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275
VIII
How to Create a Recurrence
evaluation, development and expansion of procedures
and techniques in minimal access or key hole surgery.
Minimal access surgery (MAS) has introduced a sweep-
ing revolution in surgical practice since its dramatic
entry more than a decade ago. We perform more than
2500 basic and advanced laparoscopic surgeries per
year, including about 500 endoscopic hernia repairs.
Patient-Related Factors
Improper patient selection in early period of experience
may become a leading cause of increased recurrence.
We have proposed a classification system based on
expected level of intraoperative difficulty of endoscopic
hernia repair. This functional classification grades groin
hernias according to the pre-operative predictive level
of difficulty of endoscopic surgery.
SGRH Classification for TEP Repair
Grade I
▬ Small, direct, reducible hernia
Swelling appears on coughing/straining and dis-
appears on lying down
Finger breadth-size defect in the functional direct
floor ( Hesselbach triangle)
Endoscopically – minimal dissection of sac from
fascia transversalis is required
Grade II
▬ Small, indirect, incomplete, reducible hernia
Hernial swelling limited to inguinal canal
Endoscopically – the sac can be reduced com-
pletely and may not require transection or liga-
tion
▬ Moderate-sized direct hernia
Swelling is present in standing and reduces in the
supine position
Thumb-sized defect in the direct floor
Endoscopically, the sac needs to be dissected
from the fascia transversalis
▬ Reducible femoral hernia
Grade III
▬ Moderate-sized indirect reducible inguinal hernia
Hernial swelling (sac) extends beyond superfi-
cial ring, up to the neck of scrotum but does not
descend to the testis
Endoscopically – this type of hernia will require
transection of sac and ligation of its proximal
part of sac
▬ Large reducible direct hernia
Involvement of the entire direct floor
Big bulge on clinical examination over the tri-
angle of Hesselbach
Endoscopically, creation of space in the midline is
difficult. Anatomical distortion – stretching and
lateral displacement of inferior epigastric vessel
▬ Recurrent groin hernia
Endoscopically – difficult dissection in region of
spermatic cord and the space lateral to it.
Grade IV
▬ Large reducible indirect inguino scrotal hernia
Large sac extending up to the testis. The testis
cannot be palpated separately from hernia in
erect position
The sac may contain omentum or small bowel,
which require manual reduction in supine posi-
tion
Endoscopically – the internal ring is enlarged
with a wide mouthed sac. There is difficulty in
dissecting sac from cord structures. Medial dis-
placement and stretching of the inferior epigas-
tric vessels may occur. Inadvertent opening of
peritoneum may lead to pneumoperitoneum and
dissection of sac becomes difficult
There is higher incidence of post-operative se-
roma/haematoma because of traction on sac
The chances of damage to the cord structures are
increased
Grade V
▬
Large, complete, indirect inguinal hernia, which is
only partially reducible or irreducible
▬ Irreducible femoral hernia
The sliding component includes bowel or blad-
der
Endoscopically the sac is bulky. Adhesions between
contents of the sac and sac wall. The sac often
needs to be opened and the contents reduced lapa-
roscopically. Injury to the contents (bowel, bladder
and omentum) while reducing them is likely
276 VIII Primary Inguinal Hernia
25
A Beginner Should Operate
▬ Patient with small direct hernias (grade I)
▬ Patient with incomplete indirect sacs (grade 2)
▬ Patients fit for general anaesthesia
▬
Patients who can safely withstand longer duration
of surgery
A Beginner Should Not Operate
▬ Patient with obstructed hernia (grade V)
▬
Patient with complete irreducible hernias (grade
V)
▬ Obese patients
▬ Patients unfit for general anaesthesia
Equipment-Related Factors
▬
The core equipment required for any laparoscopic
procedure is the endovision system, which consists
of the telescope, endovision camera, light source,
fibreoptic cable and video monitor.
▬
Better vision results in better surgery and 10 mm
30° scope is used.
▬
Poor vision can lead to surgical difficulties and com-
plications.
