This is the first comprehensive study exploring the impact of going back to work early in the laparoscopic hernia repair era. Our study demonstrated that going back to work within one week after laparoscopic TEP hernia repair dose not increase inguinal hernia recurrence and seroma formation. In addition, patients going back to work early had significantly less chronic inguinal pain. Early and late groups had similar functional outcomes at three months after operation. These findings suggest early return to work is feasible and safe for patients who underwent laparoscopic TEP.
In the open hernia repair era, early return to work was an important convalescence goal of operation. It was associated with socioeconomic advantages, including decreasing loss of productivity and earning of workers 7. A review made by Forbes et al. recommended that patients could return to work 1 to 2 weeks after open hernia repair if little or no lifting was involved or 6–8 weeks if lifting more than 10 kilograms8. The Hernia Surge Group recommended that patients could resume work or activity within 3–5 days after elective laparoscopic or open hernia repair (upgraded to strong recommendation by panel discussion)9. Furthermore, a recent study investigated the determinants of short convalescence after laparoscopic hernia repair showed a median of 5 days of convalescence from work10. In our study, we classified patients into the early group if resuming work within 7 days after surgery and the results showed similar recurrence and complication rate compared to the late group. Based on our findings, patients are free to go back to work early after laparoscopic TEP hernia repair.
One of the important considerations of early return to work is inguinal hernia recurrence. Our study revealed that returning to work within one week did not increase inguinal hernia recurrence. From the experience of open hernia, Taylor reported that patients had comparable hernia recurrence rates between early (full work duties at 21 days after surgery) and late (full work duties at 3 months) return to work 11. Another large-scale open hernia repair study by Bay-Neilsen et al. presented no significant difference in recurrence rate between non-restrictive (n = 1059) and restrictive (n = 1306) convalescence recommendation groups (0.7% versus 1.6%, p = 0.186), in which median time off work after surgery was 7 days in non-restrictive recommendation groups12. As compared to open hernia repair, laparoscopic TEP hernia repair offers an earlier return to work (6.4 days versus 11.5 days, p < 0.001)13. Therefore, it is reasonable to define early return to work as within one week after surgery in our study. The early and late groups had comparable hernia recurrence rates (1.7% versus 2.9%, p = 0.386) after follow-up of more than 6 months (Table 3). From the results of our study, early return to work did not increase the incidence of inguinal hernia recurrence.
Chronic postoperative inguinal pain is a bothersome complication for patients. A review by Poobalan et al. showed that patients who underwent laparoscopic hernia repair had great variations in incidence of chronic pain (0.8–29%)14. Our study revealed the incidence of chronic pain is 4.8% and 11.6 % in the early and late groups, respectively (p = 0.006). A younger age was one of the risk factors of chronic postoperative inguinal pain in previous studies15–17. In our study, the early group was younger than the late group. After adjusting for age, multivariate regression revealed early return to work had significant less chance of developing chronic pain than the late group. Persistent neuralgia resulting from intraoperative neural injury and neuron entrapment could be the main reason of chronic pain18–21. Theoretically, early return to work is associated with more early postoperative physical activity. Physical activity can stimulate blood circulation and angiogenesis, which is beneficial to wound healing22–24. Early activity may stimulate tissue regrowth and further prevent nerve irritation by mesh, which in turn decreases chronic pain. The present study demonstrates that returning to work within one week after laparoscopic TEP hernia repair is associated with significant less chronic inguinal pain than those returning more than one week or being unemployed. Based on our findings and references, we recommend patients return to work within one week after laparoscopic TEP hernia repair owing to less chronic inguinal pain.
Post-operative urine retention is one of the common complications after laparoscopic hernia repair. Previous studies identified some risk factors, including age, narcotic medication used, and history of benign prostate hyperplasia25,26. Patel et al. reported that patients older than 50-years-old were associated with post-operative urine retention (odds ratio 3.0, p = 0.01)25. In our study, the late group was older (51.3 versus 58.2, p < 0.001) and had more benign prostate obstruction (BPO) at presentation (19.5% versus 28.7%, p = 0.016) (Table 1). Although the two groups had comparable post-operative narcotic use (Table 3), more patients with BPO had post-operative urine retention in the late group (3.9% versus 8.7%, p = 0.028). The way to prevent post-operative urine retention is an important issue warranting further study.
There are some limitations in our study. First, this is a retrospective cohort study. Further prospective investigation with measurable post-operative activity is warranted. Second, the two groups had different distributions in physical loading of work. Limited evidence is available for convalescence from light to heavy work after TEP repair. In addition to work, leisure activity is also an important convalescence factor, and this was not analyzed in the current study.