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ORIGINAL ARTICLE
Year : 2015  |  Volume : 3  |  Issue : 1  |  Page : 7-11

A comparative study on outcome of Lichtenstein's hernioplasty done by residents and by the consultant surgeon


Department of General Surgery, IPGMER and SSKM Hospital, Kolkata, West Bengal, India

Date of Web Publication23-Mar-2015

Correspondence Address:
Bappaditya Har
82/6 Goutamnagar, New Delhi - 110 049
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3846.153800

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  Abstract 

Introduction: Surgeon's case volume,hospital volume and specialisation improve the outcome of many major surgical procedures gastrectomy, esophagectomy and rectal surgery. The exact role of specialist centers in more common surgical operations like inguinal hernioplasties and varicose vein, is still not so clear. Hernioplasty done by a resident may allow consultant to concentrate on major critical cases. In this study we analysed whether well-trained surgical residents are able to perform Lichtenstein operation with an acceptable immediate and long-term outcome compared to the experienced specialist consultants in hernia surgery. Materials and Methods: Patients were subjected randomly to lichenstein mesh hernioplasty by well trained residents (after assisting 10 operation with consultant) and consultants. Parameters were noted during operation and in follow up accordingly. Hernioplasty done by experienced consultant surgeon (n=51) and by residents (n=53). Results: The mean operating time taken by the residents (66 ± 10 minutes) was significantly higher than that of the consultant surgeons (49 ± 10 minutes). The post-operative infection rates in the current study for surgeries done by residents and consultants were 7.7% and 3.9%, respectively. The occurrence of post-operative wound hematoma, scrotal oedema and hospital stay,resumption to normal activity was not significantly different (P>0.05) between patients operated by residents and consultants. Severity of post-operative pain (based on VAS scores) was also not significantly different (P>0.05) between patients operated by consultants and those operated by residents. Only 1 patient (1%) had recurrence of hernia after 6 months following hernia repair. Conclusion: Open mesh repair under local anaesthesia was a safe operation and the long-term results were acceptable among the patients operated by surgical trainees. There was no statistcally significant difference in the occurrence of post-operative complications except for increased operative time.

Keywords: Consultant, hernioplasty, Lichtenstein, resident


How to cite this article:
Prasad A, Har B, Chatterjee A, Chattopadhyay BK. A comparative study on outcome of Lichtenstein's hernioplasty done by residents and by the consultant surgeon. Saudi Surg J 2015;3:7-11

How to cite this URL:
Prasad A, Har B, Chatterjee A, Chattopadhyay BK. A comparative study on outcome of Lichtenstein's hernioplasty done by residents and by the consultant surgeon. Saudi Surg J [serial online] 2015 [cited 2021 Jan 27];3:7-11. Available from: https://www.saudisurgj.org/text.asp?2015/3/1/7/153800


  Introduction Top


A hernia is defined as an area of weakness or disruption of the fibro muscular tissues of the body wall. Often hernia is also defined as an actual anatomical weakness or defect. [1] Greek word hernia means offshoot, a budding/bulge. [2] Latin word hernia means rupture or tear.

There are many ways of repairing an inguinal hernia defect with over 80 techniques described since 1887 when Bassini reported his method. Extensive clinical research has been undertaken to assess the outcome following inguinal hernia repair. Large series, including multiple types of repairs, have suggested that recurrence ranges from 1.7% to 10%. [3],[4],[5] High recurrence rates using fascia for inguinal hernia repair or suturing under tension prompted the development of minimal tension nylon darn and then prolene mesh to reinforce the posterior wall of the inguinal canal during hernia repair.

Lichtenstein group popularized routine use of mesh and coined "tension-free" hernioplasty where instead of suturing anatomic structures entire defect is reinforced by sheet of mesh. Hence, it is both therapeutic as well as prophylactic. [6]

The main interest is to reveal whether well-trained surgical residents are able to perform Lichtenstein operation with an acceptable immediate and long-term outcome compared to the experienced specialist in hernia surgery. Although inguinal hernioplasty is one of the first operations performed by surgical residents, only a few studies have compared the immediate results between residents and their consultant. [5],[7],[8],[9],[10] Therefore in a country like ours where there is dearth of surgeons, surgeries like Lichtenstein's mesh hernioplasty can be done by well-trained resident surgeons thereby enabling the consultant surgeons to deal with more complex surgeries which demand higher skills.


