a metal mesh, more than 20 years after open inguinal hernia repair. This complication has not previously been reported.

Groin hernias — four year results of two randomised prospective studies comparing the Shouldice operation and the Stoppa procedure using a totally pre-peritoneal laparoscopic approach (461 patients)

Abstract: The aim of this study is to estimate, at a mean follow up period of 1464 days (4 years), the incidence of hernial recurrence after initial treatment by a laparoscopic approach (using a totally pre-peritoneal route-TPP) as compared with the Shouldice operation, and that of Stoppa. The patients were submitted to rigorous controls of inclusion and exclusion and were divided into two controlled studies. The operations were reviewed at one month, six months, one year and every year thereafter. The follow-up rate was 100% at one month, 90% at six months, 95% at one year, 92% at two years, 84% at three years, 79% at four years and 61% at five years. The incidence of early recurrence (one year) seems to be higher in the laparoscopic group (2.2%) as compared with the two other techniques (Shouldice 1.2% and Stoppa 0%) though this is not significant. At three years, the recurrence rate is comparable (not significant) in the three groups: 3.6% for laparoscopy, 5.1% for Shouldice, 5.2% for Stoppa. At four years, the incidence of recurrence was lower (not significant) for the laparoscopic approach 7.4% and for the two other techniques 12.5% and 10.5% respectively. Analysis of the factors for recurrence in the laparoscopic approach (TPP) made clear the determining role of the experience of the operator and of the size of the prosthesis which was used.

Herniology 1948–1998: Evolution toward excellence

Abstract: A historical review is presented of progress in the approach to the diagnosis and treatment of groin hernias during the years 1948–1998. This time frame includes many advances important to the improvement of our patient care for this very common entity. Four areas of especial interest were selected for review, including: 1. Importance of the posterior inguinal wall; 2. Fundamental changes in our use of prosthetic mesh, type and technique; 3. Individualization of hernia repair and 4. An appraisal of operative approaches and techniques extant at the end of the second millennium.

The open tension-free mesh repair of inguinal hernia Analysis of 1,235 cases

Abstract: 1235 outpatient repairs of inguinal hernias under local anesthesia with IV sedation were performed between September 1993 and June 1997. The average age was 63. Twelve percent were recurrent repairs. All indirect hernias and all focal diverticular type V direct defects were treated with a cone-shaped polypropylene plug plus an overlay mesh strip. All broad fusiform type IV direct defects were repaired either by the same plug method or in the manner of a Lichtenstein repair. Mortality was zero. There were 3 recurrences, 5 superficial hematomas, 5 seromas, 1 questionable neuralgia, 1 dysejaculation, 1 ischemie orchitis, 1 flare-up of gout and 1 TIA, for a complication rate of 1.46%. Infection rate was zero. Recurrence rate thus far is only 0.24%, 0.16% for primary repair and 0.67% for recurrent repair.

Incisional hernia following appendectomy. Surgical experience

Abstract: Appendectomy is a very frequent cause of incisional hernia. In this paper the rate of recurrence after the hernia repair by simple suture and mesh repair was studied. 17 lateral incisional hernias secondary to appendectomy were repaired over a 9 year period. Prosthetic repair was carried out in 9 cases and primary closure in the remaining 8 cases. All the patients were followed over a period that ranged from 1 to 8 years (mean 5.6 years). There was one recurrence, though 2 patients (11.7%) with mesh repair complained about abdominal pain during the first postoperative year. The study concludes that both techniques can be successfully implemented if the correct indications based on the extent of the defect and the clinical characteristics of the patient are respected.

Is high ligation of the indirect hernia sac essential in inguinal hernioplasty

Abstract: High ligation of indirect hernias sacs, once considered essential in groin hernioplasties, is now thought superfluous by some authors. Between 1970 and 1990, 2120 indirect hernioplasties in men were performed using the Shouldice technique. In 923 of this group, the indirect inguinal hernia sacs were ligated high before amputation and in 1197 of them the indirect hernia sacs were amputated high without ligation and the edges of the sac allowed to retract. The recurrence rate in the ligated group was 0.43 % (4/923) and in the non-ligated group was 1.7 % (20/1197) respectively. The difference between the two groups is significant (p = .0058, Fisher's exact test by chi-square) and indicates that for good results indirect hernia sacs should be ligated during Shouldice inguinal hernioplasties.

