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Title: The evaluation of the effectiveness of inguinal hernia repair usingvarious tension-free techniques (Lichtenstein, Rutkow-Robbins, andPHS) in the analyzed group of patients operated on between 1999-2009 at the Ist Chair of General and Gastrointestinal Surgery,Jagiellonian University Medical College


ObjectivesThe aim of the dissertation was to compare treatment resultsfrom the patients operated for inguinal hernias with Lichtenstein,Rutkow-Robbins, and PHS techniques. The other endpoint was theanalysis of the associations between:· the technique and the frequency of early complications, such aswound suppuration, hematoma in the wound, seroma, edemaof scrotum, pudendal lip or of testicles, spermatic cord cyst,testicle atrophy, and the frequency of late complications, i.e.hernia recurrence,· hernia recurrence and timing of surgery, duration of hospitalstay, and electiveor emergency surgery,· frequency of complications and type of hernia acc. to the Nyhusclassification,· postoperative pain duration (>3mo., chronic pain) and painintensity (scored by the10-point VAS scale),· pain intensity, age and body mass (BMI) of the patients,· BMI and frequency of recurrences (average BMI among thepatients with and without hernia recurrence),· hernia repair technique and problems with assuming dailyactivities,· sexual functions and hernia repair technique,· timing of surgery and individual hernia repair techniques. ; Method and subject of the researchAll patient undergoing hernia repairs were followed-up 10 daysafter surgery, and then every 3 months during the first year, andsubsequently every 6 months, or in case of any symptoms related tosurgery. The patients, who developed postoperative complications,were consulted more frequently in the outpatients’ clinic depending onthe indications. The analysis was conducted based on the findingsfrom the case histories of the patients focusing on the followingparameters: age, sex, body weight, type of hernia acc. to the Nyhusclassification, timing of surgery, and duration of hospital stay. Thepatients were asked to complete specially designed questionnaire andprovide all necessary information. The study group consisted of 567patients (546 men and 21 women), aged 19-91 years, who underwentinguinal hernia repair at the Ist Chair of General and GastrointestinalSurgery, Jagiellonian University Medical College between 1999-2009.A total of 624 hernia operations were performedin these patients, including 295 Lichtenstein operations, 93 RutkowRobbins,and 326 PHS. The questionnaires were completed andreturned by 44.7% cases (279/624). Among those missing were 15death cases before the study was initiated. In the analyzed group therewere more right inguinal hernias (361, 57.9%) than left ones (263,42.1%). Five hundred and sixty-one (89.9%) hernia repairs wereperformed electively, and 63 (10.1%) on emergency.There were 508 (89.6%) patients with unilateral hernias and 59(10.4%) with bilateral. According to the Nyhus classification, 22%(137) hernias were classified as type I, 27.2% (170) as type II, 27.1%(169) as type IIIa, 11.5% (72) as type IIIb, 12.2% (76) as type IV.There were 424 (67.9%) indirect, and 200 (32.1%) direct hernias. Of86 recurrent hernias,34 were operated with Lichtenstein technique, 17 with Rutkow-Robbins, and 35 with PHS.In 72.3% cases regional anesthesia was used, general anesthesia in26.4%, and local anesthesia in 1.3% cases. ; ResultsPostoperative complications included seroma in surgicalwound that occurred in 4% cases, more frequently after Lichtensteinhernia repairs compared with other techniques, independently of theelective or emergency type of surgery and without statisticalsignificance. Wound suppuration occurred in 1.6% of patients, andscrotum/pudendal lip edema, being most common complication wasfound in 9.9% of cases. It developed more frequently after PHS repairsbut without statistical significance. Testicle atrophy was found in0.5% cases. Using truss by the patients had no effect on the numberearly complications, however the number of late complications, suchas hydrocele, testicle atrophy or spermatic cord cyst was higher in thisgroup. These patients reported more frequently pain up to 7 dayspostoperatively. Frequency of hernia recurrences was 1.6%. Neitherelective /emergency type of surgery nor body weight had effect on thisresult. Recurrences were significantly more common afterLichtenstein operations compared with other techniques. Norecurrences were found after PHS repairs. Postoperative pain wasreported by 16.5% patients, and chronic pain (persisting over 3months) by 2.9% of them, more frequently after Lichtenstein operationand infrequently after PHS repairs, however, without statisticalsignificance. The same result was obtained for the chronic painintensity, most often reported by the patients at younger age. Otherfactors, such as BMI, elective/emergency surgery, hernia recurrence,and complications had no effect on the incidence of chronic pain. ; Summaries and ConclusionsBased on the results obtained it was observed that:§ There was no significant statistical difference between herniarepair technique and the incidence of complications, such aswound suppuration, fever, wound dehiscence, testicle hydrocele,testicle atrophy, spermatic cord cysts. After Lichtenstein herniarepairs there were more cases of seroma and inflammatoryinfiltrations in surgical wound. Scrotum/pudendal lip edemaoccurred more frequently after PHS repair. Significantly morecases of haematoma were observed after Lichtenstein operations,fewer cases after PHS and Rutkow-Robbins repairs. Significantlymore cases of recurrent hernia occurred after Lichtenstein, fewerafter Rutkow-Robbins and PHS.§ No correlation was found between hernia recurrence and timing ofsurgery, hospital stay, and elective or emergency type of surgery.§ Only in case of scrotum/pudendal lip edema after surgerycorrelation was found with Nyhus type of hernia. This occurredsignificantly more frequently in Nyhus type II and IV hernias, andless commonly in Nyhus I cases.§ Hernia repair technique had no effect on the incidence ofpostoperative pain. However,it was reported more frequently after Lichtenstein herniaoperations and less frequently after PHS repairs. No correlationwas found between hernia repair technique and pain intensityscored by the VAS scale.§ No correlation was found between pain intensity (VAS scores) andbody weight (BMI). There was correlation between pain intensityand age: patients, aged 21-34 years, reported more frequentlychronic pain compared with elderly patients over 65 years.§ No correlation was found between body weight and frequency ofrecurrences: BMI was comparable in the groups of patients withand without hernia recurrence.§ The level of physical activity of the patient after Lichtensteinhernia repairs was lower compared with PHS repairs.§ The choice of the technique had no effect on sexual activity of thepatients after surgery.§ No significant statistical difference was found between timing ofsurgery and technique of hernia repair. ; The analysis of the results led to the conclusion thatLichtenstein technique for inguinal hernia repair is not a therapeuticgolden standard. Small number of patients operated with Rutkow-Robbins technique does not allow formulating explicit thesis on itseffectiveness. PHS repairs were connected with lower number ofrecurrences, and therefore this technique seems to be a method ofchoice for the treatment of inguinal hernias. Despite slight differences,each technique may be safely used independently of the patients’ age,and elective or emergency type of surgery. As there is no clearstatistical difference among analyzed parameters, final decision as tothe choice of the technique depends on the intraoperative findings andskills of the operating surgeon. There is still a problem of the qualityof life after inguinal hernia repairs and postoperative chronic painreported by some patients. Many studies concentrate currently on thecauses and management of the postoperative pain.Chronic pain after inguinal hernia repairs has been a subject ofstudies on the use of the new generation biomaterials.

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2 - studia doktoranckie

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Uniwersytet Jagielloński. Collegium Medicum. Wydział Lekarski.


Andrzej Matyja

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Biblioteka Medyczna Uniwersytetu Jagiellońskiego- Collegium Medicum

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Oct 16, 2019

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ZB-115822 Oct 16, 2019


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