Abstract
Objectives: To study the type of anaesthesia,
local or general, that patients prefer for an
open hernia repair procedure and the reason for
their choices.
Patients and methods: This study was conducted
at Royal Medical Services during the period between
January 2011 and June 2013. A sample of 150 consecutive
patients awaiting open hernia repair and considered
suitable for day case surgery, under local or
general anaesthesia were chosen according to the
following criteria: age between 20 and 75 years;
primary hernia repair (irreducible or complicated
hernias were excluded). The patients were interviewed
at the hospital. The questionnaire ascertained
the patients' willingness to have day case hernia
repairs under local or general anaesthesia, the
reasons for their choice and any previous experience
of these procedures.
Results: The mean age of patients was 58.4
years with 114 males and 36 females. Hernia types
were 98 inguinal, 30 paraumbilical, 12 small incisional
and 10 femoral.
87% of patients preferred day case hernia repair
and these patients were younger in age in comparison
to those opting for in-patient surgery. 13% of
patients expressed a strong preference for general
anaesthesia, all of whom also stated 'a dislike
or feeling of anxiety if awake during surgery'.
The reasons stated for choosing local anaesthesia
included, 'dislike/fear of loss of consciousness
with GA' (75%), previous adverse experiences with
surgery under general anaesthesia (8%) and slower
post-operative recovery with general anaesthesia
(4%).
Conclusion: The majority of patients preferred
local anaesthesia for their hernia repair procedure;
the mean reason was dislike of loss of consciousness
with general anaesthesia.
Key words: Hernia, local anaesthesia, general
anaesthesia, in-patient and day case.
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Introduction
In selected patients, day case herniorrhaphy has a similar
clinical outcome but is more economical than in-patient
care. Herniorrhaphy may be performed under local or
general anaesthesia. General anaesthesia requires an
anaesthetist and greater post-operative nursing care.
Use of local anaesthesia compared with regional or general
anaesthesia results in a shorter duration of hospital
admission and less postoperative pain, as well as fewer
micturition difficulties, in patients undergoing hernia
repair(1).
Day case herniorrhaphy under local anaesthesia is more
economical, but of similar clinical outcome compared
to in-patient care(2,3). It is therefore likely to ease
the current pressures on finances and in-patient beds
without detrimental effects on patient care. Despite
the advantages of day case surgery it is not fully exploited
in many hospitals. This is in part due to a lack of
enthusiasm and adequate facilities(3). In this respect,
patient preference for day case hernia repair is also
likely to be important. We report our findings on patient
willingness to undergo day case hernia surgery under
local or general anaesthesia.
Patients
and Methods
This study was conducted in Royal Medical Services during
the period between January 2011 and June 2013. A sample
of 150 consecutive patients awaiting open hernia repair
and considered suitable for day case surgery, under
local or general anaesthesia were chosen according to
the following criteria: age between 20 and 75 years;
primary hernia repair (irreducible or complicated hernias
were excluded).
The patients were interviewed at the hospital. The procedures
for day case or in-patient hernia repairs were explained
as follows: Provided there are no complications the
patient will be discharged the same day or the following
day; herniorrhaphy involves the same type of repair
and overall, the post-operative discomfort, size of
scar, complication and recurrence rates are similar;
earlier mobilisation may be possible with local anaesthesia;
the patient is awake under local anaesthesia, although
they are unlikely to feel any pain, need not to see
the operation itself and may choose to have light sedation.
The questionnaire ascertained the patients' willingness
to have day case hernia repairs under local or general
anaesthesia, the reasons for their choice and any previous
experience of these procedures.
Results
The mean age of patients was 58.4 years with 114 males
and 36 females. Hernia types were 98 inguinal (65%),
30 paraumbilical (20%), 12 small incisional (8%) and
10 femoral (7%).
Thirty-six (24%) patients had previous hernia repairs
(95% of which were under general anaesthesia). There
was a negative association between previous hernia repair
and preference for day case surgery. Sixty-four (43%)
patients had previous experience of day case surgery
and 38 (25%) knew of others who had had day case surgery.
