Return to work after inguinal hernia repair

Return to work after inguinal hernia repair

Surgical outcomes research Return to work after inguinal hernia repair Katherine R. Jones, RN, PhD, FAAN, Richard E. Burney, MD, Melissa Peterson, RN,...

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Surgical outcomes research Return to work after inguinal hernia repair Katherine R. Jones, RN, PhD, FAAN, Richard E. Burney, MD, Melissa Peterson, RN, MS, and Barbara Christy, RN, MSN, Denver, Colo, and Ann Arbor, Mich

Background. There is much variation in the time when a patient returns to work after inguinal hernia repair. Most surgical research has focused on the type of operation performed, but other factors may be equally or more important. This study attempted to identify these factors. Methods. We prospectively studied the return to work after inguinal hernia repair in a convenience sample of 235 patients who were operated on by one surgical group. Ninety-three of these subjects, who were working and had complete data, were included in this analysis. Data were gathered through personal interviews, written surveys, and medical record reviews. The main outcome measures were actual and expected return to work. Results. Primary tissue repair was done in 94% of the patients. The mean age was 49 years; 90% were male. The expected return to work was 10 days; the actual mean return to work after operation was 12 days (median, 7 days; range, 2 to 60 days) and was unrelated to preoperative functional status. Bivariate analysis showed that age, educational level, income level, occupation, symptoms of depression, and the expected return to work accounted for 61% of the variation in actual return to work. Conclusions. Factors other than operative technique, including patient expectations, are strongly associated with return to work after inguinal hernia repair. Depression significantly delayed return to work. More research is needed to understand how expectations are formed and how decisions are made regarding return to work, and whether these can and/or should be influenced by surgeons, employers, or others to promote earlier return to work. (Surgery 2001;129:128-35.) From the University of Colorado School of Nursing, Denver, the Department of Surgery, University of Michigan Medical School, and the University of Michigan School of Nursing, Ann Arbor

AMERICAN BUSINESS SPENDS approximately $37 billion a year related to employees’ absences from work.1 A large percentage of these work days lost is the result of employees undergoing routine surgical procedures to correct acute health problems. Among the most common surgical procedures is inguinal hernia repair (IHR) in men. The lifetime risk of having an inguinal hernia has been estimat-

Supported by grants provided by the University of Michigan Medical Center Small Grants Program and by the Section of General Surgery, University of Michigan. Accepted for publication September 18, 2000. Reprint requests: Katherine R. Jones, RN, PhD, Professor, School of Nursing, University of Colorado Health Sciences Center, 4200 E Ninth Ave, Box C-288, Denver, CO 80262. Copyright © 2001 by Mosby, Inc. 0039-6060/2001/$35.00 + 0 11/60/111696 doi:10.1067/msy.2001.111696


ed as high as 27% in men and 3% in women.2 Each year, 750,000 herniorrhaphies are performed in the United States and are associated with up to 10 million days of work lost per year.3 The traditional prescribed interval between IHR and return to work for many years was 6 or even 8 weeks. The rationale for this time period is uncertain but is commonly attributed to beliefs about wound healing and the possible benefits of a prolonged period of inactivity in preventing recurrences. This practice began when a greater percentage of the workforce was engaged in jobs requiring more physical effort than is true today and when spending a week or more in the hospital after operation was a routine occurrence. A growing number of reports have promoted the idea that an earlier return to work can be achieved and may be both desirable and cost-effective.4,5 These and other reports,6-12 whose primary purpose has been to compare surgical techniques,

