Ellis, Chairman of Committee for the Annals.

Transcription

1 Harold Ellis, Chairman of Committee for the Annals. I I Gordon Fordyce, Associate Editor, Faculty of Dental Surgery. 1. Donald Crowther, past Executive Editor, with Mrs Crowther. Robert Horton, retiring Executive Editor.

2 Annals of the Royal College of Surgeons of England (1984) vol. 66 Inguinal hernia repair using local anaesthesia* FRANK GLASSOW FRCS FRCS(C) Associate Surgeon, Shouldice Hospital, Thornhill Key words: HERNIA, INGUINAL; LOCAL ANAESTHESIA; REPAIR; SHORT-STAY; RECURRENCE RATES Summary This is a review of a large and long experience in one hospital with more than elective inguinal hernia repairs using local anaesthesia and emphasising the advantages of this type ofanaesthetic. Subsections deal briefly with facets of this experience such as age, preoperative assessment, skin incision, the cremaster muscle, the testis, bilateral hernias, hernias in women, short hospital stay, follow-up, return to work and recurrence rates. Considerable emphasis is given to the principles of technique and this is described in detail. Introduction John Hunter had an intimate knowledge of the anatomy of the inguinal region. He would have been satisfied to realise that today, as surgeons, we consider a good inguinal repair to be based entirely upon such a detailed understanding of the anatomy of this region. Since the mid 1940s more than hernia repairs have been performed in this hospital and more than 6000 annually since Approximately 12% were for repair of a recurrent hernia. In a 31-year association the author has performed more than of these, of which more than 2000 were recurrent repairs. In the first 5 or 6 years the technique of the repair was being developed by the late Dr E E Shouldice. It has now become standardised. Only elective inguinal repairs are considered in this review. There are many different operations for the repair of inguinal hernia, each with its own followers. The operation performed here is a modified Bassini. At every operation the internal ring is routinely strengthened and likewise the posterior inguinal wall, using a multi-layered technique to achieve this. The recurrence rates recorded have remained consistently around 10% for many years. However, an operation can only be considered truly successful when other surgeons around the world achieve comparable results using the same technique. Hernia repair is the most common operation in men. The recent upsurge in interest is motivated by both a genuine concern by all surgeons in improving results and by an increasing appreciation of the important socio-economic implications of the operation. Preoperative assessment All medical conditions are carefully assessed and priorities judged. Many patients are in the older age groups so that Address for correspondence: Dr Frank Glassow, 30 Colborne Street, Thornhill, Ontario, Canada L3T 1Z7. * Based on a Hunterian lecture delivered at the Royal College of Surgeons on 13th April The Editor would welcome any comments on this paper by readers cardiac, pulmonary and prostatic problems are common but overweight and obesity are the most common. Such patients are encouraged to lose excess weight slowly before operation. Using a diet sheet they are instructed to lose the weight gradually at about 1 to 2 pounds a week. The operation is scheduled accordingly. AGE Age in itself is no bar to operation. Ten per cent of patients were over 70 years old. Older patients do just as well as the younger age groups and their recurrence rates are no different. I have operated upon a man of 91 years who had a recurrent hernia. He lived until he was 96 and was very grateful for the relief provided by the operation. The average age was 58. Anaesthesia Local anaesthesia is used in more than 950 of cases. A general anaesthetic is used only for children less than 12 years of age, for a few of the patients who have multirecurrent hernias, and very rarely, for a very apprehensive patient. A local anaesthetic is preferred for many reasons (1). It avoids the risks of general anaesthesia. In some poor-risk patients it is the anaesthetic of choice. In less advantaged countries where first-class anaesthesia is less available it is ideal. Induction is quicker. The interval between operations in the operating theatre is lessened. It imposes a gentle technique upon the surgeon because the patient is only interested in a painless operation at this stage. The surgeon is less likely to use tension with the repair. A conscious patient can be asked to cough to identify an evasive hernia or to test a repair. The patient can walk out of the operating theatre which boosts his morale preoperatively and subsequently has a great impact on his short hospital stay. He is ambulant throughout. Many patients specifically request local. Almost without exception, including those who previously had had a general or a spinal anaesthetic, they state after operation that they prefer local. Immediate postoperative complications are less with the questionable exception of the degree of discomfort experienced in the first 24 hours (2). Catheterisation is eliminated. Although a general anaesthetic is still popular the alternative use of a local anaesthetic is steadily gaining ground (3) and eventually it may become the anaesthetic of choice (4). A number of local anaesthetic agents are employed. My experience is limited almost entirely to the use of 2% procaine hydrochloride without epinephrine but recently I have been using 1% and 1% for the over-70 age group.

