|Year : 2020 | Volume
| Issue : 4 | Page : 122-127
Sports rehabilitation after laparoscopic hernioplasty
Osvaldo Santilli, Hernan Santilli, Nicolas Nardelli, Daniel Tripoloni, Hernan Etchepare
Centro de Patología Herniaria Argentina, Peña, Argentina
|Date of Submission||08-Jul-2020|
|Date of Decision||23-Jul-2020|
|Date of Acceptance||11-Aug-2020|
|Date of Web Publication||30-Nov-2020|
Dr. Osvaldo Santilli
Centro de Patologia Herniaria Argentina. Echeverria 1200. (1617), Buenos Aires
Source of Support: None, Conflict of Interest: None
INTRODUCTION: The development of minimally invasive procedures and analgesic drug evolution has contributed to reduce the rest period after inguinal hernia repair; nevertheless, there is still no scientific evidence to establish optimal postsurgery rest time and sequence for resuming activity until reaching full performance. Early and controlled rehabilitation by physical therapists has proven beneficial in postsurgery for athlete groups, although no publications are available on experiences in nonathlete patients.
OBJETIVE: The aim was to analyze the results of a rehabilitation program applied to post-transabdominal preperitoneal (TAPP) hernioplasty in non-athletic patients.
PATIENTS AND METHODS: The first 1,000 nonathlete patients who performed the postoperative sports rehabilitation plan from January 2012 to December 2016. We used TAPP laparoscopic hernioplasty. Postsurgery exercise program guided by objectives and supervised by physical therapists in four growing-intensity phases. Postsurgery complications, hernia recurrence, pain intensity (numeric scale) while exercising at 2 and 10 days after surgery; start time and duration for the first phase in the rehabilitation plan; and timing of return to work were evaluated.
RESULTS: The objectives of the first phase were reached by 92% of the patients on the 7th day. Work activities started in 97% of the patients before the 5th day.
CONCLUSIONS: Application of a sports rehabilitation program does not increase the recurrence rate nor complications and may speed up the return to full physical activity in nonathletic patients.
Keywords: Laparoscopic hernioplasty, laparoscopic inguinal hernia repair, postoperative outcomes, postoperative rehabilitation, transabdominal preperitoneal
|How to cite this article:|
Santilli O, Santilli H, Nardelli N, Tripoloni D, Etchepare H. Sports rehabilitation after laparoscopic hernioplasty. Int J Abdom Wall Hernia Surg 2020;3:122-7
| Introduction|| |
Historically, rest has been recommended during the inguinal hernioplasty postoperative period to protect sutures and prevent movement-related pain.
The development of minimally invasive procedures, the use of prosthetic materials, and the evolution of analgesic drugs have allowed to reduce restrictions and to accelerate social and labor re-insertion processes.
Although this trend is accepted by surgeons and patients, there are still no evidence to establish optimal post-surgery rest period, activities restricted through such stage, and restart sequence until achieving full performance.,,,,
The question arises, whether rest exerts a positive or a negative influence on the recovery process, that is:
- At which point does physical inactivity protects tissue, prevents pain, and benefit functional recovery?
- Is pain a sign to discontinue the physical activity, or could it be beneficial if pain is properly treated and physical activity is performed in a controlled manner?
Criteria for standards of practice are to allow movements that do not cause pain until managing the execution of those movements that, due to their extensiveness or intensity, are considered analog to movements that patients are likely to encounter when returning to their work activities.
This approach makes a recovery highly dependent on the patient's personality to endure pain and fear of complications and recurrence.
Conversely, early and controlled rehabilitation managed by physical therapists is advantageous throughout the postoperative period or recovery from bone, muscle, or tendon's injuries in athlete groups,,,, but no publications were found on experiences regarding their application after inguinal hernioplasty in those individuals who do not practice sports.
High-performance athletes accept rehabilitation exercises as the final stage in treatment, essential to resume competitions and recreational athletes also admit their importance to gradually get back to physical activity; both groups find rehabilitation exercises to be motivating, although this is usually not the case in nonathletic patients. However, incentives by physical therapists may persuade them to adhere to an exercise program, overcoming fear of pain, and hernia recurrence.
This study aims to analyze the results of a sports rehabilitation program (SRP) applied to postoperative laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair in nonathletes patients.
| Patients and Methods|| |
This study was based on collected data stored on a database and supplemented with details from follow-up. The assembled dataset was of first 1,000 nonathletes patients that underwent the first phase of the Sports Rehabilitation Protocol after a laparoscopic TAPP hernioplasty. Patients were invited to participate in the postoperative rehabilitation program that we routinely apply to recovery high-performance athletes.
