Comparative study between Levobupivacaine and Bupivacaine for hernia surgery in the elderly

Pediatric Groin Surgeries: A Comparison of Analgesic Effects of Caudal Block and Inguinal Field Block Using Plain Bupivacaine

INTRODUCTION

There is a paucity of studies in the West African sub-region which have compared both the intraoperative and postoperative analgesic effects of caudal block and inguinal field block using plain bupivacaine in groin surgeries in children. The study aimed to compare the duration of analgesia and complications of caudal block and inguinal field block in pediatric groin surgeries.

PATIENTS AND METHODS

This was a prospective, double-blind randomized study conducted at a tertiary health institution in North Central, Nigeria, over a period of 6 months. A total of 74 children scheduled for day case groin surgeries for inguinal hernia, hydrocoele and palpable undescended testis were recruited into the study. The effectiveness of the analgesic effect was assessed by measuring serum cortisol levels before surgery (i.e. baseline at 8am), 5minutes after caudal block or inguinal field block, and 1-hour after surgery. Post-operative pain was determined using FLACC score (Face, Legs, Activity, Crying and Consolability) every 15 minutes till 6 hours after surgery when the patients were discharged home and the caregivers measured the patients' pain scores using the FLACC score every 1 hour to a maximum duration of 10 hours after surgery. Data obtained from the study was entered into the study proforma and analysed using IBM SPSS version 21.0. The P value was considered statistically significant at <0.05.

RESULTS

A total of 74 patients were recruited for this study, with 68 males (91.9%) and 6 females (8.1%). The children's age range was 6 months to 7 years, with a mean age of 3.35 ± 1.90 years. The mean basal serum cortisol levels of the caudal block group and inguinal block group were 11.15 ± 5.38 µg/dL and 10.79 ± 4.92µg/d respectively (p-value = 0.767). Five minutes after caudal block, the mean serum cortisol level was 10.50 ± 5.39µg/dL while inguinal field block was 10.63 ± 4.68µg/dL (p-value = 0.288). The mean serum cortisol level obtained one hour after each procedure was 9.34 ± 4.05 µg/dL for the caudal block group and 10.00 ± 3.56 µg/dL in the inguinal field block group with p-value = 0.275.Using the FLACC score, the mean duration of analgesia in caudal block group was 372.00 ± 71.55 minutes and was inguinal field block group was 387.43 ± 62.65 minutes with a p-value = 0.116. There was no anaesthetic technique related complications that was recorded in both caudal block group and inguinal group during the study period.

CONCLUSION

This study demonstrated that caudal block and inguinal field block using plain bupivacaine provided comparable duration of analgesia in paediatric groin surgeries. Therefore, caudal block or inguinal field block using plain bupivacaine should be recommended for both intraoperative and postoperative analgesia in elective paediatric groin surgeries.

Late hyaluronidase injection in local anesthesia: Morphofunctional evaluation in rat sciatic nerve block

Introduction

Despite the enhancing effects of hyaluronidase (HYAL) over duration of anesthesia, this enzyme could cause adverse effects when injected concomitantly with local anesthetics in dental blocks.

Objective

This study aimed to assess the tissue alterations caused by a local anesthetic protocol consisting of a late HYAL injection and confirm its functional effectiveness.

Materials and Methods

The protocol efficacy was proved by evaluating sensory and motor functions in rats. The sciatic nerve was blocked with 2% lidocaine (LID) with epinephrine (n = 25). Thirty minutes later, 75 TRU/ml HYAL was injected into the same site (experimental group, LID/HYAL). One week later, this protocol was repeated in the contralateral hindlimb, injecting only HYAL's vehicle (control group, LID/vehicle [LID/V]). To observe the integrity of the local tissues, histological specimens were obtained 1, 24, 48, and 72 h after treatment with LID/HYAL or LID/V (n = 16 each) and stained with hematoxylin/eosin and picrosirius red.

Results

Local inflammation was similar in both groups. The integrity of the nerve fibers was preserved, in spite of some inflammation-associated injuries in the surrounding tissues. The reversible tissue disorganization caused by HYAL, probably facilitated the diffusion of the residual anesthetic to the nerve, resulting in a prolonged anesthetic effect (P < 0.05).

Conclusions

No irreversible morphological alterations are caused by the administration of HYAL prior the end of the LID-induced block. Moreover, this protocol prolongs LID's anesthetic effect.