3 Premedication commences 14 hours preoperatively with oral administration of mg sodium pentobarbital. Then 20 minutes preoperatively mg meperidine hydrochloride is given intramuscularly. A total of approximately 150ml of local may be used; ml is initially injected as a subcutaneous regional infiltration in the line of the inguinal canal. A further 10-20ml is used beneath the external oblique aponeurosis and a third injection of a similar amount is given around the internal ring, avoiding the inferior epigastric vessels. This volume of local has been used many thousands of times without adverse effects, given the adequate premedication cover described. Operative technique SKIN INCISION Immediately after the subcutaneous local has been given this is made in the line of the inguinal canal. It is straight or slightly convex downwards. Pfannenstiel incisions are not used. A scar from a previous repair may require excision. CREMASTER MUSCLE This structure is often ignored in descriptions of technique. It is identified surrounding the spermatic cord once the external oblique has been divided in the line of the inguinal canal. It is divided longitudinally along the cord so defining and mobilising two separate leaves one lateral, one medial. The lateral one is more bulky containing the cremasteric vessels, in its base, and the genital branch of the genitofemoral nerve. Once the cord is isolated and retracted laterally the third injection of local is given at the internal ring. INTERNAL RING I regard all inguinal hernia repairs as having two main components. The first is the dissection at the internal ring, the second the dissection of the posterior inguinal wall. This ritual attitude is very helpful when confronted by a very large primary hernia or by a difficult recurrent hernia. For example, all scrotal hernias are not indirect and I have operated upon a number which were direct. Defining the inferior epigastric vessels will eliminate any such misdiagnosis. High ligation of the indirect sac is standard practice and standard teaching yet I do not regard it as vitally important (5). I regard the complete freeing of the indirect sac from its fascial investments at the internal ring to be of equal or even greater importance. If this freeing is really complete, whether the sac were ligated high or low, the remaining ligated stump will retract out of sight within the internal ring. If the freeing is inadequate the stump remains adherent at the internal ring, a potential hazard for the future. The most obvious justification for this attitude is that the recurrence rate achieved for primary indirect inguinal hernia repair is 10%. Utilising these same principles, the treatment of sliding indirect inguinal hernia is an extension of this argument. It converts a difficult operation into an easy one. Once identified the sliding hernia is simply freed completely at the internal ring and reduced within it without further treatment even when large. The recurrence rate for sliding indirect hernia so achieved was also 1 %, and indeed few of these recurrences were sliding themselves (6). Sliding hernias are nearly always indirect and left-sided. They occur usually in men who are overweight and more than 50 years old. At this stage careful examination at the internal ring will detect the rare unsuspected interstitial hernia. In the absence of an indirect inguinal hernia a peritoneal protrusion must be identified on the cord at the internal ring as a small whitish convex crescent. This eliminates the risk of missing an indirect hernia, especially if the surgeon's attention is already focussed on an obvious direct hernia. The combination of an indirect and direct hernia is encountered in 8% of cases. Inguinal hernia repair using local anaesthesia 383 The two cremasteric leaves are now excised. This important step clearly demonstrates the whole posterior inguinal wall. If omitted a direct hernia may be missed. POSTERIOR INGUINAL WALL AND THE TRANSVERSALIS LAMINA The dissection and treatment of this layer is the second main component of any inguinal hernia operation and is of vital importance. Primary indirect hernia is twice as common as primary direct, yet recurrent indirect is less common than recurrent direct. This finding reflects the importance of