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Table of Contents
Year : 2019  |  Volume : 2  |  Issue : 3  |  Page : 83-88

Impact of institutional hernia programme on guideline conformity of surgical approach and mode of anesthesia for inguinal hernia repair and analysis of the outcomes

1 Department of General Surgery, Navy General Hospital, Colombo; Department of Surgery, Faculty of Medicine, General Sir John Kotelawala Defence University, Rathmalana, Sri Lanka
2 Department of General Surgery, Navy General Hospital, Colombo, Sri Lanka

Date of Submission26-Apr-2019
Date of Acceptance25-Jun-2019
Date of Web Publication30-Aug-2019

Correspondence Address:
Dr. Keerthi Rajapaksha
91/B/03, Raddoluwa, Seeduwa
Sri Lanka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_14_19

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AIM: The objective of this study is to elucidate the guideline conformity of surgical approach and mode of anesthesia for inguinal hernia (IH) treatment together with analysis of the outcomes on the implementation of “guideline-based treatment for IH” as a part of institutional hernia programme (IHP) in a single surgical unit.
METHODS: This is a retrospective analysis of health records of the male patients who underwent surgery for IH at a single surgical center, during the period May 1, 2015–May 1, 2016, where the surgeons adhered to “guideline-based treatment for IH.” Health records of the patients who underwent surgery for IH from May 1, 2014, to April 30, 2015, too were collected for comparison. Data related to demographics, surgical approach, mode of anesthesia, and surgical complication were analyzed.
RESULTS: Sixty-two male patients with a mean age of 33.5 (range: 22–54) years and 99 male patients with a mean age of 32.84 (range: 22–70) years have undergone IH repair before the IHP and during the IHP, respectively. The overall use of local anesthesia (LA) for unilateral IH had increased from 3.5% (n = 2) to 83.12% (n = 65) (P ≤ 0.0001) during IHP. The laparoscopic approach was used in 83.34% of patients with bilateral IH during IHP (P = 0.0007). All (n = 3) the recurrences following open repair were attempted to treat laparoscopically during the IHP. Laparoscopic approach was not utilized to treat IH before the IHP. Overall recurrence rate increased to 4.04 (n = 4) during IHP from 0% (P = 0.299). Overall complication rate increased from 3.22% (n = 2) to 8.08% (n = 8) during IHP (P = 0.319).
CONCLUSION: Surgical approach and mode of anesthesia for IH treatment showed high conformity with the guidelines during the IHP. The increased recurrence and complication rates were statistically insignificant.

Keywords: Anesthesia, inguinal hernia, laparoscopy, mesh repair, recurrence

How to cite this article:
Rajapaksha K, Silva L J, Herath A, D Anandappa M J, Bandara T M. Impact of institutional hernia programme on guideline conformity of surgical approach and mode of anesthesia for inguinal hernia repair and analysis of the outcomes. Int J Abdom Wall Hernia Surg 2019;2:83-8

How to cite this URL:
Rajapaksha K, Silva L J, Herath A, D Anandappa M J, Bandara T M. Impact of institutional hernia programme on guideline conformity of surgical approach and mode of anesthesia for inguinal hernia repair and analysis of the outcomes. Int J Abdom Wall Hernia Surg [serial online] 2019 [cited 2019 Oct 19];2:83-8. Available from: http://www.herniasurgeryjournal.org/text.asp?2019/2/3/83/265859

  Introduction Top

Inguinal hernia (IH) repair is one of the most common general surgical operations performed globally and is a major health-care burden in developing countries.[1],[2],[3] Based on evidence, guidelines have been published to offer more effective treatment for IH.[4],[5],[6] Open mesh repair (MR) under local anesthesia (LA) is the preferred option for unilateral primary cases. Bilateral and recurrences following open repair are best treated with laparoscopic techniques, which require general anesthesia (GA).

Deviations from the guidelines are common, and institutional hernia program (IHP) appears to be a solution to treat IH effectively.[6], [7,[8],[9],[10],[11] The current study is an audit to elucidate the guideline conformity of surgical approach and mode of anesthesia of IH treatment and to analyze outcomes of IH treatment during IHP at a single surgical unit.

