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Intra-abdominal and intra-oral blowing pressure: preference for laparoscopic inguinal hernia repair in wind instrument players.

F.M. (Frits) van der Linden, M.D. General surgeon, Groene Hart Ziekenhuis, Gouda
A.B.M. (Boni) Rietveld, M.D., B.A.(mus.), orthopaedic surgeon & musician, Medical Centre for Dancers & Musicians, MCH , The Hague.

In the treatment of inguinal hernia, in the last 2 decades the use of polypropylene mesh has become the standard technique, usually placed anteriorly (“outside”) using a standard inguinal incision and performed with loco-regional anaesthesia. Laparoscopic treatment of inguinal hernias is becoming more popular, in which the mesh is placed in the pre-peritoneal space, posteriorly (“inside”), by using laparoscopic techniques and equipment. Anatomically, this “inside” location seems to be ideal because under intra-abdominal pressure the mesh is compressed against the abdominal wall, thus closing the hernia (instead of the mesh being pushed away from the abdominal wall by intra-abdominal pressure if it is placed anteriorly (“outside”) using the standard “open” technique). Besides, less postoperative pain, quick recovery, and fewer recurrences are described. The disadvantage is that general anaesthesia is used, the technique is more difficult to learn in residency, and, above all, it is more expensive.

Due to the high pressures that may be produced during trumpet playing, the laparoscopic, pre-peritoneal technique seems more suitable for trumpet players suffering pain from an inguinal hernia. To analyze and describe pressure differences in the oral cavity and intra-abdominal space (urinary bladder) during trumpet playing, measurements were made with standard equipment normally used for patients in intensive care.

Bladder pressure is a good representative of intra-abdominal pressure, which normally is 0 – 10 mmHg ( = 0 - 1,33 kPa *). In the diagnosis of so-called abdominal compartment syndrome, this technique is used in every-day clinical practice on intensive care units. A continuous pressure above 25 mm Hg (= 3.33 kPa * is believed to decrease blood flow to the intra-abdominal organs and lead to decreased kidney function and hemodynamic regulation problems.

In our study, we used a semi-professional trumpet player, in whom a bladder catheter was placed and connected to a monitor. Measurements were made while the trumpet player played different types of trumpets and musical passages. Then, the same measurements were repeated using a different catheter in the oral cavity during playing. Bloodpressure was monitored during testing and raised slightly from 115 / 75 mmHg to 130 / 90 mmHg (= 15,3 / 9,98 kPa to17,29 / 11,97 kPa *). Low, medium, and high tones were produced, with different levels of loudness. Low volume and low sounds produced pressures of 45 – 60 mmHg (= 5,99 – 7,98 kPa *). Pressures rose to a maximum of 140 mmHg(= 18.62 kPa *) during high tones with high-volume playing. Above these pressures, the soft palate did leak air into the nasal cavity as a kind of “safety valve”. The pressure differences during all these measurements were equal in the oral cavity and urinary bladder.
Pressures during lifting 20 kg (= 44 lbs.) raised to 20 mmHg (= 2,66 kPa *) only, during yelling to 85 mmHg ( = 11,31 kPa *) and during coughing and laughing up to 120 mmHg ( = 16,96 kPa *).

Allthough we are aware this is a pilot-study, we conclude that rising tones and rising blowing volume in trumpet playing do increase the pressures in the oral cavity and urinary bladder equally, up to a maximum pressure of 140 mmHg(= 18.62 kPa *). This is well above diastolic and even above systolic bloodpressure and thus must compress the vena cava totally, blocking blood flow to the heart. Unexpectedly, laughing produces much higher intra-abdominal pressures than lifting.

Because of the high pressures that are produced during trumpet playing, the laparoscopic, preperitoneal technique is recommended for trumpet players, suffering pain from an inguinal hernia.

* 1 mmHg = 1.36 cmH2O = 0.133 kPa = 0.0193 PSI

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