the quality of the repair. The repair performed here and described in detail later is based upon an oblique linear division of the transversalis with subsequent overlap of the two leaves so obtained, both leaves being considered important. In the Cooper ligament repair (7-9) the lower part of the transversalis, which is equivalent to the lower leaf just described, is not utilised because it is not attached to the inguinal ligament (10). BILATERAL REPAIRS One patient in 10 has a bilateral hernia on admission. Using local, the repairs are staged 48 hours apart for several reasons. A simultaneous bilateral repair would double the volume of local used. The timing of the second repair may be altered; for example, in patients who have bilateral recurrent hernia or unilateral testicular atrophy, or in an elderly patient in whom the first repair was difficult, or in an extremely obese or tense individual. Occasionally the patient decides upon delay. The external pudendal vessels should be preserved on one side at least to minimise prepuceal oedema. Recurrence rates in bilateral repairs are slightly higher. Possibly tension is a factor. TESTIS Orchidectomy is rarely performed. It is usually possible to preserve the testis even in cases with multi-recurrent hernia. The recurrent hernia patient is routinely warned of the risks and a consent form for orchidectomy should be obtained in most cases. Testicular atrophy postoperatively is uncommon. In recurrences where records are unavailable the cord may lie subcutaneously and be easily damaged. Patients of all ages welcome a conservative attitude to testicular problems. Length of hospital stay and economics (11) Medical care costs rise rapidly everywhere.. With good surgery very early discharge from hospital is possible, consistent with an early return to work and good long term results (12). A period off work of longer than 4 weeks is rarely authorised. A greater combined effort on the part of both surgeon and GP would help shorten longer periods allowed elsewhere. Patients here are ambulant throughout. They remain in hospital 2 or 3 days because many live far away and earlier travel is inconvenient. In 1972 the average hospital stay in one large centre in Britain was 10 days but now everywhere these periods are very much shorter. One study showed that patients ambulant early did better in all respects than those kept for longer periods in bed (13). Some operations are performed on an outpatient or day care basis (14-17). Hernias in women Groin hernias are approximately 25 times less common in women. While the inguinal-femoral ratio is 40 to 1 in men and only 3 to 1 in women nevertheless inguinal hernia is also more frequent in women (18). However in women a primary inguinal hernia is almost always indirect. Primnary direct hernia is very rare because the posterior inguinal wall is strong (19). This is a good reason for performing a low operation for repair of a primary femoral hernia in women. However, recurrent direct inguinal hernia in women is more

4 384 Frank Glassow common than recurrent indirect suggesting an iatrogenic aetiology. Follow-up With the very large and ever-increasing number of repairs performed here follow-up becomes increasingly more difficult, burdensome and expensive. Completely adequate long term follow-up of very large series is impossible for a number of reasons, such as shifting population, loss through death and indifference to correspondence. The data assembled here were from a combined survey consisting of an annual examination at this hospital, an examination by a local physician or a reply to a questionnaire. The argument that the patient who is lost to the follow-up may be the one with the recurrence is unanswerable, but unlikely. All the evidence we can muster is to the contrary. Of all recurrent hernias which followed a repair here, 50, had developed at the end of 5 years, and 750' at the end of 10 years. This suggests a minimum follow-up period of 10 years. If such rates are plotted graphically it is possible to predict eventual long term recurrence rates if the rates for a shorter period are known. Recurrences One of the main criteria of success in any series of inguinal hernia repairs is the recurrence rate. As recently as 1977 a British Medical Journal