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The object of study is to determine the frequency of operative postoperative complications of local anaesthesia and its safety during mesh hernioplasty in inguinal hernia.
Method: This is prospective study done at surgical unit II ward-12 of Liaquat University Hospital Jamshoro. Patients admitted from 1st January 2008 to 31st October 2009. Only male patients age between 20-65 having reducible direct or indirect complete or incomplete inguinal hernia were studied .
Patients having criteria like ,female patient, recurrent hernia, huge hernia, obstructed hernia , inflame hernia, incarcerated hernia, sliding hernia etc, and patients having chronic diseases e.g ischemic heart disease , diabetes mellitus , renal failure were not included in this study.
In operation theatre local anaesthesia lignocain and bupivacain in ratio of 2:1 was infiltrated at the site of hernia . The recommended open procedure was followed with application of poly propylene mesh . The patients were shifted toward ward where they were watched for pain severity, vomiting, hypotension , urinary retention and wound haematoma formation hourly for six hours and then onward till discharged from hospital.
Result: 108 male patients were studied. Age from 20 to 65 years (mean age 35.5). 90(83.33%) patients were had indirect inguinal hernia , while 18(16.67%) had direct variety. With in 06 hours post-operatively moderate pain was felt in 15( %) patients, vomiting in 02( %) and urinary retention in 01( %) patient .No patient show hypotension . 29( %) patients felt pain after 10 hours postoperatively , no patient complained of vomiting, no patient developed urinary retention after six hour postoperatively. Post-operative hospital stay range from six hour to 50 hour (mean 20hrs)
Conclusion : Evidences from the present study suggest that the tension free inguinal hernia repair under local anaesthesia is safe and convenient . It has the benefits to reduce the risk of cardiopulmonary complications , short hospital stay , early return to routine life and also to reduce cost .
The ââ‚¬Ëœherniaââ‚¬â„¢ is a Latin word that means rupture of a portion of a structure( 1). The Hernia is abnormal protrusion of visus through weak wall of cavity (abdomen) containing it . Weakness of abdominal wall is either congenital or acquired in origin . The hernia can be reducible/irreducible/obstructed or strangulated. The external abdominal hernia is the commonest form of spontaneous hernia , and these are inguinal, femoral and umbilical in percentages 73 %, 17%, 8.5% respectively. 80 to 90% repair are carried out on male , and frequent type in right indirect inguinal hernia(2).
The inguinal hernia may be indirect if passing through deep inguinal ring or direct , resulting from weakness in the transversalis fascia in the posterior wall of inguinal canal . The factors leading to the development of a hernia can be divided into congenital and acquired defects . The former may be responsible for the majority of groin hernia .
The surgical treatment of inguinal hernia can be carried out by so many technique e.g , Bassani repair , Darning , Shoudiceââ‚¬â„¢s repair, Lichtenstein repair and Laparoscopic hernia repair . Inguinal hernia repair is one of the most commonly performed operations worldwide (3) . However there is no common consensus among surgeons regarding the best choice of anaesthesia . Several studies have shown that local anaesthesia provide the best clinical and economic benefits to the patient (4) . The spinal anaesthesia is an easy option ,but the most likely complication like urinary retention , spinal headache and hypotension are frequently encounter (5) . In elderly patients with co morbidity surgeons should offer repair under local anaesthesia . The advantage include 1-safety 2- simplicity 3-on table assessment of repair 4-early post operative mortality 5- short stay in hospital.
So keeping the above advantages in view we utilized this technique for all our hernia patients who fulfilled the inclusive criteria .
Methods: This is prospective study conducted at surgical unit II Ward-12 of Liaquat university Hospital Jamshoro Pakistan . In this study 108 patients , admitted between 1st January 2008 to 31st October 2009, having inguinal hernia were studied. Patients having the criteria (male patients, age between 20 to 65 year, reducible direct or indirect inguinal hernia) .Patients having features(female patients, Recurrent hernia , huge hernia , obstructed hernia , inflamed hernia , incarcerated hernia , sliding hernia, cardiac or renal failure patients or patients having chronic debilitating disease ) were not included in this study.
For all patients injection cephradine was used as prophylactic antibiotic , and operative field shaved in operation theatre , intra-venous line was maintained with 18G canula & Ringer lactate solution was started . Local anaesthetic technique comprised of infiltration anaesthesia and nerve block . Lignocain in the concentration of 0.5% with adrenaline (1:200000) and injection bupuvacain in 0.25% concentration was used in all cases. Local anaesthesia (L/A) was given within safe dose(i.e Lignocain with adrenalin safe dose is 7mg/Kg) . Using small bore , 22G needle three skin wheel were raised.
1-Two centimetre medial to the anterior superior iliac spine .
2-Directly over the pubic tubercle .
3- over the deep inguinal ring , 1-2 centimetre above the midpoint of inguinal ligament.
Using 22G. needle 5ml. L/A solution was injected subcutaneously between wheel 1 and the anterior superior iliac spine . Three doses of 10 ml solution, each injected in a fan shape , in the transverse plane deep to external oblique aponeurosis (total 35 ml. L/A). Through wheel 2 , 5ml solution was injected directly on to the pubic tubercle , a further 5ml lateral to the tubercle at a depth of 3 cm. and a further 10 ml. subcutaneously towards the umbilical for the distance of about 8 cm.(L/A ,total 55 ml.) . Through wheel 3 , needle was passed perpendicularly backwards to penetrate external oblique apponeurosis , 20 ml. solution injected in the line of inguinal ligament (total volume-75ml. ) . 10 ml. solution injected subcutaneously in the line of skin crease .During dissection of hernial sac if pain was felt due to peritoneal traction . This was treated by injecting 10ml. solution into neck of sac.
