Short note

Br. J. Surg. 1993, Vol. 80, June, 745-746

Return to work after inguinal hernia repair

M. A. Rider, D. M. Baker, A. Locker and A. N. Fawcett

University Hospital, Queen‘s Medical Centre, Nottingham, UK Correspondence to: Dr M. A. Rider, 80A Pierrepont Road, West Bridgford, Nottingham NG2 5DW, UK

Repair of inguinal hernia is one of the most common operations performed on men; convalescence time away from work after such surgery constitutes an important loss of income to both individual and nation’. It is now generally accepted’-5 that the patient should return to work within 4 weeks of an uncomplicated inguinal hernia repair. Regardless of occupation, this ‘early’ return is not associated with an increase in recurrence rate6, and no discrimination should be made for those in physically demanding employment. Despite this, the authors suspected that patients still remain off work for periods much longer than 4 weeks, largely on the advice of their general practitioners (GPs). This is a report of a retrospective postal survey, investigating when patients return to work after hernia repair and some of the factors influencing this.

Patients and methods A postal questionnaire was sent to men aged 18-65 years who had undergone unilateral inguinal hernia repair performed as a first-time procedure by a single consultant surgeon (A.N.F.) from January 1982 to December 1991. The operation was performed by the consultant in person, using an overlapping repair of the transversalis fascia for direct hernia and herniotomy with repair of the deep inguinal ring for indirect hernia. The questionnaire asked:

1 . Before coming to hospital, how long did you initially expect to need off work’?

2. Who gave you this impression? 3. After your hernia repair, how long did you stay off work? 4. Did you think you were off work for an appropriate length of time‘? 5. Could you have gone back earlier: ( a ) to a lighter job? or (b) to

your own job? 6 . Who decided you could return to work?

Patients were also asked to classify their work as light, moderate or heavy. to indicate whether it was manual, sedentary or mixed, to describe their work briefly and to give an indication of the heaviest object they may have had to lift. The definition of light, moderate or heavy work used was based on the patient’s own classification and standardized using other information provided.

Results A total of 420 questionnaires were sent to patients, 292 of which were returned, a response rate of 70 per cent. Seventy-one of these were invalid for various reasons including unemployment and early retirement. Of the 221 remaining patients, 76 (34 per cent) described their work as light, 85 (38 per cent) as moderate and 60 (27 per cent) as heavy. The intervals from operation to return to work are shown in Figure 1 .

In all, 194 patients (88 per cent) had a preoperative expectation of convalescence time. This expected time correlated well with the time actually taken ( r s = 0.63,

Light I

Moderate H * I I

Heavy I-( j I

Tota l i I I I I I I I

0 20 40 60 80 100 120

Time off work (days )

Figure 1 median (box , inieryuurtile range; bars, runye)

Time qly w>ork according to type of occupation. Values are

P < 0.0001). In 131 patients (68 per cent) the expected time was based on information from colleagues, in 54 (28 per cent) from the referring GP and in nine ( 5 per cent) from the surgeon. Forty patients performing heavy work (73 per cent of those giving valid replies) thought they were off too long and could have returned earlier, to lighter work in 32 cases and to their own job in eight. Thirty-one (46 per cent) of the light workers thought they could have returned sooner. Only 31 (14 per cent) of all patients thought they had returned to work too early and the majority of these were self-employed.

The main influence in the decision to return to work varied with occupation. In men doing heavy work the G P made the decision most frequently (24 cases; 41 per cent) whereas in those performing light work it was more often made without consultation (40 cases; 56 per cent). The early and late returners were also advised from different sources. Of 55 patients who returned within 16 days (first quartile), 38 (69 per cent) made the decision themselves and only seven (13 per cent) were returned ‘early’ by their GP. However, in the fourth quartile (return to work after 47 days) 34 patients (62 per cent) stated that the GP was the main influence in this delayed return.

Discussion There have been few recent studies of convalescence after herniorrhaphy. Two surveys in 1981 and 1980 gave mean times of 65 and 51 days r e s p e c t i ~ e l y ~ ~ ~ . The overall median time of 28 days for patients in the present study is considerably lower than both these and suggests there has been a marked trend towards earlier return to work as advocated by a number of

following studies carried out in the 1970s. The misconception that those with physically demanding

jobs need longer off work persists. In this study the median time off for men in heavy work was 42 (interquartile range 30-68) days, with 75 per cent being off work for > 4 weeks. Almost three-quarters of this group thought they could have returned to some form of work earlier. Men performing heavy work represent roughly one-third of the workforce and there is considerable financial and psychological benefit, both to the individual and in general, in their early return to employment.

The GP was seen as the most important factor in this delayed return to work by both the group performing heavy work and those who returned to work latest. Actual time off work correlated strongly with the preconceived time, and so education at the preoperative stage, initially by the referring GP and reinforced by the surgical team, may be effective.

