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Fast-track surgery and inguinal hernia

Hospital Healthcare Europe spoke with Frederik Berrevoet, Current President of the Belgian Section of Abdominal Wall Surgery, about fast-track protocols and the management of inguinal hernia
Frederik Berrevoet MD PhD FACS
Associate Professor of Surgery,
HPB surgeon and Abdominal  Wall specialist,
Current President of the Belgian Section of
Abdominal Wall Surgery (BSAWS);
Department of General,
Hepatobiliary surgery and Liver Transplantation Service,
University Hospital Ghent, Belgium
The University Hospital Ghent is a university hospital and medical school training facility in Belgium. The facility is one of the largest in the country and has approximately 1000 beds and 6000 members of staff. In order to satisfy the needs of increasing subspecialisation, the surgical department was reorganised in 2004, with the creation of three divisions:
  1. General, hepato-biliary surgery and transplantation service 
  2. Gastro-intestinal surgery 
  3. Thoracic and vascular surgery.
I am one of the senior surgeons in the general and hepato-biliary section, together with three fellows and two surgical trainees. The diseases we treat at our department are: abdominal wall pathology; gallbladder disease; biliary tract; pancreatic surgery; liver surgery; liver transplantation; surgery of the spleen.
What is fast-track surgery?
The term fast track surgery was developed in the 1990s by the Danish surgeon, Professor Henrik Kehlet. Fast track surgery or enhanced recovery after surgery (ERAS) is a multidisciplinary surgical method, utilising an evidence-based and structured surgical pathway-based approach to the preoperative, perioperative and postoperative period, emphasising patient optimisation, education, minimal access surgical techniques, multimodal opioid-sparing analgesic techniques, early mobilisation, early nutrition, and early goal-directed physical activity. This is aimed at supporting a faster recovery from surgery, earlier hospital discharge, and ultimately earlier return to normal function and quality of life.
Organisation and effectiveness of a fast-track protocol requires participation and commitment from a multidisciplinary team, including surgeons, anaesthetists, nursing staff, social services, and hospital administration.
Many of the objectives targeted by ERAS are also likely to reduce postoperative surgical infection by reducing the duration of hospital stay, achieving early mobilisation, achieving adequate analgesia, and minimising the impact of the postoperative catabolic state.
The main components of an ERAS program are shown in Figure 1.
Initially, fast-track surgery protocols converted many operations performed as inpatient procedures to outpatient ‘day surgery’ procedures. As experience developed with these protocols, the principles of enhanced recovery were applied to increasingly complex procedures to reduce hospital length of stay and expedite return to baseline health and functional status. 
Fast track surgery improves the efficiency of the time a patient is admitted in the hospital while maximising patient outcomes, so to avoid extra ‘unexpected admissions’ after discharge because of complications. In our hospital, this is used in liver surgery, abdominal wall and gallbladder surgery. 
Has the process been widely adopted?
Adoption in different countries depends mainly on the healthcare situation. In Belgium, patients are usually free to stay in hospital as long as they wish after a procedure as part of their insurance conditions, so fast track surgery can be limited. Patients are also free to select the hospital and their doctor, so discharging a patient before he/she feels is appropriate could be ‘bad for business’ for the hospital. However, whenever possible, doctors will try to get their patients home as soon as possible, to free up beds, which of course is good for hospital income.
Patient selection in hernia
An inguinal hernia or hernia inguinalis is a protrusion of the contents of the abdominal cavity or preperitoneal fat through a hernia defect in the inguinal area, irrespective of whether this is preformed (congenital). This situation can give rise to complaints such as discomfort and pain. Sometimes, it is not possible to reduce the contents of the hernia sac (non-reducible hernia).
In the case of a narrow hernia defect, there is a risk of the hernia sac contents becoming incarcerated, resulting in an obstruction of the intestine (ileus) and/or a circulatory disorder of the incarcerated content (strangulation), which can lead to necrosis and possible perforation of the intestine. Patients will be selected on the type of inguinal hernia repair (for example, a third recurrence of an inguinal hernia might be treated more invasively, so not a suitable indication for fast track) and on the co-morbidities, and whether they require clinical assessment.
Key studies
An inguinal hernia repair performed in the outpatient department under local anaesthetic, in which the patient goes home shortly after the intervention, is considered to be day surgery.
As early as 1955, the advantages of inguinal hernia repair as day surgery were already described in the literature: quicker mobilisation, patient-friendly and lower costs.(1) Some time later,(2,3) as well as two small randomised studies in which day surgery was compared with inpatient treatment.(4–6) In a large American cohort study, the costs of an inguinal hernia repair in a clinical setting were found to be 56% higher than those for day surgery.(7)
In addition to the few randomised studies, there are a multitude of cohort studies concerning patients successfully operated on as day surgery, under general, regional and local anaesthetics, and with both classical operation techniques as well as open tension-free repairs and endoscopic techniques. A large study conducted in Denmark noted the hospital readmission rate of 0.8%.(8) 
On a worldwide basis, there is a clear increase in the percentage of inguinal hernia repairs that are being carried out as day surgery.(9,10) There is considerable variation between different countries, which cannot be clarified solely by the degree of acceptability of day surgery among patients and surgeons but, to a significant extent, is also determined by the healthcare financing system.
In a study by Kark et al,(11) 2906 consecutive unselected adult patients underwent 3175 primary inguinal hernia repairs using polypropylene mesh, under local anaesthesia on an ambulatory basis. The age range was 15–92 years. The study specifically investigated the postoperative course with regard to pain, complications, and time of return to work.
