Perineural bupivacaine injection reduces inguinodynia after inguinal hernia repair

Chronic inguinal pain post-hernioplasty. Laparo-endoscopic surgery vs lichtenstein repair: systematic review and meta-analysis

PURPOSE

Annually, over 20 million patients worldwide undergo inguinal hernia repair procedures. Surgery stands as the recommended treatment, however, a consensus on the optimal method is lacking. This study aims to conduct an updated systematic review and meta-analysis to compare the risk of chronic inguinal pain and recurrence between laparo-endoscopic mesh repair (TAPP and TEP) versus Lichtenstein repair for inguinal hernia.

METHODS

Searches were conducted in Ovid MEDLINE, PubMed, EBSCO, Cochrane, and Google Scholar. Inclusion criteria encompassed randomized controlled trials (RCTs) involving adults, published in English and Spanish, comparing surgical outcomes among the Lichtenstein open technique, TAPP, and/or TEP. Adherence to the PRISMA guidelines was maintained in the methodology, and the CASP tool was employed to assess the quality of the articles. Statistical analysis involved mean [± standard deviation (SD)], Odds Ratio (OR), and Confidence Interval (CI).

RESULTS

Eight RCTs encompassing 1,469 patients randomized to Lichtenstein repair (n = 755) and laparo-endoscopic repair (n = 714) were included. Laparo-endoscopic repair was associated with a lower likelihood of chronic inguinal pain compared to Lichtenstein repair (OR = 0.28, 95% CI [0.30-0.56], p = 0.0001). There were no significant differences in recurrence rates between the laparo-endoscopic and the Lichtenstein group (OR = 1.03, 95% CI [0.57-1.86], p = 0.92).

CONCLUSIONS

This systematic review and meta-analysis demonstrate that laparo-endoscopic hernia surgery leads to a lower incidence of chronic inguinal pain compared to Lichtenstein repair, while maintaining similar rates of recurrence.

Effect of perineural bupivacaine infiltration on reducing inguinodynia in patients undergoing inguinal meshplasty - a randomized controlled trial

INTRODUCTION

Inguinodynia after inguinal meshplasty is a notable complication with an incidence of 13-37%. We wanted to determine if a perineural infiltration of bupivacaine given intraoperatively would reduce the incidence of immediate postoperative pain and inguinodynia.

METHODOLOGY

We have conducted a single-blinded randomized controlled trial including 100 patients with inguinal hernia. Patients in the control group received only spinal anaesthesia. The intervention group received perineural bupivacaine infiltration in addition to spinal anaesthesia. Intraoperatively Ilioinguinal, iliohypogastric, and genital branch of the genitofemoral nerve was identified and 2 mL of 0.5% bupivacaine was given perineurally along these identified nerves. Presence of inguinodynia, immediate post-operative pain scores using the Wong-Baker faces pain scale, duration of analgesics use, use of additional analgesics along with Paracetamol 500 mg tablet, and the length of hospital stay between the groups were recorded.

RESULTS

100 patients were randomized in the study, 49 in control and 51 in the intervention group. Both the group was comparable in terms of demographic characteristics. The intervention group had significantly lower median pain score at 3 h [4 ± 1.662 vs. 6 ± 1.55; p = .0001] and 6 h [4 ± 1.33 vs. 6 ± 1.307; p = .0001]. The incidence of inguinodynia did not significantly differ between the two groups (p-value = .12).

CONCLUSION

Intraoperative Perineural bupivacaine infiltration significantly reduces the immediate postoperative pain. However, there was no significant reduction in the incidence of inguinodynia or additional analgesic requirement.

Inguinodynia: review of predisposing factors and management

Herniorrhaphy is one of the most common surgical procedures, with an estimated 20 million operations performed annually worldwide. One of the common complications associated with this procedure is inguinodynia, defined as pain beyond three months after inguinal hernia surgery. In this review, we have addressed the main aspects of this complication with current articles, published in the last five years. Inguinodynia has a multifactorial nature and studies have shown that its development is related to the surgical technique and intrinsic factors of the patient that imply greater predisposition to this phenomenon. In this regard, it has been discussed which surgical techniques imply a lower incidence of this complication. Many studies have focused on understanding intrinsic features of each patient, both in physical and cognitive aspects, and how the approach of these factors can favor a better post-surgical recovery. The treatment of this condition is still challenging, and there are no established universal guidelines. We believe that due to its multifactorial nature, the treatment is hampered due to the individuality inguinodynia presentations.

Finding the body mass index cutoff for hospital readmission after ambulatory hernia surgery

BACKGROUND

The suitability of ambulatory surgery in obese patients remains controversial. This study aimed to investigate the "cutoff" value of body mass index (BMI) associated with increased likelihood of hospital readmissions within the first 24 hours of surgery in patients undergoing ambulatory hernia repair.

MATERIALS AND METHODS

The study used data from the 2012-2016 American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP). Cochran Armitage trend tests were conducted to assess progression in rates hospital readmissions across categories of patient BMI. The minimum p-value method, Kolmogorov-Smirnov goodness of fit tests, logistic regression, and receiver-operating characteristic (ROC) curve analyses were used to investigate the cutoff of patient BMI indicative of increased likelihood of readmissions.

RESULTS

A total of 214,125 ambulatory hernia repair cases were identified. Of those, 908 patients (0.42%) had an unexpected hospital admission within the first 24 hours after surgery. The readmission rates did not significantly increase across the categories of BMI. However, some of the reasons for readmission significantly differed by BMI category. Logistic regression analysis revealed no statistically significant association between BMI and hospital readmissions (odds ratio [95% Cl], 0.96 [0.91-1.02] P = .179). An optimal BMI threshold predictive of an increased likelihood of hospital readmissions was not identifiable by any of the statistical methods used.

CONCLUSIONS

Although reasons for readmission differed by BMI category, there is no clear cutoff value of BMI associated with increased hospital readmission within the first 24 hours after surgery.

Chronic postsurgical pain and cancer: the catch of surviving the unsurvivable

PURPOSE OF REVIEW

Chronic postsurgical pain (CPSP) is an important and well recognized cause of much long-term suffering, which in some cases may be preventable and affects many people living with cancer. Unfortunately, general consensus is lacking as to how best reduce the risk of developing CPSP.

RECENT FINDINGS

Cancer is now not always a short-lived, fatal disease and is now moving towards a chronic illness. Poorly managed perioperative pain is the greatest risk factor for CPSP. Recent trials have examined preventive strategies for CPSP associated with breast surgery and thoracotomy, two operations used in cancer treatment. Standard antinociceptive drugs, 5% lidocaine patches and ketamine do not prevent CPSP. The evidence for gabapentinoids is conflicting. Intravenous lidocaine and, separately, regional anaesthesia appear beneficial.

SUMMARY

Well-managed pain, irrespective of technique, reduces the risk of CPSP. The literature is inconclusive regarding an 'optimal approach.' Regional anaesthesia, intravenous lidocaine and the aggressive management of perioperative pain using multimodal analgesia including antineuropathic pain agents such as gabapentinoids and certain antidepressants are recommended. Clinicians should not rely on general anaesthesia, opioids, NSAIDs and ketamine to prevent CPSP. A blanket approach using gabapentinoids for all patients undergoing major surgery is not indicated. Instead, the presence of perioperative neuropathic pain should be checked for regularly.