In conclusion, this study indicates that the time off work following routine inguinal hernia repair is reducing and coming into line with current surgical thinking. However, spurious factors such as the type of work continue to influence this time interval. Education of GPs and, before operation, of patients may be one of method of successfully influencing this.

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0007-1 323/93/060745-02 0 1993 Butterworth-Hememann Ltd 745

Short note

References 1.

2.

4.

5.

6.

Barwell NJ. Recurrence and early activity after groin hernia repair. Lancet 1981; ii: 985. Semmence A, Kynch J. Hernia repair and time offwork in Oxford, J R Coll Gen Pract 1980; 30: 90-6. Ross APJ. Incidence of inguinal hernia recurrence. Ann R Coll Surg Engl 1975; 51: 326-8.

Glasgow F. Surgical repair of inguinal and femoral hernias. Can Med Assoc J 1973; 108: 308-13. Bourke JB, Lear PA, Taylor M. The effect of early return to work after elective repair of inguinal hernia: clinical and financial consequencesat one year and three years. Lancet 1981; ii: 623-5. Taylor EW, Dewar AP. Early return to work after repair of unilateral inguinal hernia. Br J Surg 1983; 70: 599-600.

3. Paper accepted 19 September 1992

Surgical workshop

Br. J. Surg. 1993, Vol. 80, June, 746

Method of separating the peritoneal sac from the spermatic vessels during laparoscopic repair of inguinal hernia

D. C. Dunn

Department of Surgery, Addenbrooke‘s Hospital, Hills Road, Cambridge CB2 2QQ. UK Correspondence to: Mr D. C. Dunn

A popular method of repairing inguinal hernia laparoscopically involves insertion of a piece of polypropylene mesh in the preperitoneal space so that it covers the internal ring, Hesselbach’s triangle and the femoral canal. To insert this mesh, it is necessary to separate the peritoneum from the underlying structures. This manoeuvre is particularly difficult over the testicular vessels and vas, which are closely applied to the peritoneum, as is the inferior epigastric artery. A technique is described that makes this part of the operation easy, quick and safe.

Surgical technique A 19-G needle swaged to a plastic tube is inserted through a small stab wound in the lateral part of the abdomen on the same side as the hernia. To date such a needle has been created by removing the wings from a ‘butterfly’ needle. The far end of the tubing is attached to a 20-1111 syringe containing normal saline and a dilute solution of bupivacaine (0.25 per cent). The needle is visualized with the laparoscope as it enters the peritoneal cavity and picked up using fine graspers. It is then steered towards the spermatic cord and delicately inserted just beneath the peritoneum alongside the spermatic vessels. This enables the tip of the needle to be clearly seen as it advances under the peritoneum (Figure I ) . When the needle is seen to be in a satisfactory position, the assistant insufflates the saline solution, raising a ‘blister’ of fluid which separates the peritoneum from the underlying vessels. After satisfactory separation has been achieved, the syringe is filled with either air or carbon dioxide from the pneumoperitoneum. Pressure is then reapplied and air enters the retroperitoneal blister. This event completes the dissection and separates the peritoneum from the underlying vessels by an air pocket. Further similar separation is achieved down the hernia sac and around the inferior epigastric vessels.

Figure 1 Injection of saline and bupiuacaine between the peritoneum and spermatic vessels, using a modijied ‘butterfly’ needle. Injection of air or carbon dioxide into the blister completes the separation of the sac and Dessels

The peritoneum is then incised cranially and a flap is raised down towards the inguinal ligament. As the air pocket is entered, it is seen that dissection over the vessels is complete.

Discussion It was previously found that separation of the peritoneum from the spermatic vessels took a great deal of time and had to be performed very carefully because of the danger of incising these vessels and causing bleeding and haematoma formation. Attempts to perform hydrodissection from a needle inserted externally proved difficult and inaccurate. Internal hydro- dissection and pneumodissection are now carried out as a first manoeuvre as soon as pneumoperitoneum has been established and the cannulas inserted. The previously difficult dissection is now completed within 1-2 min. This technique has allowed a reduction in the mean operating time for laparoscopic inguinal hernia repair from 70 to 58 min and is strongly recommended for general adoption. Care must be taken to ensure that the needle is not inserted into a blood vessel, but this can be avoided as the manoeuvre is carried out under direct vision with laparoscopic magnification. The injection of fluid alone results in oedema and does not give rise to a clear dissection plane. The secondary injection of air or carbon dioxide overcomes this problem. A special needle with attached tubing is being developed to allow easier insertion into the peritoneal cavity than is possible with the modified butterfly needle.

Paper accepted 22 November 1992

746 0007-1323/93/06074&01 C 1993 Butterworth-Hememann Ltd