Surgeons have traditionally advised patients recovering from groin hernia repairs not to drive for a month or two. This is based on the concern that postoperative pain could prolong reaction times and, to a lesser degree, that there is a risk of early recurrence as a result of the inertial forces that occur during a sudden impact or stop. However, preclusion from driving, particularly in the major cities around the globe, can have socioeconomic consequences.
Fortunately, by alleviating traditional concerns (and restrictions) about driving, the modern method of hernia repair is improving not only patients' physical wellbeing but their social and psychological recovery as well.
The pain that follows the repair of hernias in the groin is caused by mechanical and chemical stimulation of large, myelinated nerve fibres (A-α fibres) or small, unmyelinated nerve fibres (C fibres). Mechanical stimulation of somatic tissues, such as that which occurs when tension is created on the fibroconnective tissue of the groin, causes pain both directly—through mechanical stimulation of A-α and C fibres—and indirectly—through the release of chemical substances that further stimulate the C fibres.1 Such chemical substances include hydrogen, potassium, bradykinin, serotonin, histamine, acetylcholine, proteolytic enzymes, and prostaglandins.1–5 In addition, the same chemical substances cause visceral pain by stimulating the C fibres that innervate the hernia sac (peritoneal sac) that is excised and ligated during the traditional repair.
The traditional method of hernia repair, which includes forceful approximation of the fibroconnective tissues of the groin, is associated with undue tension on the suture line, which leads to somatic pain through C and A-α nerve fibres. In addition, ligation of the hernia sac results in visceral pain, caused by mechanical stimulation and ischaemic changes in the peritoneum that lead to the release of chemical substances. Fortunately, modern hernia repairs avoid approximating tissues under tension by using a layer of synthetic mesh. These repairs are associated with a reduction in postoperative pain because they eliminate the somatic component of the pain (the tissues are not put under tension) and because the hernia sac is not ligated, leading to a reduction in the visceral component of the post-herniorrhaphy pain.
Concern about the recurrence of a hernia in the groin from the inertial force of an impact or sudden stop while driving is based on the fact that it takes between six and eight weeks for a hernia defect to heal when its repair has involved forcefully approximating the edges of the defect. A sudden increase in intra-abdominal pressure resulting from the inertial force of an impact or sudden stop can potentially disrupt the suture line of the repair. However, hernia repairs that do not use tissue tension are not at risk for this since the technique does not involve pulling together and suturing the edges of the defect. Rather, the recovery period is solely dependent on the amount of postoperative discomfort, which is minimal and usually does not require narcotic analgesics. Many prospective and randomised studies comparing laparoscopic hernia repair with tissue approximation under tension and with open repair carried out without tissue tension have concluded that open repair without tension and laparoscopic repair are equally associated with decreased postoperative pain.6–8 More importantly, a meta-analysis of randomised controlled trials of laparoscopic versus open inguinal hernia repair showed that repairs carried out without tension, whether open or laparoscopic, result in less postoperative pain and faster recovery.9
The reduction in postoperative pain and the risk of recurrence associated with the different types of hernia repairs carried out without tissue tension have allayed concerns over allowing patients to return to normal daily activities, including driving. Now, patients can resume driving as early as one week or less after surgery depending on their comfort and whether they are using narcotic analgesics. In fact, the postoperative handout at our clinic clearly says that “Your physical activities are in no way restricted.”
As Ismail et al point out in this week's issue of the BMJ (p 1056), modern techniques of hernia repair have changed the pattern of convalescence after this surgery.10 These days individual variations in postoperative pain and the use of opiates (if any) should be considered. Those who drive different types of vehicles need different advice. More importantly, I agree with Ismail et al that national guidelines should be developed. Such guidelines would benefit hernia patients around the globe whichever side of the road they drive on.
Papers p 1056
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