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have used return to work as an outcome measure, but have not examined or addressed any of the complex methodologic issues associated with the definition, collection, and application of this variable. It is not surprising, therefore, that a wide variation in the reported return to work is found in the current literature. For open repairs, the reported return to work varies from 1.5 days to 6 weeks.13,14 Laparoscopic repairs have been shown to have somewhat shorter, but still variable, return-to-work intervals.6-12 The data on expected and actual return to work for a group of subjects undergoing IHR at one major medical center are examined in this study. We asked subjects prospectively to record how many days they expected to be off from work, and then, after operation, asked how many days it was before they returned to work. We also asked subjects to identify all the factors that influenced the decision to return to work. The purpose of the study was to better define the factors, or confounding variables, that affect the decision to “return to work.” Unless we understand these factors, return to work will continue to be a frequently used—but inconsistent, poorly understood, and not very useful—outcome measure. MATERIALS AND METHODS During a 4-year period beginning in 1994, we prospectively collected data on the outcomes of 3 commonly performed surgical operations including IHR at the University of Michigan, Ann Arbor. Subjects were identified in the ambulatory clinic when they arrived for their preoperative history and physical examination. Graduate nurse research assistants obtained informed consent, enrolled the subject in the study, and administered a set of baseline surveys eliciting demographic information, comorbid conditions, the Medical Outcomes Study (MOS) SF-36 Health Survey, and condition-specific data. The condition-specific questions to be answered by patients undergoing IHR focused on the degree of pain or discomfort they were experiencing, the presence of other symptoms, their work status, whether the hernia was thought to be associated with work, and history of prior inguinal hernia and hernia repair. All subjects were asked preoperatively: “How soon after surgery do you expect to return to work or to resume your normal activities? Please specify the exact number of days, weeks, or months.” All subjects underwent open repair, with high ligation of an indirect sac when present, and primary repair of the internal ring or inguinal floor as

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appropriate. Mesh was used in only 6 patients. Four surgeons participated; 1 surgeon performed the majority of repairs. Two months after operation, when it was assumed almost all patients would have returned to work, and again 6 months after operation, patients were sent a packet of survey forms by mail along with a pre-addressed, pre-stamped return envelope. Each packet contained the SF-36 questionnaire and the inguinal hernia questionnaire. Herniarelated questions related to the presence of herniarelated pain or discomfort; other symptoms such as bulge or pressure; resumption of normal sexual activity; and fear of recurrence. Each subject was also asked: “How soon after surgery did you return to work or resume your usual activities? Please specify the exact number of days, weeks or months. What things influenced your decision whether to go back to work? Include all you can think of.” Medical records were reviewed for data on type of hernia, type of surgical repair, and occurrence of complications. The questionnaire data were coded and entered into a Microsoft Access database program (Microsoft Corp, Redmond, Wash), checked for accuracy, and then converted to a SAS data set (SAS Institute, Cary, NC). Descriptive statistics were run on all variables to detect illegal codes and outlier values and to determine the distribution of responses. Scales were constructed as outlined in the guidelines developed by Ware15 and the Medical Outcomes Trust. Univariate statistics were calculated for the dependent variables (expected return to work [ERTW] and actual return to work [ARTW]), and for all the potential explanatory variables. Student t tests and analysis of variance tests were conducted to determine whether ARTW or ERTW varied significantly by categories of the independent variables. Stepwise multiple linear regression models were constructed to predict ARTW and ERTW by using patient demographic and clinical variables as independent variables. The research protocol was approved by the medical center Institutional Review Board. RESULTS Two hundred and thirty-five patients with inguinal hernia entered the study. Many were students, unemployed, disabled, or retired persons, who were not employed. After excluding these persons, and a small number for whom we did not have complete 2-month follow-up data, there were 93 patients who underwent IHR who were used and for whom we had complete baseline and follow-up data, including ERTW and ARTW. These patients

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Table I. Demographic and medical characteristics of study population (n = 93) Characteristic



Age (y) (mean) (range) Male White Married Education Less than college College graduate Post graduate Income < $80,000 ≥ $80,000 Insurance HMO/PPO/POS BC/commercial Other Occupation Professional/manager Sales/clerical Craftsman/operator Self-employed

49 22-70 84 92 73

— — 90% 99% 79%

21 29 43

23% 31% 46%

43 50

46% 54%

53 25 15

57% 27% 16%

70 7 16 8

75% 8% 17% 9%

HMO, Health maintenance organization; PPO, preferred provider organization; POS, point of service BC, Blue Cross.

