Inguinal Hernia Repair: The Impact of Ambulatory and Minimal Access Surgery

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This dissertation, "Inguinal Hernia Repair: the Impact of Ambulatory and Minimal Access Surgery" by Hung, Lau, 劉雄, was obtained from The University of Hong Kong (Pokfulam, Hong Kong) and is being sold pursuant to Creative Commons: Attribution 3.0 Hong Kong License. The content of this dissertation has not been altered in any way. We have altered the formatting in order to facilitate the ease of printing and reading of the dissertation. All rights not granted by the above license are retained by the author. Abstract: ABSTRACT of thesis entitled: "Inguinal hernia repair: The impact of ambulatory and minimal access surgery" Submitted by Dr. Hung LAU for the degree of Master of Surgery in May 2002 Inguinal hernia repair is one of the commonest operations in the world (Rutkow et al.,1993). In contrast to Western surgical centres, where day surgery has been in practice for more than 20 years (Ruckley et al., 1973), ambulatory surgery was introduced in most Asian countries in the last decade. The objective of the present thesis was to identify strategies by which the surgeon could improve the outcome of ambulatory inguinal hernia repair. Between 1995 and 1998, 271 consecutive day case open inguinal hernia repairs were performed and the outcomes were promising (Lau et al., 2000). Wound pain was the commonest discomfort after inguinal herniorrhaphy (Lau et al., 2001). Multiple regression analysis of various clinicopathologic factors demonstrated that age was the only independent predictive factor of pain following inguinal herniorrhaphy. Most Chinese patients managed to return to work within 3 weeks following ambulatory inguinal hernia repair (Lau et al., 2001). On multi-variate analysis, occupation was the only independent factor affecting the duration of time off work. iiWith regard to the recruitment process for day surgery in Hong Kong, social grounds (61%) was found to be the most common reason for exclusion from day case hernia repair after pre-anaesthetic assessment (Lau et al., 2000). A survey demonstrated that the majority of the respondents (>80%) preferred to undergo day surgery again in case of hernia recurrence (Lau et al., 2000). Our findings proved that ambulatory surgery had a high level of acceptance in Chinese patients. Since the inception of a Hernia Specialist Service in 1999, endoscopic totally extraperitoneal inguinal hernioplasty (TEP) was offered to patients presenting with inguinal hernias. The clinical outcome of 500 consecutive TEPs was prospectively analyzed. The learning curve for unilateral TEP by a general surgeon peaked after performing 80 procedures. Unilateral TEP can be safely accomplished within an hour for most patients after a surgeon has attained sufficient proficiency in surgical skills and knowledge. Postoperative morbidity rate was low. TEP has also been performed as a day case procedure in selected patients since February 2001. The clinical outcomes of these patients were compared to a cohort of patients who had day case Lichtenstein hernioplasty. Ambulatory TEP conferred a significant reduction of postoperative pain scores compared to Lichtenstein hernioplasty. A lower incidence of wound complication was also observed in patients who underwent ambulatory TEP. In conclusion, both ambulatory Lichtenstein hernioplasty and TEP carried little morbidity. Although ambulatory TEP conferred a lower pain scores during iiithe early postoperative period, superiority of one procedure over another is determined by multiple factors, including learning curve, perioperative and postoperative complications, simplicity of the technique, postoperative pain, recurrence rate and convalescence time. The choice of technique should be based on the patient's preference and the available surgical expertise. At present, Lichtenstein hernioplasty remains the simplest and safest approach for the repair of primary inguinal hernia. The development ambulatory

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