Quality of life after inguinal hernia repair
Jakość życia po zabiegu plastyki przepukliny pachwinowej
Nazish Iftikhar
1ABF, Asad Ali Kerawala
2CDEF1Department of Surgery, Indus hospital, Korangi, Karachi, Pakistan
2Fellow, Surgical Oncology, The Cancer Foundation Hospital, Karachi, Pakistan
Article history: Received: 14.12.2020 Accepted: 30.03.2021 Published: 31.03.2021
ABSTRACT: Introduction: Inguinal hernias are the most commonly presented abdominal hernias with approximately 20 million people operated annually throughout the world. Severe chronic pain after hernia repair effects social life, daily activity and overall quality of life. The Short Form-36 is (SF-36) a validated indicator of overall health status. Studies have shown that the reliability of the SF-36 is exceeding 0.80.
Aim: Our aim of study is to determine the effect of unilateral open mesh repair by using SF-36 on pain control and quality of life of patient.
Methods: This cross-sectional study was carried out at Indus Hospital Karachi from 1st April 2018 to 10th September 2018. 88 patients were enrolled in this study according to the inclusion and exclusion criteria. A written and informed consent was taken from all of them. After surgery they were sent home on painkillers. They were called at 4 weeks and were required to fill a pre designed questionnaire Short form-36.
Results: Results showed that out of the 88 patients enrolled in this study 35 (39.8%) experienced mild pain, 37 (42%) experience moderate pain and only 16 (18.2%) experienced severe pain. Quality of life was satisfactory in 72 (81%) and unsatisfactory in 13 (14.7%).
Conclusion: Hence it is concluded that post operatively patients experienced better physical functioning and emotional role functioning whereas their perceptions about their general health and energy were satisfactory. Hernia surgery should be offered to all the patients with a clinically detectable hernia.
KEYWORDS: chronic pain, hernia, Inguinal, mesh, quality of life
STRESZCZENIE: Wprowadzenie: Przepukliny pachwinowe są najczęściej obserwowanymi przepuklinami jamy brzusznej. Rocznie na całym świecie operacjom plastyki przepuklin pachwinowych poddaje się około 20 milionów ludzi. Silny, przewlekły ból po tego typu zabiegu wpływa na życie społeczne, codzienną aktywność i ogólną jakość życia pacjentów. Kwestionariusz oceny jakości życia SF-36 jest zwalidowanym miernikiem ogólnego stanu zdrowia. Badania wykazały, że stopień niezawodności pomiarów SF-36 przekracza 0,80.
Cel: Celem niniejszego badania jest ustalenie wpływu jednostronnej otwartej plastyki przepukliny z wykorzystaniem siatki na kontrolę bólu i jakość życia pacjenta w oparciu o wyniki uzyskane przy użyciu kwestionariusza SF-36.
Metody: Niniejsze badanie przekrojowe było przeprowadzone w szpitalu Indus w Karaczi od 1 kwietnia 2018 r. do 10 września 2018 r. Do badania, w oparciu o przyjęte kryteria włączenia i wykluczenia, włączono w sumie 88 pacjentów; wszyscy udzielili pisemnej, świadomej zgody na udział w nim. Po operacji pacjenci byli wypisywani do domu z przepisanymi lekami przeciwbólowymi. Kontaktowano się z nimi po upływie 4 tygodni, prosząc o wypełnienie przygotowanego kwestionariusza SF-36.
Wyniki: Wyniki badania pokazały, że spośród 88 pacjentów uczestniczących w badaniu: 35 (39,8%) doświadczyło łagodnego bólu, 37 (42%) – umiarkowanego bólu, zaś tylko 16 (18,2%) – silnego bólu. Jakość życia oceniono jako zadowalającą w 72 przypadkach (81%), zaś jako niezadowalającą w 13 przypadkach (14,7%).
Wniosek: W oparciu o uzyskane wyniki stwierdza się, że pacjenci po operacji wykazywali poprawę funkcjonowania fizycznego i psychicznego oraz deklarowali zadowolenie z ogólnego stanu własnego zdrowia i poziomu energii. Operacje przepukliny powinno się oferować wszystkim chorym z klinicznie wykrywalną przepukliną.