Local anesthesia underutilized for inguinal hernia repair in northern Ghana

Introduction

Inguinal hernia repair is a common procedure and a priority for public health efforts in Ghana. It is essential that inguinal hernia repair be performed in a safe, efficient manner to justify its widespread use. Local anesthesia has many favorable properties and has been shown to be superior, compared to regional or general anesthesia, in terms of pain control, safety profile, cost-effectiveness, resources required, and time to discharge. Local anesthesia is recommended for open repair of reducible hernias, provided clinician experience, by multiple international guidelines. Regional anesthesia is associated with myocardial infarction and other complications, and its use is discouraged by multiple guidelines, especially in older patients. This study aims to assess the current state of anesthesia for inguinal hernia repair in the northern and transitional zone of Ghana. In addition we will assess the perceptions of different types of anesthesia along with understanding of evidence-based guidelines among clinicians participating in inguinal hernia repair.

Methods

We performed a retrospective review of all inguinal hernia repairs for male patients, 18 and older, in over 90% of hospitals in northern Ghana. All 41 hospitals were visited and caselogs and patient charts were manually reviewed to extract data. Multivariate logistic regression was used to determine predictors of local anesthesia use. We designed a survey instrument to assess the perceptions of physicians and anesthetists regarding different types of anesthesia for inguinal hernia repair. The survey was designed by a Ghanaian surgeon, reviewed by all co-authors, and tested prior to implementation using a sample (n = 8) of clinicians having similar practices to those of the survey population. Of 70 clinicians, 66 responded, yielding a response rate of 94%.

Results

8080 patients underwent hernia repair of which 37% were performed under local anesthesia, while the majority, 60%, were performed under regional anesthesia. Negative predictors of local anesthesia were emergent repair (OR = 0.258, p < 0.001), surgery performed at a teaching hospital (OR = 0.105, p < 0.001), and bilateral hernia repair (OR = 0.374, p < 0.001). 1,839 (22.8%) of IH repairs were done on patients age 65 or older and RA was most frequently used among the elderly population (57.8%), while local anesthesia was used 39.5% of the time. Sixty-six clinicians participated in the survey with the majority reporting that local anesthesia requires fewer staff, less equipment, has a shorter recovery, is more cost-effective, and might be safer for patients. However 66% were unfamiliar with or incorrectly perceived international guidelines.

Conclusion

To our knowledge, this study is the largest assessment of anesthesia use for inguinal hernia repair in an LMIC. Although the selection of anesthetic technique should be guided by a patient’s general health, the anatomy of the hernia, and clinician judgment, local anesthesia appears to be underutilized in northern Ghana. Survey responses demonstrate high rates of unfamiliarity or incorrectly perceived evidence-based guidelines. Future research should assess how education on the benefits and technique of local anesthesia administration may further increase rates for inguinal hernia repair, especially for older patients.

Are reinfusion drains safe to use with periarticular liposomal bupivacaine? An analysis of systemic bupivacaine toxicity

Background

Intraoperative periarticular injection (PAI) with local anesthetic is an important component of multimodal pain control in total joint arthroplasty (TJA). A potential risk of this practice is serum anesthetic toxicity resulting from the autotransfusion of blood collected from a reinfusion drain. The purpose of this study is to evaluate the levels of bupivacaine in blood collected in an autotransfusion system after use of a PAI in TJA.

Methods

In this prospective study, each TJA patient had an identical PAI consisting of 20 cc of liposomal bupivacaine, 30 cc of 0.25% bupivacaine with epinephrine, and 10 cc of normal saline. An autologous reinfusion drain was utilized in all patients. At 2 and 5 hours postoperatively, blood was collected from the autotransfusion canister and sent to the laboratory to quantify bupivacaine levels. The sums of these levels were compared to the lowest reported serum bupivacaine dose associated with toxicity (1.1 mg/kg).

Results

Eleven unilateral TJA patients were enrolled (6 total knee arthroplasties, 5 total hip arthroplasties). The average 2-hour serum bupivacaine level was 2.9 μg (range 0.8-5.6) while the average 5-hour serum bupivacaine level was 4.5 μg (range 0.4-10.0). The average sum of the 2-hour and 5-hour serum bupivacaine level was 5.6 μg (range 0.8-13.6). Each of the 11 patient samples were well below their minimum serum bupivacaine dose toxicity.

Conclusions

Use of a reinfusion drain after PAI with liposomal bupivacaine in TJA appears safe, as bupivacaine levels in the autotransfused blood remains well below the reported minimum serum toxic dose.

Level of Evidence

IV.