▬
An electronic insufflation is necessary for all lapa-
roscopic surgery but for an extraperitoneal hernia
repair, high capacity insufflator, i.e. 18–30 l/min, is
required because of small working space and loss of
space when pneumoperitoneum occurs.
Surgeon-Related Factors
▬ There is no question that the endoscopic approach
is difficult and intense study is required to master
this technique [6], but if appropriate skill sets are
achieved, the reported result are excellent, repro-
ducible and quite different from those reported by
inexperienced surgeons [7].
▬
Some say that repair is too difficult, takes too much
time to perform or too costly. If a repair works, all
patients should benefit from this modern approach,
including those patients who have only a unilateral
hernia.
▬
Before attempting the endoscopic repair of complex
or bilateral hernias a surgeon must learn the anatomy
and technique by repairing simple ones. The learn-
ing curve can be steep and sometimes prolonged but
with proper instruction and supervision operative
times are short and equal to open approaches.
▬
In the hands of experienced surgeons beyond the
learning curve, time for laparoscopic repairs are
usually equal to or even faster than times reported
for open repairs [8]. Hernia surgery should only be
attempted after adequate experience of minimum
of 50 to 100 basic laparoscopic procedures.
Technique-Related Factors
▬
Most important endpoint of any hernia surgery is
the rate of recurrence. It is the single most factor
which judges all repair methods. Several studies have
focussed on causes of recurrence after laparoscopic
hernia repair.
▬ Good understanding of endoscopic anatomy of pre-
peritoneal space is important prerequisite for per-
forming endoscopic total extraperitoneal repair for
groin hernia. It is a potential space created between
fascia transversalis above and peritoneum below
(
⊡
Fig. 25.18).
▬
The lateral extent is from one anterior superior iliac
spine to the other. The region which marks site of
femoral and inguinal hernias lies within a quadran-
gle known as myopectineal orifice of Fruchaud.
▬
The anatomical space includes the preperitoneal
space of Bogros and Retzuis and endoscopic view
is horizontal plane from level of umbilicus.
▬
Creation of preperitoneal space is important step
and all precautions should be taken. An infraumbili-
cal, transverse 12-mm incision is made on anterior
rectus to avoid inadvertent opening of peritoneum.
A space is created and balloon is introduced and
⊡
Fig. 25.18. TEP apporoach for right inguinal hernia – ana-
tomical landmarks
277
VIII
How to Create a Recurrence
inflated with 100–150 ml saline. The balloon is
made by tying two fingerstalls of size 8 latex surgical
gloves on 5-mm laparoscopic suction cannula and
Hassan’s trocar is placed. Accessory ports which are
5 mm should be put in midline under vision to avoid
haemorrhage and injury to bladder (
⊡
Fig. 25.19).
▬ Injury to peritoneum during trocar insertion can
lead to pneumoperitoneum with decrease in work-
ing space. The urinary bladder should be kept empty
at the time of surgery.
▬
Sharp dissection is done with use of short burst of
cautery, which helps in creating adequate space and
ensuring proper haemostasis. This space has loose
areolar tissue, and blunt dissection can lead to stain-
ing of tissue (
⊡
Fig. 25.20).
▬
First structure to identify is the pubic bone and next
is the cooper’s ligament as it may be get occluded by
hernial sac (
⊡
Fig. 25.21).
▬
In case of direct inguinal hernia, an indirect sac
should be looked for along cord structures and
treated. In indirect hernia, sac should be separated
from cord structures.
▬
Dissection should be done closer to deep ring. In
case of direct inguinal hernia after reduction of in-
guinal hernia sac, margins of defect should be free
all adhesions otherwise peritoneum can slide along
adhesions and cause recurrence (
⊡
Fig. 25.22).
▬
The peritoneum should be well reflected proximally
from cord structures and complete parietalization
should be done (
⊡
Figs. 25.23, 25.24).
▬ Indirect sac should be transected in case of complete
inguinal hernia so as to avoid pneumoperitoneum.
