Download Day-case surgery for inguinal hernia: A private hospital expericnce

DAY-CASE SURGERY FOR INGUINAL HERNIA: A MULTISPECIALIST PRIVATE HOSPITAL EXPERIENCE IN NIGERIA
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, D.C. OBALUM, 3S.U. EYESAN, 2C.N. OGO, 2O.A. ATOYEBI
1
DEPARTMENT OF SURGERY, HAVANA SPECIALIST HOSPITAL,
LAGOS, NIGERIA
2
DEPARTMENT OF SURGERY, COLLEGE OF MEDICINE, UNIVERSITY
OF LAGOS (CMUL)/LAGOS UNIVERSITY TEACHING HOSPITAL (LUTH),
LAGOS
3
DEPARTMENT OF SURGERY, NATIONAL ORTHOPAEDIC HOSPITAL
LAGOS
CORRESPONDENCE TO
D.C. OBALUM
DEPARTMENT OF SUGERY
CMUL/LUTH
LAGOS
[email protected].
SYNONYMS AND KEY WORDS
INGUINAL HERNIA
DAY-CASE SURGERY
NIGERIA
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DAY-CASE SURGERY FOR INGUINAL HERNIA: A MULTISPECIALIST PRIVATE HOSPITAL EXPERIENCE IN NIGERIA
D.C. OBALUM, S.U. EYESAN, C.N. OGO, O.A. ATOYEBI
SUMMARY
Background: The growing popularity of day-case surgery derives mainly from its twin
benefits of convenience and cost-effectiveness. It is particularly useful in treating
inguinal hernia which remains one of the most common presenting surgical problems.
Objective: To evaluate the results of inguinal herniotomy or herniorrhaphy done as daycase.
Methods: A cross-sectional study of 72 cases of inguinal hernia treated by day-case
herniotomy or herniorrhaphy at Havana Specialist Hospital, Lagos, Nigeria between July
2002 and June 2004. Post-operative follow up ranged from 2 to 4 years. Patients with
concurrent systemic illness that needed admission as well as those who preferred
admission were excluded. Data including age, gender, hernia characteristics, type of
anaesthesia, complications and outcomes were collected and analysed.
Results: A total of 72 cases were studied. Only 4 were females, the remaining 68 were
males. Ages 6 months to 60 years were affected with a mean age of 26.7 years and a peak
incidence in the 21-30 years age group. The commonest complication was pain felt postoperatively by 62.5% of the study population. However, wound infection (seen in 11.2%)
was the most significant complication. Other complications were wound and scrotal
haematoma(8.3%), hernia recurrence (1.4%) and hypertrophic scar(1.4%). No mortality
was recorded.
Conclusion: The study showed that post-operative pain is the commonest complication
of day-case inguinal herniotomy and herniorrhaphy. Wound infection was however the
most common significant complication. The overall outcome was good.
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INTRODUCTION
There is a growing popularity of day-case surgery globally. This derives mainly
from its twin benefits of convenience and cost effectiveness1. Day-case surgery is
particularly suitable for a common surgical problem such as inguinal hernia. Many
patients with inguinal hernia are poor and are unable to afford the costs of peri-operative
admission especially in private hospitals.
World wide, inguinal hernia remains a common problem presenting to
surgeons2,3. At many hospitals in developing countries, the waiting period for admission
is often long owing to long list of patients, limited bed spaces and inadequate qualified
manpower2. Day-case surgery for inguinal hernia is therefore the panacea to these many
challenges.
Possible complications at home after day-case surgery is one of the often highlighted
shortcomings. However many authors have studied and documented comparably good
outcome after day case surgery for inguinal hernia as against those who had perioperative admission4,5,6. Also, the cost-effectiveness of day-case surgery for inguinal
hernia has been found not to compromise safety3,4.
These benefits and possible short comings of day-case inguinal hernia surgery
with the background of challenging load of patients with inguinal hernia necessitated this
study and report of our experience. The objective of the study is to evaluate the results of
day-case surgery for inguinal hernia and compare cost of day surgery versus
hospitalization for uncomplicated inguinal hernia surgery.
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PATIENTS AND METHODS
This prospective study was carried out at Havana Specialist Hospital (HSH),
Lagos, Nigeria between 1st July 2002 and 30th June 2004. HSH is one of the foremost
private multi-specialist hospitals in Lagos metropolis. Most of the patients attending HSH
are mainly of the upper and upper middle socio-economic class. However, some patients
of low socio-economic class who are entitled to health insurance also utilize the hospital
services.
The ethical approval to undertake this study was obtained from the ethics
committee of HSH and informed consent obtained from patients or their proxies.
Inclusion criteria were patients with uncomplicated inguinal hernia with anticipated
surgery duration of less than one hour. All patients with co-morbidities requiring
admission and those that preferred admission were excluded.
