European Survey of Mesh Fixation Techniques in Laparoscopic Groin Hernia Surgery

Transcription

1 Hernia/Soft Tissues 0023 European Survey of Mesh Fixation Techniques in Laparoscopic Groin Hernia Surgery S. Jegatheeswaran*, J. Kingston, A. Sheen Manchester Royal Infirmary, Manchester, UK Aims: There are various recognised techniques of mesh fixation in laparoscopic groin hernia surgery. The use of staples for fixation is associated with increased pain in the immediate postoperative period. Tissue glue is being adopted by some specialist surgeons as an alternative to staples to reduce the likelihood of post-operative pain. An online survey was undertaken among specialist hernia surgeons to examine current fixation methods and what factors would determine a change in practice to use tissue glue. Methods: An online survey was ed to members of general surgical societies within Europe. The survey was live from 6 th -30 th September Results: Seventy four recipients responded to the survey of whom 74% (n=55) undertook laparoscopic groin hernia surgery. The overall percentage practicing TAPP was slightly more than TEP (44% vs 36%). Less than 25% of respondents undertook both TAPP and TEP. Among those who used both techniques, 67% preferred TEP. From the laparoscopic method they originally learnt 78% percent of surgeons have changed, this change was 100% from TAPP to TEP. The majority of respondents fixate the mesh (62%) with staples being the most common fixation method (58%). The majority of respondents agreed that fixation in the triangle of pain could lead to post-operative discomfort. Seventy-five percent of the respondents would consider changing their method of fixation if there was sufficient evidence to suggest fibrin glue reduced pain. Conclusions: Laparoscopic TAPP remains the most common method employed with an increasing use of TEP. Staples remain the most common method employed in mesh fixation, but a change in practice to tissue glue may be considered with sufficient good evidence that it can reduce pain.

2 Hernia/Soft Tissues 0145 Mesh repair of inguinal hernias in an African district hospital setting C. Grimes* 1, A. Chamdula 2, A. Likaka 2, A. Kingsnorth 3, P. Thomas 4 1 Croydon University Hospitals NHS Trust, London, UK, 2 Thyolo District Hospital, Thyolo, Malawi, 3 Plymouth Hospitals NHS Trust, Plymouth, UK, 4 Epsom and St Helier Hospitals NHS Trust, Surrey, UK Aims: To measure the outcome of inguinal herniorraphy following tension-free mesh repair within an African district hospital setting. Methods: All patients undergoing elective inguinal herniorraphy over a four day period at Thyolo District Hospital, Malawi. All hernia operations were performed under local anaesthetic and using a mosquito net mesh. After undergoing training, the operations were performed by Malawian Clinical Officers with supervision. Patients returned to clinic at three months for follow up. Results: 29 patients (all men) underwent elective inguinal hernia repair over a four day period. At three month follow up, there was one haematoma and one wound infection which settled with antibiotics alone. There were no early recurrences. Conclusions: Mesh repair of inguinal hernias is safe and practical within a rural African district hospital setting.

3 Hernia/Soft Tissues 0151 Peri-operative pain and patient satisfaction following mesh repair of para-umbilical hernia under local anaesthesia: The West Suffolk Experience P. Bennett*, B. Kumar, E. Coveney West Suffolk Hospital, Suffolk, UK Aims: Para-umbilical hernia is a common condition that often requires surgery. However there is a dearth if literature on its surgery performed under local anaesthesia (LA). The aims of this study were to assess peri-operative pain and satisfaction with their experience in patients having repair under LA. Methods: All patients having para-umbilical repair under a single consultant between January 2010 and December 2011 were eligible to participate. Patients chose to have either general anaesthetic (GA) or LA repair of their hernia. Demographic and operative details were collected on all patients. Patients having LA repair were asked to record their peri-operative pain and satisfaction using visual analogue scales. Data were analysed using Minitab15. Results: 63 patients underwent para-umbilical hernia repair during the study period (31 GA; 32 LA). 28/32 of LA repair patients agreed to participate. There were no differences in patient age or gender between LA and GA repairs (48[38-63] vs. 51[39-60] years, p=0.837 and 43.8% vs. 35.5% female, p=0.503 respectively). LA patients had a lower body mass index than GA (27.1[3.7] vs. 30.3[5.1], p=0.007). The median length of LA procedure was 24[ ] minutes, no longer than the procedure under GA. The median LA solution infiltrated was 25[20-32]ml. Peri-operative pain scores were low (11[3-29]%) and patient satisfaction was high (96[91-99]%). There were no differences in pain, patient satisfaction, duration of procedure and amount of LA infiltrated when BMI was categorised at a level of 25(Overweight) and 30 (Obese). When comparing LA procedures performed by higher surgical trainees (HST) and consultant, the former took longer (30[25-36] vs. 20[16-24] minutes, p=0.0007), infiltrated more LA (34.5[26-47] vs. 20[ ]ml, p=0.0039), and patients experienced greater peri-operative pain (27.5[ ] vs. 4[2-17]%, p=0.029), though this still correlated with mild pain. There was no difference in overall patient satisfaction (95.5[ ] vs. 96.3[ ]%, p=0.684) between HST and consultant. Conclusions: Open mesh repair of para-umbilical hernia is associated with low pain and very high satisfaction scores, regardless of BMI. This procedure is also well tolerated in the hands of higher surgical trainees.