Transected sac may be closed using endloop or free
suture tie.
▬
No dissection should be done in triangle of doom
(
⊡
Fig. 25.25)
. Lateral dissection till anterior su-
⊡
Fig. 25.19. TEP repair – port placements
⊡
Fig. 25.20. Extraperitoneal landmarks on the right side
⊡
Fig. 25.21. Retropubic dissection
⊡
Fig. 25.22. Extraperitoneal dissection
278 VIII Primary Inguinal Hernia
25
perior iliac spine over psoas muscle should be
done and injury of nerves should be avoided
(
⊡
Fig. 25.26).
▬
The minimum size of mesh to avoid recurrence is
15×15 cm.
▬ To handle a mesh of this size in restricted preperi-
toneal space is not easy. Thus we have developed a
technique of introducing a rolled mesh in this space
for easy handling and accurate fixation. The mesh is
rolled like a carpet to 2/3 of its length leaving 5 cm
free, Stay sutures are tied using absorbable sutures
3 cm away from margins to keep the rolled mesh
in position (
⊡
Fig. 25.27). The rolled mesh is put
through 10-mm subumbilical port and the free mar-
gin of mesh is pushed into retropubic space medially
and psoas muscle laterally.
▬
A two-point fixation at cooper’s ligament should
be done to prevent migration. In case of large deep
inguinal ring, lateral fixation should be done above
iliopubic tract.
▬
After cutting the stay sutures mesh is unrolled to
lie within the preperitoneal space and none of the
edges of the mesh should be partially rolled at the
time of exsufflation, as this may lead to further
rolling and the likelihood of future recurrence of
hernia.
Summary
▬
Dissect the entire myopectineal orifice to ensure
extensive parietalization of peritoneum – the more
proximal, the better
▬
Do not slit the mesh. Immobilize the mesh with two
point fixation over Cooper’s ligament – avoid mesh
migration
⊡
Fig. 25.23. Extraperitoneal dissection on the left side
⊡
Fig. 25.24. Extraperitoneal dissection on the right side
⊡
Fig. 25.25. Dissection on left side – triangle of doom
⊡
Fig. 25.26. Inferior limit of dissection
279
VIII
How to Create a Recurrence
▬
Use two separate meshes for bilateral hernias – pre-
vents recurrence
▬
No suture or tacks below iliopubic tract – avoids
neuralgia
▬
Mesh implanted without creases – avoids pressure
on nerves
▬
Laying the mesh on the roof and not the floor – aids
in better placement of mesh
▬
Use large mesh at least 15×12 cm – mesh shrinks
postoperatively
▬
Bulge postoperatively may be seroma or haematoma
– wait and watch
▬
Adequate dissection, complete coverage of myopec-
tineal orifice and proper fixation – must for endo-
scopic inguinal hernia repair
References
1. Schultz L, Graber J, Pietrapitta J et al. Laser laparoscopic
herniorraphy: A clinical trial: Preliminary results. J Laparosc
Surg 1990; 1(1): 41–45
2. Leibl BJ, Schmedt C, Kraft K, Ulrich M, Bittner R. Recurrence
after endoscopic transperitoneal hernia repair (TAPP): causes,
reparative techniques and results of reoperations. J Am Coll
Surg 2000; 190: 651–655
3. Lowan AS, Filipi CJ, Fittzgibbons JR, Stoppa R, Wantz GE,
Felix EL, Crafton WB. Mechanisms of hernia recurrence after
preperitoneal mesh repair, traditional and laparoscopic. Ann
Surg 1997; 225: 422–431
4. Felix E. 10 year experience with laparoscopic hernioplasty.
Presented 9th World Congress of Endoscopy, Cancun Mexico,
February 2003
5. Phillips EH, Rosenthal R, Fallas M, et al. Reasons for early
recurrence following lap. Hernioplasty Surg Endsc 1995; 9(2):
140–144
6. Wright D, O’ Dwyer P. The learning curve for laparoscopic
hernia repair. Semi Laparosc Surg 1998; 54: 227–232
7. Felix E, Scott S, Crafton B, Geis P, Duncan T, Swell R, Mckernan
B. Causes of recurrence after laparoscopic hernioplasty. Surg
Endosc 1998; 12: 226–231
8. Schurab J, Beaird D, Ramshaw B, et al. After 10 years and 1903
inguinal hernias, what is outcome for laparoscopic repair?
