Rehabilitation following surgery: clinical and psychological predictors of activity limitations.

PURPOSE/OBJECTIVE: Activity limitations following surgery are common, and patients may have an extended period of pain and rehabilitation. Inguinal hernia surgery is a common elective procedure. This study incorporated fear-avoidance models in investigating cognitive and emotional variables as potential risk factors for activity limitations 4 months after inguinal hernia surgery. METHOD: This was a prospective cohort study, predicting activity limitations 4 months postoperatively (Time 3 [T3]) from measures taken before surgery (Time 1, [T1]) and 1 week after surgery (Time 2 [T2]). The sample size at T1 was 135; response rates were 89% and 84% at T2 and T3 respectively. Questionnaires included measures of catastrophizing, fear of movement, depression, anxiety, optimism, perceived control over pain, pain, and activity limitations. Biomedical and surgical variables were recorded. Predictors of T3 activity limitations from T1 and T2 were examined in hierarchical multiple regression equations. RESULTS: Over half of participants (57.7%) reported activity limitations due to their hernia at 4 months post-surgery. Higher activity limitation levels were significantly predicted by older age, higher preoperative activity limitations, higher preoperative anxiety, and more severe postoperative pain and depression scores. CONCLUSIONS/IMPLICATIONS: Interventions to reduce preoperative anxiety and postoperative depression may lead to reduced 4-month activity limitations. However, the additional variance explained by psychological variables was low (ΔR² = 0.05). Our models, which included biomedical and surgical variables, accounted for less than 50% of the variance in activity limitations overall. Therefore, further investigation of psychological variables, particularly cognitions related specifically to activity behavior, would be merited.

Post-Surgical Pain, Physical Activity and Satisfaction with the Decision to Undergo Hernia Surgery: A Prospective Qualitative Investigation.

Surgical repair is a common treatment for inguinal hernias but a substantial number of patients experience chronic pain after surgery. As some patients are pain-free on presentation, it is important to investigate whether patients perceive the treatment to be beneficial. The present study used qualitative methods to explore experiences of pain, activity limitations and satisfaction with treatment as people underwent surgery and recovery. Twenty-nine semi-structured interviews were conducted. Seven participants were interviewed longitudinally: before surgery and two weeks and four months post-surgery. Ten further participants with residual pain four months post-surgery were interviewed once. Semi-structured interviews included experience and perception of pain; activity limitations; reasons for having surgery; satisfaction with the decision to undergo surgery. A thematic analysis was conducted. Pain did not cause concern when perceived as part of the usual surgery and recovery processes. Activity was limited to avoid damage to the hernia site rather than to avoid pain. None of the participants reported dissatisfaction with the decision to have surgery; reducing the risk of life-threatening complications associated with untreated hernias was considered important. These findings suggest that people regarded surgical treatment as worthwhile, despite chronic post-surgical pain. Further research should ascertain whether patients are aware of the actual risk of complications associated with conservative rather than surgical management of inguinal hernia.

Preservation of small bowel with the selective use of heparin and second look laparotomy in acute mesenteric ischaemia: A case report.

INTRODUCTION: Acute mesenteric ischaemia may occur due to mesenteric arterial embolus, thrombosis, non-occlusive mesenteric ischaemia or venous thrombosis resulting in ischaemia of the bowel wall. PRESENTATION OF CASE: A 41year old woman presented with worsening abdominal pain, decreased appetite, nausea and vomiting. Examination revealed right lower quadrant tenderness. Investigations revealed elevation of her inflammatory markers. At laparotomy two separate segments of ischaemic but potentially viable small bowel were identified secondary to mesenteric venous thrombosis. Bowel salvage was attempted with the use of intravenous unfractionated heparin and this was confirmed following a second look laparotomy. DISCUSSION: Despite a normal platelet count at presentation a diagnosis of JAK-2 positive essential thrombocythaemia was made thus explaining the acquired prothrombotic state underlying the venous thrombosis. The selective use of intravenous unfractionated heparin and second look laparotomy may provide a means for bowel preservation in these cases. CONCLUSION: This case highlights the potential of bowel salvage can be achieved following an episode of acute mesenteric ischaemia with the use of intravenous unfractionated heparin and selective second look laparotomy and the importance of considering underlying myeloproliferative disease in such cases even in the absence of a thrombocytosis at presentation.

