Less Pain 1 Year After Total Extra-peritoneal Repair Compared With Lichtenstein Using Local Anesthesia: Data From a Randomized Controlled Clinical Trial.

OBJECTIVE: The aim was to compare long-term postoperative pain after inguinal hernia surgery using 2 techniques that have shown favorable long-term outcome in previous randomized studies: Lichtenstein using local anesthesia (LLA) and endoscopic total extra-peritoneal repair (TEP) under general anesthesia. BACKGROUND: Patients often experience pain after inguinal hernia surgery. These 2 methods in their optimal state have not yet been sufficiently compared. METHODS: A randomized controlled trial was conducted to detect any difference in long-term postoperative inguinal pain. Altogether 384 patients were randomized and operated using either TEP under general anesthesia (n = 193) or LLA (n = 191). One year postoperatively, patients were examined by an independent surgeon and requested to complete the Inguinal Pain Questionnaire (IPQ), a validated questionnaire for the assessment of postoperative inguinal pain. RESULTS: Three hundred seventy-five (97.7%) patients completed follow-up at 1 year. In the TEP group, 39 (20.7%) patients experienced pain, compared with 62 (33.2%) patients in the LLA group (P = 0.007). Severe pain was reported by 4 patients in the TEP group and 6 patients in the LLA group (2.1% and 3.2%, respectively, P = 0.543). Pain in the operated groin limited the ability to exercise for 5 TEP patients and 14 LLA patients (2.7% and 7.5%, respectively, P = 0.034). CONCLUSIONS: Patients operated with TEP experienced less long-term postoperative pain and less limitation in their ability to exercise than those operated with LLA. The present data justify recommending TEP as the procedure of choice in the surgical treatment of primary inguinal hernia.

Limited potential for prevention of emergency surgery for femoral hernia.

BACKGROUND: Femoral hernias are frequently operated on as an emergency. Emergency procedures for femoral hernia are associated with an almost tenfold increase in postoperative mortality, while no increase is seen for elective procedures, compared with a background population. OBJECTIVE: The aim of this study was to compare whether symptoms from femoral hernias and healthcare contacts prior to surgery differ between patients who have elective and patients who have emergency surgery. METHODS: A total of 1,967 individuals operated on for a femoral hernia over 1997-2006 were sent a questionnaire on symptoms experienced and contact with the healthcare system prior to surgery for their hernia. Answers were matched with data from the Swedish Hernia Register. RESULTS: A total of 1,441 (73.3%) patients responded. Awareness of their hernia prior to surgery was denied by 53.3% (231/433) of those who underwent an emergency procedure. Of the emergency operated patients, 31.3% (135/432) negated symptoms in the affected groin prior to surgery and 22.2% (96/432) had neither groin nor other symptoms. Elective patients had a considerably higher contact frequency with their general practitioner, as well as the surgical outpatient department, prior to surgery compared with patients undergoing emergency surgery (p < 0.001). CONCLUSIONS: Patients who have elective and patients who have emergency femoral hernia surgery differ in previous symptoms and healthcare contacts. Patients who need emergency surgery are often unaware of their hernia and frequently completely asymptomatic prior to incarceration. Early diagnosis and expedient surgery is warranted, but the lack of symptoms hinders earlier detection and intervention in most cases.

TEP under general anesthesia is superior to Lichtenstein under local anesthesia in terms of pain 6 weeks after surgery: results from a randomized clinical trial.

BACKGROUND: Persistent pain is common after inguinal hernia repair. The methods of surgery and anesthesia influence the risk. Local anesthesia and laparoscopic procedures reduce the risk for postoperative pain in different time perspectives. The aim of this study was to compare open Lichtenstein repair under local anesthesia (LLA) with laparoscopic total extraperitoneal repair (TEP) with respect to postoperative pain. METHODS: Between 2006 and 2010, a total of 389 men with a unilateral primary groin hernia were randomized, in an open-label study, to either TEP (n = 194) or LLA (n = 195). One patient in the TEP group and four in the LLA group were excluded due to protocol violation. Details about the procedure and patient and hernia characteristics were registered. Patients completed the Inguinal Pain Questionnaire (IPQ) 6 weeks after surgery. [The study is registered in ClinicalTrials.gov (No. NCT01020058)]. RESULTS: A total of 378 (98.4 %) patients completed the IPQ. One hundred forty-eight patients (39.1 %) reported some degree of pain, 22 of whom had pain that affected concentration during daily activities. Men in the TEP group had less risk for pain affecting daily activities (6/191 vs. 16/187; odds ratio [OR] 0.35; 95 % CI 0.13-0.91; p = 0.025). Pain prevented participation in sporting activities less frequently after TEP (4.2 vs. 15.5 %; OR 0.24; 95 % CI 0.09-0.56; p < 0.001). Twenty-nine patients (7.7 %) reported sick leave exceeding 1 week due to groin pain, with no difference between the treatment groups. CONCLUSIONS: Patients who underwent the laparoscopic TEP procedure suffered less pain 6 weeks after inguinal hernia repair than those who underwent LLA. Groin pain affected the LLA patients' ability to perform strenuous activities such as sports more than TEP patients.