form the basis for our analysis. The SF-36 data demonstrated high levels of internal consistency and reliability, with Cronbach α scores of 0.90 at baseline and 0.91 at follow-up. The condition-specific data collection forms are currently undergoing psychometric testing to establish their reliability and validity. Face and content validity and test-retest reliability have been supported by initial analyses. The mean age of the patients was 49 years (SD ± 12). Subjects were primarily male (90%), white (99%), married (79%), college-educated (77%), and had a high income level (54% more than $80,000 a year). Table I shows the other demographic characteristics of the sample. Of these patients, 18% had recurrent inguinal hernias. Sixteen percent had undergone a prior repair of a contralateral hernia. Fifty-one patients (55%) had indirect hernias; they underwent high ligation and ringplasty (23%), Bassini’s (15%), Cooper’s ligament (15%), or other (2%) repair, depending on the extent of inguinal floor weakness. Forty-two patients (45%) had a direct hernia; almost all of these underwent Cooper’s ligament repair. Six patients had mesh placed, 3 were “tension-free” repairs, and 3 had preperitoneal mesh placement for recurrent hernia. Hypertension was the most frequent patientreported comorbid condition (18%) followed by

Table II. SF-36 functional health status at baseline (n = 93) and 2 months after inguinal hernia repair (n = 68)* Health domain Physical function Role-physical General health Pain Vitality Social function Role-emotional Mental health



Two months post-op

90 75 83 76 67 89 85 79

87 86 73 76 63 86 85 76

91 80 79 86 66 89 88 79

*Changes or differences of 10 points or more are statistically significant. †Normal values for males, aged 45-54 years.

hearing loss (10%), sciatica or low back pain (9%), arthritis (9%), asthma (7%), and prior myocardial infarction (4%). Baseline functional health status scores (Table II) were generally high, with some role limitations caused by physical problems and somewhat lower vitality-energy scores than population norms. Twomonth health status scores showed a modest improvement in role limitations caused by physical problems and significant improvement in pain. There was no association found between functional health status and return to work. Subjects expected to return to work an average of 10 days after IHR; they actually returned to work an average of 12 days after operation (Table III). The median for both expected and actual return to work was 7 days. The range of days reported was wide, with subjects returning to work as quickly as 2 days and as long as 60 days after operation. The difference between total actual days of work lost and total expected days lost for all 93 workers was 194. Table IV shows the results of the bivariate analyses. For ERTW, significant differences were noted for income level. Earlier ARTW, on the other hand, was significantly associated with college education, holding a white-collar position, and higher income level. Persons who reported symptoms of depression—specifically those that answered “yes” to the question “Have you felt sad or blue for 2 weeks in the past year?”—took much longer to return to work (25 vs 10 days). Patients who reported postoperative complications (8 patients), paradoxically, returned to work earlier than those without complications. Sex, marital status, self-employment status, insurance status, other comorbid conditions, previous hernia, fear of recurrence, self-reported health status before the operation, preparation for the operation, preparation for discharge, and per-

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Table III. Expected and actual return to work (days) for all patients and for patients by type of occupation (univariate analysis) All patients (± SD) Expected return to work (days) Median Mode Actual return to work (days) Median Mode Sum of expected work days missed Sum of actual work days missed

10.3 ± 10.8 7.0 7.0 12.4 ± 13.1 7.0 5.0 958 1152

ceived quality of care did not achieve statistical significance in the bivariate analyses. Persons with less than a college education, bluecollar workers, and persons reporting symptoms of depression showed the greatest discrepancies between ERTW and ARTW (Table IV). Subjects who were self-employed expected to return to work in 6 days after operation, but actually took an average of 14 days. Tables V and VI show the results of the stepwise multivariate regression analyses for ERTW and ARTW. To reduce the problem caused by multicollinearity among the several socioeconomic variables, the following predictors were included in the model: age, education level, self-employment status, occupation, health insurance, hearing loss, hypertension, arthritis, sciatica, a history of depression, and a history of previous hernia. For ARTW, we added postoperative pain and the perceived risk of hernia recurrence. The model for ERTW was significant (P = .0013) and explained 18% of the variance. Four variables achieved statistical significance at or below P = .15 and were entered into the model: having a reported hearing loss, being in a professional or managerial occupation, being employed outside the home, and, finally, being in a sales or clerical occupation. The model for ARTW was also statistically significant (P = .0001) and explained 61% of the variance. Eight predictor variables achieved statistical significance at or below P = .15. These were, in order of importance: ERTW, less than college education, report of depression, age, sales or clerical occupation, hearing loss, college graduate, and professional or managerial occupation. Each additional day in ERTW was associated with 0.54 additional actual days. Having less than a college education was associated with 10.3 additional days; reporting a history of depression was associated with 9.4 additional days. Each additional year of patient age was associated with 0.20 fewer actual