SŁOWA KLUCZOWE: ból przewlekły, jakość życia, pachwina, przepuklina, siatka
Authors’ Contribution:
A – Study Design B – Data Collection C – Statistical Analysis D – Manuscript Preparation E – Literature Search F – Funds Collection
weakness (due to previous surgeries) [7], connective tissue dis- orders [8] and increased intra-abdominal pressure (either due to chronic cough or constipation, etc.) are common risk factors that play role in the development of inguinal hernia.
After hernia surgery, chronic pain and discomfort has frequently been reported [9] with a frequency varying from 0 to 53% [10].
INTRODUCTION
Inguinal hernias are the most commonly presented abdominal her- nias [1, 2] with approximately 20 million people operated on annu- ally throughout the world [3, 4]. They are more commonly reported in young males [5], manual workers and in low socioeconomic pop- ulation [6]. Increasing age, low physical activity, smoking, muscle
As many as 10% of the patients report increased pain following surgery.
Such a chronic pain is often developed due to the use of open ingui- nal technique along with heavyweight mesh, presence of severe pain before surgery and young age [10]. Prosthetic mesh materials, such as
nonabsorbable polypropylene used in hernia repair have been known to cause physiological reactions causing pain and heaviness [11], whereas, recently used light-weight Prolene mesh has de- creased pain and groin symptoms [12]. After hernia surgery, severe chronic pain not only affects the working life of a patient but also the social life along with daily activities, resulting in poor quality of life [13].
As per European Hernia Society guidelines, in asymptomatic patients, watchful waiting is a valid option [14], however it was concluded from indecisive results of two controlled studies. The debate is that such patients develop symptoms at some stage of their life [10], hence surgery often gets necessary, which later has an impact on their quality of life.
The Short Form-36 (SF-36) is used as a common validated indica- tor for determining the overall health status of patients. Studies have shown the SF-36 reliability greater than 0.80 [15]. Therefore, it is a highly validated indicator for assessing the health status. The quality of life determined by the increase in pain and discomfort after hernia surgery varies but Poobalan et al. [10] reported an in- crease in up to 53% of patients.
Inguinal hernia patients commonly present with pain. There- fore, the impact of open hernia repair on their life is important.
For developing countries, like Pakistan, it is important that such frequently performed surgery does not hamper or impact the life of individuals and that they return to their routine activity soon.
There is no available local data that shows the effect of hernia sur- gery on the quality of life of patients. Therefore, our study aims to determine the effect of unilateral open mesh repair by using SF-36 on pain control and quality of life of patients.
MATERIALS AND METHODS
This observational cross-sectional research on hernia patients was performed at XYZ Hospital, over the period from 1st April 2018 to 10th September 2018 after approval from the relevant Institutional Review Board. Written informed consents were taken from hernia patients after explaining the importance of the study. Confidentiality of the patients was ensured at all times.
A total of 88 patients were included in the research, aged 18–80, requiring unilateral inguinal hernia repair. Those having a recur- rent hernia or signs of obstruction or strangulation of the hernia were excluded. A single surgeon operated all the patients and the patients were discharged post-surgery as per routine. Patients were followed up in the clinic after 2 weeks for removal of stitch- es and then after 4 weeks post-surgery for assessment. Patients lost during follow-up were also excluded from research. At the 4-week follow-up visit, a pre-designed questionnaire was filled by the primary investigator. The form used was SF-36 with eight sections and the results were interpreted in Tab. I. The frequency of pain was determined in patients after surgery and discharged from hospital by the need of analgesia. Pain was categorized as:
mild (≤ 2 analgesics/week), moderate (3–10 analgesics/week) and severe (≥ 10 analgesics/week). The results were interpreted with SPSS 21. They were either presented as mean (SD) or in fre- quency tables or in cross tabulation by using the chi-square test with a P-value of ≤ 0.05 as significant.
S: NO SECTIONS
1 Vitality
2 Physical functioning
3 Bodily pain
4 General health perception 5 Physical role functioning 6 Emotional role functioning 7 Social role functioning
8 Mental health
Result Interpretation Score Interpretation
1–50 Unsatisfactory (More disability) 51–100 Satisfactory (Less disability)
PAIN NUMBER FREQUENCY
MILD 35 39.8%
MODERATE 37 42%
SEVERE 16 18.2%
AGE YEARS NUMBER FREQUENCY
19–29 28 31.8%
30–40 15 17%
41–50 16 18.2%
51–60 13 14.2%
61–70 15 17%
71–80 1 1.1%
DURATION OF SYMPTOMS
MONTH NUMBER FREQUENCY
3–22 50 56.8%
23–42 26 29.5%
43–63 6 6.8%
64–84 6 6.8%
GENDER NUMBER FREQUENCY
MALE 88 100%
FEMALE 0 0
SIZE NUMBER FREQUENCY
COMPLETE 54 61.4%
INCOMPLETE 34 38.6%
Tab. I. SF-36 Form Sections and Interpretation.
