Ambulatory lnguinal Hernia Repair Compared with Short-Stay Surgery Sven Kornhall, MD, Lund, Sweden Arne M. Olsson, MD, Lund, Sweden
Inguinal hernia repair is, apart from cholecystectomy, the most common operation in Sweden today. In the county of Malmohus (approximate population, 500,000) from 1969 to 1971 the average hospital stay for uncomplicated inguinal hernia repair was 5.9 days. This agrees with experience in other countries [1,2]. Eveg fifth hernia operation in Sweden is acute, owing to strangulation. Similar figures are reported from other countries [3-51. The mortality with this acute operation is between 5 and 10 per cent [6,7]. To put a patient on the waiting list for hernia operation is dangerous and ineffective. Great effort is therefore made in many clinics to eliminate the waiting lists [S-21]. Some surgeons have tried to perform the hernia repair as an outpatient procedure [12-151. For more than four years we have operated for inguinal hernias both as an outpatient procedure and in the traditional way with the patient hospitalized, although for a short period (short-stay surgery). The present study was aimed at evaluating these methods of treatment by comparing two similar groups of patients. Material
The material consists of two groups of patients: group A of fifty-four patients operated as outpatients (ambulatory group) and group B of fifty-four patients chosen at random from the inpatients (short-stay group) but matched for sex and age. Figure 1 shows age and sex distribution. Two patients in group A and five in group B had recurrent hernias. The methods of repair employed were largely those of Bassini [16] and McVay [17]. Only a few operations were performed according to Marcy [I&?],Nyhus [I9], and Girard [20]. Both groups were treated during the same period, January 1971 to August 1973. Follow-up was made by inquiry. Results
The time on the waiting list has generally been considerably shorter for the outpatients. In the last year, however, all inpatients underwent operation within three months. Nine of 108 patients, (8 per From the Department of Svgery, University of Lund, S-221 Reprint requests should be addressed to Sven Kwnhall, of Surgery, University of Lund, S-221 85, Lund, Sweden.
32
85 Lund, Sweden. MD, Department
16 .I
OUT - PATIENTS
6. ‘a g 4. g b
2.
4
2.
2
4. 6. 8.
. 12.
10
14 s
IN - PATIENTS
Figure 1. Age and sex distribution.
cent) were unable to work for a mean number of 32 days (range, 3 to 90 days) during the waiting period because of severe distress caused by their hernias. Among the outpatients, inhalation anesthesia was used in fifty-three patients and epidural anesthesia in one. Among the inpatients, twenty-one were given inhalation anesthesia whereas thirty-three were given epidural anesthesia. It is remarkable that seven of the thirty-three patients were dissatisfied with the epidural form of anesthesia for various reasons: pain during the operation, necessitating additional analgesic drugs or inhalation anesthesia; nausea; and pain in the head and back for some days after the operation. However, only three of the seventy-four patients in the two groups that were given inhalation anesthesia were troubled during the awakening period by pain and nausea. Since local anesthesia at hernia repair often causes patient discomfort, we abandoned this method many years ago. The mean hospital stay for inpatients was 3.4 days, that is, 1.4 postoperative days, which is short compared with national and international reports [1,2]. What was the patient experience during the immediate postoperative period? Nearly twice as many outpatients as inpatients classed the day of operation and the following days as very troublesome, and one had to be readmitted owing to pain and social invalidity. (Figure 2.) Almost twice as many inpatients judged the experience as not at all troublesome. Only
The American Journal of Surgery
lnguinal Hernia Repair
Y 5
35. 30.
c
25.
i3i
3i
5
g
Out-patients Intended
out-patients
‘G 2 20. z L 15. d
Troublesome
Tolerable
Comfcftable
F&we 2. Patients’ experience during immadiate postoperative period.