Elective herniorrhaphy in the aged

Abstract: The aged are the most rapidly growing population subset in the United States. The 1995 Census figures recorded eight million persons over the age of 80. This was 3% of the total population. It is projected that this figure will double by the year 2050. Between 1994 and 1996, 62 elective operations for hernias of the abdominal wall were performed in 55 patients between the ages of 80 and 95.39 patients had severe systemic disease with definite functional limitations (A.S.A. Class III), and the disease in four patients constituted a continuous threat to life (A.S.A. Class IV). Six bilateral inguinal repairs were staged, and one was performed at the same operation. Fifty-height operations were performed in an ambulatory setting. Four cases were admitted on the morning of surgery and discharged on the first postoperative day. All groin hernias were repaired using local anesthesia monitored by an anesthesiologist. There were no perioperative complications and there was no mortality. One patient developed an asymptomatic recurrence. Neither chronological age nor severe systemic disease need be a contraindication for hernia repair. Local anesthesia is strongly recommended whenever possible.

A suggested method for laparoscopic herniorrhaphy resident training

Abstract: The learning curve for laparoscopic herniorrhaphy (LH) is relatively long. Resident training is ideal for the acquisition of operative skills and yet intensive feedback is necessary for more complex procedures. A method whereby faculty provide objective and specific feedback for the technical details of operative LH is described. First a pretest focusing on important aspects of LH and relevant anatomy is given to the resident the day prior to the procedure. Immediately following the operation, the faculty and resident complete an evaluation form together to stimulate discussion and provide constructive feedback. This method of teaching is especially applicable at the resident training level but can be utilized by postgraduate surgeons willing to undergo the criticisms associated with objective operative feedback. Instant operative feedback is beneficial for all including the faculty member who by necessity is forced to communicate in specific terms the operative steps leading to the safe and effective conduct of LH.

Postoperative analgesia in herniorrhaphy with local anesthesia and monitored anesthesia care

Abstract: In this study the authors evaluated the grade of acceptance and the operating conditions of unilateral primary herniorrhaphy under local anesthesia and monitored anesthesia care (MAC). The amount of pain in the immediate postoperative period was assessed and the efficacy of treatment using a popular non-opiate analgesic, magnesic metamizol, by the oral route was studied. In a period of six months 63 consecutive patients were operated on by the same surgeon using the same technique of hernia repair (Shouldice technique) with local infiltration anesthesia supplemented by MAC in the form of conscious sedation. A mixture of 300 mg of plain mepivacaine and 50 mg of plain bupivacaine was used for infiltration. A standard dose of fentanyl 0.10 mg and midazolam 2 mg was used for conscious sedation. Propofol in continuous infusion was also employed. The average dose of propofol varied from 1–3 mg/kg/h. Conscious level was assessed using a five-point sedation score. A level-3 end point was persued (closed eyes, but answer verbal orders). Pain intensity in the postoperative period was measured by the visual analogue scale (VAS) and the verbal pain scale (VPS), based on the McGill pain questionnaire. The operating conditions were excellent in all cases except in three patients. In no case conversion to general anesthesia was necessary. In the postoperative period, 5 patients (8%) never felt pain and 58 (92%) felt pain on the average 4 hours 36 minutes after the local infiltration (VAS=2.5; VPS=1.45). Of the 58 patients 49 took the first dose of oral analgesic 6 hours 40 minutes after infiltration (VAS=4; VPS=1.97). All patients were satisfied with the anesthetic-surgical technique and were ready to repeat the experience. However, when the patients took the second dose of oral analgesic 28% of them had moderate pain and 9% severe pain. Our conclusions are that local infiltration with MAC is a valid and satisfying experience for both the patient and the surgeon. Nevertheless, further attempts should be made to better the postoperative pain relief when the oral route is elected.