Professional/managerial 9.0 (1-42) — — 9.8 (2-56) — —

Sales/clerical 11.0 (2-42) — — 11.3 (3-42) — —

Operator/craftsman 15.8 (3-60) — — 24.2 (3-60) — —

days until return to work. Being in a sales or clerical position was associated with 12.2 fewer days compared with being in a physically oriented occupation. The report of a hearing problem was associated with 5.7 additional days compared with having no reported hearing problems. Having a post-graduate degree was associated with 3.7 fewer days than having a college degree and being in a professional or managerial occupation was associated with 4.4 fewer days compared with having a job requiring heavy physical labor. Hearing loss, college graduate, and professional-managerial employment all had P values of .05 or less. Table VII displays the reasons subjects cited that influenced the decision to return to work. The sample is divided in 2 groups: those taking the median or fewer days to return to work and those taking more than the median number of days. The most frequently cited reasons in both groups were “feeling better” and “feeling ready to return to work.” The early return group also reported that specific aspects of their jobs either allowed or prevented them from returning to work. Comments such as feeling pressure from work, being bored and restless, and a positive mental attitude and enjoyment of work were described. The delayed return to work group mentioned work pressure, concerns about finances and use of sick time, and feeling recovered from the operation. DISCUSSION All of the patients in this study underwent ambulatory IHR and were encouraged to return to normal activities and work as quickly as tolerated. They returned to their jobs an average of 12 days (median, 7 days) after operation. A substantial variation was seen, however, with return to work ranging from 2 to 60 days. A similar range was seen in the preoperatively reported ERTW, which ranged from 1 to 60 days. Given that IHR is performed on a broad array of patients who span a range of ages,

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Table IV. Bivariate analyses of expected and actual return to work by patient demographic and clinical information Characteristics Male Female Married Not married Less than college education College graduate Post-graduate degree Symptoms of depression No symptoms of depression Income < $80,000 Income ≥ $80,000 White collar Blue collar Hearing loss No hearing loss Surgical complications No surgical complications HMO/PPO/POS BC/commercial Other Employed by other Self-employed Perceived health status Excellent Very good Good Previous hernia No previous hernia Fear of recurrence Yes Not sure No Postoperative pain No postoperative pain

ERTW (days)

ARTW (days)

10.0 13.4 13.4 12.6 13.3 9.4 9.4 11.3 10.1 13.7 7.4 (P = .0002) 9.2 15.8 22.1 9.0 (P = .0215)

10.0 11.2 10.0 10.7 6.4

12.3 13.3 13.3 13.2 22.1 11.8 8.1 (P = .0002) 25.2 10.3 (P = .0403) 18.1 7.5 (P = .0073) 9.9 24.2 (P = .0115) 28.6 10.7 (P = .0823) 6.9 14.1 (P = .012) 12.4 13.2 11.0 12.2 14.1

9.9 10.3 10.8 11.3 9.8

10.5 14.1 11.9 13.0 12.1

9.8 12.4 9.0

12.5 15.8 9.8 13.3 12.0

HMO, Health maintenance organization; PPO, preferred provider organization; POS, point of service; BC, Blue Cross.

physical conditions, and comorbidities, and who perform a wide range of jobs, this kind of variation should not be surprising. Since there was little variation in the surgical approach used in this cohort of patients—94% had open, primary repairs and there were no laparoscopic repairs—the study group provides a good basis for the examination of other factors that may influence expected and ARTW. The chief finding of this study is that more than half of the variation in return to work after IHR can be explained by demographic, socioeconomic, and other factors unrelated to the surgical procedure. These factors are: ERTW, having less than a college education, report of depression, age, sales or clerical occupation, hearing loss, college level education, and professional or managerial occupation.