three of the fifty-four inpatients could contemplate having to leave the hospital on the day of operation. Ten of the fifty-four outpatients had to remain on a trundle bed during the night after operation. Retrospectively, another twelve would have preferred to do so. Postoperative complications were noted in three patients in group A (2 with hemorrhage, 1 with pneumonia) and in five patients in group B (3 with hemorrhage, 2 with wound infection). There were no wound infections among the outpatients. One of the inpatients required reoperation for hemorrhage. The mean period of inability to work for group A was 4.0 weeks and for group B 4.1 weeks, that is, no difference. Comments
Our experience is that approximately 40 per cent of the patients who have had ambulatory operative treatment for inguinal hernia prefer to rest overnight in the hospital after the operation. There is no surgical disadvantage with hernia repair as an outpatient procedure. It means a big saving for the hospital and a shorter waiting period for the patients. Probably 90 per cent of the patients with hernia can be treated as outpatients [Xl. If 90 per cent of the approximately 20,000 elective inguinal hernia operations performed annually in Sweden (population, S,OOO,OOO) were carried out as outpatient procedures and the remaining 10 per cent required a mean hospital stay of 3.4 days, 290 beds would be free for other purposes. Arnesjii et al [21] have predicted that a similar gain could be made with an early discharge of the cholecystectomized patient. If the chief for a surgical unit is conscious of economic realities, he can save money as well as lives not only in the operating theater but also on the waiting list. Summary
Two groups of patients operated on for inguinal hernia, one outpatient group and one inpatient
Volume
132,
July 1976
group, are compared with respect to subjective distress and immediate postoperative complications. The groups were chosen at random and matched for sex and age. A large number of those who received treatment as outpatients suffered marked distress during the first postoperative days. Some form of intermediary or light nursing should be tried out for the outpatients so that if necessary they can stay the night after operation at the hospital. The number of postoperative complications was equal in the two groups. With suitable patient selection and with a small number of reserve places in a light-care ward, the majority of inguinal hernia operations can be performed on outpatients, resulting in a considerable economic saving and shorter waiting time. References 1. Doran FSA, White M, Drury M: The scope and safety of shortstay surgery in the treatment of groin herniae and varicose veins. Br J Swg 59: 333, 1972. Hughes EFX, Fuchs VR, Jacoby JE, Lewitt EH: Surgical work loads in a community practice. Surgery 71: 315, 1972. Gandhi RK, Mody AE, Sen PK: External abdominal hernia. J Postgradhfed9: 15, 1963. Lawrence GA: External abdominal hernia. J PostgradA&d 17: 64, 1971. Saran HS, Naruta IS, Katra VB, Sodhi BC. Aggarwal RK: Patterns of external abdominal hernia, an analysis of 1,600 consecutive cases. Ind J /L&d Sci 26: 707, 1972. 6. Fenyo G: Acute abdominal diseases in the aged. Diagnostic problems and results of treatment. (In Swedish with English summary.) Opuscula Medica (Opmeer) 17: 309, 1972. 7. Kozlov EZ, Androsov Tp: Analysis of lethal outcome in patients operated on for strangulated abdominal hernia. (In Russian with English summary.) Chirurgib 48: 75, 1972. 8. Atdrkfge LW: Cooperative effrxt to reduce a waiting-list. f3r Med J 1: 183, 1965. 9. Chant ADB, Hishon S, Spencer T, Wiicher D, Brooks A: Another approach to the hernia waiting-list. Lancet 2: 10 17, 1973. 10. Morris D, Ward AWM, Handy&de AJ: Early discharge after hernia repair. Lancet2: 681, 1968. 11. Stallworthy JA: Hotels or hospitals. Lancer 2: 103, 1960. 12. Farquharson E: Early ambulation with special reference to hernorrhaphy as an outpatient procedure. Lancet 2: 5 17, 1955. 13. Persson 6, Wallensten S: Ambulatorisk kirurgisk behandling av ljumskbrilck. (In Swedish.) L&ikartidningen 66: 3189, 1969. 14. Stephens FO, Dudley HAF: An organisation for out patient surgery. &met 1: 1042, 1961. 15. Williams JA: Out-patient operations. I. The surgeon’s view. Br MedJ 1: 174, 1969. 16. Bassini E: Sopra 100 casi di crtra radlcale dell’ernta inguinate operatacolmetododell’autore.Ard,AftiSocllal~~r5:315, 1888. 17. McVay CB: Preperitoneal hernioplasty. Surg Gynecol Obstet 123: 349,1966. 18. Marcy HO A new use of carbolized catgut ligatures. Boston Msd Surg J85: 315, 1871. 19. Nyhus LM: The preperitoneal approach and iriic tract repair of all groin hernias, p 271. Hernia.Fhitadelphia, JB Lippincott, 1964. 20. Girard C: Radicaloperation von Inguinalhernien. Korresp BI Schweiz Aerzte 24: 186, 1894. 21. Arnesjo B, Bengmark S, Enger H, Pettersson BG, Ulvengren M: Tidig hernsandning efter galloperation. (In Swedish with English summary.) Ukafkfnlngen 70: 3155, 1973.