  Methods Top

This is a retrospective analysis of health records of all the male patients who underwent surgery for IH, during the period from May 1, 2015, to May 1, 2016, where the unit implemented guideline-based IH treatment as part of IHP. Data of patients who underwent surgery for IH from May 1, 2014, to April 30, 2015, where the unit has not had organized care for IH were collected for comparison.

Guidelines were adopted from the European Hernia Society guidelines. According to the guidelines, unit intended to offer open MR for most of the patients with primary unilateral IH. Bilateral IH and recurrences following previous open repairs were intended to treat with laparoscopic approach. LA was considered in all possible open surgeries. Patients and surgeons were allowed to choose the appropriate mode of anesthesia when a patient refuses LA or upon a decision by the surgeon to reject LA. GA is required for laparoscopic procedures.

Demographic, surgical approach, surgical technique, mode of anesthesia, and outcome data were collected and analyzed. Outcome data consisted of surgical complications and recurrences. Both intraoperative and postoperative complications were collected as per the Swedish Hernia Registry.[12] Surgical site infections were diagnosed as per the criteria for surgical site infection classification published by the Center for Disease Control.[13] Persistent postoperative pain (PPP) defined as persistence of pain for >3 months after the operation.[14] Health records were followed up to 2 years to identify recurrences.

The statistically significant differences were analyzed using Fisher's exact test. Prism software version 8.00 (San Diego, CA, USA) was utilized for statistical analyses. P < 0.05 was considered statistically significant.

This study is approved by the Ethics Review Committee of General Sir John Kotelawala Defence University, Sri Lanka.

  Results Top

Sixty-two and 99 male patients have undergone IH repair at the surgical unit 1 year before and 1 year during the IHP, respectively. Mean ages were 33.5 (22–54) and 32.84 (22–70) years before and during the IHP, respectively.

Fifty-seven and 77 patients underwent open MR for unilateral IH before and during the IHP, respectively. The most common mode of anesthesia before the IHP was spinal anesthesia (SA)and used in 94.73% (n = 54) patients, whereas SA was used in 10 (12.99%) patients during the IHP. LA was sparingly used (n = 2, 3.5%) for open MR of IH before the IHP. In contrast, LA was the most commonly utilized mode of anesthesia during the IHP and used in 64 (83.12%) patients with unilateral IH (P ≤ 0.0001). GA was used in 1 (1.75%) and 3 (3.9%) patients, respectively, before and during the IHP for open MR of unilateral IH.

The technique used for all the open repairs was Lichtenstein technique both before and during the IHP.

There were 5 and 24 bilateral IH repairs performed before and during the IHP. All 5 (100%) cases before the IHP were performed as open repairs. Conversely, the procedure of choice for bilateral IH during the IHP was the laparoscopic approach under GA and performed in 20 (83.34%) patients (P = 0.0007). Indications for open technique (16.66) during IHP were large bilateral IH (n = 3) and chronic obstructive pulmonary disease (n = 1).

During the IHP, four unilateral recurrences following open MR were treated, and laparoscopic approach was utilized in all the cases (100%).

The technique of all the laparoscopic procedures was total extraperitoneal (TEP) repair. During TEP, the procedure for recurrence following previous open MR of IH required conversion to transabdominal preperitoneal repair (TAPP) and subsequently to an open procedure due to the presence of extensive adhesions both preperitoneally and intraperitoneally.

Recurrent IH was not treated before the IHP.

Overall complication rates were 3.22 (n = 2) and 8.08 (n = 8) before and during the IHP (P = 0.319), respectively, as shown in [Table 1].
Table 1: Surgical complications before and during the Institutional Hernia Programme (IHP)

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All the surgical site infections were superficial infections and managed with short course of antibiotics and recovered. Patients with PPP were noted to be pain free at 1-year follow-up and treated with nonsteroidal anti-inflammatory drugs and paracetamol.

The overall recurrence rate has risen to 4.04% during the IHP, from 0% before the IHP (P = 0.299). In total of 41 (19 bilateral and 3 unilateral) laparoscopic IH repairs in 22 patients, 3 patients developed unilateral recurrences during the IHP, and recurrence rate in laparoscopic IH repair is 7.31%. A single patient (1.3%) developed a recurrence of IH following open MR during the IHP.