4 Hernia/Soft Tissues 0250 Herniotomy in children long term follow up B. Mothe*, M. Hanafy Leighton General Hospital, Cheshire, UK Aims: Primary inguinal hernia occurs in 1 to 5 percent of all newborns and 9 to 11 percent of those born prematurely [1]. Inguinal hernia repair is the most commonly performed surgical procedure in children [2]. Recently published data suggests that herniotomy operation in children carries a very low complication and recurrence rates[3]. This study was carried out to evaluate the long term recurrence rates in Leighton General Hospital. Methods: Retrospective case notes study of all children with recorded age of less than 16 years who had herniotomy procedure between 2000 to 2009 was carried out. The age at operation and their current age were recorded as well as the complications. Notes were reviewed comprehensively to check if the patients re-visited post-operatively for any problems including paediatric clinic letters even after many months of the initial procedure. Also questionnaire and telephone survey was conducted to acquire the necessary information for the study Results: Total number of patients identified were 85 out of which 78 patients were able to provide the required follow up data (Range 14 months to 14 years). 7 patients were recorded as paediatric admissions even though they were just above 16 years of age. Male preponderance was evident with only 6/71 being girls. 33 out of 71 (46.4%) were below 5 yrs, 15.4% (11/71) were 2 years or below. Further 27/71 (38%) were above 5 years of age. 4/71 children (5.1%) were found to have an associated hydrocele with patent processus vaginalis. Median follow up from operation was 7 years with a minimum follow up of at least 1 year. 3 patients (4.2%) of the group developed recurrence at 1, 3 and 4 years from their initial operation. 1 child (1.2%) developed hematoma and wound infection post-operatively which was managed conservatively. Conclusions: Hernia surgery in children is associated with very low complications and long term follow up study suggests most recurrences occur within 5 years of original operation. Our study suggests recurrence is more common in above 2 year old repairs. Although this is a small study it opens a debate whether this group needs long term follow up or not.

5 Hernia/Soft Tissues 0255 Improving elective services for patients with groin herniation T.D. Reid*, J. Lloyd-Evans, Z.M. Saeed, G.L. Williams, B.M. Stephenson Royal Gwent Hospital, Newport, UK Aims: We assessed the results of an inguinal hernia pathway to improve groin hernia services in a large DGH hoping to increase rates of day case repair. Methods: GP referrals were scrutinized and patients sent an appointment where a nurse and surgeon assessed their suitability. This occurred whilst the surgeon attended an adjacent endoscopy session. Appropriate patients were allocated for surgery at this visit (<45 minutes). Data was collected prospectively on all patients seen over 26 months. The first 100 patients undergoing surgery completed satisfaction questionnaires. Results: Two hundred and eighty-two patients were seen (median age 61 years; range 20-87). Of these 214 (76%) underwent repair whilst 59 (21%) had no hernia. 5 patients declined surgery and 4 had their repair deferred for medical reasons. Median intervals from referral to assessment and assessment to surgery were 5.7 (1.6-22) and 5.4 (0.1-21) weeks respectively. Day case surgery was achieved in 199 (93%) patients, with local anaesthesia (LA) in 121 (57%). Of 100 questionnaire respondents 98 were happy to be assessed by a nurse specialist and surgeon simultaneously, and 99 rated the quality of information provided as very good or good. The overall quality of the service was rated as very good (77) or good (23) by all respondents who would all recommend it. Of the 58 respondents who underwent LA repair, 86% would recommend this approach. Conclusions: A consultant supervised inguinal hernia pathway reduces the demand on outpatient appointments and shortens the time to surgery. This fixed sessional approach offers distinct advantages to units struggling with targets. The use of LA also allows increased day case repair irrespective of ASA grade.