33
Inguinal hernia repair is, apart from cholecystectomy, the most common operation in Sweden today. In the county of Malmohus (approximate population, 500,000) from 1969 to 1971 the average hospital stay for uncomplicated inguinal hernia repair was 5.9 days. This agrees with experience in other countries [1,2]. Eveg fifth hernia operation in Sweden is acute, owing to strangulation. Similar figures are reported from other countries [3-51. The mortality with this acute operation is between 5 and 10 per cent [6,7]. To put a patient on the waiting list for hernia operation is dangerous and ineffective. Great effort is therefore made in many clinics to eliminate the waiting lists [S-21]. Some surgeons have tried to perform the hernia repair as an outpatient procedure [12-151. For more than four years we have operated for inguinal hernias both as an outpatient procedure and in the traditional way with the patient hospitalized, although for a short period (short-stay surgery). The present study was aimed at evaluating these methods of treatment by comparing two similar groups of patients. Material
The material consists of two groups of patients: group A of fifty-four patients operated as outpatients (ambulatory group) and group B of fifty-four patients chosen at random from the inpatients (short-stay group) but matched for sex and age. Figure 1 shows age and sex distribution. Two patients in group A and five in group B had recurrent hernias. The methods of repair employed were largely those of Bassini [16] and McVay [17]. Only a few operations were performed according to Marcy [I&?],Nyhus [I9], and Girard [20]. Both groups were treated during the same period, January 1971 to August 1973. Follow-up was made by inquiry. Results
The time on the waiting list has generally been considerably shorter for the outpatients. In the last year, however, all inpatients underwent operation within three months. Nine of 108 patients, (8 per From the Department of Svgery, University of Lund, S-221 Reprint requests should be addressed to Sven Kwnhall, of Surgery, University of Lund, S-221 85, Lund, Sweden.
32
85 Lund, Sweden. MD, Department
16 .I
OUT - PATIENTS
6. ‘a g 4. g b
2.
4
2.
2
4. 6. 8.
. 12.
10
14 s
IN - PATIENTS
Figure 1. Age and sex distribution.
cent) were unable to work for a mean number of 32 days (range, 3 to 90 days) during the waiting period because of severe distress caused by their hernias. Among the outpatients, inhalation anesthesia was used in fifty-three patients and epidural anesthesia in one. Among the inpatients, twenty-one were given inhalation anesthesia whereas thirty-three were given epidural anesthesia. It is remarkable that seven of the thirty-three patients were dissatisfied with the epidural form of anesthesia for various reasons: pain during the operation, necessitating additional analgesic drugs or inhalation anesthesia; nausea; and pain in the head and back for some days after the operation. However, only three of the seventy-four patients in the two groups that were given inhalation anesthesia were troubled during the awakening period by pain and nausea. Since local anesthesia at hernia repair often causes patient discomfort, we abandoned this method many years ago. The mean hospital stay for inpatients was 3.4 days, that is, 1.4 postoperative days, which is short compared with national and international reports [1,2]. What was the patient experience during the immediate postoperative period? Nearly twice as many outpatients as inpatients classed the day of operation and the following days as very troublesome, and one had to be readmitted owing to pain and social invalidity. (Figure 2.) Almost twice as many inpatients judged the experience as not at all troublesome. Only
The American Journal of Surgery
lnguinal Hernia Repair
Y 5
35. 30.
c
25.
i3i
3i
5
g
Out-patients Intended
out-patients
‘G 2 20. z L 15. d
Troublesome
Tolerable
Comfcftable
F&we 2. Patients’ experience during immadiate postoperative period.