Healing by primary versus secondary intention after surgical treatment for pilonidal sinus.

BACKGROUND: Pilonidal sinus arises in the hair follicles in the buttock cleft. The estimated incidence is 26 per 100,000, people, affecting men twice as often as women. These chronic discharging wounds cause pain and impact upon quality of life. Surgical strategies centre on excision of the sinus tracts followed by primary closure and healing by primary intention or leaving the wound open to heal by secondary intention. There is uncertainty as to whether open or closed surgical management is more effective. OBJECTIVES: To determine the relative effects of open compared with closed surgical treatment for pilonidal sinus on the outcomes of time to healing, infection and recurrence rate. SEARCH STRATEGY: For this first update we searched the Wounds Group Specialised Register (24/9/09); The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library Issue 3 2009; Ovid MEDLINE (1950 - September Week 3, 2009); Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations (September 24, 2009); Ovid EMBASE (1980 - 2009 Week 38); EBSCO CINAHL (1982 - September Week 3, 2009). SELECTION CRITERIA: All randomised controlled trials (RCTs) comparing open with closed surgical treatment for pilonidal sinus. Exclusion criteria were: non-RCTs; children aged younger than 14 years and studies of pilonidal abscess. DATA COLLECTION AND ANALYSIS: Data extraction and risk of bias assessment were conducted independently by three review authors (AA/IM/JB). Mean differences were used for continuous outcomes and relative risks with 95% confidence intervals for dichotomous outcomes. MAIN RESULTS: For this update, 8 additional trials were identified giving a total of 26 included studies (n=2530). 17 studies compared open wound healing with surgical closure. Healing times were faster after surgical closure compared with open healing. Surgical site infection (SSI) rates did not differ between treatments; recurrence rates were lower in open healing than with primary closure (RR 0.60, 95% CI 0.42 to 0.87). Six studies compared surgical midline with off-midline closure. Healing times were faster after off-midline closure (MD 5.4 days, 95% CI 2.3 to 8.5). SSI rates were higher after midline closure (RR 3.72, 95% CI 1.86 to 7.42) and recurrence rates were higher after midline closure (Peto OR 4.54, 95% CI 2.30 to 8.96). AUTHORS' CONCLUSIONS: No clear benefit was shown for open healing over surgical closure. A clear benefit was shown in favour of off-midline rather than midline wound closure. When closure of pilonidal sinuses is the desired surgical option, off-midline closure should be the standard management.

Healing by primary closure versus open healing after surgery for pilonidal sinus: systematic review and meta-analysis.