The data collected in the clinical history of the postoperative evaluation include: Demographic data, the intensity of pain during physical efforts (cough, ambulation, or exercises rehabilitation) at the 2nd and 10th postoperative days were assessed using a numerical scale from 0 (no pain) to 10 (maximum pain); the duration of the initial phase of the rehabilitation plan (days it took each patient in achieving the objectives), the time they resumed work activities and postoperative complications were recorded.
Specific information was collected at the initial consultation performed by surgeons. Further clinical information was gathered from operation notes and physiotherapist records during postoperative recovery.
All patients had follow-up appointments for 1 year.
Wilcoxon–Mann–Whitney test for continuous scale variables and the Pearson Chi-square test for dichotomous variables were used; statistical significance was set at P < 0.05. Calculations were performed using the SPSS package for Windows, version 17.0 (Chicago, Illinois, USA).
The cohort comprised 3,517 patients nonathletes undergoing laparoscopic tapp hernioplasty in the period December 2012 to December 2016. The average age was 48.68 years (standard deviation [SD] = 13.684); surgical risks ASA categories are I (45%), II (51%), and III (4%).
During the preoperative consultations, all patients received extensive information on the fundamentals of the SRP performed for elite athletes that we routinely apply since 2003. They were invited to participate in the initial phase relying on their safety and potential benefits, but there was no motivation strategy aimed at increasing recruitment.
Included patients did not have intra-operative complications or during the immediate postoperative period, and hence, all patients discharged during operation day.
The laparoscopic (TAPP) approach was performed under general anesthesia through a 10 mm umbilical access and two trocars of 5 mm on the flanks. For the repair, we used 15 by 13 cm-Polypropylene mesh, fixed with tackers, in pubis and Cooper ligament, Stitches of Polyglactin 2/0 in rectus and transversus abdominis muscles. Parietal peritoneum was closed using polyglactin 2/0 and polyglactin 1 for aponeurosis in umbilical trocar incision.
The patients were evaluated on the 2nd postoperative day in the clinic rooms. The SRP was proposed to start, then to have confirmed the absence of early complications and good response postoperative. The patients were guided at the gym by trainers and physiotherapist who collected data about their recovery.
All patients were evaluated on the 10 and 30 postoperative days. They were contacted by phone calls every 6 months for 2 years.
Sport rehabilitation protocol
Physical therapists and trainers developed the program. It is made up of different stations which include growing-intensity exercises that progress to the maximum standardized level. The program ends when the maximum level is reached without pain. Pain intensity throughout the exercise was assessed by a numeric scale starting at 0 (absence of pain) to 10 (maximum pain) [Figure 1].
|Figure 1: Sport rehabilitation protocol after a laparoscopic transabdominal preperitoneal hernioplasty|
Click here to view
Tissue extensibility (abdominal wall and other tissues), lying thoracic mobility, Isometric Core Muscle activation, Gluteus medius and Maximus activation, low intensity, and volume of cardiovascular activities (running, cycling).
| Results|| |
From December 2012 to December 2016, 1,000 nonathletes patients performed Sport Rehabilitation Protocol postlaparoscopic (TAPP) inguinal hernioplasty. Demographic characteristics are detailed in [Table 1]. The average age was 49.73 (SD = 14,82). 920 Male (92%) and 80 female (8%). 827 patients (82.7%) underwent bilateral repair, 124 patients (12.4%) unilateral right sided repair, and 49 (4.9%) unilateral left sided repair Were repaired 1,514 inguinal hernias. 1,370 primary hernias (90.4%) and 114 recurrent hernias (9.6%). 886 lateral, 594 medial, 34 femoral using the European Hernia Society classification.
The SRP was initiated by 70 patients (7%) on the 2nd postoperative day, 230 (23%) in the third, 450 (45%) in the 4th day, and 250 (25%) after the 5th day.
The objectives of the first phase were reached by 920 patients (92%) on the 7th day, and work activities started in 970 patients (97%) before the 5th day.
Postsurgery follow-up was 12.42 months on an average.
There were no significant differences when comparing the results between patients who underwent bilateral TAPP repair and unilateral TAPP repair. There was also no significant difference according to the hernia type classification.
When we compared the groups with and without rehabilitation, the patients who completed the rehabilitation program resumed their activities earlier and reported the presence of less severe pain 10 days after hernia repair.
The comparison between the groups with and without rehabilitation is summarized in [Table 2].
|Table 2: Pre- and post-operative data of rehabilitation and non-rehabilitation groups|
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There were no intraoperative complications or during the immediate postoperative period, so all patients discharged during operation day.
Omphalitis were registered in 5 cases; there were 39 self-limiting sero-hematomas and 1 umbilical incisional hernia 5 months after inguinal hernia repair.