Surg Endosc 2002; 168; 1201–1206
Discussion
Ferzli:
A short comment: we avoid opening or tying the
sack. We just prepare it and reduce it.
Chowbey:
If you have a large sac to prepare, the patients
suffer from cord indurations postoperatively but if you
transect the sac and leave the distal part in place the
patients don’t have this problem.
Miserez:
Two remarks: very delicate manipulation of the
vas is important, and secondly the lateral lowest part of
the mesh should be exactly fixed when you desufflate.
Chowbey:
We fix the lateral lower part of the mesh with
a forceps during desufflation to avoid the peritoneal sac
going under the mesh.
Köckerling: You showed how you dissect the medial ex-
tension of the transversalis fascia. Our experience is that
it’s good to reduce this extension. We grasp the transver-
salis fascia and suture it to the Cooper’s ligament to avoid
a sudden recurrence.
Chowbey:
There are two ways to handle a big direct sac.
One is to pull it down and fix it to the Cooper’s ligament.
Another is to fenestrate the transversalis fascia to avoid
a big seroma formation.
Kingsnorth:
Prof. Schumpelick asked the chairmen to give
some recommendations at the end of a session. I would
like to give recommendations not to the experts but to the
surgical community. I would say the Lichtenstein repair
could be the first operation of choice for a general surgeon
with a patient with a straightforward primary hernia. In
those places where they prefer a tissue repair, they should
teach an adequate technique of the Shouldice operation.
But there are countries where a tissue repair is obsolete.
The PHS and the plug repair are still discussed controver-
sially. More results are necessary. Those surgeons who are
beyond their learning curve can apply the TAPP or TEP
repair very well, but extrapolation of these techniques to
other surgeons must be done carefully and with caution.
⊡
Fig. 25.27. Preparation of mesh
280 VIII Primary Inguinal Hernia
25
Introduction
The large interposition [1] of a synthetic non-absorbable
mesh is able to hold face with the neighbouring layers
and to support instantly and permanently the inguinal
wall between the deeper inguinal layer and the visceral
sac (
⊡
Fig. 25.28
) in the retroperitoneal cleavable space
[2]. This prosthesis, extended broadly beyond the weak
inguinal area in all directions, completely covering the
Fruchaud’s musculo pectineal hole [3] is pressed by in-
tra-abdominal pressure against the inner face of the ab-
dominal wall and quickly attached by the development
of connective tissue through the mesh. This definition
includes all the technical aspects that can explain a re-
currence after a GPRVS.
Operative Circumstances: Foreseeable
Diffuse medial scarrring represents a rare but difficult
challenge following transvesical prostatectomy or trau-
matic lesion of the pelvic rim. Trying to dissect pro
vesical space leads to a high risk of a vesical wound so at
the beginning of our experience we cut the medial part
of the prosthesis vertically and we observed a lateral
sliding of the sheets and internal inguinal recurrence
occurred (
⊡
Fig. 25.29).
A previous aorto-femoral prosthesis, needing an
inguinal incision and often a femoral inguinal section,
is often associated with large scarring: it is a contra-
indication for GPRVS use.
Complicated appendicectomy will produce a diffuse
scarring in the right iliac fossa. In this case the peritoneal
dissection must be performed upper from the Douglas
arch and by a circular movement and a limited open-
ing of peritoneal bag, which will be closed in a second
time.
Female inguinal hernia is more difficult, because
the teres uteri ligament adheres strongly to the peri-
toneal bag and cannot be parietalized correctly. Cut-
ting the teres uteri ligament liberates the region
and allows a large posterior peritoneal bag dissec-
tion.