Patients in “favorable” categories returned to work very quickly. Others took longer. There has been little consensus or scientific evidence regarding either actual or appropriate return to work after IHR. The traditional long duration of convalescence has been attributed to factors such as custom, complications, pain, or fear of recurrence.14,16 Herniorrhaphy patients in the United States are routinely advised to limit their physical activity for 6 to 8 weeks postoperatively, presumably as a measure to prevent recurrence, although we are aware of no scientific evidence supporting such advice. Rider et al17 have stated that patients should return to work within 4 weeks of an uncomplicated IHR, with no differentiation made on the basis of type of employment. Shulman et al18 propose that earlier return to work is safe, if

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Surgery Volume 129, Number 2 Table V. Stepwise multivariate linear regression model predicting ERTW* Independent variable Professional/managerial job Hearing loss Employed outside home Sales/clerical job

Days (n)

P value

–7.82 10.44 6.73 –7.18

.009 .009 .100 .144

Model F-value, 4.91; P = .0013; adjusted R2 = .1790; reference categories: self-employed, physical job, no hearing loss. *These variables explained 17.9% of the variance in expected return to work. Second column (days) shows positive or negative effect of that variable on expected days to return to work.

open hernia repair with prosthetic mesh is performed. Of course, the long-held fear that early return to full activity leads to an increased risk of recurrence may be unfounded, regardless of the type of repair performed, and earlier return to full activity may be safe for all types of repair. Walsh et al1 stated that the typical periods of post-hospital convalescence have not kept pace with changing views of the recovery process. They have proposed return-to-work guidelines for typical patients undergoing IHR of 1 week for desk work, 10 days for light work, and more than 4 weeks for heavy work. These recommendations correspond well to the mean of 9.9 days until return to work for patients in “white collar” (professional, managerial, sales, and clerical) positions, such as those seen in the current study. They also correspond well to the return to work after laparoscopic repair of 7 days reported by Stoker et al11 and 10 days reported by Liem et al.12 Nevertheless, even within each occupational category, we observed a substantial variation in ARTW: professionals and managers had a range extending from 2 to 56 days; clerks and salespersons had a range from 3 to 42 days; and operators/transporters/laborers had a range from 3 to 60 days. Walsh et al1 have noted that employers can usually cite dramatic anecdotal evidence of wide discrepancies in the time employees lose from work while recovering from seemingly comparable surgical episodes. The primary influences that shape a patient’s decision to return to work have not been clearly or fully elucidated. Lawrence et al19 examined SF-36 scores at 10 days and 6 weeks after IHR and found, as we did, that factors other than health status, such as social class, played an important role in the variation in time to return to normal activity. They concluded that time to normal is, therefore, not a good outcome measure of surgical benefit. Liem et al12 attributed lengthy delays in returning to work to the type of job and to insurance cov-

Table VI. Stepwise multivariate linear regression model predicting ARTW* Independent variable

Days (n)

P value

Expected return to work Less than college education Depression Age Sales/clerical job Hearing loss College graduate Professional/managerial job

0.54 10.27 9.44 –.20 –12.20 5.71 3.69 –4.36

.000 .000 .002 .027 .005 .118 .116 .143

Model F-value, 16.76; P = .0001; adjusted R2 = .6092; reference categories: post-graduate education, physical job, no hearing loss, no depression. *Second column refers to positive or negative effect of that variable on actual days to return to work. This model explains 61% of the variance in actual return to work.

erage. In other studies, self-employed patients tended to take the shortest time off work, while those receiving Workers’ Compensation took much longer.20 Callesen et al13 recently reported that pain and advice from general practitioners not to resume activity were the most important factors prolonging convalescence. Expectations, personal motivation, and confidence in the surgical repair are also thought by surgeons to influence the decision to return to work.18 Written educational materials may play a role, although such material may recommend lengthy recovery periods.17 Rider et al17 found that those returning early to work after initial hernia repair most often acted independently, while those returning later tended to rely on medical advice and written material. This phenomenon was also noted among the patients we studied. We found that socioeconomic variables could explain most of the variation in ARTW. Persons with higher levels of education and those in professional occupations returned to work much sooner than persons with lower levels of education and those in nonprofessional jobs. We could not determine what the underlying motivations of these patients might be. Some of these individuals may simply have a more positive mental attitude or sense of obligation about work, thus encouraging earlier return. The return to work decision-making described by our subjects also indicated that the nature of some jobs and job environments facilitated earlier return to work. Such things as a high degree of personal control over working conditions, lighter physical job requirements and/or lighter work loads or reduced assignments when first returning to the job after operation, may play a role in facilitating early return to work. More