Chronic pain after femoral hernia repair: a cross-sectional study.

OBJECTIVE: To explore the prevalence of and to identify possible risk factors for chronic pain after surgery for femoral hernia. BACKGROUND: Chronic pain has become a very important outcome in quality assessment of inguinal hernia surgery. There are no studies on the risk for chronic pain after femoral hernia surgery. METHODS: The Inguinal Pain Questionnaire was sent to 1967 patients who had had a repair for primary unilateral femoral hernia between January 1, 1997 and December 31, 2006. A follow-up period of at least 18 months was chosen. Answers from 1461 patients were matched with data recorded in the Swedish Hernia Register and analyzed. RESULTS: Some degree of pain during the previous week was reported by 24.2% (354) of patients. Pain interfered with daily activities in 5.5% (81) of patients. Emergency surgery (OR = 0.54; 95% CI = 0.40-0.74) and longer time since surgery (OR = 0.93; 95% CI = 0.89-0.98 for each year added) were associated with lower risk for chronic postoperative pain, whereas a high level of preoperative pain was associated with a higher risk for chronic pain (OR = 1.17; 95% CI = 1.10-1.25). Surgical technique was not found to influence the risk for chronic pain in multivariate logistic regression analysis. CONCLUSIONS: Chronic postoperative pain is as important a complication after femoral hernia surgery as it is after inguinal hernia surgery. In contrast to inguinal hernia surgery, no risk factor related to surgical technique was found. Further investigations into the role of preoperative pain are necessary.

Validation of Gastrointestinal Quality of Life Index in Swedish for assessing the impact of gallstones on health-related quality of life.

OBJECTIVE: The aim of the present study was to validate a Swedish translation of the Gastrointestinal Quality of Life Index (GIQLI) questionnaire in patients with gallstone disease. METHODS: Sensitivity to change, internal consistency, and test-retest stability were tested in 187 consecutive patients who underwent planned cholecystectomy. Construct validity was assessed by comparing the GIQLI score with the bodily pain scale of SF-36 and four single-item questions in a separate group of 104 patients. RESULTS: A significant increase in all five domains as well as in the overall GIQLI score 6 months after surgery (all P < 0.05) was seen. All five domains correlated significantly with other measures of gallstone-related symptoms except one single-item question. Intraclass correlations ranged from 0.62 to 0.87. Cronbach's alpha ranged from 0.77 to 0.89. CONCLUSION: The Swedish translation of GIQLI has a high validity and reliability for assessing the impact of gallstones on quality of life.

Emergency femoral hernia repair: a study based on a national register.

OBJECTIVE: To describe the characteristics of femoral hernias and outcome of femoral repairs, with special emphasis on emergency operations. BACKGROUND: Femoral hernias account for 2% to 4% of all groin hernias. However, the lack of large-scale studies has made it impossible to draw conclusions regarding the best management of these hernias. METHODS: The study is based on patients 15 years or older who underwent groin hernia repair 1992 to 2006 at units participating in the Swedish Hernia Register. RESULTS: Three thousand nine hundred eighty femoral hernia repairs were registered, 1490 on men and 2490 on women: 1430 (35.9%) patients underwent emergency surgery compared with 4.9% of the 138,309 patients with inguinal hernias. Bowel resection was performed in 22.7% (325) of emergent femoral repairs and 5.4% (363) of emergent inguinal repairs. Women had a substantial over risk for undergoing emergency femoral surgery compared with men (40.6% vs. 28.1%). An emergency femoral hernia operation was associated with a 10-fold increased mortality risk, whereas the risk for an elective repair did not exceed that of the general population. In elective femoral hernias, laparoscopic (hazard ratio, 0.31; 95% confidence interval, 0.15-0.67) and open preperitoneal mesh (hazard ratio, 0.28; confidence interval, 0.12-0.65) techniques resulted in fewer re-operations than suture repairs. CONCLUSIONS: Femoral hernias are more common in women and lead to a substantial over risk for an emergency operation, and consequently, a higher rate of bowel resection and mortality. Femoral hernias should be operated with high priority to avoid incarceration and be repaired with a mesh.

Early results of a single-blinded, randomized, controlled, Internet-based multicenter trial comparing Prolene and Vypro II mesh in Lichtenstein hernioplasty.

BACKGROUND: The standard polypropylene mesh used in Lichtenstein's operation induces a strong foreign-tissue reaction with potentially harmful effects. A mesh with less polypropylene could possibly be beneficial. PATIENTS AND METHODS: Six hundred men with inguinal hernias were randomized to Lichtenstein's operation with Prolene or Vypro II in a single-blinded multicenter trial. The randomization was performed by a computer algorithm in a database through the Internet. All data were entered and directly validated in the database through the Internet. RESULTS: The meshes had comparable results in return to work, return to daily activities, complications, postoperative pain, and quality of life during the first 8 weeks of rehabilitation. CONCLUSIONS: Lichtenstein's operation with either Prolene or Vypro II is safe and well tolerated with an acceptable postoperative rehabilitation time and a high quality of life 2 months after surgery. The study was facilitated by the use of a database through the Internet.