A Comparative Study on Pre- and Post-operative Quality of life of Hernia patients

 

Reeja T Reji¹, Athira Roy¹, Krishna Ravi²*, R Sambath Kumar³

¹Pharm D Intern, Department of Pharmacy Practice, J.K.K. Nattraja College of Pharmacy,

Kumarapalayam, Namakkal, Tamil Nadu, India.

²Assistant Professor, Department of Pharmacy Practice, J.K.K. Nattraja College of Pharmacy,

Kumarapalayam, Namakkal, Tamil Nadu, India.

³Professor and Principal, Department of Pharmaceutics, J.K.K.Nattraja College of Pharmacy,

Kumarapalayam, Namakkal, Tamil Nadu, India.

 

ABSTRACT:

Hernia repair is one of the common surgical procedures performed all over the world. Sociodemographic factors as well as lifestyle do have a greater weight on the development of hernia. Open and laparoscopic techniques are available for hernia repair, although most of the patients prefer laparoscopic techniques to open surgical procedure due to its minimum invasive capacity, reduced wound infection, shorter hospital stays etc. While considering the risk involved with surgery, evaluating the patient’s quality of life both before and after surgery is critical. This study was conducted among 104 eligible hernia patients and their data were collected by interviewing them. The pre- operative quality of life eligible candidates is compared to post-operative quality of life using a scale called European Registry for Abdominal Wall Hernias Quality of life (QOL) assessment scale (EuraHS) consist of 9 questions, for an interval of 6 months for each patient. The most common hernia type, risk factors, causes and post-operative complications were also noted. It was found out that there was a significant hike in QOL of hernia patients after surgery. This study shows the effectiveness of EuraHS-QOL Score in QOL Assessment of hernia patients. This scale has an excellent reliability and applicability in both ventral and groin hernias.

 

 

 

INTRODUCTION: 

A hernia is the abnormal exit of tissues or an organ such as bowel, through the wall of the cavity in which it normally resides¹. Hernia is often associated with abdominal complaints which are usually straightforward to diagnose, simply by feeling and looking for the bulge². According to the National centre for Health Statistics 2015 report abdominal hernias is a common problem in the general population with prevalence of 1.7% for all ages and for those aged over 45, it increased by 4%. Inguinal hernia accounts for about 75% of all hernias with a lifetime risk of 27% in men and less than 3% in women³.

 

The etiological as well as predisposing factors for the hernia include abdominal pressure, pre-existing weakness of abdominal muscles, gender, obesity, age, diet, lack of regular exercise, smoking, comorbidities such as Chronic obstructive pulmonary disease (COPD), congenital abnormalities, previous abdominal surgery/trauma, family history of hernia and grand multi Para⁴. The treatment goal is to improve quality of life and to prevent recurrence, adverse events such as incarceration, while keeping the rate of surgical complications low⁵. Open and laparoscopic techniques are used for hernia repair⁶. Post-operative complications include wound infection, chronic pain, groin oedema, urinary retention, and bladder injury. Late complication includes recurrence, neuropraxia, hydrocele and even death⁷. It is essential to consider the Quality of Life of hernia patients since this condition can alter one's beliefs of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns⁸. This study was conducted to identify the most common type of hernia in our study site, risk factors, etiology, post-operative complications and quality of life of hernia patients before and after surgery.

 

MATERIALS AND METHODS:

This prospective observational study was conducted among 104 hernia patients admitted in the surgical department of a Tertiary care hospital, Tamil Nadu from NOV 2019 to AUG 2021. Ethical clearance and approval were obtained from Institutional Ethical Committee. Written agreement was acquired from all participants, and they were ensured that their identities would be kept private. The patients who were clinically confirmed with hernia of both genders involved in the study. Mentally retarded patients, patients below the age of 18 years and those who were not interested to take part in the study were excluded.