6 Hernia/Soft Tissues 0446 Long-term outcomes of laparoscopic TEP hernia repair in females a prospective study O. Khan, S. Pugh, D. Mayo*, C. Wakefield Royal County Hampshire Hospital, Winchester, UK Aims: Although a number of series have described TEP groin hernia repairs in males there is limited female data due to paucity of numbers. We report our experience of the long-term outcomes of TEP repair in females using a modified technique with preservation of the round ligament. Methods: Over an eight year period, a single surgeon prospectively evaluated the efficacy of TEP repair of groin hernias in females undergoing elective repair. The modified technique involved creation of preperitoneal space with preservation of the round ligament for use as a buttress for the mesh. Operative time, post-operative morbidity and recurrence rates were all prospectively recorded. Results: There were a total of 36 patients with 23 unilateral and 13 bilateral repairs; 12 of these were femoral hernias and 5 were recurrent herniae Mean operative time was 42 minutes and 22 patients (61%) were completed as day case procedures. There was one complication of a haematoma and 2 conversions to open. At a mean follow up of 4½ years there have been no recurrences in the cohort. Conclusions: TEP groin hernia repair in females is feasible and results in a low long-term recurrence rate which may in part be due to our technique of buttressing the mesh with the round ligament.

7 Hernia/Soft Tissues 0514 Lightweight versus heavyweight mesh in controlling chronic groin pain following laparoscopic inguinal hernia repair: a review and meta-analysis M.S. Sajid, N. Ladwa*, C. Leaver, P. Sains, M.K. Baig Worthing Hospital, Worthing, UK Aims: The objective of this study is to systematically analyse the randomised, controlled trials comparing lightweight mesh (LWM) versus heavyweight mesh (HWM) in laparoscopic inguinal hernia repair (LIHR). Methods: Randomised, controlled trials comparing LWM versus HWM in LIHR were analysed systematically using RevMan, and combined outcomes were expressed as risk ratio (RR) and mean difference (MD). Results: Eleven randomised, controlled trials encompassing 2189 patients were retrieved for the electronic databases. There were 1187 patients in the LWM group and 1002 patients in the HWM group. In the fixed effects model, operating time (p = 0.34), post-operative pain (p = 0.16) and recurrence rate (p = 0.12) were not statistically different between LWM and HWM. Patients with LWM returned to work earlier (p < 0.007). LWM was associated with fewer peri-operative complications (RR, 0.76; 95% CI, 0.59, 0.99; z = 2.04; p < 0.04) and a reduced risk of developing chronic groin pain (RR, 0.48; 95% CI, 0.31, 0.75; z = 3.27; p < 0.001). There was also a reduced risk of developing other groin symptoms, such as stiffness and foreign body sensation but it did not reach statistical significance. Conclusions: The use of LWM for LIHR does not increase the risk of hernia recurrence and reduces the incidence of chronic groin pain. LWM also reduces the risk of developing groin stiffness and foreign body sensations. Therefore, LWM may routinely be used in LIHR.

8 Hernia/Soft Tissues 0516 Tacker fixation versus fibrin glue fixation of mesh in laparoscopic inguinal hernia repair: A systematic review and meta-analysis M.S. Sajid*, N. Ladwa, P. Sains, M.K. Baig Worthing Hospital, Worthing, West Sussex, UK Aims: The objective of this study is to systematically analyse the randomised, controlled trials comparing tacker mesh fixation (TMF) versus fibrin-glue mesh fixation (FMF) in laparoscopic inguinal hernia repair (LIHR). Methods: Randomised, controlled trials comparing the TMF versus FMF in LIHR were analysed systematically using RevMan, and combined outcomes were expressed as risk ratio and standardised mean difference. Results: Four randomised trials encompassing 912 patients were analysed. In the random effects model, operating time, post-operative pain, post-operative complications, hospital stay and risk of hernia recurrence were statistically comparable between two techniques of mesh fixation in LIHR. However, FMF was associated with a reduced risk of developing chronic groin pain. Conclusions: FMF in LIHR does not increase the risk of hernia recurrence. It is comparable to TMF in terms of operation time, post-operative pain, complications, and hospital stay. FMF is associated with a reduced risk of chronic groin pain. The FMF approach may be adopted routinely for mesh fixation in LIHR.