Medial Preperitoneal Approach
Limited parietalization of the spermatic cord is prob-
ably the most frequent pitfall.
Two mechanisms explain this occurrence:
▬
If the dissection is not begun medially in contact
with the anterior part of the peritoneal bag, the nov-
ice surgeon, laterally, is embarrassed by constant
limited bleeding because he is progressing too su-
perficially and wounding small epigastric vessels
branches. The limited vision explains why he stops
too early.
▬
Lack of knowledge of embryology explains why
some surgeons open the prosthesis (
⊡
Fig. 25.30
)
to let the cord go through. The uro-genital fascia
[4] is a protection for deferent canal and spermatic
vessels; this fascia will also protect the iliac vessels
from prosthesis contact. A precise dissection of the
limit between peritoneal hernia sac and uro-genital
fascia is bloodless, can lead to a limited opening of
the peritoneum (sutured) but the posterior dissec-
tion will be easy and must be done as far as the psoas
muscle.
25.7 GPRVS
P. V, F. D, R. S
⊡
Fig. 25.28. Mesh between the deeper inguinal layer and the
visceral sac
281
VIII
How to Create a Recurrence
Prosthesis Preparation
A large prosthesis is an essential element of the success;
this prosthesis largely covers the peritoneal bag.
▬ Some surgeons use folded prosthesis (two or three
layers!). So the prosthesis cut large (25 or 28 cm),
finally covers no more than 14 or 9 cm, which is
certainly too small for bilateral hernia [6].
▬
A small prosthesis, shrunken by fibrosis, will not
cover the two inguinal holes
▬
A horizontal inferior section of the prosthesis is not
favourable to a good wrapping: the three-dimen-
sional curvature of the pelvis needs a chevron section
of the inferior line of the prosthesis, so the inferior
triangles will develop inferiorly and medially.
▬
Insertion of two separate prostheses on each side
seems to cover the same surface, but the Pascal prin-
ciple is not respected, so these prostheses can move
laterally more easily.
Prosthesis Handling
The use of too small forceps (less 30 cm long) does not
allow the surgeon to keep the prosthesis far enough
back and does not facilitate a large wrapping.
Conclusions
The GPRVS is a reproductible technique providing a re-
currence rate of less than 1% in skilled hands; most recur-
rence can be avoided by good anatomical knowledge.
References
1. Stoppa R, Petit J, Abourachid H (1973) Procédé original de
plastie des hernies de l’aine l’interposition sans fixation d’une
prothèse en tulle de dacron par voie médiane sous-péritoné-
ale. Chirurgie 99: 119–123
2. Odimba BFK, Stoppa R, Laude M (1980) Les espaces clivables
sous pariétaux de l’abdomen. J Chir (Paris) 117: 621–627
3. Fruchaud H (1956) Anatomie chirurgicale des hernies de
l’aine. Doin edit, Paris (The surgical anatomy of hernias of
the groin. Translated by R. Bendavid and P. Cunningham.
Pandemonium books. Toronto, 2006)
4. Stoppa R, Diarra B, Mertl P (1997) The retroparietal spermatic
sheath. An anatomical structure of surgical interest Hernia
1: 55–59
5. Verhaeghe P, Rohr S (2001) Chirurgie des hernies inguinales
de l’adulte. Arnette edit, Paris
6. Stoppa R (2003) Wrapping the visceral sac into a bilateral
mesh prosthesis in groin hernia repair. Hernia 7: 2–12
Discussion
Kingsnorth: There is a large publication of 1000 prosta-
tectomies from the USA looking at a subgroup of patients
who previously had laparoscopic mesh repair. There was
no increase in complications in this subgroup. So carry
on with mesh placement in the preperitoneal space, there
will be no dispute with the urological surgeons.
Verhaeghe:
Prof. Stoppa never told us to use GPRVS in all
inguinal hernias. The indications are recurrences and bilat-
eral hernia, which accounts for about 10% of all hernia.
