Pakistan Journal of Medical Sciences

Published by : PROFESSIONAL MEDICAL PUBLICATIONS

ISSN 1681-715X

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ORIGINAL ARTICLE

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Volume 22

October - December 2006

Number 4


 

Abstract
PDF of this Article

Groin Sepsis Following Lichtenstein
Inguinal Hernioplasty Without Antibiotics
Prophylaxis: A Review of 100 Cases

Raja Najam-ul-Haq1, Ishtiaq Ahmed Chaudhry2, Bashrat Ali Khan3, Muhammad Afzal4

ABSTRACT

Objective: To see the prevalence of groin sepsis following Lichtenstein inguinal hernioplasty without antibiotics prophylaxis

Design: A prospective observational study

Place and Duration: Department of Surgery Fauji Foundation Hospital Rawalpindi from Dec 2002 to July 2004.

Patient and Methods: A total of first consecutive 100 cases of inguinal hernia were included in the study. All patients were subjected to Lichtenstein repair without antibiotic prophylaxis. Prolene mesh was used in all cases.

Results: Three percent of patients developed postoperative wound infection, which was treated conservatively without any significant morbidity.

Conclusion: Lichtenstein’s repair is an easy procedure with less complication rate even without antibiotic prophylaxis

KEY WORDS: Inguinal Hernia, Lichtenstein’s Repair, Complications, Infection.

Pak J Med Sci October - December 2006 Vol. 22 No. 4 416-419


1. Dr. Raja Najam-ul-Haq FCPS
Senior Registrar Surgery,

2. Dr. Ishtiaq Ahmed Chaudhry FCPS
Assistant Professor Surgery,

3. Dr. Bashrat Ali Khan FRCS
Associate Professor Surgery

1-3: Foundation University Medical College
Rawalpindi.

4. Dr. Muhammad Afzal FCPS
Surgical Specialist
Combined Military Hospital, Kohat

Correspondence:
Dr. Raja Najam-ul-Haq,
Street # 6, House # 9,
Hill view lane, Adyala Road,
Rawalpindi – Pakistan.
E-Mail: salar_minhas@yahoo.com

* Received for Publication: November 14, 2005

* Accepted: May 25, 2006


INTRODUCTION

The use of prosthetic material for inguinal hernia repair has increased dramatically ever since described by Giraud and colleagues using Nylon mesh in 1951.1 Various meshes have since been developed consisting mainly of non absorbable materials such as polypropylene, polyester and polytetraflouroethylene. The presence of plastic biomaterial increases the incidence of complications relating to the mesh itself, in addition to other recognized complications of the hernia repair. The most serious complication is the development of mesh infection leading to groin sepsis sometimes necessitating the removal of mesh implant. To prevent this mesh infection, antibiotic prophylaxis is often indicated and recommended.2 Most surgeons have used prophylactic antibiotics for Lichtenstein hernia repair.3 The true incidence of mesh infection is not exactly known because in some series infection rates of 1.9% to 7.5% has been reported.4,5

Use of prophylactic antibiotics in Lichtenstein hernia repair is still debatable. Some surgeons prefer not to use prophylactic antibiotics in order.

1. To prove the fact that if strict aseptic measures are opted use of antibiotics can be reduced
2. To save the patient from hazards of antibiotics
3. To reduce the emergence of resistant organisms
4. To reduce patient and hospital expenditures

We conducted this study to see the incidence of infection and other complications without antibiotic prophylaxis.

PATIENTS AND METHODS

This study was conducted in the Department of Surgery, Fauji Foundation Hospital Rawalpindi from December 2002 to July 2004. First consecutive one hundred cases were included in the study. All patients with inguinal hernia reporting to surgical OPD were selected for Lichtenstein repair and included in the study. Children and adolescents less then 20 years of age, patients with obstructed /strangulated hernias, diabetes mellitus, recurrent hernia and patients on steroids were excluded. Obesity, huge hernias, scrotal hernias were also excluded.

All patients were admitted and evaluated carefully preoperatively. All necessary investigations were carried out. Operations were performed under strict aseptic conditions by registrars, senior registrar or consultants. Proline mesh was used in all cases. Majority of the patients were discharged on 3rd post operative day after wound inspection. Then they were reviewed in Surgical Out Patient on 7th post operative day for wound inspection and removal of stitches.

All the patients were followed up for one year as per guidelines given by The National Nosocomial Infection Surveillance system (NNISS).6 Initially, they were reviewed as out patient on monthly basis for first three months and then every 3 months for the rest of the year. During their OPD visits, wounds were examined carefully for development of infection, recurrence or any other complications. Any patient showing signs of wound infection during follow up period was admitted, appropriately treated and all records were maintained.

RESULTS

Majority of the patients (48%) in this study were in the fifth decade of their life. Among all patients 47% had right sided, 29% had left sided and 24% had bilateral inguinal hernia (Table-I).

The overall incidence of post operative complications was 11% (Table-II). Wound infection was noted in three (3%), scrotal edema/haematoma two (2%), wound redness one (1%), wound seroma one (1%), post operative residual pain one (1%), urinary retention two (2%). All complications were treated conservatively with no significant post operative morbidity or mortality. Post operative infection was treated conservatively with antibiotics, drainage of pus and repeated dressings. Mesh removal or exploration of wound was not required post operatively. The post operative complications were minimal and managed conservatively.