9 Hernia/Soft Tissues 0518 A systematic review and meta-analysis of tacker fixation versus no-fixation of mesh in laparoscopic inguinal hernia repair. N. Ladwa*, M.S. Sajid, M.K. Baig, P. Sains Worthing Hospital, Worthing Hospital, West Sussex, UK Aims: The objective of this study is to systematically analyse the randomised, controlled trials comparing tacker mesh fixation (TMF) versus no mesh fixation (NMF) in laparoscopic inguinal hernia repair (LIHR). Methods: Randomised, controlled trials comparing TMF versus NMF in LIHR were analysed systematically using RevMan, and combined outcomes were expressed as risk ratio and standardised mean difference. Results: Eight randomised trials encompassing 1386 patients were analysed. In the fixed effects model, operating time, post-operative pain, post-operative complications and length of hospital stay were statistically comparable between two techniques of mesh fixation in LIHR. The risk of developing chronic groin pain and risk of hernia recurrence was also similar. Conclusions: NMF in LIHR does not increase the risk of hernia recurrence. It is comparable with TMF in terms of operation time, post-operative pain, post-operative complications, hospital stay, and chronic groin pain. Therefore, the NMF approach may be adopted routinely and safely in LIHR.

10 Hernia/Soft Tissues 0519 Suture mesh fixation versus glue mesh fixation in open inguinal hernia repair: a systematic review and meta-analysis N. Ladwa*, M.S. Sajid, P. Sains, M.K. Baig Worthing Hospital, Worthing, West Sussex, UK Aims: The objective of this study is to systematically analyse the randomised, controlled trials comparing suture mesh fixation (SMF) versus fibrin-glue mesh fixation (FMF) in open inguinal hernia repair (OIHR). Methods: Randomised, controlled trials comparing the TMF versus FMF in LIHR were analysed systematically using RevMan, and combined outcomes were expressed as risk ratio and standardised mean difference. Results: Five randomised controlled trials encompassing 679 patients were retrieved from the electronic databases. There were 315 patients in the SMF group and 364 patients in the GMF group. There was a significant heterogeneity among trials (p < ). In the fixed effects model, operating time (SMD, 0.10; 95% CI, -0.08, 0.27; z = 1.08; p = 0.28), post-operative pain (SMD, 0.35; 95% CI, -0.23, 0.94; z = 1.18; p = 0.08), chronic groin pain (RR, 2.59; 95% CI, 0.16, 43.12; z = 0.66; p = 0.51) postoperative complications (RR, 1.36; 95% CI, 0.55, 3.33; z = 0.66; p < 0.51) and length of hospital stay (SMD, -0.04; 95% CI, -0.28, 0.36; z = 1.15; p = 0.25) were statistically comparable between two techniques of mesh fixation in OIHR. Conclusions: FMF in LIHR does not increase the risk of hernia recurrence. It is comparable to TMF in terms of operation time, post-operative pain, chronic groin pain, complications, and hospital stay. FMF is an additional method of mesh fixation in inguinal hernia repair however it provides no additional benefit to suture mesh fixation in open repair.

11 Hernia/Soft Tissues 0525 Diagnostic laparoscopy through the deep inguinal ring during inguinal hernia repair: a literature based review N. Ladwa*, M.S. Sajid, M.K. Baig, P. Sains Worthing Hospital, Worthing, West Sussex, UK Aims: The objective of this article is to systematically review the published literature on the role of diagnostic laparoscopy through deep inguinal ring during inguinal hernia repair. Methods: Standard electronic databases were searched reporting articles on the role of diagnostic laparoscopy through the deep inguinal ring during inguinal hernia repair. We included all types of published studies in any language and on patients of any age and gender. Results: Twenty-eight articles on 5834 patients undergoing diagnostic laparoscopy through the deep inguinal ring during inguinal hernia repair were retrieved from the electronic databases. There was one randomized, controlled trial, 5 case reports and 24 case series. Seven articles were reported to assess the bowel viability following spontaneous reduction of strangulated hernia in adults. Overall, the laparoscopy group had a reduced operative time, reduced length of hospital stay, lower complication rates and earlier return to normal activities. Twenty-one articles were reported to assess the contralateral deep ring in paediatric patients. Laparoscopy success rate was reported in more than 95 % patients. Contralateral patent processus vaginalis indicative of inguinal hernia was found in more than 48 % children undergoing diagnostic laparoscopy through deep inguinal ring. There was no major morbidity reported in any group. Conclusions: Diagnostic laparoscopy through the deep inguinal ring during inguinal hernia repair may be performed safely when indicated. Routine use of deep ring laparoscopy is an established practice in children. There is still insufficient evidence to recommend the routine use in adults. A major randomized, controlled trial is required to validate these findings.