Tab. II. Basic demographics of data.
RESULTS
All hernia patients were male. Most commonly patients presented with a complete type of hernia – 54 (61.4%). Most of the patients did not have any comorbidity – 56 (63.6%) The technique that was used commonly was mesh repair – 82 (93.2%). The results showed that 35 (39.2%) patients suffered from mild pain, and most of them were from the young age group. Thirty-seven (42%) patients expe- rienced moderate pain, and most of them were from the middle age group, i.e. 41–50 years old. Sixteen (18.8%) patients suffered severe pain, with most of them being from the old age group (61–70 years).
Results also showed that 72 (81.8%) patients felt that their qual- ity of life was satisfactory after the hernia repair, with most of them being from the age group of 19–29 years, i.e. 27 (30.6%).
Thirteen (14.2%) thought that their quality of life had become worse and graded it as unsatisfactory, with the highest propor- tion of those patients in the old age group 61–70 , i.e. 6 (6.8%).
On stratification of pain with the size of hernia, out of 54 patients who had a complete hernia, 23 (26.1%) experienced mild pain, 23 (26.1%) experienced moderate pain, and 8 (9.0%) experienced se- vere pain .Out of the 34 patients that had an incomplete hernia, 12 (13%) had mild pain, 14 (15.9%) had moderate pain, and 8 (9.0%) had severe pain.
DISCUSSION
In spite of the fact that recurrence rates have decreased thanks to using Lichtenstein mesh, this approach is not perfect. Chronic groin pain following hernia surgery is a very common and severe prob- lem of hernia specialists worldwide. This grievous reaction follow- ing IHR is withouth doubt the most significant result variable today.
Additionally, chronic groin pain is directly correlated with decreased quality of life of hernia patients [16, 17].
Small studies reported a 10.0% to 12.0% incidence of chronic groin pain following IHR with the use of the mesh [10, 18], whereas a few large studies reported a 57.0% to 63.0% incidence of chronic groin pain after one year of surgery [9]. Previous studies have proposed that the occurrence of chronic groin pain after surgery diminishes after some time.
There was a researcher who defined the term postoperative chron- ic pain as “Pain of any severity” or “discomfort on exertion” [10], whereas another researcher used the definition of the Internation- al Association of the Study of Pain (IASP) “pain persisting beyond the normal tissue healing time assumed to be 3 months”. Another most common definition was presented by Alfieri et al.: “pain aris- ing as a direct consequence of a nerve lesion or a disease affecting
the somatosensory system, in patients who did not have groin pain before their original hernia operation, or, if they did, the post-op- erative pain differs from the pre-operative pain” [19].
Quality of life in hernia patients can be defined as "perception of patient’s daily life with respect to the quality of well-being". How- ever, different factors including social or emotional ones, or physical activity should be considered before assessing the quality of life of a patient. In health care setting, the quality of life of a patient can be assessed with respect to how the patient's well-being is influenced with passing time by any disease or disability.
SF-36 is a commonly used instrument for assessing the quality of life of patients. This tool covered 8 distinct dimensions of health as- pects for calculating the health score, used for estimating the qual- ity of life of patients. In brief, SF-36 questionnaire contains thirty- six different questions related to physical as well as mental health of a patient in the most recent weeks. Eight distinct dimensions of the SF-36 questionnaire were subdivided into two equal dimensions including four dimensions related to the physical health and four dimensions related to the mental health. Patients scored between 1-100 on the basis of thirty-six different questions, with 1 represent- ing a poor score, with more chances of disability, and 100 represent- ing a good score, with less chances of disability.
Laparoscopic approaches to inguinal hernia surgery have been as- sociated with a lower risk of pain in the immediate postoperative period than conventional open surgery.
