Influence of nerve identification and the resection of nerves 'at risk' on postoperative pain in open inguinal hernia repair.

BACKGROUND: Surgical strategy regarding nerve identification and resection in relation to chronic postoperative pain remains controversial. A central question is whether nerves in the operation field, when identified, should be preserved or resected. In the present study, the hypotheses that the identification and consequent resection of nerves 'at risk' have no influence on postoperative pain has been tested. METHODS: A single-centre study was conducted in 525 patients undergoing Lichtenstein hernioplasty. One surgeon (364 operations, Group A) consequently resected nerves 'at risk' for being injured and nine surgeons (161 operations, Group B) adhered to the general routine of nerve preservation. All cases were ambulatory surgery on anaesthetised patients and the groups were similar with regard to age, body mass index (BMI) and preoperative pain. Self-reported pain at 3 months was recorded on a 10-box visual analogue scale (VAS). The identification and resection of nerves were continuously registered. Statistical calculations were performed with Fisher's exact test and ordinal logistic regression. RESULTS: There was no significant difference in the number of identified nerves in the two groups of patients (iliohypogastricus, P = 0.555; ilioinguinalis, P = 0.831; genital branch, P = 0.214). However, the number of resected nerves was significantly higher in Group A for the iliohypogastric nerve, P < 0.001, but not for ilioinguinalis, P = 0.064, and genital branch, P = 0.362. Non-identification of the ilioinguinal nerve correlated to the highest level of self-reported postoperative pain at 3 months. Patients in Group A, who had nerves 'at risk' resected from the operation field, reported significantly less postoperative pain at 3 months, P = 0.007. CONCLUSION: This register study confirms the importance of nerve identification. Nerve resection strategy with the consequent removal of nerves 'at risk' gives a significantly better outcome in Lichtenstein hernioplasty.

Chronic pain after open inguinal hernia repair: a longitudinal self-assessment study.

INTRODUCTION: The aim of the present study was to assess the variation of self-reported pain over a period of 2 years in three groups of patients with no, moderate and severe pain at 3 months after primary open inguinal hernia repair. METHODS: In two cohorts of patients from 2004 (n = 272) and 2005 (n = 292) who had given a self-report of postoperative pain at 3 months, 79 randomly selected patients without pain (box visual analogue scale [VAS] level 10) and all patients with moderate (Box VAS level 7-9) and severe pain (Box VAS level 1-6), 91 and 9, respectively, were included in the case series. The self-assessments were repeated for all patients 1-1.5 and 2-2.5 years after surgery (November 2006). RESULTS: It was observed that moderate pain reappeared among the pain-free patients in 28 and 23% after 1-1.5 and 2-2.5 years, respectively. Of those patients with moderate pain at 3 months, 39 and 49% reported 'no pain' at 1-1.5 and 2-2.5 years, respectively, after surgery. A worsening from moderate pain to severe pain was reported by 22% of patients after 1-1.5 years and by 15% of patients after 2-2.5 years. Hernia recurrence (n = 3) was observed only in patients with increased pain. All nine patients with severe pain at 3 months reported less pain, but only one was pain-free at 2-2.5 years after surgery. CONCLUSION: The study shows that a significant proportion of the patients developed pain later than 3 months after the operation. It further points to a difference in pain evolvement in patients with moderate pain and those with severe postoperative pain at 3 months. Pain can increase in intensity from moderate to severe, both with and without the presence of a clinical recurrence.

Classification of procedures in the domain of thoracic surgery--a study of reliability in coding.

This paper relates a study of reliability of coding of surgical procedures in the domain of thoracic surgery. The reliability measured is inter-coder variability in form of agreement. Four classifications were used by four physicians on 100 patient cases. The classifications, having differing granularity and structure, were analyzed using a statistical method (kappa). These results are discussed and related to the differences between the classifications. One of the topics for discussion is how the granularity affects the degree of agreement, coupled to the usefulness of the classification. Also the concept of using formal methods for representing classifications is discussed, how this will affect how classifications are designed and used.

Modelling and reclassification of surgical procedures--experiences from the use of GALEN methods in the domain of thoracic surgery.

This paper reports on experiences from the evaluation of GALEN methods for mapping of follow-up categories in the domain of thoracic surgery to an existing classification of surgical procedures. The mapping of the aggregated levels or groups of thoracic procedures presents a genuine problem in relation to strict hierarchical classifications, since the follow-up categories do not necessarily fit in the pre-set structure of the classification. Experiences from modelling of the traditional classification and of the follow-up categories are reported, and an analysis of the results is presented along with a discussion of opportunities and potential problems and pitfalls when applying GALEN models and tools.

Scanning electron microscopic evaluation of clinically cemented cast gold restorations.

Copper replicas were made of well-fitting, clinically cemented cast gold restorations. The replicas were scanned in the scanning electron microscope to measure the accuracy of fit at the margins. The margin discrepancies observed compared with findings of laboratory studies. Numerous microscopic cracks were found in the cervical enamel of these restored, vital, and asymptomatic teeth.

Aerobic power during maximal exercise in untrained and well-trained persons with quadriplegia and paraplegia.

The aerobic power during maximal exercise was studied in 58 males with traumatic spinal cord lesions from C4 to L4 (25 well-trained "world-class athletes" and 33 untrained). For comparison we tested five well arm-trained and five arm-untrained able-bodied subjects. During maximal wheelchair exercise the aerobic power (VO2 peak), pulmonary ventilation and blood lactate concentration was higher in subjects with lower levels of spinal cord injury. At each injury level above C6-C7, nearly all trained subjects reached higher VO2 peaks than untrained subjects with the corresponding level of lesion. The mean values for trained paraplegic persons were 2.16 +/- 0.38 l x min-1, corresponding to 33.6 +/- 6.7 ml x kg-1 x min-1. The peak heart rate was lower in the quadriplegic than in the paraplegic group with no or only small difference between trained and untrained subjects at the same level of spinal cord injury. Spinal cord lesions with pareses reduce the total active skeletal muscle mass. This can cause physical inactivity, medical complications and social isolation. As a consequence, cardiovascular disorders as cause of death is higher in this group compared to the general population. Therefore, one aim of rehabilitation is to increase the individual's performance in daily life activities. It has been shown that the normal daily life activities of quadri- and paraplegic individuals with no additional physical training are not intense enough to maintain a satisfactory level of physical fitness.(ABSTRACT TRUNCATED AT 250 WORDS)

Neoplastic human T-cells capable of responding to multiple human alloantigens.

Monoclonally-derived neoplastic T-cells from a patient with cutaneous T-cell lymphoma respond to multiple human HLA-D antigens in mixed lymphocyte culture. The implications of this phenomenon relevant to normal T-cell function and to malignancy are discussed.