  Materials and Methods Top


This is a comparative prospective trial of 103 patients (age 15-60 years) with inguinal hernia [[Table 1]]. Recurrent hernia, femoral hernia, obstructed/strangulated hernia was excluded from the study. Two consultant surgeons or three residents of general surgery (3 years of residency) performed all operations. The residents were well-trained before the study by assisting 10 hernioplasty with consultant. For ethical reasons, no sealed envelopes or computer programs were used in the patient selection between trainees and surgeon. Patients are fulfilling the surgery criteria received written and oral information about the aims and content of the study. The staff of our day-case surgery told to the patient that the operation is performed by the attending surgeon of the day (either resident or specialist). The patients knew that they were part of the trial, and an informed consent was signed. The ethics committee in our hospital approved the study protocol.
Table 1: Initial operative data of 103 patients undergoing Lichtenstein hernioplasty under local anesthesia

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The procedure was always performed under local infiltration anesthesia using 7 cm × 12 cm polypropylene mesh. The sac of the indirect hernia was either resected or just inverted into the abdomen. If the hernia sac was large and direct, it was inverted with absorbable 2-0 absorbable sutures. The inguinal nerves were tried to identify and save if possible. We did not try to identify the three inguinal nerves systematically at operation nor record the nerve identification. The mesh was trimmed and placed between the conjoint tendon, inguinal ligament, pubic bone and external oblique aponeurosis. Mesh was always fixed with 2-0 nonabsorbable polypropylene sutures. Local infiltration anesthesia was a 1:1 mixture of bupivacaine (5 mg/ml) and adrenalin (10 mg/ml) with an average total volume of 40-50 ml. A single dose intravenous prophylactic antibiotic was given prior to the procedure.

The patient characteristics, type of hernia, operation time and wound complications were recorded by an independent researcher. Operative time was recorded from infiltration of local anesthetic to skin closure. The short-term outcome was evaluated 1-month postoperative. The long-term results (6 months) were asked using the questionnaire and clinical examination. This includes pain (day 1, 7, 30, 180), scrotal edema, hematoma, resumption to normal activity, wound infection and recurrence.

All the data were initially entered to Microsoft Excel and later these spreadsheets were used for analysis. Statistical analysis was done using IBM SPSS Statistics version 20.0. Descriptive statistics were calculated as the frequency, percentage, mean and standard deviation, median, and inter-quartile range. Descriptive data were represented using various tables, graphs, diagrams, etc., For inferential statistics, various tests of significance were used according to the type of variables dealt with. For all the statistical tests of significance, P < 0.05 was considered to reject the null hypothesis.


