Health-related quality of life following ambulatory surgery procedures: assessment by RAND-36

Background

Increasing numbers of elective surgical procedures are performed as day-cases. The impact of ambulatory surgery on health-related quality of life in the recovery period has seldom been described.

Methods

We assessed health-related quality of life in 143 adult outpatients scheduled for arthroscopic procedures of the knee and shoulder joints, laparoscopic cholecystectomy and inguinal hernia repair using the RAND 36-Item Health Survey preoperatively and one week after patients had returned to work or comparable normal daily routines.

Results

Postoperatively all patient groups reported significant improvements in bodily pain and vitality. Physical functioning improved significantly in orthopedic and inguinal hernia patients. However, in the orthopedic groups, postoperative scores for physical health were still relatively lower compared to the general population reference values.

Conclusions

Ambulatory surgery has a positive impact on health-related quality of life. Assessment of the recovery process is necessary for recognition of potential areas of improvement in care and postoperative rehabilitation.

     

超声引导下QLB复合气管插管全麻对于老年患者TEP腹股沟疝无张力修补术影响因素分析

摘要 目的：探讨与分析超声引导下腰方肌阻滞(quadratus lumborum block,QLB)复合气管插管全麻对于老年患者腹腔镜下全腹膜外（totally extraperitoneal prosthetic,TEP）腹股沟疝无张力修补术的影响,以促进该方法的临床使用。方法：2014年9月到2020年6月选择在本院诊治的腹股沟疝老年患者180例,根据随机数字表法分为QLB组与对照组各90例。所有患者都给予腹腔镜下全腹膜外腹股沟疝无张力修补术,对照组给予气管插管全麻,QLB组在对照组麻醉的基础上给予超声引导下QLB,记录两组镇痛与麻醉效果。结果：两组的术中出血量、手术时间等对比差异无统计学意义(P>0.05),QLB组的术后住院时间、术后胃肠功能恢复时间、术后下床活动时间显著短于对照组(P<0.05)。与术后12 h对比,两组术后24 h与36 h的疼痛VAS评分均降低(P<0.05),且QLB组术后12 h、24 h与36 h的疼痛VAS评分都显著低于对照组(P<0.05)。QLB组术后7 d的血肿、呼吸抑制、脏器损伤、腹股沟区包块等并发症发生率为8.9 %,显著低于对照组的21.1 %(P<0.05)。QLB组的瑞芬太尼用量、术后48 h内有效按压自控静脉镇痛泵次数、自控静脉镇痛泵累计用量都显著少于对照组(P<0.05)。结论：超声引导下QLB复合气管插管全麻在老年患者腹腔镜下全腹膜外腹股沟疝无张力修补术中的应用能提高镇痛与麻醉效果,减少术后并发症的发生,有利于促进患者康复。     

充填式无张力疝修补术及并发症防治

目的：探讨无张力疝修补术的应用价值及及并发症防治的意义。方法：回顾性分析填充式无张力疝修补术治疗腹股沟疝52例的临床资料。结果：全组手术时间（46±22）min,切口均一期愈合,术后3～7d出院,并发症发生率仅1．9％,随访无复发。结论：无张力疝修补术创伤小、疼痛轻、恢复快,是治疗腹股沟疝的最佳术式,熟练的技术和规范化操作是预防并发症发生的关键。     

Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: outcome and cost

Objective: To compare tension-free open mesh hernioplasty under local anaesthetic with transabdominal preperitoneal laparoscopic hernia repair under general anaesthetic. Design: A randomised controlled trial of 403 patients with inguinal hernias. Setting: Two acute general hospitals in London between May 1995 and December 1996. Subjects: 400 patients with a diagnosis of groin hernia, 200 in each group. Main outcome measures: Time until discharge, postoperative pain, and complications; patients’ perceived health (SF-36), duration of convalescence, and patients’ satisfaction with surgery; and health service costs. Results: More patients in the open group (96%) than in the laparoscopic group (89%) were discharged on the same day as the operation (χ²=6.7; 1 df; P=0.01). Although pain scores were lower in the open group while the effect of the local anaesthetic persisted (proportional odds ratio at 2 hours 3.5 (2.3 to 5.1)), scores after open repair were significantly higher for each day of the first week (0.5 (0.3 to 0.7) on day 7) and during the second week (0.7 (0.5 to 0.9)). At 1 month there was a greater improvement (or less deterioration) in mean SF-36 scores over baseline in the laparoscopic group compared with the open group on seven of eight dimensions, reaching significance on five. For every activity considered the median time until return to normal was significantly shorter for the laparoscopic group. Patients randomised to laparoscopic repair were more satisfied with surgery at 1 month and 3 months after surgery. The mean cost per patient of laparoscopic repair was £335 (95% confidence interval £228 to £441) more than the cost of open repair. Conclusion: This study confirms that laparoscopic hernia repair has considerable short term clinical advantages after discharge compared with open mesh hernioplasty, although it was more expensive.

Key messages

• In the 4 hours after surgery laparoscopic hernia repair with general anaesthesia causes more pain than open repair with local anaesthesia (mainly because of the anaesthesia used) and necessitates longer stay in hospital. Laparoscopic hernia repair, however, causes less pain than open hernia repair during the first 2 weeks after discharge
• Laparoscopic hernia repair results in fewer episodes of wound infection, persistent local pain, genital swelling, numbness, and constipation than open repair. Urinary disturbances are more common after laparoscopic than after open repair
• Patients’ perception of health 1 month after the operation (assessed with the SF-36) and satisfaction with treatment is superior for laparoscopic patients who also have a shorter period of convalescence after surgery
• The health service cost of day case laparoscopic repair is £335 more than the cost of open mesh hernioplasty performed on a day case basis

     

腹股沟疝腹腔镜下修补术与无张力修补术应用于老年患者的综合疗效研究

目的:腹股沟疝是外科中最常见的疾病之一,手术治疗是腹股沟疝的惟一可靠方法。腹腔镜下腹股沟疝修补术,尤其是完全腹膜外腹腔镜(Totally Extra-preperioneal Prosthetic,TEP)疝修补术,已经成为腹股沟疝治疗的"金标准"。然而,针对65岁以上老年人群,心血管基础疾病较多,全麻风险大,TEP术式疗效是否优于无张力疝修补术还未有报道,本研究拟探讨针对老年人腹股沟疝修补的最佳手术方式。方法:排除两种修补术明确的禁忌症患者,对研究入组的92例≥65岁腹股沟疝老年患者,根据手术方式(TEP术或无张力疝修补术)进行分组,术后分别统计:(1)围手术期评价指标(手术时间、术中出血量、手术并发症、疼痛等级、离床活动时间、住院时间及住院总费用);(2)远期随访指标(术后2年内的慢性疼痛和复发情况)。综合评估腹腔镜下修补术与无张力修补术应用于老年腹股沟疝气治疗的综合疗效。结果:TEP术相比于无张力疝术只显示出在平均减少20 m L出血量及缓解术后24小时1个AVS疼痛数量级的优势(P0.01);在术后下床活动时间、手术时间、术后96小时疼痛指数、围手术期并发症、住院天数、慢性疼痛指数及远期疗效等主要评价指标中均与无张力修补术相当(P0.05);但却大大增加了手术费用(P0.01)。结论:针对≥65岁腹股沟疝老年患者,尤其是基础疾病多,对医疗费用敏感的人群,开展无张力修补术仍不失为目前最佳选择。     

前入路腹膜前修补腹股沟疝82 例临床分析

目的:探讨Modified Kugel补片治疗腹股沟疝的手术操作要点,并评价其疗效。方法:对2010年1~12月我院应用ModifiedKugel补片行开放性前入路腹膜前修补术的82例临床资料进行回顾性分析。结果:平均手术时间(55±10)min,术后住院(5.2±1.4)d。术后无尿潴留、切口感染等并发症。全组病人伤口一期愈合,无浆液肿及感染发生。术后随访12-23个月,无复发。结论:应用Modified Kugel补片修补腹股沟疝是一种创伤小、无张力、安全的手术方式,术后恢复快,近期疗效满意。     

The external oblique flap for reconstruction of the rectus sheath.