OBJECTIVE: To determine the relative effects of open healing compared with primary closure for pilonidal sinus and optimal closure method (midline v off-midline). DESIGN: Systematic review and meta-analyses of randomised controlled trials. DATA SOURCES: Cochrane register of controlled trials, Cochrane Wounds Group specialised trials register, Medline (1950-2007), Embase, and CINAHL bibliographic databases, without language restrictions. DATA EXTRACTION: Primary outcomes were time (days) to healing, surgical site infection, and recurrence rate. Secondary outcomes were time to return to work, other complications and morbidity, cost, length of hospital stay, and wound healing rate. STUDY SELECTION: Randomised controlled trials evaluating surgical treatment of pilonidal sinus in patients aged 14 years or more. Data were extracted independently by two reviewers and assessed for quality. Meta-analyses used fixed and random effects models, dichotomous data were reported as relative risks or Peto odds ratios and continuous data are given as mean differences; all with 95% confidence intervals. RESULTS: 18 trials (n=1573) were included. 12 trials compared open healing with primary closure. Time to healing was quicker after primary closure although data were unsuitable for aggregation. Rates of surgical site infection did not differ; recurrence was less likely to occur after open healing (relative risk 0.42, 0.26 to 0.66). 14 patients would require their wound to heal by open healing to prevent one recurrence. Six trials compared surgical closure methods (midline v off-midline). Wounds took longer to heal after midline closure than after off-midline closure (mean difference 5.4 days, 95% confidence interval 2.3 to 8.5), rate of infection was higher (relative risk 4.70, 95% confidence interval 1.93 to 11.45), and risk of recurrence higher (Peto odds ratio 4.95, 95% confidence interval 2.18 to 11.24). Nine patients would need to be treated by an off-midline procedure to prevent one surgical site infection and 11 would need to be treated to prevent one recurrence. CONCLUSIONS: Wounds heal more quickly after primary closure than after open healing but at the expense of increased risk of recurrence. Benefits were clearly shown with off-midline closure compared with midline closure. Off-midline closure should become standard management for pilonidal sinus when closure is the desired surgical option.

A United Kingdom survey of surgical technique and handling practice of inguinal canal structures during hernia surgery.

BACKGROUND: Recent trials have assessed the impact of elective nerve division on patient outcome after inguinal herniorrhaphy. The aim of this study was to establish UK surgical practice of handling of structures in the inguinal canal during herniorrhaphy. METHODS: A cross-sectional survey of all Fellows (n = 1113) of the Association of Surgeons of Great Britain and Ireland (ASGBI) was performed. The main outcomes were to determine method of inguinal hernia repair and routine practice for intra-operative handling of structures in the inguinal canal. RESULTS: A total of 852 (77%) questionnaires were returned, of which 784 (92%) surgeons performed inguinal herniorrhaphy. Approximately two-thirds (63%) of responding surgeons performed less than 50 procedures per annum and 37% conducted more than 50 procedures annually. Mesh was the preferred method used by 90% of surgeons; 6% used non-mesh, and 4% used other (laparoscopic) methods. Routine practice in relation to the inguinal structures varied by volume of hernia surgery; surgeons who conducted more than 50 procedures annually were more likely to visualize and preserve inguinal nerve structures. However, inconsistency in the answers suggested confusion over anatomy. CONCLUSION: This is the first UK survey to investigate method of hernia repair and usual handling practice of inguinal canal structures. There was wide acceptance of the use of mesh in inguinal hernia repair, with the majority of UK surgeons favoring an open approach. Surgeons performing high volumes of herniorrhaphy were more likely to preserve, rather than transect, inguinal nerve structures. This variation in practice may confound assessment of long-term neuralgia and other post-herniorrhaphy pain syndromes.

A review of chronic pain after inguinal herniorrhaphy.

BACKGROUND: Chronic pain was believed to be a recognized but infrequent complication after inguinal hernia repair. Evidence suggests that patients with chronic pain place a considerable burden on health services. However, few scientific data on chronic pain after this common elective operation are available. OBJECTIVES: To review the frequency of chronic pain and to discuss etiological theories and current treatment options for patients with chronic post herniorrhaphy pain. MATERIALS AND METHODS: All studies of postoperative pain after inguinal hernia repair with a minimum follow-up period of 3 months, published between 1987 and 2000, were critically reviewed. RESULTS AND DISCUSSION: The frequency of chronic pain after inguinal hernia repair was found to be as high as 54%, much more than previously reported. Quality of life of these patients is affected. Chronic pain is reported less often after laparoscopic and mesh repairs. Recurrent hernia repair, preoperative pain, day case surgery, delayed onset of symptoms, and high pain scores in the first week after surgery, however, were identified to be risk factors for the development of chronic pain. Definition of chronic pain was not explicit in the majority of the reviewed studies. Accurate evaluation of the frequency of chronic pain will require standardization of definition and methods of assessment. Prospective studies are required to define the role of risk factors identified in this review.