⊡
Fig. 25.29. Medial part of the prosthesis is cut because of
postoperative previous fibrosis
⊡
Fig. 25.30. Vertical sections in front of the internal inguinal
ring create a weak point
282 VIII Primary Inguinal Hernia
25
Kingsnorth: Are you still using Mersilene?
Verhaeghe:
Yes, and as with polypropylene, we also never
put Mersilene in contact with the bowel. If you do so, it
will migrate into the bowel. It might take 4 or 5 years, but
it will happen. Recently, I re-operated a patient of Prof.
Stoppa. He had done a mesh repair of an umbilical hernia
15 years before and in histology there was a penetration of
the mesh into the layers of the bowel. It was only a ques-
tion of time until a complete fistula would occur.
Bendavid: In large hernias there might be a bulge in the
region of the defect. Do you have an idea how to avoid
this phenomenon?
Verhaeghe:
This is a real problem in very large in-
guinal hernia. The bulge is a result of seroma forma-
tion. You have to explain this to your patients. You
might reduce seroma formation by leaving the peri-
toneal sac in the defect and just cut the peritoneum
in these large hernias rather than preparing it com-
pletely.
Bendavid:
Could it happen that the mesh itself bulges
into the defect in very large hernias?
Verhaeghe:
This event is very rare. If it happens, you can
repair it by a simple transinguinal suturing of the caudal
margin of the mesh to the Cooper ligament.
Introduction
Groin hernia surgery is one of the most frequent opera-
tions performed in general surgery. The introduction of
mesh techniques has led to a marked reduction in recur-
rence rates and attention has now shifted to other aspects
of hernia surgery. For the important question as to method
of anaesthesia, there is still no consensus about the best
choice. In general surgical practice, regional and general
anaesthesia are the preferred choice [1–3], whereas local
anaesthesia is almost exclusively used in centres with a
special interest in hernia surgery [4–8]. Most reviews and
case series [9–12] as well as randomized trials [13–17], bear
witness to its advantages over regional and general anaes-
thesia. Its reported major advantages are simplicity, safety
for high-risk patients, extended postoperative analgesia,
early mobilization without post anaesthesia side effects
and low cost [4–7].
The long-term outcome of hernia repair is generally
assumed not to be affected by the method of anaesthesia
used [18]. However, the evidence on which this assump-
tion is based is far from convincing. The few studies on the
topic have produced conflicting results [19–21].
The Swedish Hernia Register (SHR) records detailed
information on the great majority of groin hernia repairs
performed in Swedish hospitals [22, 23]. During 1992–
2004, 107,838 hernia repairs were prospectively recorded.
With such large numbers of data it is possible to study time
trends for anaesthetic methods and repair techniques.
Furthermore, multivariate analysis of risk for re-opera-
tion associated with alternatives in anaesthesia may also
be undertaken with appropriate adjustment for possible
confounding factors. In the present investigation SHR data
was used to estimate the relative risk of re-operation for
recurrence with the three anaesthetic alternatives.
Patients and Methods
Data were retrieved from the SHR and comprise all
patients over 15 years of age who underwent groin her-
nia repair between 1 January 1992 and 31 December
2004. In 2004 approximately 95% of all hernia opera-
tions done in Sweden were documented in the SHR. In
this register each operation for groin hernia on patients
15 years of age and older is recorded according to a
protocol where variables such as patient characteris-
tics, type of hernia, method of repair, suture material,
anaesthesia, complications and re-operation for recur-
rence (if applicable) are noted. Clinical follow-up is not
mandatory, but any complication that is observed by
the operating unit has to be recorded in the register.
External review of register data is performed on an an-
nual basis [23]. Patients are identified through a person
number [24] unique for each citizen in Sweden, thereby
making it possible to link re-operations to previous
operations performed within the framework of the
register.