Despite the availability of synthetic materials and distant fascial flaps, primary closure of ventral abdominal defects with contiguous tissues remains the preferred solution. Increased experience with such defects in the lower abdomen, particularly at the time of bilateral rectus muscle transposition, led in 1985 to the investigation of an external oblique abdominis flap for closure of the anterior rectus sheath. From October of 1985 to October of 1990, 33 patients underwent repair of bilateral lower rectus abdominis defects with the help of bilateral external oblique flaps. Each of the patients had undergone synchronous chest or breast reconstruction using a transverse rectus abdominis musculocutaneous flap including bilateral rectus muscle pedicles. Although all patients in this study had undergone double-pedicle rectus muscle procedures, not all patients having had double-pedicle rectus muscle procedures required this maneuver. External oblique flaps were performed at the time of rectus sheath repair only if fascia could not be approximated without tearing. After closure of the bilateral paramedian defect, synthetic mesh overlay was added only if the direct closure still appeared excessively tight. At the time of advancement of the external oblique muscle and fascia, the internal oblique abdominis muscle and lateral cutaneous nerve of the thigh were preserved. Of the 33 patients who underwent this procedure, 7 required the addition of mesh overlay. Thirty-two patients healed uneventfully with a remarkably solid ventral abdominal wall. One patient developed an early postoperative hernia subsequent to a major and prolonged abdominal-wall infection and abscess. Patient follow-up ranged from 1 to 36 months, with a mean of 12 months.(ABSTRACT TRUNCATED AT 250 WORDS)     

Lipid peroxidation and inguinal hernia repair. Tension-free vs. Andrews technique

AIM OF THE STUDY: To evaluate the early effect of inguinal hernia repair by the tension-free method compared to the conventional Andrew's technique on lipid peroxidation. PATIENTS-METHODS: Thirty-four patients subjected to elective hernia repair were enrolled in the study divided in two groups. Group A (n=18) underwent hernia repair by the tension-free method using a polypropylene mesh. Group B (n=16) underwent hernia repair by the Andrew's technique (i.e. a modification of the Bassini's technique). Venous blood samples were drawn preoperatively and at 12, 24 and 48 h postoperatively. Malondialdehyde (MDA) was estimated by the thiobarbiturate assay. RESULTS: Neutrophil counts were significantly higher in patients of group B compared to group A at 12 and 48 h postoperatively. Concentrations of fibrinogen were similar between the two groups. MDA was significantly higher in patients of group B hours compared to group A at 12, 24 and 48 h postoperatively. Positive correlation was found between neutrophil counts and MDA at 12 h (r: +0.43, P: 0.015) and 48 h (r: +0.496, P: 0.005) but not at 24 h. No correlation was found between serum fibrinogen and MDA. CONCLUSION: Hernia repair by the Andrews's technique elicits a sustained triggering of lipid peroxidation, compared to the tension-free method.     

局麻下无张力修补腹股沟疝56例分析

目的总结无张力疝修补治疗腹股沟疝56例的效果。方法局麻下、使用聚丙烯编织而成的平片对56例各类腹股沟疝患者进行无张力修补治疗。结果与在硬麻或全麻下与传统的修补方法相比,具有手术适应证广、方法简单、创伤小,恢复快,并发症少和复发低率。结论应用国产的平片修补腹股沟疝效果良好,价格便宜,局麻下施行无张力疝修补术适合在基层医院推广。     

Abdominal wall function after rectus abdominis transfer.