 

After obtaining the consent from the patient, their sociodemographic information, lifestyle, and medical history were obtained by means of a questionnaire. After the clinical examination of the patient, we noted the type of hernia and the type of surgery patient had undergone. EuraHS QOL assessment scale was used to assess the pre- and post-operative quality of life of hernia patients. This verbal scale consists of nine questions in three domains that seem most relevant for evaluating patient’s QOL after hernia repair. This scale analysed pre- and post-operative pain associated with hernia patient as first domain, physical discomfort as second domain, aesthetic discomfort as third domain. Hernia patient’s QOL before surgery were collected and the mean value of each domain compared against the mean value of each domain after six months of surgery. We kept in contact with patient up to 6 months through phone calls and messages to collect their QOL score as well as post-operative complications.

 

Statistics:

The QOL scores verbally obtained from each patient were entered into Microsoft excel and this data collectively exported to GraphPad Prism version 9.0.0. (121) for statistical analysis. Wilcoxon signed rank test was used to compare the QOL of patient before and 6 months after surgery. The mean value of preoperative EuraHS QOL scale was compared against mean value of post-operative score.

 

RESULT:

In this study males 68 (65.38%) had more hernia than females 36(34.61%) out of 104 patients. The most affected age group was found to be ≥ 58 years 33 (31.73%). In our study majority of hernia patients were non- alcoholic 60 (57.69%) patients followed by 34 (32.69%) alcoholic, and 10(9.61%) past –alcoholic patients. Among 104 patients 67 patients (64.42%) were reported as Non-smoker, accompanied by 25 patients (24.03%) as smoker and 12(11.53%) as past smokers. Out 104 patients 57(54.8%) had inguinal hernia followed by hiatal 11(10.57%), epigastric 10 (9.65%), umbilical 10(9.65%), para umbilical 9 (8.65%), incisional 5(4.80%) and femoral 2(1.92%). In our study 59 patients (56.73%) undergone laparoscopic surgery and 45(43.26%) undergone Open hernia repair surgery.

 

Table 1: Basic characteristics of study population

 

Table 2: Risk factors

 

 

Table 3: Post-Surgical Complications

 

 

 

QOL Assessment using EuraHS score

 

Figure 1: Domain 1

 

Figure 2: Domain 2

 

 

Figure 3: Domain 3

 

The mean value of preoperative EuraHS QOL scale was compared against mean value of post-operative score. P value of <0.0001 indicates there is a significance difference in the QOL of patient before and 6 months after surgery.

 

DISCUSSION:

Hernia is one of the most common surgical procedures all over the world. In this study majority of hernia patients were male. The preponderance of males to females was also noted in a study conducted by Balram et al., This preponderance of hernia in males was attributed to involvement of strenuous exercises, lifting of weights by them and the anatomical difference between the two⁹. The most affected age group in our study was found to be ≥ 58, followed by age group 44-57 years. Our study result concordance with the study conducted by Basu et al., were Hernia seen to be less common among the adolescents¹⁰. Hernia risk remains high in elderly, since ageing is correlated with increased body fat, decreased muscular mass, and diminished abdominal muscle strength^{11, 12}. In our study about 42 % of population were had a history of alcohol intake and most of them belong to middle aged males. The alcohol consumption has an impact over the incidence of hiatal hernia especially in males. This is similar to a study conducted by Shahnawaz AT, et al., Alcohol consumption leads to decline in health, development of chronic health conditions such as hernia due to remodelling of abdominal muscle ruling to loss of support or structural alteration^{13, 14}. In this study about 35 % population held a habit of smoking. Smoking can induce several negative effects on body such as COPD and abnormal connective tissue metabolism which eventually act as an etiology for herniation^15,16,17. The leading risk factors in our study were lifting heavy weights and involving in activities that result in excessive pressure over abdomen. This result of our study is highly due to the nature of job of the patients who were participated since most of them were labourers in construction sites or loom industries. Hernia due to lifting heavy object was similar to a study conducted by Veerabhadrappa, et al., were there study represented 48.9% of the patient had hernia due to lifting heavy objects¹⁸. In our study other prominent risk factors were constipation (14.42%), obesity (13.46 %), and frequent cough (13.46%). Indians are generally vulnerable to weight gain especially around the waist leads to obesity and cause various musculoskeletal disorders like hernia^{19, 20}. Family history is an important predictor for development of inguinal hernias; in our study 9 % of patients had a family history of hernia. This study result was similar to the study by Junge, et al.,²¹. Most of the study population had an inguinal hernia due to heavy weightlifting, similar to a study conducted by Balamaddaiah et al.,²².  The other types of hernia such as epigastric, umbilical, paraumbilical, hiatal hernia and femoral hernia were also noted during the study period. Due to past surgeries of improper healing and brisk physical activity after surgery also made 4.8% of study population to suffer incisional hernia. About 11.53%, patients of this study had a past surgical history of different abdominal surgeries. Most common etiology of Incisional hernia in this study was previous surgery wound infections and inadequate rest. This result was similar to a study conducted by Pattanaik, et al.,²³. Adult patient who were involved in socioeconomic activities might make them vulnerable to diseases which may further results in recurrence, post operative complications and need for surgical intervention²⁴. More than half of the patient’s undergone Laparoscopic surgery due to its minimum invasion ability and rest of the patient population undergone open hernia repair surgery. Laparoscopic surgery has a shorter length of hospital stay. The post-operative complications found in this study were suffered pain, bladder dysfunction, bowel dysfunctions and Infections. One of the most often reported complications include pain after surgery Despite the frequency of the surgical procedure, no surgeon had produced ideal results, in terms of rate of complications, such as postoperative pain, nerve injury, infection and recurrence remain and this study results were similar to the results of Bay, et al., and Vrijland, et al., studies^25,26.QOL of patients were analysed using EuraHS scale before and after six months of surgery and it was found that there is a significant hike in QOL of hernia of patients after surgery. This study result was similar to a study conducted by muysoms, et al., studies²⁷. The EuraHS-QOL score selected nine questions in three domains that seem most relevant for evaluating patient’s QOL after hernia repair. This scale analysed pre- and post-operative pain associated with hernia patient as first domain, physical discomfort as second domain, aesthetic discomfort as third domain. This study shows the effectiveness of EuraHS-QOL score in QOL Assessment of hernia patients. This scale has an excellent reliability and applicability in both ventral and groin hernias. The first domain in the EuraHS Questionnaire dealing about pain, consist of three questions (pain in rest, pain during activities and pain felt during the last week). From this, three answered questions we observed a significant hike of QOL after three months of surgery (Each questions score ranges from 0 to 10). Post operative pain is caused by trauma to tissues and nerves results in unnecessary physical, psychological and emotional manifestations which may lead to reduction in QOL^{28, 29}. In second domain (Restrictions of activities because of pain or discomfort at the site of hernia) contains four questions, Restriction from daily activities, Restrictions outside the house, Restrictions during sports, Restrictions during heavy labour. The statistical outcome of second domain also indicates there is an increase in QOL of hernia patients, 3 months after surgery. One of the most important features of EuraHS QOL scale, which analyse the cosmetic discomfort considered as third domain contain two questions namely shape of your abdomen and site of the hernia. Cosmetic discomfort scores before and after 6 months of surgery also shows an increase in QOL of hernia patients after surgery. QOL scale that has been used in the study limits its use to the patients aged above 18 and communication with study population was limited to phone calls, which hindered our robust interaction with patients.

 

CONCLUSION:

Our study concludes, the inguinal hernia is most frequently occurring hernia with prevalence more in male and the risk increases over age and in people who were involved in weightlifting or in other activities exert pressure over abdomen. In this study most of the patients has undergone Laparoscopic surgery. There is a significant rise in the QOL of hernia patients before and 6 months after surgery. This study also manifests the importance of the post-operative quality of life of patients which can achieve through education which eventually turn down the number of recurrences, pain, and other complications. The study concludes with a suggestion for conducting check-up for hernia for those who present symptoms since the risk increases with age, diabetes mellitus, frequent cough, obesity, previous unhealed wound, and weightlifting. An early diagnosis and treatment decrease the morbidity and mortality associated with hernia. The study also creates new area for further studies regarding hernia by researchers specially to work in developing diagnostic and treatment related affairs, which is a need for the society particularly in this period.

 

CONFLICT OF INTEREST:

The authors have no conflict of interest regarding this investigation.

 

 

 

ACKNOWLEDGEMENT:

The authors would like to thank the faculties of JKKN Institution for their support throughout the study.

 

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Accepted on 05.02.2022           © RJPT All right reserved

Research J. Pharm. and Tech 2023; 16(1):41-45.