three of the fifty-four inpatients could contemplate having to leave the hospital on the day of operation. Ten of the fifty-four outpatients had to remain on a trundle bed during the night after operation. Retrospectively, another twelve would have preferred to do so. Postoperative complications were noted in three patients in group A (2 with hemorrhage, 1 with pneumonia) and in five patients in group B (3 with hemorrhage, 2 with wound infection). There were no wound infections among the outpatients. One of the inpatients required reoperation for hemorrhage. The mean period of inability to work for group A was 4.0 weeks and for group B 4.1 weeks, that is, no difference. Comments
Our experience is that approximately 40 per cent of the patients who have had ambulatory operative treatment for inguinal hernia prefer to rest overnight in the hospital after the operation. There is no surgical disadvantage with hernia repair as an outpatient procedure. It means a big saving for the hospital and a shorter waiting period for the patients. Probably 90 per cent of the patients with hernia can be treated as outpatients [Xl. If 90 per cent of the approximately 20,000 elective inguinal hernia operations performed annually in Sweden (population, S,OOO,OOO) were carried out as outpatient procedures and the remaining 10 per cent required a mean hospital stay of 3.4 days, 290 beds would be free for other purposes. Arnesjii et al [21] have predicted that a similar gain could be made with an early discharge of the cholecystectomized patient. If the chief for a surgical unit is conscious of economic realities, he can save money as well as lives not only in the operating theater but also on the waiting list. Summary
Two groups of patients operated on for inguinal hernia, one outpatient group and one inpatient
Volume
132,
July 1976
group, are compared with respect to subjective distress and immediate postoperative complications. The groups were chosen at random and matched for sex and age. A large number of those who received treatment as outpatients suffered marked distress during the first postoperative days. Some form of intermediary or light nursing should be tried out for the outpatients so that if necessary they can stay the night after operation at the hospital. The number of postoperative complications was equal in the two groups. With suitable patient selection and with a small number of reserve places in a light-care ward, the majority of inguinal hernia operations can be performed on outpatients, resulting in a considerable economic saving and shorter waiting time. References 1. Doran FSA, White M, Drury M: The scope and safety of shortstay surgery in the treatment of groin herniae and varicose veins. Br J Swg 59: 333, 1972. Hughes EFX, Fuchs VR, Jacoby JE, Lewitt EH: Surgical work loads in a community practice. Surgery 71: 315, 1972. Gandhi RK, Mody AE, Sen PK: External abdominal hernia. J Postgradhfed9: 15, 1963. Lawrence GA: External abdominal hernia. J PostgradA&d 17: 64, 1971. Saran HS, Naruta IS, Katra VB, Sodhi BC. Aggarwal RK: Patterns of external abdominal hernia, an analysis of 1,600 consecutive cases. Ind J /L&d Sci 26: 707, 1972. 6. Fenyo G: Acute abdominal diseases in the aged. Diagnostic problems and results of treatment. (In Swedish with English summary.) Opuscula Medica (Opmeer) 17: 309, 1972. 7. Kozlov EZ, Androsov Tp: Analysis of lethal outcome in patients operated on for strangulated abdominal hernia. (In Russian with English summary.) Chirurgib 48: 75, 1972. 8. Atdrkfge LW: Cooperative effrxt to reduce a waiting-list. f3r Med J 1: 183, 1965. 9. Chant ADB, Hishon S, Spencer T, Wiicher D, Brooks A: Another approach to the hernia waiting-list. Lancet 2: 10 17, 1973. 10. Morris D, Ward AWM, Handy&de AJ: Early discharge after hernia repair. Lancet2: 681, 1968. 11. Stallworthy JA: Hotels or hospitals. Lancer 2: 103, 1960. 12. Farquharson E: Early ambulation with special reference to hernorrhaphy as an outpatient procedure. Lancet 2: 5 17, 1955. 13. Persson 6, Wallensten S: Ambulatorisk kirurgisk behandling av ljumskbrilck. (In Swedish.) L&ikartidningen 66: 3189, 1969. 14. Stephens FO, Dudley HAF: An organisation for out patient surgery. &met 1: 1042, 1961. 15. Williams JA: Out-patient operations. I. The surgeon’s view. Br MedJ 1: 174, 1969. 16. Bassini E: Sopra 100 casi di crtra radlcale dell’ernta inguinate operatacolmetododell’autore.Ard,AftiSocllal~~r5:315, 1888. 17. McVay CB: Preperitoneal hernioplasty. Surg Gynecol Obstet 123: 349,1966. 18. Marcy HO A new use of carbolized catgut ligatures. Boston Msd Surg J85: 315, 1871. 19. Nyhus LM: The preperitoneal approach and iriic tract repair of all groin hernias, p 271. Hernia.Fhitadelphia, JB Lippincott, 1964. 20. Girard C: Radicaloperation von Inguinalhernien. Korresp BI Schweiz Aerzte 24: 186, 1894. 21. Arnesjo B, Bengmark S, Enger H, Pettersson BG, Ulvengren M: Tidig hernsandning efter galloperation. (In Swedish with English summary.) Ukafkfnlngen 70: 3155, 1973.
33