  Discussion Top

IH is one of the most common surgical conditions globally.[1],[2] Surgery is the mainstay of treatment for the majority of patients with IH.[4],[15],[16],[17],[18]

Surgical techniques have evolved over the time with early darn repair to Shouldice and to the current day Lichtenstein MR to minimally invasive techniques such as laparoscopic and robotic approaches.[19],[20],[21],[22] Based on evidence, the current guidelines have been published to offer the best effective treatment to most of the patients with IH.[3],[4],[5] However, deviations from guidelines are common and are a major concern, particularly in publicly funded hospitals.[6],[8],[9],[10] Reasons to deviate from guidelines include lack of training, financial constraints, insufficient evidence, individual surgeon's preferences, surgical environment, and motivation of the surgical team.[6],[7],[8],[23]

IHP is a novel productive concept based on team approach, voluntary motivation, collaboration, and continuous quality improvement.[10] IHP appears to be promising in improving the quality and value of care delivered to hernia patients and may open avenue for patients to receive most cost-effective treatment.[10],[11],[24] Rational utilization of costly devices, continuous improvement of the outcomes, and allowing surgeon to identify strengths and improve the weaknesses are the other potential benefits of IHP.[10]

The current study describes the impact of IHP on surgical approach, mode of anesthesia, and outcomes of IH repair in a single surgical unit.

Surgical approach

Open approach is the recommended surgical approach for unilateral IH.[1],[3],[4] Tension-free Lichtenstein MR is the recommended surgical technique for open approach.[2],[3] Other open MR techniques include transinguinal preperitoneal repair, repair with self-gripping mesh, three-dimensional hernia systems, and variations of the above.[25],[26],[27] The current study shows that open approach with Lichtenstein technique is utilized for all the unilateral IHs both before and during the IHP. Lichtenstein repair is not inferior to other techniques with regard to short-term and medium-term outcomes.[25],[26],[27],[28],[29],[30],[31] Lesser cost, use of lesser amount of prosthetic material, not requiring to open the posterior tissue planes, ability to perform using low-cost materials, and ability to perform under LA are the advantages of Lichtenstein repair when compared to other open surgical techniques.[28],[29],[30],[31],[32],[33] Further, open repair remains as the most practical solution for IH repair in certain countries.[34]

Laparoscopic approach is recommended in guidelines for bilateral IH and recurrent IH following previous open repairs.[1],[2],[3],[4] The laparoscopic approach is not advisable routinely for unilateral IH repair as laparoscopic approach for unilateral IH is associated with both hospital and long-term higher cost.[2],[34],[35],[36],[37],[38],[39] However, laparoscopic unilateral IH can be performed with similar costs as open repairs if performed using reusable equipment by an expertise and in places where the adequate facilities available. Laparoscopic approach is recommended for recurrences following open repairs as the hernia defects can be approach through posterior tissue planes which are not disturbed during the open approach.[1],[2],[3],[40],[41] Advantages of laparoscopic approach for bilateral IH are approach to both sides with midline three port techniques and esthetically more acceptable than bilateral open incisions. Further, laparoscopic repair appears to be cost-effective in treating bilateral IH when compared to open repair for bilateral hernia.[2],[36],[37],[38],[39],[40],[41],[42] The faster return to normal activities and lesser incidence of chronic inguinal pain and numbness are the other advantages of laparoscopic approach.[2]

TEP repair, TAPP repair, and intraperitoneal onlay mesh (IPOM)[43] repair are the surgical techniques for laparoscopic IH repair. IPOM approach is not preferred for routine practice than the TEP and TAPP, as IPOM can lead to significant intraperitoneal adhesions and requirement of costly meshes to minimize intraperitoneal adhesion formation.[43] With regard to clinical outcomes and complications, both TEP and TAPP appear equally effective.[44],[45],[46],[47] TEP appears to be more complex surgery to perform than TAPP.[43],[45] It is observed in our study, and all the laparoscopic IH repairs attempted to perform as TEP repairs. However, a single patient with recurrent IH following previous open MR had to convert to TAPP due to the presence of insurmountable amount of dense adhesions in the preperitoneal space. The current study shows the utilization of laparoscopic approach during IHP for the vast majority of patients with bilateral IH and recurrent IH. The only valid reason for not to offer laparoscopic surgery for bilateral IH in this cohort is unsuitable for GA due to chronic obstructive airway disease.[43] Severe benign prostatic hyperplasia, cirrhotic ascites, acute incarcerated or strangulated hernia, and skin infection on the lower abdominal wall are the other contraindications in addition to inability to tolerate GA.[43] Large IH per se is not an absolute contraindication and can be successfully laparoscopically repaired by an expert.

