Pre-peritoneal local anaesthetic does not reduce post-operative pain in laparoscopic total extra-peritoneal inguinal hernia repair: double-blinded randomized controlled trial

PURPOSE

Laparoscopic total extra-peritoneal hernia repair (TEP) is associated with less post-operative pain and earlier return to normal activity compared to open hernia repair (OHP). Despite this, post-operative pain remains a major issue. The aim of this double-blinded randomized controlled trial was to identify whether the instillation of local anaesthetic in the pre-peritoneal space improves pain scores following TEP.

METHODS

One hundred patients undergoing laparoscopic total pre-peritoneal hernia repair (TEP) between the years of 2009-2014 were included. Patients were randomly assigned to receive either 20 mL of normal saline or 0.25% bupivacaine with adrenaline. Visual analogue scores (VAS 0-10) were recorded post-operatively at the 4 h, 1 day, 2 weeks, and 6 week mark. Secondary endpoints included complications, time to discharge, and return to normal activity.

RESULTS

51 patients were allocated to the local group. 49 patients were allocated to the placebo group. The baseline characteristics and demographics of patients in both groups were comparable. Patients in the local group had similar VAS scores compared to the placebo group at both 4 h (1.1 vs. 1.4, respectively; p = 0.19) and 24 h (2.1 vs. 2.3; p = 0.63). No statistically significant difference noted in other primary and secondary outcomes.

CONCLUSION

Although the concept of pre-peritoneal local anaesthetic instillation following laparoscopic TEP is attractive, this appropriately powered study has failed to show any advantage in pain scores at 4 and 24 h. The pain scores recorded, however, were remarkably low in both groups.

A comparison of the cost of primary closure or rectus abdominis myocutaneous flap closure of the perineum after abdominoperineal excision

AIM

Perineal wound complications following abdominoperineal resection continue to be a major challenge. The aim of this study was to compare the clinical outcomes and cost of primary closure (PC) and rectus abdominis myocutaneous (RAM) flap reconstruction.

METHOD

This was a retrospective case review of consecutive patients by one surgeon over 11 years. Patient demographics, risk factors, operative details and complications were identified. Inpatient and outpatient costs were calculated.

RESULTS

A total of 31 patients underwent a RAM reconstruction and 37 a PC. There were no significant differences in the incidence of wound complications or in the overall costs for either method of perineal closure. When there were no complications the mean costs were significantly higher in the RAM group ($20 948 vs $17 189, P = 0.005), mainly because of the longer operating time. However, the costs of perineal wound complications were greater in the PC group (8394 vs 25 911, P = 0.012). These wounds took longer to heal (median 2 months vs 5.5 months, P = 0.005) and more often required a further reconstructive surgical procedure (RAM 0 vs PC 8, P = 0.006).

CONCLUSION

This is the first study reporting on the cost implications of PC and RAM flap reconstruction. The overall costs were similar. This implies appropriate clinical selection when choosing between procedures. While the RAM flap is more expensive to perform, the finding that it decreases the clinical severity and cost of perineal wound complications supports its use when there is a high risk of perineal wound complications.

Laparoscopic excision of a retrorectal schwannoma

Retrorectal tumors are uncommon and are usually managed by open surgical excision. Recent advances in laparoscopic techniques have led to the use of laparoscopy for a variety of problems in colorectal surgery, including the excision of retrorectal tumours. This case report, which describes the laparoscopic excision of a benign schwannoma arising from the second sacral nerve root, highlights the benefits of accurate preoperative diagnosis with MR imaging and the advantages of a laparoscopic approach while pointing out principles that should be adhered to when using this approach. The tumour was successfully resected without neural compromise and with a prompt and full postoperative recovery.

A case report of acute gastric volvulus with avulsion of the splenic vessels

Gastric volvulus is a rare condition which usually presents with intermittent abdominal pain. It is typically associated with a paraoesophageal hiatus hernia and may present with acute strangulation or perforation. The mortality associated with an acutely obstructed volvulus may be up to 50%. Correspondingly, this condition is regarded as a surgical emergency. We present the history of a patient with an acute gastric volvulus and unexplained hypotension.

Hemorrhoids

Understanding of hemorrhoidal pathology and treatment has come a long way. The theory of a sliding anal canal lining and the knowledge that hemorrhoidal cushions are a normal part of the anal anatomy should encourage symptom control rather than radical removal of tissue. Techniques that fix the cushions back in position can be performed in outpatients with reasonable success rates. When required, surgery should be aimed at symptomatic hemorrhoids. It is hoped that new developments such as circular stapling and better pain management will promote increased day surgery, better pain control, and less time off work for patients.

On-the-table colonic lavage

Single-stage surgery is an acceptable option in the modern management of many acute colonic conditions. Anastomosing unprepared colon is a major concern. A technique is described that allows on-the-table colonic lavage to be performed without contamination of the abdominal cavity.

A prospective audit of Lichtenstein's tension-free herniorrhaphy in Taranaki, New Zealand

BACKGROUND

This study was undertaken to assess the outcome of Lichtenstein's tension-free mesh inguinal herniorrhaphy as practised by surgeons in a provincial centre in Taranaki, New Zealand.

METHODS

A prospective audit was carried out on all patients who underwent this procedure in Taranaki. They were followed up at 1 month and again at 1 year. Results were entered on a standardized pro forma.

RESULTS

One hundred and twenty-four patients underwent 134 repairs by four different surgeons and their registrars. Eighty-two per cent of them had a general anaesthetic, and 13% had local anaesthestic. Twenty-five per cent of the repairs were performed as day surgery and a further 53% required overnight stays. Complication rates were 6% in hospital, 12.7% at I month and 8% at 1 year. Recurrence occurred in one repair (0.9%) and there were no cases of mesh rejection. The wound infection rate was 3% and all were minor. Only 45% of the patients who had an inguinal hemiorrhaphy were employed and they took an average of 16 days (range 2-30) to return to work. Over half felt that that they could have returned to normal activities within 2 weeks.

CONCLUSIONS

The Lichtenstein technique of inguinal herniorrhaphy is a technically simple, reliable procedure with minimal morbidity and patients may expect a reasonably prompt return to work and to normal activities.