The age and gender of the patients as well as the characteristics of the hernia were
documented. Detailed physical examination, haemoglobin level estimation and urinalysis
were done for each patient to ascertain their fitness for surgery. Adult patients were
instructed to abstain from all food and fluid from 10pm on the day before surgery, while
parents of children were instructed to allow them liquids up to 4 hours before surgery. All
patients were told to report at the hospital before 8am on the day of surgery.
The anaesthetic technique was determined by the consultant anaesthetist. The
techniques used included general anaesthesia, local infiltration anaesthesia and spinal
anaesthesia. The authors performed the surgeries. Children had herniotomy while adults
had herniorrhaphy by Bassini technique. The patients had intravenous prophylactic broad
spectrum antibiotics administered at induction of anaesthesia and 6 hours after surgery.
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Wound dressing was with dry gauze and plaster. Oral antibiotics were thereafter offered
for 5 days.
Post-operatively, all patients were observed for 1 hour in the recovery room and
then for further 4-6 hours in the wards. Parenteral dipyrome or pentazocine were given as
appropriate for analgesia while in hospital and oral acetaminophen was given to be taken
at home. All patients were discharged from hospital on the day of surgery after full
recovery from anaesthesia with stable vital signs. They all walked home accompanied by
an adult.
On discharge patients were advised to report back to the hospital if they had
complaints. They were instructed to keep the wound dressing dry. The patients were seen
on the 7th day post-surgery for removal of stitches, interview and examination for
complications. Follow-up was continued for 2 to 4 years post-surgery especially for
evidence of recurrence.
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RESULTS
A total 84 patients had day-case surgery for inguinal hernia during the study
period. Seventy-six consented to the study out of which 4 did not keep follow-up
appointments. Seventy-two patients were studied, 68 (94.4%) were males, while 4 (5.6%)
were females giving a male to female ratio of 17:1 Ages 6 months to 60 years were
affected. The mean age was 26.7 years; and peak incidence was 21 - 30 years. The age
distribution is shown in table 1.
Three patients (4.2%) had bilateral hernia, 40 (55.6%) had right sided hernia
while 29 (40.2%) had left sided hernia. Forty-eight patients (66.7%) had general
anaesthesia, 50% of those that had general anaesthesia were aged below 15 years and had
herniotomy. Four (5.6%) had spinal anesthesia, while 20 (27.8%) had local infiltration
with xylocaine with adrenalin. These are shown in table 2.
Post-operative pain was reported by 45 (62.5%) of patients within 48hours of
surgery, but only 12 (16.7%) reported that the pain was severe enough to stop them from
sleeping or doing their usual chores at home. Only 6 patients (8.3%) had pain after 48
hours of surgery. Eight (11.2%) of the study population had mild wound infection
(redness of wound edges) but none had purulent discharge nor wound breakdown. Six
patients (8.3%) had post-operative scrotal haematoma, but all of them resolved
spontaneously. There was no incidence of re-admission into hospital after discharge.
All through the follow up period, only one patient (1.4%) each had recurrence and
hypertrophic scar. Fourteen patients (19.4%) would have preferred admission, while 54
(75.0%) were satisfied with the day-case surgery they had, while six (8.3%) were
indifferent.
For the purpose of determining comparative cost, the average cost of care for
hospitalized uncomplicated inguinal hernia surgery and day –case surgery were
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computed. The cost to hospitalized (inclusive of fee for surgery, medications, nursing
care and bed space) was N77,000 ($640.00) compared to N42,000 ($350) for day-case
hernia surgery. In government hospitals, the costs are about N45,000 ($375) and N38,000
($316) respectively.
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DISCUSSION
The dual benefits of convenience and cost effectiveness of day-case surgery are
especially pertinent in communities like ours with few surgeons and many indigent
patients who can hardly afford the cost of in-patient treatment. It is established that many
surgeries are done as day-cases4,7.
The male preponderance found in this study had been generally reported by other
authors2,8,9. However our finding of male to female ratio of 17:1 is lower than the ratio
reported in another study based in a government secondary care hospital in Lagos9. The
peak age incidence in this study was 21-30 years. This is younger than 4th decade of life
found by Ibrahim et al9 and 5th decade reported by Rai et al8. The difference may
represent the difference in age distribution of patients in private versus government
hospitals.
In adults, undergoing day-case surgery for inguinal hernia, local anesthesia is
preferred to general anaesthesia to reduce the anaesthetic risk in general and to reduce
and incidence of post-operative ileus and urinary retention in particular. Also, local and
spinal anaesthesia affords the surgeon the opportunity of testing the integrity of the repair
on table by asking the patient to cough. However, in some adults excessive anxiety and
low pain threshold may indicate the use of general anaesthesia. This explains why many
(50%) adults in this study had general anaesthesia. However, the consensus in children
having inguinal herniotomy is to use general anaesthesia10 and this was the preffered
protocol in this study.