25.8 Anaesthesia and Recurrence in Groin Hernia Repair
P. N, S. H
283
VIII
How to Create a Recurrence
Statistics
Statistical analyses were performed using SPSS version
12.0.1 (Chicago, IL). Differences between groups were
tested by chi-square analysis and cumulative incidence
of re-operation was measured through actuarial analy-
ses. Relative risks of re-operation were estimated with
the Cox proportional hazards regression model [25],
first performing univariate analyses for assumed risk
variables and then selecting variables with the high-
est or lowest univariate risks for multivariate analysis.
Re-operation, for the Cox analysis, was defined as a
hernia repair in the same groin as the previous repair,
performed within the framework of the SHR.
Results
Hernia repairs, participating units and percentage of
operations done for recurrent hernia in SHR are given
in
⊡
Table 25. 5.
During the 13-year period 107,838
hernia repairs have been performed; 60,925 (57%) re-
pairs were performed under general anaesthesia, 30,398
(28%) in regional anaesthesia and 16,515 (15%) in local
anaesthesia. Since the start of the registration, 12,982
operations for recurrent hernia have been carried out.
This amounts to 12% of all operations registered. The
percentage of operations done for recurrent hernias has
decreased from above 16% 1992–95 to 10% 2004. As
can be seen in
⊡
Fig. 25.31
, great changes have taken
place concerning the choice of anaesthesia. In the early
⊡
Table 25.5. Swedish Hernia Register 1992–2004
Year Participat-
ing units
Hernia
repairs
Recurrent
hernia [%]
1992 8 1690 16.4
1993 8 1647 15.9
1994 9 2287 16.5
1995 19 3331 17.1
1996 21 4056 15.8
1997 29 5923 14.4
1998 37 8263 15.2
1999 45 9307 13.1
2000 53 10602 12.3
2001 73 13143 11.4
2002 79 14714 11.0
2003 86 16092 10.5
2004 90 16783 10.1
Total – 107838
0
year
20
40
60
80
1992
1993
1994
1995
1996
1997
1998
1999
2004
2000
2001
2002
2003
percentage
local
regional
general
⊡
Fig. 25.31. Choice of anaesthesia in the
SHR between 1992 and 2004 (107,838 her-
nia repairs)
284 VIII Primary Inguinal Hernia
25
1990s the use of local anaesthesia was limited to a few
cases, but by the middle of that decade its use had
started to increase and reached 23% in 2004. During
the same 13-year period the use of regional anaesthesia
decreased from 75 to 14%.
The percentage of patients treated on an outpa-
tient basis increased from 33% in 1992 to 74% in 2004
(
⊡
Fig. 25.32
) with wide variations among participating
units. Of all repairs performed under local anaesthesia,
82% were carried out on an outpatient basis. The cor-
responding percentages for regional and general anaes-
thesia were 48 and 61%, respectively. The differences
between the three groups are statistically significant
(p < 0.001).
Univariate analysis (without any adjustments) of the
cumulative incidence of re-operation for recurrence
after 5 years following all 107,838 hernia repairs was
4.0%, and for the three anaesthetic alternatives local,
regional and general anaesthesia it was 3.7, 4.0, and
4.0%, respectively (
⊡
Fig. 25.33).
The data of all 107,838 operations were also used to
analyze the relative risk for re-operation after surgery
with the three forms of anaesthesia. As indicated in
⊡
Table 25. 6, no significantly difference in risk for re-
operation was found between local, regional or general
anaesthesia in univariate analyses. However, multivari-
ate analyses demonstrated a significant increased rela-
tive risk for re-operation with local anaesthesia in pri-
⊡
Fig. 25.32. Day-case surgery in the SHR,
1992 to 2004 (107,838 hernia repairs)
⊡
Fig. 25.33. Univariate analysis of the
cumulative incidence of reoperation with
107,838 primary and recurrent hernia
operations
30
year
40
50
60
80
1992
1993
1994
1995
1996
1997
1998
1999
2004
2000
2001
2002
2003
percentage
70
years
0.00
0.02
0.04
0.05
percentage
0
0.01
0.03
0.06
0.07
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local
regional
general
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