Return to Work After Elective Inguinal Hernia Repair

Elective surgery for hernia repair is one of the most common procedures performed in the world. Data from the United Kingdom show that approximately 13 herniorrhaphies are performed for every 10 000 inhabitants, without taking into account surgeries done in private hospitals.¹ For many years, the scientific community has focused on improving the clinical outcomes of this technique by reducing hospitalization and even day hospitalization for this procedure, thus also reducing costs.² In our setting, however, there are few studies and little information about adequate recovery time after surgery, and specifically how long we should delay the patients’ return to work. This is the final objective of the treatment process.

Ruiz-Moraga et al.³ have conducted a very interesting study that provides experience in this regard in our country. From among the results presented, what stands out is that the average time off work for elective inguinal hernia surgery is more than 2 months. These data are not isolated and were confirmed by our group when compared with other procedures such as elective laparoscopic cholecystectomy.⁴ The data would not be of interest if we did not know that in other countries, and even in our own, there is some consensus among experts about the need for a standard time for return to work after uncomplicated elective inguinal hernia repair. It has been proposed that this time should not exceed 30 days (if the job requires physical exertion) and should even be shorter under other circumstances or when the surgical intervention is laparoscopic.^2,5,6

A prolonged period of convalescence is a burden on the healthcare system of a country. In the UK, a total cost estimate of 32 billion pounds has been attributed to convalescence, and medical leaves from work after elective surgery is the second most frequent cause of medical leave (up to 40%).⁷ In Spain, the cost of absenteeism from work was calculated some years ago to be about 120 euros per patient per day.⁸ Given the current economic situation, this is not a trifling amount. Furthermore, it has also been shown that returning to work earlier provides better overall recovery from disease, as isolation and depression are avoided, as is the risk of job loss.⁷

Thus, it would be very interesting to identify the reasons for delaying the return to work after elective inguinal hernia surgery. It is understandable that convalescence longer than the recommended time depends on one's condition and complications (risk of recurrence after re-employment), the patients themselves, surgeons and their recommendations and the type of physical exertion done at work, as well as the necessary paperwork from Primary Care physicians.

Reducing recurrence after elective inguinal hernia is an objective of enormous interest.^2,6 In addition to more widely studied aspects, such as surgical technique or patient comorbidities, for many years postoperative physical activity has been the object of study in our specialty.¹ That is why this period has been reduced at the same rate that our knowledge has improved about how this time influences possible recurrences.⁷

While the wound healing is considered adequate after 12 weeks, 70% of the strength in the wound is recovered after 6 weeks. With the use of mesh, this 70% is supposedly recovered in the immediate postoperative period.⁹ The latest scientific evidence has not shown a significant increase in hernia recurrence or chronic postoperative groin pain after early incorporation to work.² With the experience of the enormous Danish database with more than 1000 surgical patients, return to work could be recommended after a week or even less if there is no excessive physical exertion and pain is controlled.^1,6,10

Patients are undoubtedly the key element in the early return to work. In other surgeries, the factors influencing early return to work after surgery include pain control, wound complications and preoperative expectations, all of which were significantly associated with convalescence time.^6,11 But there are also other aspects that should be considered with regards to our patients: motivation, culture of the population and administrative aspects, such as whether or not compensation is received during sick leave or type of occupation.¹² In this sense, it is likely that the global economic crisis will change the attitude and motivation of our patients towards an earlier return to work.

A recent study in patients undergoing elective cholecystectomy using focus group methodology in patients and doctors revealed the presence of some discrepancies between the two groups. While doctors believed that their advice was the key factor in determining the best time to return to work, patients rarely mentioned their doctor's advice and, conversely, the main factor that they said most influenced their return to work was physical symptoms (postoperative pain control).¹³

Surprisingly, recommended patient convalescence times vary significantly among specialists themselves.^7,14 In inguinal hernia repair, and even with the lack of relevant scientific information, there is still a certain popular belief that you have to wait to prevent recurrence, and it is the specialists themselves who recommend that patients limit physical activity for at least 6–8 weeks. In this sense, it seems essential to attempt to standardize the information given to patients with informational pamphlets in which the recommendations are very clear (ambiguous terms are avoided) and clearly define when they could go back to normal daily activities, participate in sports or other types of physical exertion, and finally return to work.^6,7

The role of Primary Care physicians in providing patients with information regarding recommended convalescence after surgery and its influence has been argued in other countries.^14,15 In Spain, their role seems to be key when attempting to reduce recovery times because it is the GPs who handle the administrative paperwork for medical leaves. Therefore, any and all information regarding the clinical safety of early return to work should be passed on to GPs and they should be appropriately integrated in the treatment process. A classic study revealed discrepancies between both groups of specialists (surgeons and primary care physicians) with regards to recommended medical leaves for common surgeries such as inguinal hernia, varicose veins, hemorrhoidectomy or cholecystectomy.¹⁴ Although this study was not done in our country, it is quite likely that the reality is Spain is similar.

In short, to minimize the time required to return to work after elective inguinal hernia repair, several steps should be considered. First of all, relevant information should be given to the patient (preferably in writing) before surgery, at discharge from the hospital and at the first postoperative outpatient visit. Second, the use of appropriate analgesia protocols in these patients is essential because, from a clinical standpoint, as soon as the pain is controlled, return to work could be considered. Finally, since specialists in Family and Community Medicine in Spain have the final say about when patients should return to work, it is equally necessary to have good communication with them as well as with the patients. Clinical guidelines provide enough information to determine that the best time to return to work could be when adequate postoperative pain control is achieved, while always taking into account the physical exertion required.^2,6