40
Tropical Doctor, January 1991
DISCUSSION
High completion rates were achieved in a number of ways. The programme was incorporated into normal ward work; the ward doctor and ward sister devoted 2 half-days each month to the programme, and one of the fortnightly follow-ups took place on the ward. This continuity of care and the relationship developed with the mothers was very important both for staff and patients. Peer pressure also played a role as small cohorts of children from the same village were often under treatment at the same time, and the mothers supported each other. The sister involved developed superb rapport with the mothers and much of the reason for success lies
A comparison of wound complications after inguinal hernia repair under local and general anaesthesia oP
Ofili MB BS FMCS University Department of Surgery, Murtala Muhammed Specialist Hospital, Bayero University, PMB 3011, Knao, Nigeria
TROPICAL DOCTOR,
1991, 21, 40-41
here. The method of giving treatment proved particularly successful and the commitment of the two staff members involved ensured early re-entry of defaulters to the programme. No extra staffing or resources were allocated to the programme. We hope our experience may provide ideas and a stimulus to others in similar situations. REFERENCES
2
Taylor SP, Benatar SR. The tuberculosis control programme a time to re-evaluate? S Afr Med J 1989;76:639-40 Kibei MA, Hussey G. Problems in the diagnosis of childhood tuberculosis. S Afr Med J 1990;77:379-80
for this procedure. This is not surprising considering the numerous advantages that have been attributed to its use':". Notable amongst these, for the surgeon in the developing country, is the circumvention of the problems of shortage of anaesthetic gases and qualified anaesthetistsl-'. There is however the theoretical possibility of trauma to small subcutaneous blood vessels as well as introduction of micro-organisms from the skin during the process of infiltration. These could result in an increase in the incidence of wound complications. This report aims to examine this hypothesis. PATIENTS AND METHODS
SUMMARY
Ninety-one male patients with unilateral reducible inguinal hernia were randomly allocated to receive either general or local anaesthesia in order to compare the incidence of postoperative wound complications following both methods of anaesthesia. Forty-seven patients received local anaesthesia while 44 received general anaesthesia. Two patients (4.3 010) who received local anaesthesia and three patients (6.8%) who received general anaesthesia developed various types of postoperative wound complications. Chi-squared test however showed no significant difference in the incidence of wound complications between the two groups of patients. INTRODUCTION
The increasing use of local anaesthesia for inguinal hernia repair justifies the prediction by Nicholls in 19771 that this would become the method of choice
Ninety-one male patients with unilateral primary reducible inguinal hernia were included in the study. They were aged between 16 and 74 years and underwent elective hernia repair between July 1989 and March 1990. Patients with giant inguinoscrotal hernia as well as those with any co-existing medical conditions were excluded. Two patients who specifically requested local anaesthesia were also excluded. All the patients had their weights and heights measured and the body mass index (BMI) for each was determined using the formula weight/heights. Those with BMI greater than 26.2 were considered obese", Thereafter, they were randomly allocated to either the general or local anaesthesia group - 44 received general anaesthesia and the remaining 47 local anaesthesia. Local anaesthesia was achieved with 0.5% plain xylocaine after premedication with intramuscular pethidine'. General anaesthesia was maintained with
41
Tropical Doctor, January 1991 Table 1. Comparison of the two groups of patients Loca/ anaesthesia
Number of patients Age range (years) Mean age ± SD (years) Mean BMI±SD No. with BMI > 26.2 (obese) Average duration of operation
Genera/ anaesthesia
47
44
16-70 43 ± 14.8 22.8± 3.3
18-74 42.8± 15.2 22.4±3.2
3 (6010)
2 (4.5010)
35 minutes
35 minutes
35 (74010) 10(21010) 1 (2010)
33 (75010) 9 (20010) 2 (4010)
Type of hernia:
direct indirect 'pantaloon' (indirect + indirect sliding
1 (2010)
halothane, nitrous oxide and oxygen after induction with thiopentone. All the operations were performed in the same operating theatre by the author. The only postoperative drugs were analgesics- tramadol hydrochloride (Tramal) capsules for the first 24 h followed by a 5-day course of paracetamol tablets. The skin stitches were removed on the 6th postoperative day, at which time the wounds were examined for the presence or absence of the following: (1) wound oedema only; (2) wound inflammation; (3) wound haematoma; (4) wound infection; (5) stitch sinus; and (6) wound dehiscence. These assessments were done by SHO/registrars who were unaware of the type of anaesthesia the patients had received and were repeated in the surgical outpatients clinic 2 weeks and 6 weeks later. RESULTS
The patients in both groups were well matched for age, body mass index (BMI), nature and variety of hernia and duration of the operation (Table 1). One patient developed a mild haematoma in the subcutaneous tissues after infiltration with the local anaesthetic. However he did not have any wound complications postoperatively.
