Ten-year Audit of Lichtenstein Hernioplasty under Local Anaesthesia Performed by Surgical Residents

Hannu Paajanen; Riitta Varjo


BMC Surg 

In This Article


This was a comparative prospective trial of 317 adult patients with inguinal hernia. The patient characteristics and types of hernia are presented in Table 1. Fourteen patients (4.4%) had recurrent hernia. No mesh implantation had been used earlier to any patients. The exclusion criteria were femoral hernia, emergency operation, allergy to polypropylene or patient's refusal to participate in the study. One consultant surgeon or twelve residents of general surgery (3–4 years of residency) performed all operations. The consultant operated annually over 200 inguinal hernias using both open mesh and laparoscopic techniques. The design and conduct of the study is presented in Figure 1. After 36 teaching operations together with residents and their consultant, 281 consecutive inguinal hernioplasties were enrolled of the study: 141 patients were operated in local anaesthesia by one consultant and 140 operated by 12 residents (Figure 1). The first three operations of the residents were supervised by the scrubbed consultant surgeon, and thereafter the consultant was on call and advised if necessary. The trainees operated about 10 patients during their 3-month rotation in the ambulatory unit. A secretary of the ambulatory unit scheduled equally the operations for surgeons, and they performed the procedures during their daily rotations in the unit. For ethical reasons, no sealed envelopes or computer programs were used in the patient' selection between trainees and surgeon. Patients fulfilling the day-case surgery criteria received written and oral information about the aims and content of the study in accordance with the Helsinki Declaration. The staff of our day-case surgery told to the patient that the operation is performed by the attending surgeon of the day (either resident or specialist). The patients knew that they were part of the trial, and an informed consent was signed. The ethics committee in our hospital approved the study protocol.

Figure 1.

Flow chart of the study.

Our hospital is a non-university teaching hospital with 6–8 surgical residents working at the same time. The annual number of inguinal hernioplasties has varied from 180 to 200 per 100 000 inhabitants. The tension-free Lichtenstein technique was started in January 1996 in our new ambulatory unit. The procedure was always performed under local infiltration anaesthesia as a rapid outpatient surgery using 9 × 13 cm polypropylene mesh (Premilene, B. Braun AG, Germany). The sac of the indirect hernia was either resected or just inverted into the abdomen.[12,14] If the hernia sac was large and direct, it was inverted with absorbable 2–0 absorbable sutures. The inguinal nerves were tried to identify and save if possible. We did not try to identify the three inguinal nerves systematically at operation nor record the nerve identification. The mesh was trimmed and placed between the conjoint tendon, inguinal ligament, pubic bone and external oblique aponeurosis.[12,15] Mesh was always fixed with 3–0 absorbable Dexon® (United States Surgical, Norwalk, CT) sutures. Local infiltration anaesthesia was a 1:1 mixture of bubivacaine (Marcain 5 mg/ml, AstraZeneca, UK) and Citanest-adrenalin (10 mg/ml + 5 μg/ml, AstraZeneca, UK) with an average total volume of 40–50 ml. After surgery, the patient was followed up for 60 - 120 minutes to observe possible wound hemorrhage and then discharged. No prophylactic antibiotics were used. A 0.5–1.0 mg bolus of intravenous alfentanil was given (Rapifen, AstraZeneca, UK), if the patient felt pain during the operation. The same standardized postoperative instructions of our ambulatory unit were given to all patients allowing normal daily activities after operation.

The patient characteristics, type of hernia, operation time and wound complications were recorded by an independent research nurse. Operative time was recorded from infiltration of local anaesthetic to skin closure. The short-term outcome was evaluated 1 month post-operation. The long-term results (3 and 10 years) were asked by using the questionnaire and clinical examination. The questions were based on the study of the Danish Hernia Database.[16] The questionnaire included data of recurrence, pain in the last month at rest and during physical exercise, pain scores (VAS 0–10), testicular pain, need of pain-relieving medications, limitations in work or leisure-time activities, feeling of foreign body in the groin and overall satisfaction with the operation. The questionnaire and clinical examination was performed in 2002 and 2009. If the patient told that the hernia had recurred or that there were problems with the operated area, a physical and ultrasound examination was performed to rule out a recurrent hernia or the etiology of chronic pain. Both ultrasound examination and operative findings during re-surgery were used to confirm recurrences of hernia. Out of 281 patients, only 247 were available for the final analysis in 2009. The patients of the original groups were dropped because they could not be contacted or they were deceased (Figure 1).

The data analysis was carried out using Statistical Package for the Social Sciences (SPPS) for Windows, version 14.0 (SPSS, Chicago, Illinois, USA). The statistical evaluation was performed with a Student's t test for paired values and χ-2 test with Yates correction between the groups. P < 0.05 was regarded as significant for both tests.