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

Hannu Paajanen; Riitta Varjo

Disclosures

BMC Surg 

In This Article

Discussion

Our results indicated that properly trained surgical residents are able to perform Lichtenstein hernioplasty without compromising patient's care and long-term outcome. This is an important finding considering quality control and economical views because the surgeon is the most important variable that influences surgical outcome.[4] The influence of training and experience on the outcome was reflected only by the shortening of operating time, but not the other outcome parameters. Our results are in line with Cueto Rozon and co-workers from France, who concluded that Lichtenstein hernia repair may be performed alone by residents if a precise teaching organization by experimented surgeon is available.[8] This conclusion is not in accordance with Wilkiemeyer and co-workers, who reported that open hernia repairs performed by junior residents were associated with higher recurrence rates than those repaired by more trained surgeons.[11] The recurrence rate in their study varied from 1.1 to 7% in 2 years of follow-up. As overall, complication rates for the open procedures were also much higher than in our study.[11] Our residents were already well-experienced to perform independently soft-tissue surgery, which may explain the different results between the present study and that of Wilkiemeyer and co-workers.[11] A properly allocated and powered randomized study between residents and specialists would be presently difficult to run, because nowadays patients demand always the best possible surgeon to operate their hernias.

Inguinal hernias are so common in population that centralization into the specific hernia centres in Europe has not been carried out. In the United States, the results of such specialist clinics have been encouraging. For example, recurrences between 0 and 1% and infections between 0 and 5% have been reported.[12,17,18] The results of non-specialist hospitals have not been as good reporting the recurrence rates between 4–8%.[3,10,19,20] Our results indicate that open tension-free technique is well suited for smaller community-based and regional hospitals yielding good immediate and long-term results. Inguinal hernioplasty is an ideal operation to teach inguinal anatomy and soft-tissue surgery because the regional anatomy has been well described and the repair techniques are well outlined and reproducible. Our results encourage to perform Lichtenstein hernioplasty safely in general hospitals by well-supervised trainees. This may indicate that the learning curve of Lichtenstein hernioplasty is relatively short and the procedure is simple enough to be part of the surgical training programs.[8,9,21]

Chronic pain after inguinal hernia repair was also noticed in the present study. Pain has been reported to occur in between 10–30% of the patients after a groin hernia repair.[16,22] The present study indicated that although 25–30% of the patients reported some pain sensations afterwards in the groin, this was mild in nature since over 90% were very satisfied with the operation. Furthermore, only 7/281 patients used occasionally pain-relieving drugs. We used local corticosteroid injections in 6 patients after 3 years and 3 patients even after 10 years to temporarily reveal pain. No patients were re-operated due to chronic pain, and no meshes were removed, although this may help in some cases.[23] It is now evident, that nerve identification shows a negative correlation with chronic postoperative pain.[24] Ten years ago we tried to save inguinal nerves if possible, but we did not systematically identify or record the nerves. Our operative policy has always been to save the nerves if possible and not to cut them routinely. Neuropathic pain may be disabling and an unfortunate complication, which should be avoided by using a careful operative technique. Our recent register-based study indicated that also in Finland chronic pain is the most frequently observed long-term complication of hernia surgery.[2] In this register-based study, the reported severe complications related to inguinal hernia surgery were not increased in the operations performed by residents.[2]

The patient selection is of utmost importance to get favourable results in the inguinal hernia surgery performed by residents. At the time of present study, two thirds of the inguinal hernia surgery was not performed in the ambulatory unit. Therefore some selection bias was happened to explain the good results. Our current policy is to operate all patients suitable for day-case surgery using Lichtenstein technique under local anaesthesia. The per cent of Lichtenstein operations under local anaesthesia is currently over 80% of all groin hernia surgery. Local anaesthesia in primary inguinal hernia repairs should be the method of choice.[25] Indications for laparoscopic hernioplasty are occasionally bilateral hernias, complicated recurrences and a suspicion of incipient hernia.

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