  Results Top


The patient characteristics were similar in both groups [[Table 1]]. The mean operating time (±standard deviation) in the current study was 57.6 (±13.6) min and about 61% of the hernia repair surgeries were completed within 1 h and only about 4% of the surgeries needed more than 75 min [[Table 1]]. The mean operating time taken by the residents (66 ± 10 min) was significantly higher than that of the consultant surgeons (49 ± 10 min) [[Table 1]]. This indicates that the training period plays a very important role in the duration of surgery. This result is in accordance with Paajanen and Varjo [11] where mean time taken by residents was 62 ± 18 min and that taken by consultants was 39 ± 13 min which too was significant. This is also reflected in a study by Cueto et al. [12] where the only significant (P = 0.01) difference concern was operative time, which increased 20% in resident groups as compared to consultants. Significant difference in operating time was also reported by Wilkiemeyer et al. [13] in groups of surgeons with different levels of experience. Since the current study was carried out in a tertiary care center, as expected the postoperative infection rate was low (5.8%) [[Figure 1]]. Paajanen et al. [14] observed infection rates of 22% in a nation-wide analysis of hernia repairs in Finland. The postoperative infection rates in the current study for surgeries done by residents and consultants were 7.7% and 3.9%, respectively. However, this difference in infection rates was not statistically significant (P = 0.549) [[Figure 1]]. According to Paajanen and Varjo, [11] infection rates were 0.7% and 1.1%, respectively, in the residents and consultant groups, and this difference was also not statistically significant. In the present study, about 5% of patients developed wound hematoma following hernia repair [[Figure 1]]. In comparison, Paajanen et al. [14] observed bleeding complications in 13%. This difference can be attributed to the fact that the later was a nation-wide analysis of inguinal hernia repairs in different hospitals unlike the present study where only one tertiary hospital was considered besides the small sample size included in the present study. The occurrence of postoperative wound hematoma was not significantly different (P > 0.05) between patients operated by residents and consultants [[Figure 1]]. About 6% of patients developed scrotal edema following hernia repair in the current study. On the other hand, Forte et al. [15] observed scrotal edema in 1.7%. In addition, the presence of scrotal edema was not significantly different between patients in the two groups operated by residents and consultants (P = 0. 414) [[Figure 1]]. The percentage of patients with mild pain decreased gradually in the postoperative period (54%, 24%, 15%, 10% on day 1, 7, 30 and day 180, respectively) [[Table 2]]. However, more patients experienced moderate pain on day 7 than day 1 (18.4% vs. 8.7%). This can be attributed to the development of scrotal edema, wound hematoma and infection in some patients during the 1 st week of the postoperative period. In addition, the prevalence of severe pain was maximum on day 7 (6.8%) and minimum on day 180 (1%). The prevalence of chronic pain (pain on day 180) in the current study was 17.5% irrespective of the severity of pain. On the other hand, chronic pain was observed in 32% by Paajanen et al. [14] This difference may be because all types inguinal hernia repairs were followed-up for chronic pain apart from Lichenstein's operation. Severity of postoperative pain (based on visual analogue scale [VAS] scores) was not significantly different (P > 0.05) between patients operated by consultants and those operated by residents during all days of follow-up such as day 1, day 7, day 30 and day 180 in the postoperative period [[Table 2]]. Similarly, Paajanen and Varjo [11] also observed that there was no difference in the occurrence of groin pain: About 20% of the patients required medication for pain after 1-week in comparison to 37% of patients requiring pain medication on day 1. However, the need for pain medication was around 12% and 9% after 1-month and 6 months, respectively, in the current study [[Figure 2]]. In addition, requirement of postoperative pain medication was not significantly different (P > 0.05) among patients operated by consultants and those operated by residents during all days of follow-up such as day 1, day 7, day 30 and day 180 in the postoperative period [[Figure 2]]. Paajanen and Varjo [11] observed that 3.5% and 4.2% of patients operated by consultants and residents, respectively, required pain medication after 3 years of hernia repair. About 81% of patients resumed their normal activities following hernia repair within 4 weeks while the remaining 19% required more than 4 weeks for resumption of their normal activities [[Table 1]]. Moreover, the time needed for the patients to resume their normal day-to-day activities did not significantly differ (P > 0.05) between patients operated by residents and consultants [[Table 1]].
Figure 1: Comparison of postoperative complications of surgeries done by consultants and residents

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Figure 2: Comparison of requirement of pain medication during followup for surgeries done by consultants and residents

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Table 2: Distribution of severity of postoperative pain on various postoperative days of follow-up according
to operating personnel (n=103)


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Only 1 patient (1%) had recurrence of hernia after 6 months following hernia repair. However, the recurrence rate was 8% in a study by Paajanen et al. [14] This difference may be because they considered all inguinal hernia repairs, unlike the present study where only Lichenstein's operation was considered. The recurrence of hernia after 6 months of the postoperative period also did not differ (P > 0.05) according to the operating personnel (consultants and residents). Similar finding was observed by Paajanen et al. [14] where too the difference in the occurrence of recurrence was not significant when compared in the two groups. On the contrary, Wilkiemeyer et al. [13] reported open hernia repairs performed by junior residents were associated with higher recurrence rates than those repaired by senior residents but he also reported that, with experience in the tension-free technique residents achieved low rates of recurrence of 1.1%.


  Discussion Top


This study was an institution-based prospective nonrandomized controlled study conducted among patients of the General Surgery Department of Institute of Post Graduate Medical Education and Research, Kolkata during the 2 academic years of 2011-12 and 2012-13. The study was aimed to determine whether well-trained surgical residents are able to perform Lichtenstein operation with an acceptable immediate and long-term outcome compared to the experienced specialist consultants in hernia surgery.