Mode of anesthesia

Guidelines highly encourage the use of LA for open MR of primary unilateral IH.[1],[2],[3],[4] Prior to the IHP, SA was the most common mode of anesthesia used for open MR of IH. With the IHP, there is an overwhelming increase in the utilization of LA for open MR in unilateral IH repair. Further, over 80% utilization of LA for open MR of primary unilateral IH in this surgical unit is among the highest documented rates in the literature.[48],[49],[50] Lesser cost, shorter hospital stay, lesser operating theater time, lesser workforce requirement, improvement in day surgery rates, lesser incidence of postoperative chronic inguinal pain, increased patient satisfaction, and enhanced human interactions are the main advantages of LA in open MR of IH.[51],[52],[53],[54],[55] Further LA appears to be convenient in older age patients and patients with ASA score of III and IV.[55],[56] Controversies exist with regard use of LA on additional work on the surgical team, patients anxiety, intraoperative intolerance by the patient, difficulty of performing larger hernias and inguinoscrotal hernia, and overdose of the local anesthetic agent.[57],[58] However, LA is more cost-effective and a practical solution in a resource-limited environment.[50],[57],[59] Strategies to minimize disadvantages of LA include prior preparation of the patient, calculation of the maximum dose of anesthesia prior to surgery, meticulous sharp dissection, and use of short-lasting sedative. GA is preferred to SA for open MR of IH, when LA is not suitable or refusal by the patient, as it allows early mobilization and discharge when compared to SA. In our study, SA is the second most commonly used mode of anesthesia during IHP. Although the guidelines recommend GA as the option of anesthesia when LA is rejected, according to the current study GA is sparingly used both before and during the IHP. The advantage of the GA is shorter anesthesia recovery enabling early discharge of the patients. However, awakened patient during SA allows a surgeon to assess the repair during the procedure.

GA is required for laparoscopic IH repair.


Increase in recurrences after IH repair in this study during IHP is insignificant. Reported recurrence rates following open and laparoscopic hernia repair may increase up to 9.7 and 25.7%, respectively, in literature.[60] The current study shows 7.31% and 1.29% recurrence rates following laparoscopic and open repair of IH, respectively, during the IHP, and we believe that this is an acceptable rate. Further higher rates of recurrence in laparoscopic IH repair group may be due to the early experiences in this surgical unit with laparoscopic techniques. We suggest further study into recurrences in the laparoscopic IH repair to identify the causes and to improve the practice.

PPP after the surgery is a serious concern.[15] Following IH repair, PPP affects up to 16% of patients.[61] Our study shows a statistically insignificant rise in persistent PPP during IHP. All these patients developed PPP following open MR of IH. The management of patients affected with PPP ranges from watchful waiting to surgical neurectomy and surgical removal of tackers.[61] It is observed that all the patients who developed PPP were pain free at 1-year follow-up with oral nonsteroidal anti-inflammatory drugs and paracetamol without requiring invasive procedures.

Complications of IH repair range from minor seroma, hematoma, urinary retention, and surgical site infections to major visceral injury.[62] The slight increase in complications during IHP is insignificant in this study. According to other studies, morbidity may affect up to 7% of patients following IH repair, and our results are comparable to the published data.[63] Rarely, mortality may result following IH repair due to patients with altered health status undergoing IH repair.[64]

  Conclusion Top

The surgical approach and the mode of anesthesia for IH repair show higher conformity with the guidelines during the IHP with similar outcomes. The authors propose IHP as an example to treat common diseases most effectively.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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