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Table VII. Patient-reported factors that influenced decision to return to work in response to open-ended question, and proportion of patients returning to work in 7 days or less, or more than 7 days, reporting that factor*

Felt better, felt ready, recovered Work pressures Aspects of job allow/prevent return Felt bored, restless; need to be busy Finances, sick time, vacation time Mental attitude, enjoy work Healed incision, able to ambulate Physician/nurse advice, written material Reduction of preoperative symptoms Pain, headache, fatigue, complications Increased energy, strength Past experience, used own judgment “Official recovery period” Went back too soon

ARTW ≤ 7 days

ARTW > 7 days

(n = 54)

(n = 39)

63% 26% 32% 17% 7% 15% 2% 2% 8% 2% 4% 4% 0% 0%

67% 28% 10% 13% 16% 8% 14% 10% 3% 8% 5% 3% 3% 3%

*Because each patient listed up to 4 self-defined factors, statistical analysis is not applicable.

research into the workplace environment as it relates to a timely return to work is needed. Individuals who took more time off from work were more likely to mention finances and having sick time as factors in their decision to return to work. It may be that some of these patients, even though their return to work was relatively late, were nevertheless returning to work sooner than they might have wished because of financial concerns. The financial concerns might have been associated with the lower income jobs in this sample or possible employer guidelines about return to work after hernia repair. We were not able to pursue and clarify the nature of these concerns. The other 2 significant predictor variables in our study, depression and reported hearing loss, are new and have not been identified by previous studies as influencing a return to work after operation. The depression question is one of the screening items on the SF-36 and was answered by all patients. It asks: “In the past year, have you had 2 weeks or more during which you felt sad, blue, or depressed, or when you lost all interest or pleasure in things that you usually cared about or enjoyed?” Answering “yes” to this question was associated with an additional 9.4 days absence from work. This suggests that work site screening programs for depression and treatment referrals might have benefits for both the employer and employee. A recent study concluded that employers, especially those with largely white collar workforces, would realize gains in productivity that would at least partially offset the costs of treatment if they were to encourage their depressed employees to

obtain treatment.21 Our results provide further support for that recommendation. Pain and pain management can affect the return to activity. Callesen et al13,14 suggest that improved pain management can shorten postoperative convalescence. In our study, postoperative pain was a not a significant predictor for a delayed return to work. This may be because of the preemptive pain management approach that was used in our patients, which includes long-acting local anesthesia and regular postoperative dosing of nonsteroidal anti-inflammatory drugs. A fear of recurrence also did not enter our model nor did preoperative functional health status. Expectations, however, proved to be very influential in determining ARTW, explaining 15% of the variation in ARTW. We were not successful in determining what factors influenced a patient’s expectations for return to work. Occupation and hearing loss were significant predictors, but they accounted for only 18% of the variation. Further studies are needed to explore in greater depth the many factors that go into developing these expectations and whether these expectations could be shaped to promote more optimal recovery periods. A particular focus needs to be placed on patients whose ARTW greatly exceeded the expected: those with less than a college education, blue collar workers, and those with depression. Limitations of this study must be acknowledged. The sample in this study is not representative of the general population, but reflects the institution’s location in a high income, well-educated, relatively