Consultants and residents performed almost equal number of hernia repairs (49.5% vs. 50.5%). About 61.1% of the hernia repair surgeries were completed within 1 h, and only about 4% of the surgeries needed more than 75 min. Only 6 patients (5.8%) had postoperative infection following hernia repair: Of the 6 patients (5.8%) who had postoperative infection, 5 patients (83.3%) had superficial incisional infection and only 1 (16.7%) patient had deep incisional infection according to Centers for Disease Control classification. About 5% of patients developed wound hematoma following hernia repair. About 6% of patients developed scrotal edema following hernia repair. The percentage of patients with mild pain decreased gradually in the postoperative period. However, more patients experienced moderate pain on day 7 than day 1 (18.4% vs. 8.7%). Opioid analgesic (tramadol) was given for severe pain while nonsteroidal anti-inflammatory drugs (diclofenac) were used for mild to moderate pain. About 20% of the patients required medication for pain after 1-week in comparison to 37% of patients requiring pain medication on day 1. However, the need for pain medication was around 12% and 9% after 1-month and 6 months, respectively. About 23% of patients had postoperative scar discomfort following hernia repair. About 81% of patients resumed their normal activities following hernia repair within 4 weeks while the remaining 19% required more than 4 weeks for resumption of their normal activities. Only 1 patient had recurrence of hernia after 6 months following hernia repair. The mean age of the patients operated by consultants did not differ significantly (P > 0.05) from the mean age of the patients operated by residents. The proportion of male and female patients operated by consultants did not differ significantly (P > 0.05) from the proportion of male and female patients operated by residents. There was no statistically significant association (P > 0.05) between the type of hernia and the operating personnel inferring that both consultants and residents operated on comparable proportion of patients in each type of hernia. The mean operating time of consultants was less than mean operating time of residents and this difference in the operating time was statistically significantly (P < 0.05). There was a statistically significant difference (P < 0.001) in the operating time of consultants and residents. The occurrence of postoperative complications such as infection, wound hematoma, scrotal edema, and the scar discomfort was not significantly different (P > 0.05) between patients operated by residents and consultants. Severity of postoperative pain (based on VAS scores) was not significantly different (P > 0.05) between patients operated by consultants and those operated by residents. The finding that the occurrence and severity of postoperative pain are comparable between patients operated by consultants and residents was observed during all days of follow-up such as day 1, day 7, day 30 and day 180 in the postoperative period. Requirement of postoperative pain medication was not significantly different (P > 0.05) among patients operated by consultants and those operated by residents. The finding that the requirement of postoperative pain medication is comparable between patients operated by consultants and residents was observed during all days of follow-up such as day 1, day 7, day 30 and day 180 in the postoperative period. The time needed for the patients to resume their normal day-to-day activities did not significantly differ (P > 0.05) between patients operated by residents and consultants. The recurrence of hernia after 6 months of the postoperative period also did not differ (P > 0.05) according to the operating personnel (consultants and residents).


  Conclusion Top


Hernia repair is one of the earliest surgeries learnt by the trainee surgeons. This study reveals that except for operating time, the surgeries performed by well-trained residents are comparable in terms of outcome of hernia surgery. Therefore in a country like ours where there is dearth of surgeons, surgeries like Lichtenstein's mesh hernioplasty can be done by well-trained resident surgeons thereby enabling the consultant surgeons to deal with more complex surgeries which demand higher skills.

 
  References Top

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Nordin P, Haapaniemi S, van der Linden W, Nilsson E. Choice of anesthesia and risk of reoperation for recurrence in groin hernia repair. Ann Surg 2004;240:187-92.  Back to cited text no. 3
    
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Bisgaard T, Bay-Nielsen M, Kehlet H. Re-recurrence after operation for recurrent inguinal hernia. A nationwide 8-year follow-up study on the role of type of repair. Ann Surg 2008;247:707-11.  Back to cited text no. 4
    
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Neumayer L, Giobbie-Hurder A, Jonasson O, Fitzgibbons R Jr, Dunlop D, Gibbs J, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 2004;350:1819-27.  Back to cited text no. 5
    
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Amato B, Moja L, Panico S, Persico G, Rispoli C, Rocco N, et al. Shouldice technique versus other open techniques for inguinal hernia repair. Cochrane Database Syst Rev 2012;4: CD001543.  Back to cited text no. 9
    
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van Veen RN, Wijsmuller AR, Vrijland WW, Hop WC, Lange JF, Jeekel J. Long-term follow-up of a randomized clinical trial of non-mesh versus mesh repair of primary inguinal hernia. Br J Surg 2007;94:506-10.  Back to cited text no. 10
    
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Cueto Rozon R, De Baerdemacker Y, Polliand C, Champault G. Surgical training and inguinal hernia repair. Ann Chir 2006;131:311-5.  Back to cited text no. 12
    
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Paajanen H, Scheinin T, Vironen J. Commentary: Nationwide analysis of complications related to inguinal hernia surgery in Finland: A 5 year register study of 55,000 operations. Am J Surg 2010;199:746-51.  Back to cited text no. 14
    
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