editorial quoted the recurrence rates for indirect hernias at 5-100, for direct hernias 15-20o0 and for recurrent inguinal hernias 300g. I consider these rates all too high. Using a careful technique, not necessarily the one described here (20), a surgeon should aim at 100 for repair of primary inguinal hernia, whether indirect or direct. Table I represents my personal recurrence rates in a favourable light since no 'allowance' has been made for the more recent repairs. I have reoperated upon 85 of these 141 recurrences. By discontinuing consideration of all cases operated on after 1971 but continuing the follow-up for a further 10 years Table II represents more closely what I consider my ultimate recurrence rate for repair of primary inguinal hernia will be. In 2412 of the 2524 personal repairs for recurrent inguinal hernia documented in Table III the original repair had been performed elsewhere while in the remaining 112 the initial repair was performed by me. Understandably these rerecurrence rates are higher than the recurrence rates achieved in the primary series. Many of the recurrent repairs were performed on patients who had undergone 2,3, 4,5 and 6 previous repairs elsewhere. With the follow-up continuing for a further 10 years for all recurrent inguinal hernia repairs performed up to 1971 Table IV likewise represents closely my ultimate re-recurrence rates for this group of cases. For a number of years now some surgeons in the USA and in the UK have been using essentially the technique described here. Each surgeon listed in Table V has a 10-year series or more. I am grateful to them all for providing me with the opportunity of summarising the up-to-date figures which they sent me and for their permission to publish them. Suture materials Monofilament stainless steel wire gauge number 34 is the suture material preferred. Occasionally number 32 is needed for greater strength. Other surgeons use different nonabsorbable sutures achieving excellent results. Absorbable sutures are unsatisfactory and should be abandoned. A continuous suture technique is used and is considered important because it distributes tensions evenly. I have repaired many direct inguinal recurrences in patients in whom individual non-absorbable sutures were visible on either side of the neck of the hernia. It was considered that such ligatures were either inadequately placed or tied with uneven tension. Although mesh is popular with some surgeons I have never used it even for the largest hernias. Indeed I have TABLE I Personal series-primary inguinal herniorrhaphies, Type of No of No. of % of primary hernia repairs recurrences recurrences Indirect Direct Combined indirect and direct Total TABLE II Personal series primary inguinal herniorrhaphies, (followed to 1981) Type of No. of Noo. of h0of primary hernia repairs recurrences recurrences Indirect Direct Combined indirect and direct Total TABLE III Personal series recurrent inguinal herniorrhaphies, Type of No. of No. of re- h of rerecurrent hernia recurrences recurrences recurrences Indirect Direct Total TABLE IV * Personal series recurrent inguinal herniorrhaphies, (followed to 1981) Type of No of No. of re- 0 of rerecurrent hernia recurrences recurrences recurrences Indirect Direct Total TABLE V Other surgeons' series inguinal herniorrhaphies (Shouldice repair) No. of No. of % of Name repairs recurrences recurrences Barwell (UK) Berliner (USA) Burson (USA) Devlin (UK) Dunn (USA) Shearburn (USA) Wantz (USA) Total encountered it many times in repair of recurrent hernia and often have removed it. Posterior inguinal wall: examination and principles of repair (21,22) The assessment of the strength of the posterior inguinal wall is fundamental. This is accomplished first by inspection and then by testing its strength using a finger inserted at the internal ring deep to the transversalis plane. A direct

5 Inguinal hernia repair using local anaesthesia FIG. 1 Intended line of incision of transversalis lamina. FIG. 2 Division of transversalis lamina. FIG. 3 First line of sutures. FIG. 4 Second line of sutures. 385 These figures were previously published in 'Hernia, 2nd edition' edited by L M Nyhus and R E Condon and are reproduced by permission of Lippincott, Philadelphia. FIG. 5 Third line of sutures.