At 1 and 4 weeks, postoperatively, our study demonstrated differ- ences between different age groups of patients experiencing a vari- able degree of pain. Surgical interventions were undertaken either to increase the survival or to enhance the quality of life of patients.
Where improved survival is not demonstrated, surgery must lead to enhancement in the quality of life in order to bring benefit. No pre- vious work has examined the direct association of inguinal hernia surgery with the quality of life, either before or after surgery. This study suggests that patients meeting our selection criteria do derive a significant benefit in terms of their quality of life after undergoing elective hernia surgery by experienced surgeons.
Comparison of SF-36 dimensions with the general population norms before and after surgery is consistent with improvement and sug- gests that such an effect is real.
Nevertheless, there may be some bias in this comparison as the general population was not subject to the same selection criteria as used for day surgery in this study. It is therefore interesting that preoperatively the hernia patients scored better than the norms on
PAIN SCALE TOTAL P-VALUE
AGE 19–29 30–40 41–50 51–60 61–70 71–80
Mild 20 (22.2%) 09 (10.2%) 05 (5.6%) 0 01 (1.1%) 0 35 (39.2%)
Moderate 08 (9.09%) 04 (4.5%) 11 (12.5%) 07 (7.9%) 07 (7.9%) 0 37 (42.5%) 0.000
Severe 0 02 (2.2%) 0 06 (6.8%) 07 (7.9%) 01 (1.1%) 16 (18.8%)
Total 28 (31.8%) 15 (17.0%) 16 (18.8%) 13 (14.7%) 15 (17.04%) 01 (1.1%) 88 (100%)
Tab. III. Stratification of pain with age.
the 'health perception' and 'role limitation because of emotional problems’, and postoperatively scored above the norms on eight of the ten dimensions. Although the size of change on SF-36 which can be regarded as clinically important (as opposed to statistically significant) is an area in need of further study, the demonstrated improvement in SF-36 scores after surgery would generally be re- garded as clinically important.
While very few research papers have so far been published exam- ining the change in SF-36 scores with treatment, the size of change found in our hernia patients can be placed in some context by ref- erence to a previously published study [19], which assessed the quality of life in patients who underwent either laparoscopic or open inguinal hernia surgery with no significant difference report- ed in either group of patients at 3 and 6 months postoperatively.
LIMITATION OF OUR STUDY
The generalizability of our study is clearly limited to that group of patients who met our inclusion criteria and who responded at this time interval postoperatively. Our study patients were also a group who had actively sought consultation from a surgical source. Further work is required to investigate the quality of life of those patients who are managed in primary care. It would also be of interest to examine whether the demonstrated improvements in the quality of life are sustained when surgery is performed outside the con- text of a randomized controlled trial.
We also recommend that the patients should be followed for at least 6 months, provided the health care is easily accessible to such patients.
CONCLUSION
Hence, it is concluded that SF-36 is a validated score to objec- tively assess pain and quality of life in different age groups in a general population. It can also be concluded that the quality of life improves in the majority of patients that undergo hernia surgery. However, keeping in mind those patients who scored for severe pain, it can also be inferred that open inguinal hernia surgery with mesh might also result in increased pain in some patients, especially the elderly.
WHAT IS ALREADY KNOWN
Inguinal hernias are a common entity. Small direct hernias, if asymptomatic, have historically been left alone in old patients.
However, these hernias have a propensity to get obstructed or strangulated, requiring emergent repair under suboptimal conditions.
RECOMMENDATIONS/ WHAT WE ADDED TO THIS
TOPIC
After obtaining the results of this study, we recommend offering to all patients with inguinal hernias a tension-free mesh repair after explaining to them the benefits of this procedure. In our opinion, the quality of life improves after a successful inguinal hernia repair. This is a safe procedure without any significant morbidities associated and hence it should be the standard of care for all hernias.
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The full terms of this license are available on: https://creativecommons.org/licenses/by-nc/4.0/legalcodeode Dr. Asad Ali Kerawala; Fellow, Surgical Oncology, The Cancer Foundation Hospital; C-130, Block 09, Gulshan e Iqbal Karachi, Pakistan; Phone: +92 3453203404; E-mail: asadali4@yahoo.com
Iftikhar N., Kerawala A.A.: Quality of life after inguinal hernia repair; Pol Przegl Chir 2021; 93(3): 35-39 DOI:
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