[Anesthesiological care of trauma patients in orthogeriatric co-management]

Elderly patients increasingly need to undergo surgery under anesthesia, especially following trauma. A timely interdisciplinary approach to the perioperative management of these patients is decisive for the long-term outcome. Orthogeriatric co-management, which includes geriatricians and anesthesiologists from an early stage, is of great benefit for geriatric patients. Patient age, comorbidities and self-sufficiency in activities of daily life are decisive for an anesthesiological assessment of the state of health and preoperative risk stratification. If necessary additional investigations, such as echocardiography must be carried out, in order to guarantee optimal perioperative anesthesiological management. Certain medical factors can delay the initiation of anesthesia and it is absolutely necessary that these are taken into consideration for surgical management. Not every form of anesthesia is equally suitable for every geriatric patient.

Fixation-free incisional hernia repair in the elderly: our experience with a tentacle-shaped implant

BACKGROUND

Incisional hernia in aged patients represents a challenge even for experienced surgeons. Besides increased risk of complications due to comorbidities, mesh fixation and assuring a sufficient mesh overlap of the defect are the main issues in carrying out the repair.

AIMS

In order to assure broader coverage of the abdominal wall and a tension- and fixation-free repair, a specifically designed prosthesis was developed for the surgical treatment of incisional hernias. The results of a fixation-free incisional hernia repair carried out in elderly patients using a tentacle-shaped implant are reported herewith.

METHODS

A tentacle-shaped flat mesh with a large central body and integrated arms was used to repair incisional hernia in 23 elderly patients. The mesh was placed fixation-free and secured in place through the friction exerted by the tentacles. All tentacle straps were positioned with a special passer needle. Implant placement was preperitoneal in 18 patients and retromuscular sublay in five.

RESULTS

In a follow-up of 18 to 59 months (mean 36 months), four seromas occurred. Postoperative fast track helped avoid the typical complications affecting this patient subset. No infection, hematoma, chronic pain, mesh dislocation or recurrence have been reported to date.

DISCUSSION

The tentacle strap system allowed for reduced skin incision thus minimizing surgical trauma and ensuring easier and faster implant placement.

CONCLUSION

The tentacle arms of the implant ensured mesh stability and broad defect overlap. Besides a very low complication rate, none of the typical postoperative complications of aged patients occurred.

Laparoscopic management of non-midline incisional hernia: A multicentric study

BACKGROUND

The laparoscopic repair of non-midline ventral hernia (LNM) has been debated. The aim of this study is to analyze our experience performing the laparoscopic approach to non-midline ventral hernias (NMVHs) in Northwest Italy for 6 years.

METHODS

A total of 78 patients who underwent LNM between March 2008 and March 2014 in the selected institutions were analyzed. We retrospectively analyzed the peri- and postoperative data and the recurrence rate of four subgroups of NMVHs: subcostal, suprapubic, lumbar, and epigastric. We also conducted a literature review.

RESULTS

No difference was found between the four subgroups in terms of demographic data, defect characteristics, admission data, and complications. Subcostal defects required a shorter operating time. Obesity was found to be a risk factor for recurrence.

CONCLUSIONS

In our experience, subcostal defects were easier to perform, with a lower recurrence rate, lesser chronic pain, and faster surgical performance. A more specific prospective randomized trial with a larger sample is awaited. Based on our experience, however, the laparoscopic approach is a safe treatment for NMVHs in specialized centers.

[Anesthesiological care in orthogeriatric co-management. Perioperative treatment of geriatric trauma patients]

Elderly patients increasingly need to undergo surgery under anesthesia, especially following trauma. A timely interdisciplinary approach to the perioperative management of these patients is decisive for the long-term outcome. Orthogeriatric co-management, which includes geriatricians and anesthesiologists from an early stage, is of great benefit for geriatric patients. Patient age, comorbidities and self-sufficiency in activities of daily life are decisive for an anesthesiological assessment of the state of health and preoperative risk stratification. If necessary additional investigations, such as echocardiography must be carried out, in order to guarantee optimal perioperative anesthesiological management. Certain medical factors can delay the initiation of anesthesia and it is absolutely necessary that these are taken into consideration for surgical management. Not every form of anesthesia is equally suitable for every geriatric patient.

Emergency inguinal hernia repair under local anesthesia: a 5-year experience in a teaching hospital

BACKGROUND

Local anesthesia (LA) has been reported to be the best choice for elective open inguinal hernia repair because it is cost efficient, with less post-operative pain and enables more rapid recovery. However, the role of LA in emergency inguinal hernia repair is still controversial. The aim of this study is to investigate the safety and effectiveness of LA in emergency inguinal hernia repair.

