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Annals of the Royal College of Surgeons of England (I975) vol 57

ASPECTS OF TREATMENT*

Incidence of inguinal hernia


recurrence
Effect of time off work after repair
A P J Ross MS FRCS
Royal Hampshire County Hospital, Winchester

Summary Group studied


A survey of 26o adult male patients who had The survey was confined to adult male pa-
undergone inguiinal hernia repair was carried tients undergoing repair of inguinal hernias
out to see how long they stayed off work at St Bartholomew's and the Whittington
after operation. There was no evidence that Hospitals, London. Shortly after they had
a prolonged convalescent period reduced the been discharged from hospital the patients
suibsequent hernia recurrence rate. were asked the following questions: What
Evidence from the North American litera- was your occupation before operation? Have
ture suggests that patients can resume their you returned to the same occupation and, if
usual physical activity without ill effect much not, what is your new occupation? How soon
sooner after operation than is the current after the day of your operation did you re-
practice in the United Kingdom. General turn to light work? How soon after your
practitioners should be informed of the ad- operation did you return to full work? The
vice that has been given to their patients patients were then classified into 3 groups-
about the resumption of physical activities light work (for example, retired, clerical
after operation. work), medium work (for example, shop-
keepers, sales representatives), and heavy
work (for example, labourers, welders, but-
Introduction chers)-according to the work being done
after the operation.
'How long should I stay off work, doctor?' Approximately 4 years later the patients
This must be one of the most common quest- were contacted again and were asked if they
ions that a surgeon or general practitioner had developed a recurrent hernia. If they
hears from patients who have recently under- were in any doubt they were examined by
gone an operation. It was my ignorance of a doctor.
the correct answer to this question from a
patient who had recently undergone a hernia Results
repair that led me to carry out the survey Of the 260 patients studied, 29 underwent
described in this paper. bilateral inguinal hernia repair, giving a
*Fellows and Members interested in submitting papers for consideration with a view to
publication in this series should first write to the Editor
Incidence of ingiiinal hernia recurrence 327
total of 289 hernias in the study. hernias, yet this is an occupation which
The number of hernias which had recur- involves lifting heavy weights. On the other
red 4 years after repair was 22. Of I52 in- hand many patients remained off work for
direct hernias, 6 recurred (3.9%). Of 92 di- an extraordinarily long time without ap-
rect hernias, 7 recurred (7.6%). Of 45 hernias parent reason. Striking examples of this tend-
that were recurrent at the initial operation, ency were a 47-year-old civil servant with a
9 recturrecl (2o/,,). This difference in the in- sedentary job who had an indirect hernia re-
cidence of the recurrence rate in different pair and then did not return to office work
types of inguinal herna is similar to that for another 7 weeks and did no gardening
found in the literature on the subject. until 3 months had passed; a 20-year-old
There was no apparent correlation between bank clerk with an indirect hernia who re-
the recurrence rate and the methods of hernia turned to light work after 8 weeks but did not
repair used during the study. However, the do any heavy work for over 4 months;
nmost significant finding was that there was and a 54-year-old bank messenger who had
no correlation between the time off work an indirect hernia repair and returned to
after operation and the subsequent develop- light work after 8 weeks and to full work
ment of a recurrent hernia. This applied after I4 weeks. It would seem from personal
whether the patient returned to light, med- communication with a number of general
ium, or heavy work (see figure). practitioners that only rarely does the hos-
There was little correlation between the pital discharge letter state what advice has
time a patient spent off work after operation been given to the patient with regard to his
and the advice given by the consultant under return to work.
whose care he had been admitted. There was
a tendency for patients who were self- Discussion
employed to return to work sooner than ad- This survey has shown that prolonged time
vised. A managing director and a consultant off work does not reduce the incidence of
haematologist both returned to full work on recurrence after hernia repair and that early
the 5th postoperative day with no untoward return to work does not increase the risk of
sequelae. Two butchers who returned to full hernia recurrence. There is evidence in the
work at 4 weeks did not develop recurrent literature from North America, where the

LIGHT WORK

30 MEDIUM

HEAVY a
25 RECURRENC ES

10 Relationship between
NO OF 15
hernia recurrence and
PATIENTS time off work after in-
10
guinal hernia repair in
adult males.
5

2 3 4 5 6 7 a 9 10 11 12 2 12
TIME OFF WORK (Weeks)
328 A P J Ross
social security system is less bountiful, strong- Conclusion
ly supporting the idea that patients should The evidence from the survey describ(
return to work much earlier than is the cur- above shows that many patients restrict the
rent practice in the United Kingdom. Surgery postoperative activities after inguinal hem
at the Shouldice Clinic in Ontario is confined repair for much longer than is necessary.
almost exclusively to the repair of inguinal It is suggested that these patients shoul
hernia, and since I945 over 50 000 patients be advised to resume their normal activiti,
have been operated on there with a recur- immediately after discharge from hospit,
rence rate of less than I %1 Iles2 has described and should remain off work for up to 4 wee]
the technique used at this clinic. The repair only if they are engaged in occupations whic
is carried out routinely under local anaes- are physically very strenuous. The advi(
thesia and the patient is helped to walk back
to his bed and is discharged from hospital given to patients should be included in ti
discharge letter from the hospital to tU
after 72 h. He is encouraged to resume im- general practitioner.
mediately all activities that can be carried
out in reasonable comfort and is expected to Action based on these conclusions wou]
have resumed his previous level of activity have a significant effect on the economy
by the 4th postoperative week. Piano-movers, the United Kingdom.
stevedores, and lumberjacks are advised to
wait 4 weeks before returning to full work. I should like to thank the general surgeons of
National Hockey League players are advised Bartholomew's and the Whittington Hospita
to avoid competitive ice hockey for 4 weeks, under whose care the patients were admitted f4
allowing mc to carry out the study.
but Iles quotes the example of one NHIL
ice hockey star who resumed practice skat- Thcsc findings have been presented previous
to the Sectioni of Surgery of the Royal Socie
ing after 7 days without ill effect. Lichten- of Medicitne as a short paper.
stein et al.3 showed that a healing wound at
8 weeks possesses only 40% of intact-tissue
strength, whereas a wound repaired with a References
non-absorbable suture immediately possesses M
Ataingot, R (I974) Abdominal Operations, 6t
70°/O of intact-tissue strength and this degree edn, Vol. 2, p. I502. New York, Appleton-Cei
of strength is still present at 8 weeks. They tury-Crofts.
reported a hernia recurrence rate of less 2 Iles, J D H (1972) Journal of the Americ6
than i% in iOOO patients who were encour- Medic al Association, 219, 385.
aged to take unrestricted physical activity im- 3 ILichtenstein, I LJ (1970) Surgery, Gynecolog
mediately after operation. n.J1 lhctotrir V TOC( fiS FT