The abdominal wall function of 57 patients who have undergone TRAM flap breast reconstructions using the whole rectus muscle, on one side (33 patients) or both (24 patients), was evaluated 6 months to 2 years after surgery. The defect was repaired with a Teflon mesh buried in the rectus sheath. There was a perfect tolerance to the mesh, and no hernia or bulging of the abdominal wall developed. Patients had less back pain after (10 patients) than before (18 patients) the operation and found their sit-up and sport possibilities about the same as before. Detailed assessment of the abdominal muscles by the physiotherapist showed, however, a decreased function, more evident in bilateral cases. CT scans demonstrated a medialization of the lateral muscles, leaving only a small medial portion of the abdominal wall devoid of muscles. On the whole, no problem of clinical significance was encountered, and patients showed a high degree of satisfaction with the operation.     

Treatment of difficult TRAM flap hernias using intraperitoneal synthetic mesh application

The authors report the successful repair of large lower abdominal hernia defects after transverse rectus abdominis muscle (TRAM) flap breast reconstruction in 11 patients using a technique of intraperitoneal application of synthetic polypropylene (Prolene) mesh anchored to the peritoneal surface of the abdominal wall tissues. Five of these patients had previously failed hernia repairs after a unipedicle TRAM flap breast reconstruction employing the onlay mesh technique, with two of the patients having undergone three previous hernia repairs. The other six patients had developed large hernias after bipedicle TRAM flap reconstruction without previous mesh supplementation of the abdominal wall repair. After their successful hernia repairs, all of the patients healed without difficulty and demonstrated no sign of recurrence in an 8 to 36-month follow-up. Each patient returned to her activity level before breast reconstruction.     

Comparison of strategies for preventing abdominal-wall weakness after TRAM flap breast reconstruction.

To determine the best method for preserving abdominal-wall integrity after TRAM flap breast reconstruction, the records of 130 patients followed for at least 6 months (mean 18 months) were examined. Three strategies for management of the abdominal-wall repair were compared. In the first group (72 patients), the entire width of the rectus abdominis muscle was harvested with the flap, and the anterior rectus sheath was closed in one layer. In the second group (20 patients), only the medial two-thirds of the rectus abdominis muscle was removed from the abdomen. The muscle and fascial donor defects were closed in separate layers. In the third group (38 patients), only one-fifth of the muscle was preserved, and a two-layered fascial closure of the anterior rectus sheath was performed, emphasizing repair of the internal oblique fascia to the midline fascia deep to the linea alba. Reinforcing synthetic mesh was used (in 10 patients) if closure was difficult or sutures tended to pull through the fascia. The incidence of abdominal weakness and/or bulging was similar in the first two groups (33 and 40 percent, respectively), but significantly lower (8 percent) in the third group (p = 0.006).     

Marlex? Mesh in Incisional and Inguinal Herniorrhaphy

Marlex® mesh was used in 31 cases of inguinal herniorrhaphy and in 15 cases incisional herniorrhaphy in a five-year period. In 14 of the inguinal and six of the incisional cases the hernias were recurrent. Marlex® mesh was used in one case to reenforce the transthoracic repair of eventration of the diaphragm, and in another to reenforce the transthoracic repair of an esophageal hiatal hernia.There were no recurrences. In one case after inguinal herniorrhaphy the mesh was removed because of persistent drainage. Wound infections occurred in two patients with incisional herniorrhaphy, and two others had the accumulation of serous fluid subcutaneously necessitating aspiration of fluid.     

Restoration of abdominal wall integrity as a salvage procedure in difficult recurrent abdominal wall hernias using a method of wide myofascial release

The management of primary and recurrent giant incisional hernias remains a complex and frustrating challenge even with multiple alloplastic and autogenous closure options. The purpose of this study was to develop a reconstructive technique of restoring abdominal wall integrity to a subcategory of patients, who have failed initial hernia therapy, by performing superior and lateral myofascial release. Over a 1.5-year period, 10 patients with previously unsuccessful treatment of abdominal wall hernias, using either primary repair or placement of synthetic material, were studied. The patients had either recurrence of the hernia or complications such as infections requiring removal of synthetic material. The hernias were not able to be treated with standard primary closure techniques or synthetic material. The average defect size was 19 x 9 cm. Each patient underwent wide lysis of bowel adhesions releasing the posterior abdominal wall fascia to the posterior axillary line, subcutaneous release of the anterior abdominal wall fascia to a similar level, and complete removal of any synthetic material (if present). The abdominal domain was reestablished by releasing the laterally retracted abdominal wall. The amount of available abdominal wall tissue was increased by wide release of the cephalic abdominal wall fascia overlying the costal margin and the external oblique fascia and muscle laterally. If needed, partial thickness of the internal oblique muscle and its anterior fascia were also released laterally to perform a tension-free primary closure of the defect. All repairs were closed with satisfactory functional and aesthetic results. All alloplastic material was removed. Fascial release was limited so as to close only the hernia defect without tension. No significant release of the rectus sheath and muscle was needed. Good, dynamic muscle function was noted postoperatively. All repairs have remained intact, and no further abdominal wall hernias have been noted on follow-up.     