12 Hernia/Soft Tissues 0533 Is groin ultrasound scan prior to hernia repair a useful diagnostic tool? R.F.R. Fisher*, A.C. Wells, S. Gergerly, F. Di Franco, A.M. Harris Hinchingbrooke Hospital, Huntingdon, Cambridgeshire, UK Aims: The aim of this study was to report the incidence of ultrasound scan (USS) prior to elective groin hernia repair and compare the USS result with clinical and surgical findings. Methods: The records of 300 consecutive patients who underwent surgery for inguinal or femoral hernias were evaluated to determine which patients had undergone pre-operative USS. The ultrasound report was compared to pre-operative clinical examination and to surgical findings. Results: 48 patients (16%) underwent USS pre-operatively. 45 patients had laparoscopic and 3 patients open repair. The majority (32) of USS were requested by the general practitioner prior to referral to surgical outpatient clinic. The table below compares clinical examination, USS and surgical findings. Yes No Did clinical examination & (excludes one patient where clinical opinion USS agree? was unsure ) Did clinical examination & (excludes one patient where clinical opinion surgery agree? was unsure ) Did USS & surgical findings agree? The positive predictive value for USS was 72% compared to 82% for clinical examination. Moreover when the clinical examination findings were incorrect, USS did not add any diagnostic benefit. USS errors were independent of grade of ultrasonographer. Conclusions: Our results contrast with previous published data suggesting a PPV for USS of 94% 1. In this study clinical examination remained the best tool for diagnosing groin hernias. Assessment in the surgical clinic prior to USS should be recommended to avoid potentially confusing results and unnecessary use of NHS resources. 1. Despasquale, R., Landes, C., Doyle, G.(2009), Audit of ultrasound and decision to operate in groin pain of unknown aetiology with ultrasound technique explained. Clinical Radiology, 64:

13 Hernia/Soft Tissues 0724 Laparoscopic or open mesh for groin hernia repair in a day surgery unit? S. Kumar* The Royal Infirmary, Edinburgh, UK Aims: To compare laparoscopic and open mesh repair of primary inguinal hernia for 23 hour discharge from the day surgery unit. Methods: The Surgical database of the Surgical Service was questioned about patients undergoing primary inguinal hernia repair in the Day Surgery unit between July and Dec The type of admission, hernia repair and hospital discharge data were retrieved from the database. Results: Laparoscopic or primary inguinal hernia repair was performed in 514 patients: laparoscopic 242 (47%) and open mesh repair in 272 (53%). Overall, 270/514 (52.5%) of the patients were discharged home on the day of surgery increasing to 463/514 (90%) within 23 hrs of surgery. Patients were significantly more likely to go home within 23 hrs of surgery after laparoscopic repair than after open mesh repair: 238/242 (98.3%) laparoscopic, 225/272(82.7%) open mesh, P < Reasons for overnight stay include late afternoon surgery, delay in voiding urine or urinary retention, significant co-morbidity, and social reasons. Conclusions: 90 % of the patients with primary inguinal hernia repair were discharged home from the 23 Hr day surgery unit and were more likely to do so after laparoscopic than after open repair.

