ARTICLE IN PRESS
Letter to the Editors Preoperative symptoms and inguinal herniorrhaphy
To the Editors: I read with interest the report by Magnusson et al1 regarding improvement in Short Form-36 scores after inguinal hernia repair. Although not cited by the authors, their report essentially duplicates and corroborates, in greater detail and with 3 times as many patients, the earlier report on the same topic in which we demonstrated the feasibility of using the Short Form-36 for outcomes measurement in inguinal hernia repair.2 Our findings were virtually identical to the results of Magnusson et al: 69% (vs 64%) of patients reported some form of pain, commonly described as a dull ache or pressure sensation. Patients with hernia had lesser scores only in physical function and physical role limitation. Postoperatively, these scores improved to normal or greater. Although Magnusson et al focus on the symptom of ‘‘pain,’’ they did not make any determination preoperatively of whether the pain being experienced by the patient was actually hernia-related or not. This focus is an important consideration because, in my experience, many if not most patients who present with postherniorrhaphy pain had the same or similar preoperative pain (often with no clinically evident hernia) for which they underwent hernia repair under the assumption that it was hernia-related. I see many patients with groin pain that in its character, location, duration, and other characteristics is clearly not related to inguinal hernia, whether a hernia is clinically evident or not. If we are to make progress in finding the reasons for pain after
hernia repair, I think we must look more carefully at preoperative pain characteristics. The vast majority of patients with inguinal hernia are functionally normal or have only a small decrement in functional status. The goal of hernia repair should be to make them better, not worse. One of the concerns that led to the watchful waiting study3 was the possibility that inguinal hernia repair might cause more functional deficits than it fixed. This possibility (luckily) was proven not to be the case, and one of the unheralded outcomes of the study was the very low incidence of postoperative pain in patient who had little if any pain prior to operation. We need to be cautious about operating on patients with apparently severe pain that may not be related to the hernia. Richard E. Burney, MD University of Michigan, Ann Arbor, MI E-mail: [email protected]
References 1. Magnusson J, Videhult P, Gustafsson U, et al. Relationship between preoperative symptoms and improvement in quality of life in patients undergoing elective inguinal herniorrhaphy. Surgery 2014;155:106-13. 2. Burney RE, Jones KR, Coon JW, Blewitt DK, Herm A, Peterson M. Core outcome measures for inguinal hernia repair. J Am Coll Surg 1997;185:509-15. 3. Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, Dunlop DD, Reda DJ, McCarthy M Jr, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA 2006;295:285-92. http://dx.doi.org/10.1016/j.surg.2014.03.028
SURGERY 1
Letter to the Editors Preoperative symptoms and inguinal herniorrhaphy
To the Editors: I read with interest the report by Magnusson et al1 regarding improvement in Short Form-36 scores after inguinal hernia repair. Although not cited by the authors, their report essentially duplicates and corroborates, in greater detail and with 3 times as many patients, the earlier report on the same topic in which we demonstrated the feasibility of using the Short Form-36 for outcomes measurement in inguinal hernia repair.2 Our findings were virtually identical to the results of Magnusson et al: 69% (vs 64%) of patients reported some form of pain, commonly described as a dull ache or pressure sensation. Patients with hernia had lesser scores only in physical function and physical role limitation. Postoperatively, these scores improved to normal or greater. Although Magnusson et al focus on the symptom of ‘‘pain,’’ they did not make any determination preoperatively of whether the pain being experienced by the patient was actually hernia-related or not. This focus is an important consideration because, in my experience, many if not most patients who present with postherniorrhaphy pain had the same or similar preoperative pain (often with no clinically evident hernia) for which they underwent hernia repair under the assumption that it was hernia-related. I see many patients with groin pain that in its character, location, duration, and other characteristics is clearly not related to inguinal hernia, whether a hernia is clinically evident or not. If we are to make progress in finding the reasons for pain after
hernia repair, I think we must look more carefully at preoperative pain characteristics. The vast majority of patients with inguinal hernia are functionally normal or have only a small decrement in functional status. The goal of hernia repair should be to make them better, not worse. One of the concerns that led to the watchful waiting study3 was the possibility that inguinal hernia repair might cause more functional deficits than it fixed. This possibility (luckily) was proven not to be the case, and one of the unheralded outcomes of the study was the very low incidence of postoperative pain in patient who had little if any pain prior to operation. We need to be cautious about operating on patients with apparently severe pain that may not be related to the hernia. Richard E. Burney, MD University of Michigan, Ann Arbor, MI E-mail: [email protected]
References 1. Magnusson J, Videhult P, Gustafsson U, et al. Relationship between preoperative symptoms and improvement in quality of life in patients undergoing elective inguinal herniorrhaphy. Surgery 2014;155:106-13. 2. Burney RE, Jones KR, Coon JW, Blewitt DK, Herm A, Peterson M. Core outcome measures for inguinal hernia repair. J Am Coll Surg 1997;185:509-15. 3. Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, Dunlop DD, Reda DJ, McCarthy M Jr, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA 2006;295:285-92. http://dx.doi.org/10.1016/j.surg.2014.03.028
SURGERY 1