Infertilité et hypogonadisme primaire acquis après herniorraphie inguinale bilatérale

Primary acquired hypogonadism due to ischemic testicular atrophy is infrequent among the causes of male infertility. The authors report a case of a 35-year-old man presenting with infertility secondary to bilateral inguinal hernia repair using Mac-Vay technique. The patient had atrophy of both testes, and endocrinal analyses were typical: high LH and FSH levels but low testosterone level. The high rate of testicular atrophy in classical inguinal repair compared with those of tension-free techniques is recalled. The current case has to be added to the rare cases of male infertility.     

腹腔镜下腹壁疝修补术的治疗现状与进展

腹壁疝是普外科最常见的疾病之一,主要包括腹股沟疝、切口疝、造口旁疝等,手术是其唯一的治愈方法。腹腔镜腹壁疝修 补术是在无张力疝修补术的基础上发展起来的一种微创技术,主要包括腹腔镜下腹壁疝修补术(LIHR),如经腹腔镜腹膜前补片修 补术(TAPP)和完全腹膜外补片修补术(TEP),腹腔镜下切口疝修补术及腹腔镜下造口旁疝修补术。其术后常见并发症与传统疝修 补术相同,但发生率显著低于传统的开腹疝修补术。与传统疝修补术相比,腹腔镜腹壁疝修补术具有术后疼痛轻、并发症少、疤痕 小、复发率低等优势,因此临床应用前景广阔。本文主要就腹腔镜下腹壁疝修补术的治疗现状与进展进行了综述。     

The long-term effect of mesh bioprosthesis in inguinal hernia repair on testicular nitric oxide metabolism and apoptosis in rat testis

Polypropylene mesh is the most widely used material in inguinal hernia repair. Although polypropylene mesh is known as an inert material, it is experimentally proven that mesh generates a chronic inflammatory tissue reaction. The aim of the present study was to investigate the long-term effects of polypropylene mesh material used in inguinal hernia operations on testicular function, testicular nitric oxide (NO) metabolism and germ cell-specific apoptosis in rats. The study comprised 40 male rats that were randomly allocated into two groups. In group 1, the left spermatic cord was elevated and a 0.5 x 1 cm polypropylene mesh was placed behind the left inguinal spermatic cord and group 2 consisted of the sham-operated controls. Blood samples were taken at 6 months preoperatively and postoperatively after to assess luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels for hormonal evaluation. Testicular NO was evaluated by the Griess method, apoptosis by a TUNEL method and inducible nitric oxide synthase (iNOS) and endothelial NOS (eNOS) expressions by immunohistochemical staining. Mild (+) eNOS expression was observed in all specimens. Mild (+) iNOS expression was only detected in ipsilateral testis of the mesh-implanted study group. Apoptotic cells were not detected in any samples. We are of the opinion that long-term polypropylene mesh implantation has no effect on testicular hormonal function and only a limited effect on nitric oxide levels and this effect is not sufficient to cause apoptosis in testis that could lead to infertility. It seems that mesh implantation is a reliable method in inguinal hernia repair; however, further work is required by more sensitive methods to fully elucidate the potential testicular damage.     