Wound complications Two patients (4%) who had local anaesthesia developed wound complications (one had oedema, the other inflammation of the wound). Three patients (7070) who had general anaesthesia developed wound complications (oedema in one, infection in one and stitch sinus in the third). Chisquared test showed no statistically significant difference between the two groups. None of the patients who developed wound complications was obese. DISCUSSION
It is possible that minor degrees of trauma to
subcutaneous vessels occur during infiltration of local anaesthetics for inguinal hernia repair but pass unnoticed. However even when overt enough to be noticed, as in one patient in this study, this does not necessarily result in postoperative wound complications. This study has further shown that when a plain local anaesthetic is used for this procedure, the incidence of wound complications is similar to that for generalanaesthesia.Thisis rather reassuringand when considered along with the numerous advantages l - 3 should further encourage a more widespread use of local anaesthesia for inguinal hernia repair. ACKNOWLEDGMENT
I am extremely grateful to Drs Esegine, Takai, Idi and Hassan for their invaluable assistance in assessing the wounds of the patients in this study. REFERENCES
1 Nicholls JC. Necessity into choice. An appraisal of inguinal herniorrhaphy under local anaesthesia. Ann R Coli Surg Eng/ 1977;59:124-7 2 Makuria T, Alexander-Williams J, Keighley MRB. Comparison between general and local anaesthesia for repair of groin hernias. Ann R Call Surg Eng/ 1979;61:291-4 3 Alade RB. A radical approach to the management of external hernias in Nigerians. Nigerian Med J 1976;6:29-31 4 Cole TJ, James WPT. The slimdictator: a slide-rule device for assessing obesity. Practitioner 1978;220:623-9 5 Ofili OP, Osime U, Morgan AA. Local anaesthesia for inguinal hernia repair: a system of objective assessment of patients tolerance. J R Coli Surg Edin 1988;33:71-4
Tropical Doctor, January 1991
DISCUSSION
High completion rates were achieved in a number of ways. The programme was incorporated into normal ward work; the ward doctor and ward sister devoted 2 half-days each month to the programme, and one of the fortnightly follow-ups took place on the ward. This continuity of care and the relationship developed with the mothers was very important both for staff and patients. Peer pressure also played a role as small cohorts of children from the same village were often under treatment at the same time, and the mothers supported each other. The sister involved developed superb rapport with the mothers and much of the reason for success lies
A comparison of wound complications after inguinal hernia repair under local and general anaesthesia oP
Ofili MB BS FMCS University Department of Surgery, Murtala Muhammed Specialist Hospital, Bayero University, PMB 3011, Knao, Nigeria
TROPICAL DOCTOR,
1991, 21, 40-41
here. The method of giving treatment proved particularly successful and the commitment of the two staff members involved ensured early re-entry of defaulters to the programme. No extra staffing or resources were allocated to the programme. We hope our experience may provide ideas and a stimulus to others in similar situations. REFERENCES
2
Taylor SP, Benatar SR. The tuberculosis control programme a time to re-evaluate? S Afr Med J 1989;76:639-40 Kibei MA, Hussey G. Problems in the diagnosis of childhood tuberculosis. S Afr Med J 1990;77:379-80
for this procedure. This is not surprising considering the numerous advantages that have been attributed to its use':". Notable amongst these, for the surgeon in the developing country, is the circumvention of the problems of shortage of anaesthetic gases and qualified anaesthetistsl-'. There is however the theoretical possibility of trauma to small subcutaneous blood vessels as well as introduction of micro-organisms from the skin during the process of infiltration. These could result in an increase in the incidence of wound complications. This report aims to examine this hypothesis. PATIENTS AND METHODS
SUMMARY
Ninety-one male patients with unilateral reducible inguinal hernia were randomly allocated to receive either general or local anaesthesia in order to compare the incidence of postoperative wound complications following both methods of anaesthesia. Forty-seven patients received local anaesthesia while 44 received general anaesthesia. Two patients (4.3 010) who received local anaesthesia and three patients (6.8%) who received general anaesthesia developed various types of postoperative wound complications. Chi-squared test however showed no significant difference in the incidence of wound complications between the two groups of patients. INTRODUCTION
