Evaluation of inguinal hernia repair using post-operative pain and quality of life metrics

BACKGROUND AND PURPOSE

Elective inguinal hernia repair is a ubiquitous procedure that carries risks; chronic pain and impacts on quality of life (QoL) must be considered when advising patients around repair. The length of time from surgery date and impacts on quality of life are often limited to only a few years of follow-up and despite hernia repair being quite common, long-term outcomes are not often reported.

METHODS

A cohort of patients who had received Lichtenstein inguinal hernia repair over the previous 10 years were contacted and surveyed using the Brief Pain Inventory Short Form (BPI) to assess chronic pain and its effects on their QoL. Patient and operative factors were correlated with pain through linear regression and t-test analysis provided statistical significance for mean comparisons (P < 0.05).

RESULTS

The rate of chronic pain was 17.2% with recurrence of 3.1% at an average post-operative interval of 5.84 years. Of the various metrics compared between groups, age was one of the only significant predictors of chronic pain with younger patients reporting higher pain. Further time from surgery also translated to significantly less pain with a difference of 1.3 years. BPI respondents identified pain that interfered to varying degrees in different aspects of life but had relatively low average magnitudes (range: 1.82/10-2.91/10).

CONCLUSIONS

These long-term considerations of post-surgical impact should be considered alongside potential benefits when advising patients about surgery and may help moderate post-operative expectations to optimize the outcome of common inguinal hernia repairs.

Mortality after emergency versus elective groin hernia repair: a systematic review and meta-analysis

BACKGROUND

Emergency groin hernia repair is associated with increased mortality risk, but the actual risk is unknown. Therefore, this review aimed to investigate 30- and 90-day postoperative mortality in adult patients who had undergone emergency or elective groin hernia repair.

METHODS

This review was reported following PRISMA 2020 guidelines, and a protocol (CRD42021244412) was registered to PROSPERO. A systematic search was conducted in PubMed, EMBASE, and Cochrane CENTRAL in April 2021. Studies were included if they reported 30- or 90-day mortality following an emergency or elective groin hernia repair. Meta-analyses were conducted when possible, and subgroup analyses were made for bowel resection, sex, and hernia type. According to the study design, the risk of bias was assessed using either the Newcastle-Ottawa Scale or Cochrane Risk of Bias tool.

RESULTS

Thirty-seven studies with 30,740 patients receiving emergency repair and 457,253 receiving elective repair were included. The 30-day mortality ranged from 0-11.8% to 0-1.7% following emergency and elective repair, respectively. The risk of 30-day mortality following emergency repair was estimated to be 26-fold higher than after elective repair (RR = 26.0, 95% CI 21.6-31.4, I2 = 0%). A subgroup meta-analysis on bowel resection in emergency repair estimated 30-day mortality to be 7.9% (95% CI 6.5-9.3%, I2 = 6.4%). Subgroup analyses on sex and hernia type showed no differences regarding the mortality risk in elective surgery. However, femoral hernia and female sex significantly increased the risk of mortality in emergency surgery, both given by a risk ratio of 1.7.

CONCLUSION

The overall mortality after emergency groin hernia repair is 26-fold higher than after elective repair, but the increased risk is attributable mostly to female and femoral hernias.

TRIAL REGISTRATION

PROSPERO protocol (CRD42021244412).

Local anesthesia as an alternative option in repair of recurrent groin hernias: An outcome study from the American College of Surgeons NSQIP® database

Introduction

There is a dearth of data about the benefits of local anesthesia (LA) and spinal anesthesia (SA) compared to general anesthesia (GA) in patients undergoing repair of recurrent groin (inguinal/femoral) hernias. We hypothesized that patients with recurrent hernias who undergo repair under LA and SA will have a better outcome.

Methods and procedures

Using the 2017 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP)® database, patients who underwent open repair of recurrent groin hernias were identified and divided into three groups: GA, SA, and LA. Outcomes evaluated included 30-day mortality and morbidity, operative time, total hospital length of stay (LOS), and reoperation and readmission rates.