14 Hernia/Soft Tissues 0814 Can pre-peritoneal mesh really prevent parastomal hernia in long term? A. Biswas*, K. Marimuthu, V. Jadhav, G. Mathew George Eliot Hospital, Nuneaton, Warwickshire, UK Aims: Incidence of parastomal hernia can be as high as 30% for end-ileostomy and nearly 50% for end-colostomy. About one-third of these patients need surgical correction and even after that the recurrence rate remains quite high. In this study the long-term result of putting prophylactic pre-peritoneal mesh during stoma formation has been analyzed. Methods: Patients who had undergone elective formation of permanent stoma during October 2002 to December 2007 had polypropylene mesh put in the pre-peritoneal plane around the stoma. Ethical approval was obtained from local research committee. These patients were followed up at regular intervals for up to 8 years to assess for recurrence of parastomal hernia or any other related complications in the long term. Results: A total of 40 patients were included in the study. Main indications for them having stoma were surgeries for cancer e.g. APR leading to formation of end-colostomy or surgeries for colitis e.g. panproctocolectomy leadimg to end-ileostomy. These patients were followed up for a median period of 61 months ( months). Twelve patients were lost due to death in longterm follow up. 2 more patients could not be contacted after 2 years. A total number of 7 patients (17.5%) developed parastomal hernia - 4 within 2 years, one within 3 years and 2 more within 5 years. Out of the four, who developed parastomal hernia within 2 years, one later died due to spread of cancer. Rest of the three had repair of parastomal hernia. The patient who developed hernia by 3 years also had it repaired. 2 patients who were found to have hernia at 5 years remain asymptomatic and they are managed conservatively. Conclusions: Parastomal hernia is a frequently occurring clinical problem potentially causing significant patient discomfort. We believe that putting pre-peritoneal mesh around stoma can have a protective role against development of parastomal hernia and thus reducing the cost of overall patient management.

15 Hernia/Soft Tissues 0839 Local anaesthetic hernia repair is well-tolerated but does not appear to reduce postoperative pain S.L. Winstanley*, F. Parkinson, D. Scott-Coombes, M. Stechman University Hospital of Wales, Cardiff, UK Aims: Hernia repair is a common surgical procedure which can be performed under general (GA), regional or local anaesthetic (LA). LA facilitates early mobilisation and is feasible in those not fit for GA. It may also reduce post-operative need for analgesia. This study examines anaesthetic recovery time, post-operative pain and analgesic requirement in those undergoing LA or GA day-case hernia repair. Methods: This was a prospective, non-randomised study of consecutive patients undergoing inguinal/paraumbilcal hernia repair with either LA infiltration (20ml 1% lignocaine, 10ml 0.5% chirocaine, 20ml 0.25% chirocaine) or GA with LA infiltration (20ml 0.5% chirocaine). A proforma was used for data collection from February 2011 to July Details on operation, type of anaesthetic, pain scores at 24 hours and day 5 were obtained in hospital and by telephone. Students T-test was used for statistical analysis and deemed significant if p<0.05. Results: Data were collected on 44 patients (40 male, 4 female)(35 inguinal hernias, 9 paraumbilical hernias) with a median age of 51 (range 25-86). Patients were divided into two groups: 1) LA field block (14 inguinal, 0 paraumbilical), 2) GA with LA infiltration (21 inguinal, 9 paraumbilical). Patients in group 1 spent significantly less time in recovery compared with group 2 (p=0.0009). Mean post-operative pain score on day 1 was 3.9 (±2.23) in group 1 and 4.6 (±1.96) in group 2 (p=0.227). Opiate requirements were lower at 24 hours in group 1 (p=0.032) but there was no difference between paracetamol (p=0.171) or NSAID (p=0.321) use. On day 5 pain scores and total analgesic requirements were similar between the two groups. One patient in each group developed a minor wound haematoma. Ninety one percent and 83% of patients in groups 1 and 2 respectively were highly satisfied with their surgery. Conclusions: LA hernia repair is safe and well-tolerated compared with GA. Improved recovery times mean better patient flow through the recovery room, followed by earlier mobilisation of the patient. Use of LA reduces opiate use at 24 hours but has no effect on pain scores or analgesia requirements by day 5. Most patients are highly satisfied regardless of the anaesthetic used.

16 Hernia/Soft Tissues 0867 Herniography: an underused investigation? P. Mistry*, V. Mistry, S. Hussain, K. Vallance, K. Marimuthu George Eliot Hospital NHS Trust, Nuneaton, UK Aims: Herniography aims to identify a hernia sac when there is a clinical suspicion of an inguinal hernia but the diagnosis is equivocal. In general, this procedure is performed less frequently than non-invasive radiological investigations. We aimed to review our experience of herniography in a district general hospital and to validate its use within our trust. Methods: This was a retrospective study looking at all herniograms done over a 2 year period from 2009 to The herniogram reports were correlated with both the clinical findings at presentation and those at the time of surgery. Results: 30 patients with suspected hernia were identified; 3 with bilateral symptoms. Herniography identified seventeen hernias in 15 patients; 6 were in the asymptomatic groin. The overall sensitivity, specificity, positive and negative predictive values of a clinical suspicion of hernia was 65, 49, 33 and 78% respectively. There were no complications of herniography. A hernia sac was identified in every patient that underwent surgery (n=9). The remaining 6 patients were kept under surveillance or declined surgery. Conclusions: Herniography is a safe and effective investigation where clinical examination is inconclusive. The sensitivity and specificity of herniography at GEH is comparable with published data. A high false positive rate associated with clinical examination supports the use of radiological investigation before surgery in equivocal cases.