After transverse incision dissection made by usual way and cord mobilized, on lay mesh of appropriate size was placed , and loose interrupted sutures applied, & overlapping the lateral tail of the mesh to provide a snug fit around the cord . After surgery patient was shifted to ward , where he was monitored for pain, vomiting , hypotension , wound haematoma , urinary retention every hour for six hour and later six hourly up to time to discharge from hospital.
Results: 108 patients were studied , all were male . The age range from 20 to 65 years . The mean age was 38.5 years. The indirect variety of inguinal was 75% (n=81) of total while the direct variety was found to be 25%(n=27) of total. The hernial content were spontaneously reducible in 61%(n=66), while manually reducible was found in 39%(n=42).
Peri-operatively all patients tolerated local anaesthesia without any adverse effect. Post operative complication were studied as early (with in 6 hours) , and , late , after six hour up to the time of discharge . 17(15.74%) patients were complained of early moderate pain post operatively . Injection Diclofenac Sodium was given intra-muscularly for relief. 14(13%) patients were complained moderate pain after six hour post operatively , for relief Tablet diclofenac sodium and tablet paracetamol or injection diclofenac sodium i/m was given. Only one(0.93%) patient had urinary retention in early phase and was catheterized . Only one(0.93%) patient in early and 03(2.77%) patients in late phase develop wound haematoma . These patients were managed conservatively .03(2.77%) patient in late phase developed wound infection , these patients managed by broad spectrum antibiotic intravenously till wound culture report come. Most of the patients 85(78.7%) started physical activity , such as taking fluid orally and going to washroom with in six hour post operatively . While 23(21.3%) started such activity after six hour , and delayed in physical activity mostly was due to pain and fear to developed pain.
The post operative hospital stay were range from 06 to 52 hours . The mean stay was 27.27 hours. The delay in discharge of most of our patients was due to lack of medical facilities in the periphery of their residential area .
Discussion : Since Bassini (1844-1924) various methods of inguinal hernia repair have been discussed for better results . The ideal method of hernia repair is one that cause minimal discomfort during and after surgery , it should be technically simple , and would have a low rate of complications and recurrence 17,18 . Shouldice method remained acceptable for several years with recurrence rate of 01 to 06 % 19,20. Inguinal hernia repair performed by suturing and displacement of anatomical structures may lead to excessive tension on the suture line and surrounding tissues , resulting in recurrence . The use of prosthetic mesh allows tension free repair of inguinal hernia with better results (21) .
The incidence of inguinal hernia is high in old and middle age (22). Most of the elderly patients having inguinal hernia also have concomitant disease (cardiac , pulmonary and diabetes) , that increase surgical risk (23). Cardiovascular , pulmonary and urinary complications can occur after inguinal hernioplasty , when procedure is performed under general anaesthesia or spinal anaesthesia (24) . On the other hand patients operated under local anaesthesia does not generally have serious peri or post-operative complications (25) . Several retrospective and randomized control trials have shown that L/A provide the best clinical and economical benefits to the patients 26-30 . despite of all these benefits the use of L/A in inguinal hernia surgery has not been established among surgeons on a wide scale .. In this study no any patient developed anaphylaxis . In study done by Davis L, and colleague in 2003 , shows the anaphylaxis rate of about 1% to L/A 31 .
Pain is the main factor in post-operative morbidity . In this study 17(15.74%) patients complaint of pain with in six hour post-operatively and 14(15%) patient have pain after six hours . Most of the patient remained pain free with in the six hour post surgery . Van Veen and colleagues (32) , between August 2004 and July 2006 , noticed in their study that inguinal hernia repair under L/A had significant less pain. Local anaesthesia is highly effective in alleviating post-operative pain when using both peripheral nerve blocking technique 33, and local wound infiltration at fascial level 34. In Young 35, study patients operated(inguinal herniorraphy) under L/A had lesser need for post-operative analgesia , because most patients felt that the subsequent pain was more tolerable as it comes gradually , compared with those who had their surgery performed under general or spinal anaesthesia .
The incidence of post-operative nausea , vomiting and hypotension was negligible in this study and this is concurrence with other studies 36,37 .We also studied post operative urinary retention rate because most of the patients were in the age of having enlarged prostate . Jenson and colleague 38 , study show that urinary retention is definitely a problem after inguinal hernia repair , when the procedure is done under spinal anaesthesia but not when it is done under L/A .This is very important observation and shed light on old age problem . Early post-operative mobilization add in lesser morbidity , and hence early discharge from hospital . Patient operated under L/A start physical activity earlier after surgery 39. Callesan also proves in his study that L/A facilitate the faster mobilization and early discharge from hospital then the other anaesthetic techniques 40.
Conclusion: L/A has easy applicability and very low rate of pain and post-operative complications . It is also encourage early mobilisation and early discharge from hospital and hence cost effective and also reduces hospital burden .
When anaesthesia related complication ( CVS, Pulmonary, DVT ) ,hospitalization time ,cost effectiveness, and applicability to all patient were take into consideration, L/A can be recommended as safe and effective technically for inguinal hernia mesh repair.
Table-1 Type of Hernia
66 ( 61%)
Table-3 operative Complications
Total - 108
Table-4 Post-operative Complications.