Early results with the Lichtenstein tension-free hernia repair.

Sir We read with interest the report on use of the Lichtenstein patch hernia repair by Mr Davies et al. (Br J Surg 1994; 81: 1478-9). We have recently evaluated the use of this technique in 85 patients, 42 day cases (41 men and 1 woman; median age 50 years, range 16-65) and 43 inpatients (41 men and two women; median age 60.5 years, range 20-85). All cases were performed under general anaesthesia, day cases using propofol infusion allowing general anaesthesia with rapid recovery and minimal sedative effects after operation. Regional blockade was provided using bupivacaine 0.5 per cent with adrenaline 1 : 200 000. Patients were given co-dydramol for 5 days as take-home analgesia, and were reviewed in outpatients at 4 weeks. Median (range) operating time was 30 (20-45)min for day cases and 35 (20-75) min for inpatients. Median postoperative stay for inpatients was 1 day (1-6), and postoperative opiate analgesia was required in 11 of 43 (26 per cent). All day cases were discharged on the day of operation, apart from two (4.8 per cent). One needed bilateral repair; one lived alone in poor home circumstances. A single dose of opiate analgesia was required in three day cases (7.1 per cent), in no case preventing discharge on the same day. Complications occurred in four day cases (9.5 per cent): serous discharge one, bleeding two, haematoma one. Only the latter was serious and required evacuation. No complications occurred in the inpatient group. No early hernia recurrence has been detected. At 1 month follow-up assessment, no day cases regarded themselves as back to full activity including heavy lifting, although 22 (52 per cent) felt comfortable with general day-today activities. The oral analgesia prescribed was required by 28 day cases (67 per cent), and 15 of these (36 per cent) required more analgesia from their own doctor. Three day cases (7.1 per cent) called their GP, one requiring a visit to arrange readmission. The other two were dealt with by a visit from a practice nurse. Of the day cases 39 (93 per cent) were happy with day-case care in spite of any discomfort suffered at home. All of these would be happy to undergo further day-case repair if required. Of the patients undergoing inpatient repair, none were back to full activity at one month, although 21 (49 per cent) were back to general activities. All 43 of these patients were happy with their care. Recent Royal College of Surgeons of England' guidelines suggest that over 30 per cent of elective hernias should be performed as day cases, which we have achieved. The guidelines also suggest that layered sutured or prosthetic repair should be used. We feel that the Shouldice repair is more difficult to learn than the Lichtenstein patch. It is too early to say whether a recurrence rate of less than 0.5 per cent at 5 years can be achieved as proposed in the Royal College guidelines. College guidelines* on day-case surgery suggest an acceptable admission rate of 2-3 per cent; this has not been achieved in our series, probably as a result of poor patient selection rather than a poor operation. Although our patients' return to work was not as rapid as reported by Mr Davies et al. and our operative time was longer, we would agree that the procedure is easy to learn, is reasonably pain-free, and without major morbidity due to the technique used. Patients were generally happy with the technique and in particular were happy to have day-case repair. The Lichtenstein patch hernia repair therefore provides a cheap alternative to laparoscopic repair and furthermore would be a good operation with which to compare laparoscopic repair in prospective studies.