There was a tendency for a positive association between
previous experience with day case surgery and a preference
for day case surgery.
87% of patients preferred day case hernia repair and
these patients were younger in age in comparison to
those opting for in-patient surgery. 13% of patients
expressed a strong preference for general anaesthesia,
all of whom also stated 'a dislike or feeling of anxiety
if awake during surgery'. The reasons stated for choosing
local anaesthesia included, 'dislike/fear of loss of
consciousness with GA' (75%), previous adverse experiences
with surgery under general anaesthesia (8%) and slower
post-operative recovery with general anaesthesia (4%).
Fourteen (9%) and twelve (16%) patients had previous
adverse experiences with surgery under local and general
anaesthesia respectively. There was a positive association
between previous adverse experiences with surgery under
local anaesthesia and a preference for general anaesthesia.
There were no other associations between the parameters
studied.
Discussion
We observed that when allowed to make an informed choice,
the vast majority of patients prefer day case hernia
repair. This bodes well for the future of day case herniorrhaphy.
A small minority of patients preferred 'in-patient surgery'
and these patients were older and had previous herniorrhaphy,
with adverse experiences from this in some cases.
There was a greater preference for general anaesthesia
as the mode of anaesthesia, partly due to previous unfavourable
experiences with local anaesthesia and an assumed feeling
of anxiety if awake during the operation. A significant
proportion of the patients of the local anaesthesia
group experience discomfort and anxiety, although this
is mild and acceptable to most patients(3). A greater
preference for general anaesthesia has important resource
implications, since this requires the services of an
anaesthetist and increased nursing care in the immediate
recovery stage. In contrast, for herniorrhaphy under
local anaesthesia it is recommended that the patient
be monitored intra-operatively by an anaesthetic nurse
and that an anaesthetist should be available if conversion
to general anaesthesia becomes necessary(2).
With a careful technique, local anaesthesia causes minimal
physiological disturbance. This may be particularly
useful for patients with cardiovascular or respiratory
disease for whom there may be advantages in avoiding
a general anaesthetic. The absence of postoperative
sedation or drowsiness allows early ambulation and diminishes
the requirement for recovery facilities. Local anaesthesia
provides postoperative analgesia for up to four hours
and may be administered by the surgeon. When adrenaline
is mixed with the
local anaesthetic (normally in a dilution of 1:200,000)
useful vasoconstriction is produced resulting in a relatively
bloodless field. On the other side, surgery on the awake
patient under local anaesthesia must be carried out
gently. Although pain sensation is usually blocked by
the anaesthetic, traction on certain tissues, particularly
the peritoneum is uncomfortable. The patient should
be warned that some sensation may be experienced during
the operation but that it will not be painful. Larger
hernias, particularly those with incarcerated bowel
may prove unsuitable for local anaesthesia. Some sedation
during the operation may be required for anxious patients
which loses some of the benefits of avoiding general
anaesthesia. Patients who are excessively nervous may
be unsuitable for surgery under local anaesthesia(4).
We are unaware of similar pre-operative studies investigating
patient preference for day case hernia repair under
local or general anaesthesia. Uncontrolled follow-up
studies and a limited number of randomised clinical
trials comparing day case herniorrhaphy under local
and general have reported high rates of patient satisfaction
post-operatively(5-7). However, in these studies, as
in most busy surgical out-patient clinics, the patients
are not routinely offered an informed choice of anaesthesia.
The choice of anaesthetic is often influenced by the
facilities available within the day case surgical unit
and the personal preferences of the surgeon.
General anaesthesia is still the preferred mode of anaesthesia
for complicated hernias and uncooperative and highly
anxious patients. Local anaesthesia is desirable for
those who are at high risk of morbidity from general
anaesthesia. But, for a majority of patients awaiting
hernia repair, day case surgery under general and local
anaesthesia is feasible, although herniorrhaphy under
local anaesthesia makes greater economic sense(8-12).
Specific measures to create a more patient friendly
atmosphere in the theatre, such as greater explanation,
reassurance to the patient during the operation and
music in theatre may help to counter the feelings of
anxiety and enable greater acceptability of local anaesthesia.
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