Pain, especially within the first 2 days after surgery remain the most common
problem experienced by patients after day-case surgery11. Pain is a recognized postoperative problem in both outpatients and inpatients. Our finding is consistent with this.
However wound infection is a more significant complication because of its consequences.
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The wound infection rate of 11.2% in this study is marginally higher than rates reported
for elective herniorrhaphy by other authors4,9. Similarly, the 8.3% of studied patients
found with post-operative haematoma in this study is higher than 5.4% reported in
another study3.
In this study only 1.4% of the subjects had recurrence of the hernia during the 2 to
4 year follow-up period. This is higher than no recurrence reported in another study,
where Bassini technique was also used for repair9. The duration of follow-up in this study
(2 to 4 years) and the earlier study by Ibrahim el al9 (2 to 5 years) is however relatively
short considering that recurrence may occur even up to 25 years after a repair2.
No re-admission and zero mortality recorded in this study highlights the neglible
morbidity and safety associated with day-case surgery for inguinal hernia. This finding is
in agreement with other studies that reported less than 0.5% re-admission rates4,5 and
neglible mortality5,9,10. The pre-operative patient selection bias inherent in this study may
have contributed to the zero mortality.
The comparative costs of day-case surgery for hernia against hospitalization for
hernia surgery shows that the former was 54.5% of the later. Based on this, as well as the
low morbidity and zero mortality recorded in this study, day-case surgery for hernia is
strongly advocated in carefully selected patients.
It was difficult to assess psychological components of some of the observations
reported by patients in this study, such as pain. It would be interesting in future to study
hospitalized patients as a control group against day case patients to overcome this
limitation.
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CONCLUSION
In our experience day-case surgery for inguinal hernia is a relatively safe
procedure. It carries a neglible morbidity and mortality when pre-operative patient
selection is meticulous and methodical. It is highly recommended to ease the waiting lists
of indigent patients in particular and all patients in general.
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REFERENCES
1. Royal College of Surgeons of England. Guidelines for Day-case surgery. 1992;
RCSE: 10.
2. Badoe EA. Hernia. In: Badoe EA, Archampong EQ, Jaja MOA. (Ed) Principles
and practice of surgery. Tema: Ghana Publishing Corporation, 1994: 461-71.
3. Keith WM, Daniel JD. The Management of Hernia – Considerations in costeffectiveness. Surgical Clinics of North America 1996; 76: 105-15.
4. Lau H, Lee F. An audit of the early outcomes of ambulatory inguinal hernia repair
at a surgical day-case centre. Hong Kong Med. J. 2000; 6 (2): 218-20.
5. Adejuyigbe O, Abubakar AM, Sowande OA, Olasinde AA. Day-case surgery in
children in Ile-Ife, Nigeria: An audit. Nigerian Journal of Surgery.1998; 5(2):60-3
6. Awojobi OA, Sagua AG, Ladipo JK. Outpatient management of external hernia:
A district hospital experience. West Afr. J. Med. 1987; 6: 201-4.
7. McHugh GA, Thomas GMM. The Management of Pain following day-case
surgery. Anaesthesia. 2002; 57: 270-5.
8. Rai S, Chandra S, Smile SR. A Study of the risk of strangulation and obstruction
in groin hernias. A N Z J Surg 1998; 88:650-4.
9. Ibrahim NA, Ugburo AO, Atoyebi OA. Early outcome of day surgery for inguinal
hernia in sub-urban general hospital in Lagos, Nigeria Medical Journal. 2005; 46
(2): 33-5.
10. Adeyemi SD, da Rocha-Afodu JT, Olayiwola B. Outpatient herniotomy with
ketamine: A prospective study of 50 herniotomized children and review of 219
herniotomies with ketamine. West Afr. J. Med 1985; 4: 151-61.
11. Kable A, Gibbend R, Spigelman A. Complications after discharge for surgical
patients. A N Z J Surg. 2004; 74: 92-7.
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LIST OF TABLES
Table 1 - Age distribution of studied patients
Age
Frequency Percentage
10 and below
8
11.1
11-20
14
19.4
21 – 30
24
33.3
31 – 40
16
22.2
41 – 50
7
9.7
51 – 60
3
4.2
60 and above
0
0
Total
72
100
Table 2 – Anaesthetic technique versus surgical procedure
Anaesthetic Techniques
Herniotomy (%)
Herniorrhaphy (%)
Total (%)
General Anaesthesia
24 (33.3)
24 (33.3)
48 (66.6)
Spinal Anaesthesia
0 (0.0)
4 (5.6)
4 (5.6)
Local Anaesthesia
0 (0.0)
20 (27.8)
20 (27.8)
Total
24 (33.3)
48 (66.7)
72 (100)
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