One patient presented lateral hernia recurrence 14 months after the hernia repair.
| Discussion|| |
Duration of convalescence postinguinal hernioplasty is determined by different factors, including kind of repair, surgeon recommendations, postsurgery pain intensity and duration, level of physical activity at work and during leisure activities and development of a complication.,
Before the generalized adoption of the current prosthetic techniques, rest would be imposed with the aim of protecting the repair of posterior wall; nowadays, although it is accepted that abdominal wall resistance is secured by the prosthesis, the literature is vague when recommending resting guidelines and time frames for resuming activities and conservative behaviors rooted in times when repairs would cause greater tension at the suture line and as a consequence, more intense pain, tend to persist.
Robertson et al. and Ismail et al. approached the lack of uniformity in postsurgery recommendations, especially concerning driving vehicles and more recently, Mills et al. and Parés proved the persistence of such disparity in criteria among surgeons in Spain and the United Kingdom respectively, even though since 2011 the Royal College of Surgeons provides precise information in its website about patients undergoing hernioplasty.
This website details wound-related phenomena (inflammation, infection), analgesic measures recommended, and time for the return to work, according to the physical effort demanded by light work and supervision (1–2 weeks), minimum-load work (2–3 weeks) and heavy-duty or intensive work (6 weeks). The brochure stimulates patients to recover mobility quickly (“get well soon”) and to reduce the period of incapacity for work (“work may be part of recovery”), which has been deemed by Lorenz et al. as the most costly item in the process of inguinal hernia repair.
Laparoscopic techniques ensure low-intensity pain and fewer wound complications,,, which support the current tendency to shorten the physical rest period; on the other hand, the literature provides no evidence about the risk of recurrence on account of early physical activity post inguinal hernioplasty.
Effective analgesia is important and just as important is empathy with the health-care team involved in postsurgery recovery,, since it is their role to stimulate physical activity and oppose to the tendency to rest; that is, to ensure analgesic treatment without limiting mobility and conveying the certainty that progressively growing-intensity physical exercise contributes to regenerate tissue without increasing pain intensity.,,,,
Different early and intensive rehabilitation programs have achieved positive clinical outcomes in patients with osteomuscular and tendinous lesions.,,,
In the specific field of inguinal hernioplasty, Pesanelli et al. have shown an occupational rehabilitation plan for patients with work-related hernias. This plan aims to try to restore muscle strength and resistance to traction in the inguinal area before resuming work activities.
Preskitt has successfully implemented a 3-phase rehabilitation plan (each phase last for 2 weeks) for Lichtenstein “sports hernia” repairs.
Some SRPs are designed in phases that start with free-weight isometric exercises and end with specific movements, including the use of balls and other elements related to the sports practiced by the patient.
In general, and provided that suitable supervision is given, exercises in the initial phase may be executed by nonathletes, hence becoming self-confident on their physical capabilities while dissipating fear of pain, as well as concern about recurrence and complications.
This certainty led us to motivate recreational athletes and nonathletes to participate in phase 1 of the program we have been applying since 2003 for high-performance athletes undergoing laparoscopic tapp hernioplasty.
Patients complying with the rehabilitation program resumed activities sooner and reported the presence of intense pain for <10 days after hernia repair.
Once early and active rehabilitation benefits are acknowledged, it is important to pinpoint the adherence-related factors to this type of program. In that sense, multiple articles,,, have pointed out that personality structure and daily mood variations influence the degree of acceptance and adherence.
These aspects were not assessed in our study; nevertheless, their importance can be inferred, since the willingness to resume physical activity in nonathletes showed no relation with other measurable factors such as age and postsurgery pain intensity. Such variables, which could presumably affect acceptance, showed irrelevant differences among patients who fulfilled rehabilitation and those who did not; however, differences were found in co-morbidities frequency as can be seen in [Table 2] showing significant statistical differences in ASA categories.
Rehabilitation development at our facilities allows for exercises to be overseen by physical therapists highly experienced in the recovery of high-performance athletes.
Controlling exercise adherence and their correct execution have enabled us to achieve a high rate of positive functional outcomes.
As far as work activity, there is proof that workers who hold private health insurance report pain for shorter periods and return to work earlier than those receiving sick leave benefit by their employers.
To overcome these methodological flaws, the advantages of the SRP, as applied, should be confirmed through a stratified randomized study with long-term follow-up.
| Conclusions|| |
Application of a sports rehabilitation protocol post laparoscopic tapp hernioplasty does not increase recurrence rate nor complications and may speed up the return to full physical activity.
Research involving human participants and/or animals
This article does not contain any studies with human participants or animals performed by any of the authors.
Approval from the institutional review board was not required for this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]