Impact of intraoral soft-tissue reconstruction on the development of quality of life after ablative surgery in patients with oral cancer

The aim of this prospective study was to assess the impact of intraoral soft-tissue reconstruction on the development of quality of life after ablative surgery for oral cancer. A total of 107 patients were enrolled in the study during the period between 1997 and 1999. Quality of life was assessed by using the quality-of-life core questionnaire and the head and neck module of the European Organization for Research and Treatment of Cancer. The questionnaires were distributed to the patients preoperatively on the day of hospital admission and 3 months, 6 months, and 12 months postoperatively. A total of 53 patients filled in all questionnaires and were available for complete longitudinal analysis. The changes in the scores and the impact of defect size, location, and anatomy, the extent of mandibular resection, and the mode of soft-tissue reconstruction were tested longitudinally for statistical significance by using repeated-measures analysis of variance procedures. Of all parameters tested, the mode of soft-tissue reconstruction had the most profound impact on the development of quality of life after ablative surgery for oral cancer in that it was associated with statistically significant changes in the most domains or items associated with postoperative quality of life. In contrast to local flaps, revascularized soft-tissue repair with forearm flaps was associated with an intermittent deterioration of physical and functional scores but was followed by improvement until the end of the first year, and it even surpassed the preoperative baseline level in oral functional and social domains. In large-volume defects, which required repair by myocutaneous grafts, quality of life was not restored to the same extent, and physical, functional, and social domains remained significantly lower.     

Contribution of the skin,rectus abdominis and their sheaths to the structural response of the abdominal wall ex vivo

A better understanding of the abdominal wall biomechanics could help designing new treatments for incisional hernia. In the current study, an experimental protocol was developed to evaluate the contributions of the abdominal wall components to the structural response of the anterior part of the abdominal wall. The specimens underwent 3 dissections (removal of (1) skin and subcutaneous fat, (2) anterior rectus sheath, (3) rectus abdominis muscles). After each dissection, they were subjected to air pressure up to 3 kPa. Ultrasound images and associated elastographic maps were collected at 0, 2 and 3 kPa in the intact state and strains on the internal surface were calculated using stereo-correlation in all states. Strains on the rectus abdominis and linea alba were analyzed. After the dissection of the anterior sheath of the rectus abdominis, longitudinal strain was found significantly different on the linea alba (5% at 3 kPa) and on the rectus abdominis area (11% at 3 kPa). The current results highlight the importance of the rectus sheath in the structural response of the anterior part of the abdominal wall ex vivo. Geometrical characteristics such as thicknesses and radii of curvature and mechanical properties (shear modulus of the rectus abdominis, e.g. at 0 pressure the average value is 14 kPa) were provided in order to facilitate future modeling efforts.     

Clinical applications of the posterior rectus sheath-peritoneal free flap

Soft-tissue injuries involving the dorsum of the hand and foot continue to pose complex reconstructive challenges in terms of function and contour. Requirements for coverage include thin, vascularized tissue that supports skin grafts and at the same time provides a gliding surface for tendon excursion. This article reports the authors' clinical experience with the free posterior rectus sheath-peritoneal flap foil dorsal coverage in three patients. Two patients required dorsal hand coverage; one following acute trauma and another for delayed reconstruction 1 year after near hand replantation. A third patient required dorsal foot coverage for exposed tendons resulting from skin loss secondary to vasculitis. In all three patients, the flap was harvested through a paramedian incision at the lateral border of the anterior rectus sheath. After opening the anterior rectus sheath, the rectus muscle was elevated off of the posterior rectus sheath and peritoneum. When elevating the muscle, the attachments of the inferior epigastric vessels to the posterior rectus sheath and peritoneum were preserved while ligating any branches of these vessels to the muscle. Segmental intercostal innervation to the muscle was preserved. The deep inferior epigastric vessels were then dissected to their origin to maximize pedicle length and diameter. The maximum dimension of the flaps harvested for the selected cases was 16 X 8 cm. The anterior rectus sheath was closed primarily with non-absorbable suture. Mean follow-up was 1 year, and all flaps survived with excellent contour and good function in all three patients. Complications included a postoperative ileus in one patient, which resolved after 5 days with nasogastric tube decompression.