METHODS

All patients underwent emergency inguinal hernia repair in our hospital between January 2010 and April 2014 were analyzed retrospectively in this study. Patients were divided into LA and general anesthesia (GA) group according to the general conditions of the patients decided by anesthetists and surgeons. The outcome parameters measured included time to recovery, early and late postoperative complications, total expense and recurrence.

RESULTS

This study included a total of 90 patients from 2010 to 2015. 32 patients (35.6%) were performed under LA, and 58 (64.4%) were performed under GA. LA group has less cardiac complications (P = 0.044) and respiratory complications (P = 0.027), shorter ICU stay (P = 0.035) and hospital stay (P = 0.001), lower cost (P = 0.000) and faster recovery time (P = 0.000) than GA group.

CONCLUSION

LA could provide effective anesthesia and patient safety in emergency inguinal hernia repair.

Fibrin glue versus stapler fixation in laparoscopic transabdominal inguinal hernia repair: a single center 5-year experience and analysis of the results in the elderly

INTRODUCTION

Inguinal hernia surgery is one of the most common surgical procedures performed worldwide. Some studies demonstrated clear advantages of laparoscopic approach in terms of chronic pain, recurrence rate and daily life activities Aim of this study was to compare short and long-terms outcome of tacks and fibrin glue used during laparoscopic transabdominal hernioplasty (TAPP).

METHODS

This is a retrospective study conducted by our division of General Surgery. From May 2008 to May 2013 we performed 116 hernioplasty with TAPP technique. We compared two groups of patients: a group of 59 patients treated with fibrin glue and a group of 57 patients treated with conventional tacks and the two subgroups of patients over 65 years old. We evaluated: perioperative outcomes, early and late complications.

RESULTS

There were no significative difference about length of postoperative stay, time to return to work, recurrence rate and complications.

DISCUSSION

This study demonstrates that fibrin glue are same tolerated than tacks by patients and that the glues lead to the same good results during initial follow-up and in long term data also in the elderly. Meticulous preparation of the groin with preservation of spermatic sheet is in our opinion necessary to provide effective pain reduction and a good result in every TAPP procedure.

Evaluation of corneal anaesthesia after the application of topical 2 per cent lidocaine, 0.5 per cent bupivacaine and 1 per cent ropivacaine in dogs

The objective of this study was to describe and compare the efficacy and duration of topical anaesthesia induced by 2 per cent lidocaine (L), 0.5 per cent bupivacaine (B) and 1 per cent ropivacaine (R) in the dog using 24 clinically healthy beagles with normal ocular examination. Dogs were randomly divided into three groups: 2 per cent lidocaine (n=8), 0.5 per cent bupivacaine (n=8) and 1 per cent ropivacaine (n=8). The baseline corneal touch threshold (CTT) was measured using a Cochet-Bonnet aesthesiometer. Following baseline CTT measurement, a single drop of the assigned anaesthetic was applied to each eye and the CTT was measured bilaterally within one minute after administration and every five minutes until the basal CTT value was restored. Data were analysed with non-parametric analysis of variance models and Dunnet's test for post hoc analysis. One per cent ropivacaine was the most effective drug (LCTTmax=3 cm, BCTTmax=2 cm, RCTTmax=0 cm; P<0.001), and had the shortest latency (LLatency=5 minutes, BLatency=5 minutes, RLatency=1 minute; P<0.001) and the smallest AUC (LAUC=80 cm×minute, BAUC=68.25 cm×minute, RAUC=36.88 cm×minute; P<0.001). There was no statistical difference in the duration of corneal anaesthesia between the groups (P=0.09) and all topical anaesthetics tested reduced corneal sensitivity, although 1 per cent ropivacaine had the maximal and quickest anaesthetic effect. This drug could be used for specific diagnostic procedures where quick and short, but effective, corneal anaesthesia is needed.

Local anesthesia for treatment of hernia in elder patients: Levobupicavaine or Bupivacaine?

Background

Inguinal hernia is one of the most common diseases in the elderly. Treatment of this pathology is exclusively surgical and relies almost always on the use of local anesthesia. While in the past hernia surgery was carried out mainly by general anesthesia, in recent years there has been growing emphasis on the role of local anesthesia.

Methods

The aim of our study was to compare intra-and postoperative analgesia obtained by the use of levobupivacaine to the same obtained by bupivacaine. Bupivacaine is one of the main local anesthetics used in the intervention of inguinal hernioplasty. Levobupivacaine is an enantiomer of racemic bupivacaine with less cardiotoxicity and neurotoxicity. The study was conducted from March 2011 to March 2013. We collected data of eighty patients, male and female, aged between 65 and 86 years, who underwent inguinal hernioplasty with local anesthesia.