6 386 Frank Glassow inguinal hernia is obvious or will be demonstrated by this manoeuvre. In some cases only a weakness is present. In either circumstance a standard repair is applicable. The opening in the transversalis already made at the internal ring (Fig. 1) is extended medially towards the pubic bone over the centre of the direct hernia which is freed. If the transversalis is strong medially it may be left undivided. Attenuated excess transversalis may require excision. Nevertheless, firm transversalis of satisfactory quality can always be found even in the presence of a large direct or a recurrent direct hernia. A funicular direct sac is excised. Otherwise the more common diffuse direct hernia is simply reduced. The lower leaf of the divided transversalis should be wider than the upper (Fig. 2). In the subsequent repair it is carried upwards and medially beneath the upper leaf which is then brought downwards over it. This overlap is further strengthened by another immediately superficial to it bringing muscular structures medially to the inguinal ligament laterally. Posterior inguinal wall: details of repair technique In the reconstruction of the posterior wall 4 continuous lines of gauge number 34 stainless steel wire are inserted using only 2 separate sutures each being responsible for 2 lines. The first line starts medially at the pubic bone (Fig. 3) where it attaches the free edge of the lower transversalis flap to the posterior aspect of the lateral edge of the rectus, easily identified as a white border inserting on to the pubic bone. The suture should start as far medially as possible and be tied without tension. The entire free edge is now attached under the upper flap. After one or two small bites on the rectus it picks up the deep surface of the transversus and internal oblique as it travels laterally. Just medial to the internal ring the upper lateral ligated cremasteric stump is included in this first line. Small bites without tension are used. At the internal ring the inferior epigastric vessels are avoided. After completion of this line it can be seen that quite a firm barrier has already been established and the defect or weakness eliminated. The suture is reversed and continues medially as the second line (Fig. 4). It brings the upper flap of divided transversalis downwards and laterally to the shelving surface of Poupart's ligament until it reaches the pubic bone again, where it is tied. This overlap strengthens the first layer and is particularly effective in the occasional case in which the first layer is of poor quality. The third line (second suture) commences at the internal ring. Travelling medially (Fig. 5) it reinforces the subjacent lines, bringing the internal oblique and transversus lying medially to the deep surface of the inguinal ligament laterally. At the pubic bone it is reversed and travels laterally again utilising the same structures. At the internal ring it is tied. The repair should be performed without tension. Relaxing incisions are not used. The spermatic cord should slide easily into the internal ring and the cord veins should not be engorged. The cord is replaced deep to the external oblique. The subcutaneous plane is separately closed eliminating dead space. Michel's skin clips are used. Typically a primary inguinal repair takes about 40 minutes. A once recurrent repair might take 80 minutes while a more difficult multi-recurrent repair 2 or 3 hours. Discussion It is customary to give a general anaesthetic when repairing an inguinal hernia. It is hoped that this paper has demonstrated how successfully such patients can be managed using local anaesthesia. Its indications and advantages have been intentionally described in detail in the hope that it may eventually become the anaesthetic of choice. Emphasis is laid on the detailed appreciation of the anatomy of the inguinal canal, in particular the internal ring and the transversalis lamina. The technique used here has been carefully described so that hopefully other surgeons may be persuaded of its efficacy. In our hands it has resulted in a short hospital stay, early return to a normal life style and a recurrence rate of approximately 10% for repair of primary inguinal hernia. Conclusion In 1971 Professor L M Zimmerman (23) of Chicago said 'The larger the series the more valuable are the figures offered and the percentage of patients returning for the follow up is also of great significance...' Moreover... 