17 Hernia/Soft Tissues 0873 Systematic review and Meta-analysis: Local, regional and general anaesthesia for elective open inguinal hernia repair in adults S. Pallett* 1, P. Sanjay 2, A. Hotouras 1, S.A. Ogston 2, M.A. Thaha 1 1 Academic Surgical Unit, Centre for Digestive Diseases, Blizard Institute, Barts and The London NHS Trust, Queen Mary University of London, London, UK, 2 Department of Surgery, Ninewells Hospital & Medical School, University of Dundee, Dundee, UK Aims: This systematic review compared the safety and efficacy of local (LA), regional (RA) and general (GA) anaesthesia in elective open inguinal hernia repair in adult patients. Methods: Using a comprehensive pre-determined protocol, electronic databases (Medline, EMBASE, CENTRAL) were searched to identify RCT s comparing LA, RA, and or GA in elective open inguinal hernia repair in adult (age > 18 years) patients. Anaesthesia related and surgical outcomes were compared. Odds ratio was calculated for categorical outcomes and mean differences for continuous outcomes. Comparison of outcome measures between anaesthetic techniques was done using fixed effects models in RevMan. Results: Twenty two randomised controlled trials were included. LA repair resulted in lower incidence of urinary retention (OR 0.30, p=0.002), nausea and vomiting (OR 0.28, p=<0.0001), sore throat (OR 0.2, p=0.0004) and increased day case rates (OR, 0.12, p=< ) compared to GA. Similarly LA resulted in lower incidence of urinary retention (OR, 0.07, P=< ) and headache (OR, 0.22, p=0.003) and increased day case rates (OR 0.31, p=0.002) compared to RA. RA was associated with fewer instances of sore throat (OR 9.7, p=0.002) and back ache (OR 5.29, p=0.03) compared to GA however nausea and vomiting (OR 0.33, p=0.02) with higher with GA. No significant difference was noted in urinary retention and hospital stay between RA and GA. No significant difference was noted between the anaesthetic techniques with regards to long term outcomes including numbness and recurrent herniation. Conclusions: A local anaesthetic hernia repair resulted in significant short term benefits compared to GA and RA for elective open inguinal hernia repair in adults. The type of anaesthesia does not seem to affect the long term outcomes.

18 Hernia/Soft Tissues 0943 Incisional hernias in the outpatient clinic: Incidence and Symptoms. E. Douglas*, T. Kallachil, P. O'Dwyer Gartnavel General Hospital, Glasgow, UK Aims: To assess the incidence and symptoms from incisional hernia in new and return patients attending a surgical outpatient clinic. Methods: All patients being a minimum of one year post laparotomy and not attending the clinic specifically for their incisional hernia were included. Consecutive patients attending the clinic were assessed. Their previous operations were recorded along with the site of their scars. Those with an incisional hernia were asked of their awareness of a hernia, pain, discomfort, cosmetic concern and functional impairment. The patient was examined for site, size and reducibility of an incisional hernia. Results: 118 consecutive patients were assessed in the clinic with an average age of 65(19-95) had 165 laparotomy scars. The mean follow up time was 13.3 years ( years). There were 108 midline laparotomies with 9 paramedian approaches 26 transverse incisions and 22 others. 26 patients had 30 incisional hernias with 25 of those having undergone at least one midline laparotomy. Half of those with patients (13) were unaware they had a hernia. 6 hernias were irreducible with all of these being symptomatic. 8 patients experienced pain with a mean pain score of 7.2(4-10), 9 had discomfort, 6 had cosmetic concerns and 4 had some degree of functional impairment. The average area was 106.2cm 2 ( cm 2 ) Conclusions: Our study shows that where a hernia is present half of those patients do not experience symptoms from their hernia and indeed are unaware of it. There is also a strong relationship between irreducible hernia and patients complaining of pain.