Spigelian hernia is a rare abdominal wall hernia. It constitutes about 0.12% of all abdominal wall herniae; the peak occurrence being between the ages of 40-70 years with a male to female ratio of 1:1.18. Owing to the rarity of the disease, lack of physician experience and absence of typical hernia-like symptoms, it is a fairly difficult condition to diagnose. There is a 20% incidence of strangulation reported in the literature. The elective treatment of a Spigelian hernia is surgical: open or laparoscopic. The latter is preferred due to reduced mortality, shorter hospital stay, better cosmetic result and perhaps a lower recurrence rate. Reported here is a case of Spigelian hernia that presented to our institution, a level 1 trauma centre, as a complication of laparoscopic abdominal surgery.

Introduction Careful identification and management of inguinal nerves during inguinal hernia repair is important to avoid iatrogenic injury. Documentation of this practice may inform postoperative clinical management. We set out to investigate how often surgeons identify inguinal nerves and document findings and management in their operation notes. Methods We carried out a retrospective review of operation notes at a single district general hospital. We analysed operation notes for documentation of identification and intraoperative management (preservation or sacrifice) of the inguinal nerves (iliohypogastric, ilioinguinal, genital branch of genitofemoral nerve). We collected data on the baseline characteristics of the patients, hernia characteristics and primary operating surgeons for subgroup analysis. Results A total of 100 patients were included in the analysis. Identification of any inguinal nerves (generic ‘nerve’) was documented in 17% of operation notes. Documentation in the operation notes of named individual nerves was limited. No documentation of intraoperative management of inguinal nerves was found in 83% of operation notes. Preservation of the inguinal nerves (generic ‘nerve’) was recorded in 8% and sacrifice recorded in 9% of cases. Subgroup analysis revealed similar incidence of documentation of identification and management of inguinal nerves across grades of primary surgeon, with overall incidence low for all grades. Conclusion This study reveals a lack of appreciation of the importance of documenting identification and management of inguinal nerves in operation notes. Further consideration of the potential implications of poor documentation would be beneficial to improve standards.

Introduction Chronic groin pain following inguinal hernia surgery is a common and potentially debilitating complication, and yet patients are infrequently informed of this risk. This leaves surgeons open to negligence claims, especially given recent changes to case law, which for the first time highlighted the need for a more patient-centred approach to risk disclosure. We investigated how these changes have influenced our consenting practice with respect to the disclosure of this risk. Methods We compared how often surgeons discussed the risk of chronic groin pain with adults undergoing elective open unilateral inguinal hernia mesh repairs in 2019 and 2009. The first 50 patients in each of these two years were retrospectively compared. Discussions during the initial consultation and on the day of surgery were assessed by reviewing clinic letters, medical notes and consent forms. Findings The risk of chronic pain was discussed with significantly more patients in 2019 than in 2009 (96% v 54%, p<0.0001). Most of these discussions occurred on the day of surgery (92% v 54%, p<0.0001). Only a few patients had these discussions during their initial consultation (18% v 4%, p<0.025). Conclusions Discussing the risk of chronic groin pain has improved significantly over the past 10 years. However, these discussions occur mostly on the day of surgery, which gives patients very little time to weigh up the risk. This potentially invalidates the consent they give for surgery. Patients should be given an opportunity to discuss their operative risks in advance of their operation.

Introduction Analgesia makes up an integral part of the management of the surgical patient. The World Health Organisation “analgesic ladder” details the escalation of analgesics from paracetamol through to opiates. Over the past decade, opiate prescriptions in the UK have increased by 22% to 40.5 million a year. Method Drug charts were reviewed on the surgical wards prior to presentation of the trust guidelines to surgical juniors. Inclusion criteria was non-cancerous adults who were not on chronic pain medications and had no known allergy or contraindication to NSAIDs. F1/2s were also surveyed on their knowledge of the trust guidelines Results Compliance improved in weak opioids (10.6%) and oramorph (19.1%) but fell in NSAIDs (-2.9%). Paracetamol was prescribed appropriately in 100%. 78% of doctors admitted to not having read the trust guidelines and 89% to not following them despite 100% being aware of the concept of the analgesic ladder. Conclusions We saw a tangible improvement in opiate prescribing by surgical juniors. However, the overall compliance to the analgesic ladder is still relatively poor given the doctors are all aware of the concept of the analgesic ladder, suggesting appropriate analgesic prescribing does not rank as highly in importance as it should.