Results

A total of 2169 patients were identified of which 1847 (85.2%) were in GA, 53 (2.4%) in SA, and 269 (12.4%) in LA groups. Overall, no statistically significant differences in demographics and comorbidities between the three groups were identified. However, patients in GA were younger and healthier with lower ASA Class (I-II) as compared to SA and LA groups. Patients in SA had a higher rate of COPD, and their overall operative time was shorter. However, LA patients had shorter LOS, and most LA patients were discharged home on the same day compared to GA, SA (92.2% vs. 77.9%, and 73.6%, p < 0.001). No differences in 30-day mortality and morbidity or reoperation and readmission rates between the three groups were noted.

Conclusion

There is an underutilization of LA in patients undergoing open repair of recurrent inguinal hernia despite favorable outcomes, even in high-risk patients, when compared to GA and SA. Further prospective studies are needed to explore the potential barriers and cost-effectiveness of implementing LA as a primary anesthetic technique in inguinal hernia repair.

Postoperative clinical outcomes and inflammatory markers after inguinal hernia repair using local, spinal, or general anesthesia: A randomized controlled trial

Background

No consensus has yet been reached regarding the best anesthetic technique for inguinal hernia repair. This study aimed to compare postoperative clinical outcomes and inflammatory markers among patients who were anesthetized using local, spinal, or general anesthesia for inguinal hernia repair.

Methods

This randomized controlled trial included patients scheduled to undergo elective unilateral inguinal hernioplasty at Siriraj Hospital during November 2014 to September 2015 study period. Patients were randomly assigned to the local (LA), spinal (SA), or general (GA) anesthesia groups. Primary outcomes were postoperative pain at rest and on mobilization at 8 and 24 hours after surgery.

Results

Fifty-four patients were included, with 18 patients randomly assigned to each group. Patient demographic and clinical characteristics were similar among groups. There were no significant differences among groups for postoperative pain at rest or on mobilization at 8 and 24 hours after surgery. No significant differences were observed for interleukin-1β, interleukin-6, and interleukin-10 at any time points in any groups. Patients with local anesthesia was associated with less time spent in anesthesia (p = 0.010) and surgery (p = 0.009), lower intraoperative cost (p = 0.003) and total cost in hospital (p = 0.036); however, patient satisfaction in the local anesthesia group (94/100) was statistically significantly lower than the spinal and general anesthesia groups (100/100) (p = 0.010).

Conclusions

No statistically significant difference was observed among groups for postoperative pain scores, duration of hospital stays, complications, or change in inflammatory markers. However, time spent in anesthesia and surgery, the intraoperative cost and total cost for hernia repair, and patient satisfaction were significantly lower in the local anesthesia group than in the other two groups.

Using Local Anesthesia for Inguinal Hernia Repair Reduces Complications in Older Patients

BACKGROUND

Inguinal hernia repair is the most common general surgery operation in the United States. Nearly 80% of inguinal hernia operations are performed under general anesthesia versus 15%-20% using local anesthesia, despite the absence of evidence for the superiority of the former. Although patients aged 65 y and older are expected to benefit from avoiding general anesthesia, this presumed benefit has not been adequately studied. We hypothesized that the benefits of local over general anesthesia for inguinal hernia repair would increase with age.

MATERIALS AND METHODS

We analyzed 87,794 patients in the American College of Surgeons National Surgical Quality Improvement Project who had elective inguinal hernia repair under local or general anesthesia from 2014 to 2018, and we used propensity scores to adjust for known confounding. We compared postoperative complications, 30-day readmissions, and operative time for patients aged <55 y, 55-64 y, 65-74 y, and ≥75 y.

RESULTS

Using local rather than general anesthesia was associated with a 0.6% reduction in postoperative complications in patients aged 75+ y (95% CI -0.11 to -1.13) but not in younger patients. Local anesthesia was associated with faster operative time (2.5 min - 4.7 min) in patients <75 y but not in patients aged 75+ y. Readmissions did not differ by anesthesia modality in any age group. Projected national cost savings for greater use of local anesthesia ranged from $9 million to $45 million annually.

CONCLUSIONS

Surgeons should strongly consider using local anesthesia for inguinal hernia repair in older patients and in younger patients because it is associated with significantly reduced complications and substantial cost savings.