DISCUSSION

Inguinal hernia is the commonest problem amongst all external hernias and Inguinal hernia repair is most frequent procedure in general surgery accounting for 10–15% of all operations.4,7 The age incidence is distributed in all decades of life. Incidence of inguinal hernia is race related. It is at least three times more common in black Africans than in the white population.8 About 80–90% of repairs are done in males. The most frequent type is right sided indirect inguinal hernia. Direct inguinal hernias are rare in females. Due to common incidence of this problem all over the world, much more is written on hernia repair than on any other surgical subject.7

Due to its common nature and increased incidence of recurrence and wound infection, a wide variety of surgical procedures and different materials were being used from time to time for hernia repair. All these procedures and materials have equivocal results and are beyond the level of satisfaction for different surgeons. All these modifications and surgical techniques have showed a common disadvantage i.e. suture line tension, which leads to increased incidence of recurrence and other complications. Post operative wound infection remains a common complication after hernia repair.

With the use of modern mesh prosthesis, it is now possible to repair all hernias without distortion of the normal anatomy and with no suture line tension.8 Modern mesh is strong monofilament, inert, and readily available. It is unable to harbor infection, is very thin and porous. Its interstices become completely infiltrated with fibroblasts and remain strong permanently .It is not subjected to deterioration or rejection or it can not be felt by patients or surgeons postoperatively.8,9

Historically Tantalum mesh was introduced by Douglas and Koontz in 1948.10 Lichtenstein introduced the prosthesis repair of inguinal hernia in 1964.7 Marlex mesh was first used by Uscher.10 Use of prosthetic material was criticized by some surgeons that being as a foreign material, it may increase the incidence of infection. This infection is difficult to treat and it may necessitate removal of mesh which causes more morbidity to the patient. So many surgeons routinely use antibiotics for a long time postoperatively to prevent postoperative mesh infection. The purpose of this study was to document number of cases of groin sepsis following Lichtenstein’s inguinal hernioplasty without antibiotics prophylaxis and also to find out the frequency of removal of mesh implant in these cases. The National Nosocomial Infection Surveillance system (NNISS) has defined surgical site infection (SSIs) /wound infection as presenting within 30 days of surgery unless a foreign body was left in situ, in which case one year must elapse before surgical wound infection can be excluded.6

The true incidence of mesh infection is not known because it varies from center to center. It has been reported between 0.7% to 15% at different centers at different time in different studies.11,12 In our study 3% of patients developed wound infection which is inconsistent with the different studies reported in literature at different times internationally and in our country. Oflio13 reported an infection rate of 4.5 % after repair under local anesthesia and 6.8% after General anesthesia. Zafar et al14 and Sattar et al5 reported incidence of wound sepsis was 1.9% and 7.5% respectively in patients who underwent Lichtenstein’s repair. Nordin et al15 reported an infection rate of 4% after Lichtenstein hernia repair in his study. Another study conducted by the Anfenacker and his colleagues16 reported 1.7% of wound infection after Lichtenstein open mesh repair and there is no significant difference between antibiotic prophylaxis and placebo group. So they also concluded that antibiotic prophylaxis is not indicated in Lichtenstein primary inguinal hernia repair.

CONCLUSION

Lichtenstein’s repair is safe, easy to perform, with no evidence of increased infection risk with mesh implant, and even there is no need to use prophylactic antibiotics provided complete aseptic measures are taken.

REFERENCES

1. Taylor SG, Dwyer PJO. Chronic groin sepsis following tension free inguinal hernioplasty. Br J Surg 1999; 86:562-5.

2. Dickenson AJ, Leaper DJ. Wound dehiscence and incisional hernia. Surgery 1999;17: 229-32.

3. Bhopal FG, Niazi GHK, Iqbal M. Evaluation of Lichtenstein hernia repair for morbidity and recurrence. J Surgery Pak 1998; 3:20-2.

4. Rasool MI. Inguinal hernia clinical presentation. Rawal Med J 1992;20(1):23-6.

5. Sattar A. Management of inguinal hernia. J Coll Physicians Surg Pak 1993;3(2):50-3.

6. Peterson SL, Eiseman B(ed). Wound infection and would dehiscence, Surgical Secret 3rd edition, London 1996: 40-3.

7. Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. The tension free hernioplasty. Am J Surgery 1989;157:188-93.

8. Davis N, Thomas M, Mcllroy B, Kingsworth AN. Early results with Lichtenstein tension free hernia repair. Br J Surg 1994;81:1478-79.

9. Horgan LF, Shelton JC, O‘Riordan DC, Moore DP. Winslet MC, Davidson BR. Strengths and weaknesses of open and laparoscopic inguinal hernia repair; A randomized controlled experimental study. Br J Surg 83:1463-7.

10. Hameed F, Hussain R. Incisional hernia repair by mesh implantation. J Surg Pak (International) 1999; 4(1):28-30.

11. Yerdel MA, Akin EB, Dolalan S, et al. Effect of single dose prophylactic ampicilline and salbectum on wound infection after tension free inguinal hernia repair with a poly propylene mesh. Ann Surg 2001;233:26-33.

12. Taylor EW, Duffy K. Surgical site infection after groin hernia repair. Br J Surg 2004; 91:105-11.

13. Ofilio OP. A comparison of wound complication of the inguinal hernia repair under local and general anesthesia .Trop Doct 1991;21(1):40.

14. Zafar. Lichtenstein repair. J Surgery PIMP 1993; 5: 18-21.

15. Nordin P, Bartelmess P, Jansson C. Randomized trial of Lichtenstein v/s Shouldice hernia repair in general surgical practice. Br J Surg 2002; 89: 45-4.

16. Aufenacker TJ, Geldere DV. The role of antibiotic prophylaxis in prevention of wound infection after Lichtenstein open mesh repair of primary inguinal hernia: A multicenteric double blind randomized controlled trial. Ann Surg 2005; 240(6):955-61.


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