The increasing use of local anaesthesia for inguinal hernia repair justifies the prediction by Nicholls in 19771 that this would become the method of choice
Ninety-one male patients with unilateral primary reducible inguinal hernia were included in the study. They were aged between 16 and 74 years and underwent elective hernia repair between July 1989 and March 1990. Patients with giant inguinoscrotal hernia as well as those with any co-existing medical conditions were excluded. Two patients who specifically requested local anaesthesia were also excluded. All the patients had their weights and heights measured and the body mass index (BMI) for each was determined using the formula weight/heights. Those with BMI greater than 26.2 were considered obese", Thereafter, they were randomly allocated to either the general or local anaesthesia group - 44 received general anaesthesia and the remaining 47 local anaesthesia. Local anaesthesia was achieved with 0.5% plain xylocaine after premedication with intramuscular pethidine'. General anaesthesia was maintained with
41
Tropical Doctor, January 1991 Table 1. Comparison of the two groups of patients Loca/ anaesthesia
Number of patients Age range (years) Mean age ± SD (years) Mean BMI±SD No. with BMI > 26.2 (obese) Average duration of operation
Genera/ anaesthesia
47
44
16-70 43 ± 14.8 22.8± 3.3
18-74 42.8± 15.2 22.4±3.2
3 (6010)
2 (4.5010)
35 minutes
35 minutes
35 (74010) 10(21010) 1 (2010)
33 (75010) 9 (20010) 2 (4010)
Type of hernia:
direct indirect 'pantaloon' (indirect + indirect sliding
1 (2010)
halothane, nitrous oxide and oxygen after induction with thiopentone. All the operations were performed in the same operating theatre by the author. The only postoperative drugs were analgesics- tramadol hydrochloride (Tramal) capsules for the first 24 h followed by a 5-day course of paracetamol tablets. The skin stitches were removed on the 6th postoperative day, at which time the wounds were examined for the presence or absence of the following: (1) wound oedema only; (2) wound inflammation; (3) wound haematoma; (4) wound infection; (5) stitch sinus; and (6) wound dehiscence. These assessments were done by SHO/registrars who were unaware of the type of anaesthesia the patients had received and were repeated in the surgical outpatients clinic 2 weeks and 6 weeks later. RESULTS
The patients in both groups were well matched for age, body mass index (BMI), nature and variety of hernia and duration of the operation (Table 1). One patient developed a mild haematoma in the subcutaneous tissues after infiltration with the local anaesthetic. However he did not have any wound complications postoperatively.
Wound complications Two patients (4%) who had local anaesthesia developed wound complications (one had oedema, the other inflammation of the wound). Three patients (7070) who had general anaesthesia developed wound complications (oedema in one, infection in one and stitch sinus in the third). Chisquared test showed no statistically significant difference between the two groups. None of the patients who developed wound complications was obese. DISCUSSION
It is possible that minor degrees of trauma to
subcutaneous vessels occur during infiltration of local anaesthetics for inguinal hernia repair but pass unnoticed. However even when overt enough to be noticed, as in one patient in this study, this does not necessarily result in postoperative wound complications. This study has further shown that when a plain local anaesthetic is used for this procedure, the incidence of wound complications is similar to that for generalanaesthesia.Thisis rather reassuringand when considered along with the numerous advantages l - 3 should further encourage a more widespread use of local anaesthesia for inguinal hernia repair. ACKNOWLEDGMENT
I am extremely grateful to Drs Esegine, Takai, Idi and Hassan for their invaluable assistance in assessing the wounds of the patients in this study. REFERENCES
1 Nicholls JC. Necessity into choice. An appraisal of inguinal herniorrhaphy under local anaesthesia. Ann R Coli Surg Eng/ 1977;59:124-7 2 Makuria T, Alexander-Williams J, Keighley MRB. Comparison between general and local anaesthesia for repair of groin hernias. Ann R Call Surg Eng/ 1979;61:291-4 3 Alade RB. A radical approach to the management of external hernias in Nigerians. Nigerian Med J 1976;6:29-31 4 Cole TJ, James WPT. The slimdictator: a slide-rule device for assessing obesity. Practitioner 1978;220:623-9 5 Ofili OP, Osime U, Morgan AA. Local anaesthesia for inguinal hernia repair: a system of objective assessment of patients tolerance. J R Coli Surg Edin 1988;33:71-4
