Letters

Driving after hernia surgery

BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7288.735/a (Published 24 March 2001) Cite this as: BMJ 2001;322:735
  1. J F Colin (PAULA.MEDLER{at}norfolk-norwich.thenhs.com), consultant surgeon
  1. Department of Surgery, Norfolk and Norwich Hospital NHS Healthcare Trust, Norwich NR1 3SR
  2. Minimal Access Therapy Training Unit, Royal Surrey County Hospital, Guildford, Surrey GU2 5XX

    Patients should be advised not to drive for 10 days

    EDITOR—Amid in his editorial and Ismail et al in their short report say that surgeons traditionally advise patients recovering from groin hernias not to drive for a month or two and recommend national guidelines be developed. 1 2 In 1976 we published the effects of surgical operation on the “brake clutch simulator”3 and showed that patients who had an inguinal hernia repair under general anaesthetic were able to perform an emergency stop in exactly the same time as they could preoperatively eight days after operation.

    In an average car braking system, in 1975, a pedal force of 600 lb per square inch would produce an emergency stop of 0.87 g deceleration from 30 mph. The brake clutch simulator consisted of an adjustable car seat with pedals attached via hydraulic links and cylinders to load syringes, together with gauges to monitor the pressure in the brake and clutch lines, and a transducer for pressure recording. Microswitches were provided that standardised the position of the feet at the beginning of the test and indicated when either foot had left the floor. Other switches indicated the start of pedal pressure, and in the case of the clutch when movement was complete. The stimulus to start the whole cycle of simulated emergency stop was provided by a light operated by a button that came on at random intervals.

    The effect of general anaesthetic was examined in five patients who had had a minor surgical procedure that did not involve an operation on the trunk or legs 24 hours previously. No adverse effect was found. Also the effects of learning the test were examined in 10 subjects with suitable rest periods in between, and no difference was found.

    Twelve men with a right inguinal hernia and 12 men with a left inguinal hernia were studied. All held current driving licences. They were tested preoperatively and on postoperative days two, four, and six, the patient with the left inguinal hernia on day eight, and the patient with the right inguinal hernia on day seven.

    The performance in patients with a left inguinal hernia returned to preoperative levels by day eight and those with a right inguinal hernia by day seven. As a result of this work it has always been my view that patients who have had an open inguinal hernia repair under general anaesthetic be advised not to drive their car for 10 days after the operation.

    References

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    1. Guy H Slater (guy{at}mattu.org.uk), research fellow,
    2. George Hopkins, laparoscopic fellow,
    3. Michael Bailey, professor of surgery
    1. Department of Surgery, Norfolk and Norwich Hospital NHS Healthcare Trust, Norwich NR1 3SR
    2. Minimal Access Therapy Training Unit, Royal Surrey County Hospital, Guildford, Surrey GU2 5XX

      Claims in editorial from Lichtenstein Hernia Institute are unsubstantiated

      EDITOR—Advice on postoperative driving is important. Ismail et al have identified serious deficiencies in the advice that is given to patients and the application of scientific evidence to this advice.1 National guidelines on driving after surgery would be welcomed by surgeons, patients, and motor insurers.

      The ability to perform an emergency stop is fundamental for safe driving. After hernia surgery, the efficiency with which an emergency stop can be executed is dependent on reaction time and unimpaired, pain free, movement of the lower limbs. Reaction times after laparoscopic and open tension free mesh hernia repair have been measured in a randomised controlled trial.2 Foot reaction times after open hernia surgery were significantly slower than after laparoscopic hernia surgery. Interestingly, after open hernia surgery hand reaction times were also longer; Wright et al attributed this difference to greater use of opiate analgesia after open hernia surgery.

      Significant postoperative groin pain will impair the performance of an emergency stop. The Lichtenstein Institute's claims in the editorial by Amid that the tension free mesh repair is less painful than conventional hernia repair and is as pain free as laparoscopic hernia surgery,3 have no scientific basis and warrant further investigation.

      Two systematic reviews of randomised controlled trials in hernia surgery were recently published in the British Journal of Surgery. The first paper compared open tension free mesh repair with conventional open hernia surgery.4 Over 4000 patients were analysed from fifteen studies. The only significant finding was that the Lichtenstein mesh repair has a lower recurrence rate. The second paper compared laparoscopic inguinal hernia repair with conventional surgery.5 Thirty four trials were identified, with 6804 participants. Postoperative pain was less in the laparoscopic group (P=0.08) and time to return to usual activity was significantly lower (P<0.001). Nine trials comparing laparoscopic repair with tension free mesh repair assessed analgesia usage. In eight studies statistically significantly less analgesia was used after laparoscopic hernia surgery.

      The Lichtenstein repair is an excellent repair in terms of recurrence rates. There is, however, no significant evidence to support the Lichtenstein Institute's other claims for their repair. The evidence suggests that patients should not drive for one week after open hernia repair but could drive earlier after laparoscopic surgery. In both groups it is important to recognise the deleterious effect that opiate analgesia can have.

      References

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