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nondiverse area of the state. It also represents the practice of only a few surgeons. The sample therefore needs to be enlarged before conclusions can be drawn about the factors that influence ERTW and ARTW in general, and about the development of specific educational and behavioral strategies to alter these factors. This study calls attention to the variety of important human characteristics, attitudes, expectations, and other factors, independent of operative technique, that influence return to work after IHR. While return to work remains an important outcome measure, surgeons should be aware that many of the factors influencing it are not easily controlled or measured. Those that are, such as age, education level, income level, type of job, reported symptoms of depression, and preoperative ERTW, should be part of future studies. In their absence, we should be cautious drawing conclusions about comparisons of surgical technique on the basis of return-to-work measurements. We wish to acknowledge the significant contributions of Dr Jane Wilson Coon, Darby Blewitt Dennis, Ann Herm, Vicky Debold, and Karen Kruzinga to the work of the Surgical Outcomes Study. REFERENCES 1. Walsh DC, Connor E, Tracey LV, Goldberg GA, Egdahl RH. Post-hospital convalescence and return to work. Health Affairs 1989;8:77-90. 2. Primatesta P, Goldacre MJ. Inguinal hernia repair: incidence of elective and emergency surgery, readmission, and mortality. Int J Epidemiol 1996;25:835-9. 3. Rutkow I, Robbins A. 1993. Demographic classificatory and socioeconomic aspects of hernia repair in the United States. Surg Clin North Am 1993;73:413-26. 4. Lichtenstein IL. Immediate ambulation and return to work following herniorrhaphy. Indust Med Surg 1966;35:754-9. 5. Kark AE, Kurzer MN, Belsham PA. 3175 primary inguinal hernia repairs: advantages of ambulatory open mesh repair under local anesthesia. J Am Coll Surg 1998;186:447-56.

6. Barkun JS, Wexler MJ, Hinchey EJ, Thibeault D, Meakins JL. Laparoscopic versus open inguinal herniorrhaphy: preliminary results of a randomized controlled trial. Surgery 1995;118:703-10. 7. Lawrence K, McWhinnie D, Goodwin A, Doll H, Gordon A, Gray A, et al. Randomised controlled trial of laparoscopic versus open repair of inguinal hernia: early results. Br Med J 1995;311:981-5. 8. Liem MS, van der Graaf Y, van Steensel CJ, Boelhouwer RU, Clevers GJ, Meijer WS, et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal hernia repair. N Engl J Med 1997;336:1541-7. 9. Maddern GI, Rudkin G, Bessell JR, Devitt P, Ponte L. A comparison of laparoscopic and open hernia repair as a day surgical procedure. Surg Endosc 1994;8:1404-8. 10. Payne JH, Grininger LM, Izawa MT, Podoll EF, Lindahl PJ, Balfour J. Laparoscopic or open inguinal herniorrhaphy? Arch Surg 1994;129:973-81. 11. Stoker DL, Spiegelhalter DJ, Singh R, Wellwood JM. Laparoscopic versus open inguinal hernia repair: randomized prospective trial. Lancet 1994;343:1243-5. 12. Liem MS, Graaf Y, Zwart RC, Geurts I, van Vroonhaven TH. A randomized comparison of physical performance following laparoscopic and open inguinal hernia repair. Br J Surg 1996;84:64-7. 13. Callesen T, Klarskov B, Bech K, Kehlet H. Short convalescence after inguinal herniorrhaphy with standardized recommendations: duration and reasons for delayed return to work. Eur J Surg 1999;165:236-40. 14. Callesen T, Kehlet H. Postherniorrhaphy pain. Anesthesiology 1997;87:1219-30. 15. Ware JE, Snow KK, Kosinki M, Gandek B. SF-36 Health survey manual and interpretation guide. Boston: New England Medical Center; 1993. 16. Majeed AW, Brown S, Williams N, Hannay DR, Johnson AG. Variations in medical attitudes to postoperative recovery period. Br Med J 1995;311:296. 17. Rider MA, Baker DM, Locker A, Fawcett AN. Return to work after inguinal hernia repair. Brit J Surg 1993;80:745-6. 18. Shulman AG, Amid PK, Lichtenstein IL. Returning to work after herniorrhaphy. Br Med J,1994;309:216-7. 19. Lawrence K, Doll H, McWhinnie D. Relationship between health status and postoperative return to work. J Public Health Med 1996;18:49-53. 20. Salcedo-Wasicek MC, Thirlby RC. Postoperative course after inguinal herniorrhaphy. Arch Surg 1995;130:29-32. 21. Kessler RC, Barber C, Birnbaum HG, Frank RG, Greenberg PE, Rose RM, et al. Depression in the workplace: effects on short-term disability. Health Aff 1999;18:163-71.

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