Results

Evaluation of intra-operatively pain shows that minimal pain is the same in both groups. Mild pain was more frequent in the group who used levobupivacaine. Moderate pain was slightly more frequent in the group who used bupivacaine. Only one reported intense pain. Two drugs seem to have the same effect at a distance of six, twelve, eighteen and twentyfour hours. Bupivacaine shows a significantly higher number of complications, as already demonstrated by previous studies. Degree of satisfaction expressed by patients has been the same in the two groups. Levobupivacaine group has shown a greater request for paracetamol while patients who experienced bupivacaine have showed a higher request of other analgesics.

Conclusions

Clinical efficacy of levobupivacaine and racemic bupivacaine are actually similar, when used under local intervention of inguinal hernioplasty. In the field of ambulatorial surgery our working group prefers levobupivacaine for its fewer side effects and for its easy handling.

Day-surgery inguinal hernia repair in the elderly: single centre experience

BACKGROUND

Inguinal hernioplasty is well established as a day-surgery procedure, our purpose is to assess the safeness of this approach in elderly patients.

METHODS

A total of 292 inguinal hernioplasty were performed between June 2009 and February 2013. Patients were divided into 3 groups depending on the age and postoperative complications were compared in these groups.

RESULTS

Despite of a large number of higher risk (ASA 3-4) patients and a higher rate of comorbidity in older patients, unplanned admission postoperative, symptoms and complications were comparable with those for the younger patients.

CONCLUSIONS

Ambulatory surgery is feasible also in older patients. Age, comorbidity and higher ASA risk should not be a barrier to elective day surgery.

Incidence of pain after inguinal hernia repair in the elderly. A retrospective historical cohort evaluation of 18-years' experience with a mesh & plug inguinal hernia repair method on about 3000 patients

Background

Chronic pain after prosthetic inguinal hernioplasty is one of the most important current issues in the current literature debate. Mechanisms related to pain development are only partially known. Influence of age as well as other factors is still unclear. The aim of this work was to evaluate whether development of chronic pain after open prosthetic plug and mesh inguinal hernioplasty is influenced by age.

Methods

Analysis was retrospectively conducted, dividing our cohort of patients (2,902) who had undergone prosthetic open plug&mesh inguinal hernioplasty from Jannuary 1994 to May 2012, following only the age criterion (cut-off 65 yrs.), into two groups (Gr.A<65 yrs, Gr.B>65 yrs.). All patients were routinely submitted to a postoperative questionnaire. Complications such as analgesic assumption were registered in both groups. Pain intensity was classified following the Visual Analogic Scale (VAS). Incidence of chronic pain, discomfort, and numbness, was assessed in both groups. Statistical significance was assessed by X₂-test.

Results

Only 0.2% of patients suffered from a recurrence in our cohort. Postoperative chronic pain was observed in Gr. A in 0.12% of patients vs Gr.B 0.09% (p>0.05). Incidence of other postoperative symptoms such as discomfort or numbness were slightly prevalent on young patients (respectively p = 0.0286 and p = 0.01), while for hyperesthesia and sensation of foreign body no statistically significant difference of incidence between groups was observed.

Conclusions

Real chronic pain after inguinal hernioplasty is a rare clinical entity. Other causes of chronic pain should be accurately researched and excluded. In young patients psychological factors seem to show a slight influence. There was no influence of age on chronic postoperative pain incidence after inguinal hernioplasty.

Emergency groin hernia repair: implications in elderly

BACKGROUND

Groin hernia is one of the most frequently encountered pathologies occurring in old age and it is often the cause of emergency procedures. In our study we evaluate the impact of emergency procedures in over 75 patients compared to younger patients.

METHODS

We conducted a retrospective study about patients who underwent emergency hernioplasty between September 2007 and January 2013. Bilateral hernias and recurrences were excluded. We divided patients into two groups by age (under and over 75 years old) and then analyzed the early postoperative surgical complications.

RESULTS

A total of 48 patients were enrolled, 18 were included in under 75 group and 30 in over 75. In the older group we found a higher rate of comorbidity and also a significant higher rate of postoperative complications. Two patients of over 75 group died.

CONCLUSIONS

Our data suggests that a quick diagnosis and elective surgical procedures are desirable in order to avoid the complications that occur in emergency operations.