'Hernia surgery demands meticulous technique, gentle handling of tissues, free anatomical exposure, accurate approximation of sutured structures, avoidance of tension and utilization of fine atraumatic needles and suture materials. The disregard of any of these attributes of good surgery will be reflected in a higher recurrence rate. With the same method the results will vary with the skill of the surgeon.' The last Hunterian Lecture on this topic was given 43 years ago by Sir Cecil Wakeley (24) in We have come a long way since then. Some of his opinions we no longer hold. For example, he said in that address that '... the question of operation for direct inguinal hernia is not so important because many patients are content to wear a truss. Operation is not nearly so satisfactory.' Regarding after-care he said'... the patient should remain in bed for at least two weeks after operation, should have a month's convalescence and should not do any hard work for at least six months'. Later he said '... nearly all the recurrences are seen in the first two years after the operation'. However in many other respects the opinions that he held then do hold true today. He said '.. gentleness is the secret of success'. I heartily concur. And he said '... but the operation whatever it be must restore structures in the inguinal canal as closely as possible to their normal conditions'. I leave his most telling comments to the very end of this presentation because he said them more eloquently than I am able. He said '... that so little interest is taken in the care of a hernia is a pity. The various operations are usually regarded as of minor importance and to be undertaken by a house surgeon being beneath the dignity of a surgeon. A surgeon can do more for the community by operating on hernia cases and seeing that his recurrence rate is low than he can by operating on cases of malignant disease.' I hope that this presentation has persuaded present day surgeons of the wisdom of those final comments made by Sir Cecil Wakeley so long ago. References I Makuria T, Alexander-WilliamsJ, Keighley MRB. Comparison between general and local anaesthesia for groin hernias. Ann R Coll Surg Engl 1982;64: Hashemi K, Middleton MD. Subcutaneous bupivacaine for postoperative analgesia after herniorrhaphy. Ann R Coll Surg Engl 1983;65: Nicholls JC. Necessity into choice: an appraisal of inguinal herniorrhaphy under local anaesthesia. Ann R Coll Surg Engl 1977;59: Teasdale C, McCrum A, Williams NB, Horton RE. A randomised controlled trial to compare local with general anaesthesia for short-stay inguinal repair. Ann R Coll Surg Engl 1982;64: Glassow F. High ligation of the sac in indirect inguinal hernia. Am J Surg 1965; 109: Ryan, EA. Analysis of 313 consecutive cases of indirect sliding inguinal hernias. Surg Gynecol Obstet 1956; 102: McVay CB. Inguinal and femoral hernioplasty. Surgery 1965;57: Halverson K, McVay CB. Inguinal and femoral hernioplasty: a 22-year study of the authors' methods. Arch Surg 1970; 101: Glassow F. Inguinal hernia repair: a comparison of the Shouldice and Cooper ligament repair of the posterior inguinal wall. Am J Surg 1976; 131 :

7 10 Glassow F. Short-stay surgery (Shouldice technique) for repair of inguinal hernia. Ann R Coll Surg Engl 1976;58: Devlin HB, Russell IT, Muller D, Sahay AK, Tiwari PN. Shortstay surgery for inguinal hernia. Clinical outcome of the Shouldice operation. Lancet 1977; 1: Adler MW. Randomised controlled trial of early discharge for inguinal hernia and varicose veins. Ann R Coll Surg Engl 1977;59: Palumbo LT, Sharpe WS. Primary inguinal hernioplasty in the adult. Surg Clin North Am 1968;48: Farquharson EL. Early ambulation with special reference to herniorrhaphy as outpatient procedure. Lancet 1955;2: Bellis CJ inguinal herniorrhaphies using local anesthesia with one day hospitalisation and unrestricted activity. Int Surg 1975;60: Ruckley CV. Day case and short stay surgery for hernia. Br J Surg 1978;65: Goulbourne IA, Ruckley CV. Operations for hernia and varicose veins in a day-bed unit. Br MedJ 1979;2: Inguinal hernia repair using local anaesthesia Glassow F. Inguinal hernia in the female. Surg Gynecol Obstet 1963;1 16: Glassow F. An evaluation of the strength of the posterior wall of the inguinal canal in women. BrJ Surg 1973;60: Kirk PM. Which inguinal hernia repair? Br Med J (Clin Res) 1983;287: Glassow F. The Shouldice repair of inguinal hernia. In: Varco RL, Delaney JP, eds. Controversy in surgery. Philadelphia: WB Saunders, 1976; Glassow F. The Shouldice repair of inguinal hernia. In: Nyhus LM, Condon RE, eds. Hernia, 2nd edition. Philadelphia: JB Lippincott, 1978: Zimmerman LM. The use of prosthetic materials in the repair of hernias. Surg Clin North Am 1968;48: Wakeley CPG. Treatment of certain types of external herniae. Lancet 1940; 1: Notes on books Retinal Detachment Surgery by J S Schutz. 