BARNES ChM FRCS Consultant Surgeon Queen Elizabeth Hospital Birmingham How long do patients convalesce after inguinal herniorrhaphy Current principles and practice We read the paper of Robertson et al Annals January 1993 vol 75 p30 with interest We ID: 51140
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216Commentnecessarilyadvocatingitasaroutine,itisextremelyusefultohavethefacilityavailableincasesofdoubtandinre-explorations.ADBARNESChMFRCSConsultantSurgeonQueenElizabethHospitalBirminghamHowlongdopatientsconvalesceafteringuinalherniorrhaphy?CurrentprinciplesandpracticeWereadthepaperofRobertsonetal.(Annals,January1993,vol75,p30)withinterest.WehaverecentlyperformedasimilarauditonwhenpatientsreturntoworkafteraroutineinguinalherniarepairinNottinghamshire.Theadviceofferedbythe32localconsultantsurgeons(100%responserate)wasinfluencedbythetypeofworkthepatientdidinallbutsixcases.Theadviceofferedbythe487Nottinghamgeneralpractitionerswassoughtandofthe337(69%)respondersonly22gaveadviceonwhentoreturntoworkthatwasnotinfluencedbythetypeofworkthepatientdid.Whenpatientsactuallydoreturntoworkwasconsideredbyasking320workingmales(224;70%responserate)afteraroutineunila-teralinguinalherniarepair.Thiswasalsostronglyinfluencedbythetypeofworkthepatientdid.Ourresults(TableI)showforthosedoctorswhoseadviceonwhentoreturntoworkvariedwiththetypeofworkthepatientdid,theadvicegivenwassimilartothatwhichRobertsonetal.suggestoccurselsewhereinthecountry.InNottingham,however,itappearsthatpatientsactuallyreturntoworkearlierthanelsewhereinthecountry.TableI.Comparisonofconvalescenceperiods(inweeks)advisedbysurgeonsandGPsafterroutineherniarepaircomparedwiththeactualtimetakenfordifferenttypesofworkSedentaryworkLightworkHeavyworkSurgeon'sadvice2.8(1.7)5.3(3.1)7.2(2.6)(mean,SD)Range1-82-124-12GP'sadvice5.1(2.1)7.3(2.9)9.9(3.2)(mean,SD)Range1-132-244-24Patientpractice3.4(2.0)4.9(3.0)7.1(3.6)(mean,SD)Range1-81-131-17Itiswellestablishedthatherniarecurrencerateisindepen-dentoftimeoffworkandthetypeofworkdone(1,2).Therefore,theconclusionfrombothstudiesmustbethattheadvicedoctorsaregivingonwhentoreturntoworkafteraroutineinguinalherniarepairisnotinlinewithcurrentsurgicalthinking.Theconvalescentperiodshouldbedictatedbywhenthepatientfindsworkactivitiescomfortable(anindividuallyveryvariablefactor)andnotbytheamountofphysicalactivityassociatedwiththeirjob.DMBAKERFRCSRegistrarinGeneralSurgeryMARIDERMBBSSHOinGeneralSurgeryALOCKERFRCSSeniorRegistrarinGeneralSurgeryANFAWCETTFRCSConsultantGeneralSurgeonQueen'sMedicalCentreNottinghamReferences1RossAPJ.Incidenceofinguinalherniarecurrence.AnnRCollSurgEngl1975;57:326-8.2TaylorEW,DewarEP.Earlyreturntoworkafterrepairofunilateralinguinalhernia.Br7Surg1983;70:599-600.IreadwithgreatinterestthearticlebyRobertson,HaynesandBurton(Annals,January1993,vol75,p30).Itismyexper-iencethatthesuspicionsvoicedintheirfinalparagrapharetrue.Patientsdoreturntoworkmuchsoonerthanshownintheirstudy,ifreassuredthattherewillbenodetrimentaleffect.Inmypractice,anearlyreturntoworkisrecommendedandencouragedinallpatients.Thosewithasedentaryoccupation(eglawyers,accountants)areadvisedtoreturntoworkafter1week.'Light'workers(egchauffeurs)after2weeksandthosewith'heavy'jobs(egconstructionwork)after4weeks.Attheirfirstconsultationeverypatientisgivenaprintedrecuperationprogrammeasshownbelow,andtheimportanceofearlymobilisationisemphasised."InguinalHerniaRepair"RecuperationprogrammeWeek1Standuprightandwalk10minutesfirstdayafteroperation.Thereafterwalkgently4timesaday(10minutes)Week2Returntowork:SedentaryoccupationWalkfor30minutes2timesadayfor4daysBriskwalkingorjoggingthereafterGentlesexualintercourseMaydriveWeek3RunninginstraightlinesGentlesit-upsGentlepress-upsModerategentlelifting(10kg)Week4Swimming(crawl)CyclingHeavylifting(15kg):MUSTAVOIDJERKINGWeek5ALLACTIVITIESALLOWEDThemajorityofoperationsarecarriedoutundergeneralanaesthesiaasadayorovernightcase.Anilio-inguinallocalanaesthetic(Marcain®0.5%)nerveblockisadministered,intheatre,toallpatients.Thisminimisespostoperativepainand,therefore,encouragesearlymobilisation.Allmypatientsareeithercoveredbymedicalinsurance(oftenpaidforbytheiremployer)orarepayingtheirownaccounts.Myreassurancethatanearlyreturntoworkwillhavenodetrimentisgenerallywellreceivedandthisadviceisfollowedbyover80%ofpatients.Itisclearthatthetraditionallyacceptednormalperiodofrehabilitationfollowingherniarepaircanbedramaticallyreducedbytheappropriatesurgeryandpsychologicalsupport.OJAGILMOREMSFRCSFRCSEdConsultantSurgeon108HarleyStreetLondonWlNIAF