Serotonin enhances oxybuprocaine- and proxymetacaine-induced cutaneous analgesia in rats

The aim of the study was to investigate the analgesic effects of adding serotonin to oxybuprocaine or proxymetacaine preparations. We employed a rat model of the cutaneous trunci muscle reflex (CTMR) to conduct the dose-response curves and duration of drugs (oxybuprocaine, proxymetacaine, or serotonin) as an infiltrative anesthetic. The use of isobolographic methods to analyze the drug-drug interactions. We showed that oxybuprocaine and proxymetacaine, as well as serotonin produced dose-dependent skin antinociception. On the basis of 50% effective dose (ED₅₀), the rank order of drug potency was serotonin [7.22 (6.45-8.09) μmol/kg] < oxybuprocaine [1.03 (0.93-1.15) μmol/kg] < proxymetacaine [0.59 (0.53-0.66) μmol/kg] (P < 0.01 for each comparison). The sensory block duration of serotonin was longer (P < 0.01) than that of oxybuprocaine or proxymetacaine at the equipotent doses (ED₂₅, ED₅₀, and ED₇₅). The mixture of serotonin with oxybuprocaine or proxymetacaine produced a better analgesic effect than the drug itself. We have concluded that oxybuprocaine, proxymetacaine, or serotonin displays dose-related cutaneous analgesia. Oxybuprocaine or proxymetacaine is more potent and has a shorter duration of cutaneous analgesia than serotonin. Serotonin produces a synergistic antinociceptive interaction with oxybuprocaine or proxymetacaine.

Comparison between dexmedetomidine and midazolam as a sedation agent with local anesthesia in inguinal hernia repair: randomized controlled trial

PURPOSE

In Japan, inguinal hernia repair is widely performed with local anesthesia. The objective of this study was to evaluate safety and efficacy of intravenous dexmedetomidine as a sedation agent with local anesthesia in inguinal hernia repair.

METHODS

We performed this randomized, single-blind study for 200 patients who were scheduled to undergo inguinal hernia repair with local anesthesia. Patients were randomly divided into two groups (dexmedetomidine group: Group D, midazolam group: Group M). The primary outcome was to evaluate the safety of intravenous dexmedetomidine. Secondary outcomes were to analyze results of operators' surveys and patients' questionnaires and evaluate implementation of conscious sedation.

RESULTS

Incidence of respiratory depression was significantly higher in Group M than Group D (p = 0.03). Other adverse events examined did not differ significantly. All three operators' questionnaires indicated that results were better in Group D than Group M. More than 70% of patients in both groups were satisfied with the surgery. More than 80% of Group D patients and 74% of Group M patients achieved a state of conscious sedation.

CONCLUSION

This study demonstrated that intravenous dexmedetomidine during hernia repair with local anesthesia is safe and the results were satisfactory to both operators and patients.

Gender disparities in the utilization of laparoscopic groin hernia repair

BACKGROUND

Clinical treatment guidelines have suggested that laparoscopic hernia repair should be the preferred approach in both men and women with bilateral or recurrent elective groin hernias. Anecdotal evidence suggests, however, that women are less likely to undergo a laparoscopic repair than men, and therefore, we aimed to delineate if these disparities persisted after controlling for patient factors and comorbidities.

MATERIALS AND METHODS

The American College of Surgeons National Surgical Quality Improvement Project data were abstracted for all elective groin hernia repairs between 2005 and 2014. Univariate analysis was used to compare rates of laparoscopic surgery between men and women. Multivariable analysis was performed, controlling for patient demographics, preoperative comorbidities, and year of surgery.

RESULTS

Over the 10-y period, 141,490 patients underwent elective groin hernia repair, of which 13,325 were women (9.4%). The rate of general anesthesia utilization was high in both men (81.3%) and women (77.2%) with 75.1% of open repairs being performed under general anesthesia. Overall, 20.2% of women underwent laparoscopic repair compared with 28.0% of men (P < 0.01). Women tended to be older, had a lesser body mass index, and slightly greater American Anesthesia Association (all P < 0.05). On multivariable regression, women had decreased odds of undergoing a laparoscopic approach compared with men (odds ratio: 0.70; 95% confidence interval, 0.67-0.73, P < 0.01).

CONCLUSIONS

In the elective setting, women were less likely to undergo laparoscopic repair of groin hernias than men. Although we are unable to ascertain underlying causes for these gender disparities, these data suggest that there remains a disparity in the management of groin hernias in women.