140 pages, illustrated. Chapman and Hall/Associated Book Publishers, Hampshire The book starts with the diagnosis and assessment of retinal detachment in relationship to timing of surgery. Subsequent chapter deal with exposure, anaesthesia and various techniques that can be used. Intracranial Aneurysms edited by J L Fox. Volume I, 604 pages, illustrated. $ Volume II, 497 pages, illustrated. $ Volume III, 360 pages, illustrated. $ Springer-Verlag, Berlin. The Editor is Professor of Neurosurgery at West Virginia University Medical Centre. In his three volumes he offers a complete review of this rapidly expanding subject. In particular he includes an up-todate view on the phenomenon of vasospasm with a discussion of aetiology and pathogenesis. He presents the variations in vascular anatomy, neuroradiologic diagnosis and therapy and the role of neuroanaesthesia and life support systems in management. Volume I has the epidemiology, clinical features, complications, assessment and methods of research. Volume II discusses anaesthesia, craniotomy and aneurysm surgery. Volume III discusses the classification, the world literature and the relation of aneurysms to brain and neoplasms, aortic stenosis and polycystic kidneys. It also includes familial intracranial aneurysms, mycotic, oncotic and traumatic intracranial aneurysms. The books are beautifully produced and illustrated. Problems in Head and Neck Surgery by 0 H Shaheen. 191 pages, illustrated. Bailliere Tindall, Eastbourne. f The author is the director of the Head and Neck Oncology Clinic at Guy's Hospital, London. He describes surgery of the thyroid, parathyroid and parotid glands together with considerations of radical neck dissection, repair ofdefects and problems related to the ear, oral cavity, larynx, trachea, hypopharynx and oesophagus. The chapters are illustrated with simple clear line drawings. Trauma and the Anaesthetist by J C Stoddart. 189 pages, illustrated. Bailliere Tindall, Eastbourne. [ This book offers a practical guide on the handling of traumatised patients and should therefore be of value not only to anaesthetists but also to casualty officers and those concerned in emergency rescue services. Its individual chapters point out priorities in care, the management of shock, the upper airway and the management of chest injuries. Subsequent chapters deal with individual disorders associated with trauma. The Design and Utilization of Operating Theatres edited by I D A Johnston and A R Hunter. 190 pages, illustrated. Edward Arnold, London. [ This book, with a foreword by Professor G Slaney PRCS, is the result of work done at the Royal College of Surgeons of England to determine operating theatre requirements in relationship to surgical training. It has contributions on safety by the Faculty of Anaesthetists of the Royal College. Topics include the objectives in planning theatre suites, bacteriological and air conditioning requirements, sterility, anaesthetic requirements and the need for education training and research. Individual requirements for other specialities than general surgery are also considered and in the appendicies there are planning norms in relation to the provision of operating theatres and a list of selected references on planning and design of operating departments. Clinical Transcutaneous Electrical Nerve Stimulation by J S Mannheimer and G N Lampe. 636 pages, illustrated. F A Davis/European book service, Weesp, Netherlands. $ The review of transcutaneous electrical nerve stimulation displays its role in the treatment of acute chronic and postoperative pain. It discusses all aspects including limitations and contraindications. Of particular interest to surgeons and anaesthetists are chapters on postoperative use in analgesia. continued on page 398