There were no postoperative deaths and no cases of urinary retention. Two per cent of patients developed a haematoma. The incidence of deep infection was 0.3%. No case of testicular atrophy occurred. Postoperatively, 19% of patients used no analgesia at all; 60% used oral analgesics for up to seven days. There was a gradual decrease in time of return to work over four successive one-year periods. Manual workers returned to work in 15 days (median) in the first year, reducing to nine days in the fourth year. The overall median time of return to work across the whole group was nine days. 
There were eight recurrences with an 18-month to five-year follow up.
Open mesh repair under local anaesthesia was shown to be an effective day case technique, particularly in the elderly and medically unfit. The economic benefits are enhanced by low morbidity, early return to normal activities and low recurrence rates.
To evaluate the feasibility and safety of unmonitored local anesthesia (ULA) for elective open inguinal hernia repair, Callensen et al(12) made a prospective, consecutive data collection from 1000 operations on primary and recurrent hernias. Follow-up consisted of a questionnaire one month after surgery and retrieval from the electronic patient data management system. In 921 ASA Group I and II and 79 ASA Group III and IV patients, the median age was 60 years (range, 18–95 years). ULA was converted to general anaesthesia in 5 of 1000 cases, and 961 patients were discharged on the day of surgery after 95 minutes; 29 patients had complications requiring surgical intervention. Within the first month, three patients died of causes unrelated to hernia surgery, and six had cardiovascular or respiratory events. The questionnaire was returned by 940 patients: 124 were dissatisfied with local anaesthesia, day-case setup, or both, primarily because of intraoperative pain (n = 74; 7.8%). The authors concluded that open inguinal hernia repair can be conducted under ULA, regardless of comorbidity, with a small rate of deviation from day-case setup and minimal morbidity. It provides a safe alternative to other anaesthetic techniques with an acceptable rate of satisfaction, but intraoperative pain relief needs improvement.
In a study by Mattila et al,(13) medically stable patients scheduled for open inguinal hernia repair, with postoperative care available at home, were randomised to receive treatment either as outpatients or inpatients. Younger patients undergoing the same procedure served as a reference group. Outcome measures during the two weeks after surgery were complications, unplanned admissions, visits to the hospital, unplanned visits to primary health care, and patients’ acceptance of the type of provided care.
Of 151 patients, 89 were included. Main reasons for exclusion were lack of postoperative company (16%), unwillingness to participate (13%), and medical conditions (10%). All outpatients were discharged home as planned, and none of the study patients were readmitted to the hospital. Patient satisfaction was high with no differences between the groups.
The authors concluded that ambulatory surgery was safe and well accepted by older, medically stable patients.
The study by Mitchell and Harrow,(7) sought to compare treatment costs and outcomes for a large number of Medicare patients undergoing inpatient versus outpatient hernia repair in the US. All patients undergoing uncomplicated inguinal hernia repair were identified from the surgeon’s bill, and the geographical location was noted (n = 27,036). Over one-third of all hernia repairs in the sample were performed on an ambulatory basis. Treatment costs were 56% higher for hernias repaired on an inpatient basis; $2341 versus $1505 for those performed in outpatient settings. There were no detectable differences between inpatients and outpatients along such outcomes as complication rates, deaths and hernia recurrence, but readmission rates were higher for inpatients. The dramatic differences in costs, along with the apparent absence of adverse outcomes, suggested that surgeons should be encouraged to perform more hernia repairs on an outpatient basis.
Fast track protocols and ERAS are of benefit in the treatment of inguinal hernia. Repair under local anaesthesia is an effective day case technique, particularly in the elderly and medically unfit. The economic benefits are enhanced by low morbidity, early return to normal activities and low recurrence rates.
  1. Farquharson EL. Early ambulation; with special reference to herniorrhaphy as an outpatient procedure. Lancet 1955;269:517–9.
  2. Goulbourne IA, Ruckley CV. Operations for hernia and varicose veins in a day-bed unit. Br Med J 1979;2:712–4.
  3. Michelsen M, Walter F. Comparison of outpatient and inpatient operations for inguinal hernia (1971 to 1978). Zentralbl Chir 1982;107:94–102.
  4. Pineault R et al. Randomized clinical trial of one-day surgery. Patient satisfaction, clinical outcomes, and costs. Med Care 1985;23:171–82.
  5. Prescott RJ et al. Economic aspects of day care after operations for hernia or varicose veins. J Epidemiol Community Health 1978;32:222–5.
  6. Ruckley CV et al. Day care after operations for hernia or varicose veins: a controlled trial. Br J Surg 1978;65:456–9.
  7. Mitchell JB, Harrow B. Costs and outcomes of inpatient versus outpatient hernia repair. Health Policy 1994;28:143–52.
  8. Engbaek J, Bartholdy J, Hjortsø NC. Return hospital visits and morbidity within 60 days after day surgery: a retrospective study of 18,736 day surgical procedures. Acta Anaesthesiol Scand 2006;50:911–9.
  9. De Lathouwer C, Poullier JP. How much ambulatory surgery in the World in 1996–1997 and trends? Ambul Surg 2000;8:191–210.
  10. Jarrett PE. Day care surgery. Eur J Anaesthesiol 2001; Suppl 23:32–5.
  11. Kark AE, Kurzer MN, Belsham PA. Three thousand one hundred seventy-five primary inguinal hernia repairs: advantages of ambulatory open mesh repair using local anesthesia. J Am Coll Surg 1998;186:447–55.
  12. Callesen T, Bech K, Kehlet H. One-thousand consecutive inguinal hernia repairs under unmonitored local anesthesia. Anesth Analg 2001;93:1373–6.
  13. Mattila K et al. Randomized clinical trial comparing ambulatory and inpatient care after inguinal hernia repair in patients aged 65 years or older. Am J Surg 2011;201(2):179–85.