Inguinal hernia repair: local or general anaesthesia?

Increased age and the volume of intraoperative fluid administered predict urinary retention after elective inguinal herniorrhaphy

BACKGROUND

Inguinal hernia repair (IHR) is a common surgical procedure worldwide. Although IHR can be performed by the minimally invasive method, which accelerates recovery, postoperative urinary retention (POUR) remains a common complication that significantly impacts patients. Thus, it is essential to identify the risk factors associated with POUR to diminish its negative impact.

METHODS

We conducted a single-center retrospective review of elective IHR from 2018 to 2021. POUR was defined as the postoperative use of straight catheter or placement of an indwelling catheter to relieve the symptoms. Adjusted multivariate regression analysis was performed to address the associations of clinicodemographic, surgical, and intraoperative factors with POUR.

RESULTS

A total of 946 subjects were included in the analysis after excluding cases of emergent surgery, recurrent hernia, or concomitant operations. The median age was 68.4 years, and 92.0% of the patients were male. Twenty-three (2.4%) patients developed POUR. In univariate analysis, POUR in comparison with non-POUR was significantly associated with increased age (72.2 versus 68.3 years, P = 0.012), a greater volume of intraoperative fluid administered (500 versus 400 ml, P = 0.040), and the diagnosis with benign prostate hypertrophy (34.8% versus 16.9%, P = 0.025). In the multivariate model, both increased age (odds ratio [OR] 1.04, 95% CI 1.01-1.08; P = 0.049) and a greater volume of intraoperative fluid administered (OR 1.12 per 100-mL increase, 95% CI 1.01-1.27; P = 0.047) were significantly associated with the occurrence of POUR.

CONCLUSIONS

We found that increased age and a greater volume of intraoperative fluid administered were significantly associated with the occurrence of POUR. Limiting the administration of intraoperative fluid may prevent POUR. From the perspective of practical implications, specific guidelines or clinical pathways should be implemented for fluid management and patient assessment.

Postoperative urinary retention (POUR): A narrative review

Postoperative urinary retention (POUR) is defined as the inability to void in the presence of a full bladder after surgery. Complications include delirium, pain, prolonged hospitalization, and long-term altered bladder contractility. Comorbidities, type of surgery and anesthesia influence the development of POUR. The incidence varies between 5% and 70%. History and clinical examination, the need for bladder catheterization and ultrasonographic evaluation are three methods used to diagnose POUR. The prevention of POUR currently involves identifying patients with pre-operative risk factors and then modifying them where possible. Bladder catheterization is the standard treatment of POUR, however, further studies are necessary to establish patients who need a bladder catheter, bladder volume thresholds and duration of catheterization.

Nationwide analysis of open groin hernia repairs in Italy from 2015 to 2020

INTRODUCTION

Inguinal hernia repair is one of the most commonly performed operations in general surgery. A total of 130.000 inguinal hernia repairs are performed yearly in Italy, and approximately 20 million inguinal hernias are treated worldwide annually. This report represents the trend analysis in inguinal hernia repair in Italy from a nationwide dataset for the 6-year period from 2015 to 2020.

MATERIALS AND METHODS

Based on regional hospital discharge records, all the inguinal hernia repairs performed in public and private hospitals in Italy between 2015 and 2020 were reviewed based on diagnosis and procedure codes. For the aim of this study, data from the AgeNas (The National Agency for Regional Health Services) data source were analyzed.

RESULTS

Elective inguinal hernia repairs outnumbered urgent operations over the 6-year study period, ranging from 122,737 operations in 2015 to 65,780 in 2020 as absolute numbers, and from 87.96 to 83.3% of total procedures in 2019 and 2020 respectively, with an annual change ranging from - 66.58%, between 2020 and 2019, to - 2.49%, between 2019 and 2018 (mean = - 18.74%; CI =- 46.7%-9.22%; p < 0.0001).

CONCLUSIONS

This large-scale review of groin hernia data from a nationwide Italian dataset provides a unique opportunity to obtain a snapshot of open groin hernia repair activity. More specifically, there is a trend to perform more elective than urgent procedures and there is a steady decrease in the amount of open hernia repairs in favor to laparoscopy.

The Impact of Body Mass Index on Local Anaesthetic Inguinal Hernia Repair

BACKGROUND

Open mesh repair of inguinal hernia is acceptable and can be performed under local anaesthesia (LA). Individuals with high BMI (Body Mass Index) have often been excluded from LA repairs for varying reasons including safety concerns. Open repair of unilateral inguinal hernia (UIH) amongst individuals with different BMI groups was studied. Its safety profile was investigated using LA volume and length of operation (LO) as endpoints. Operative pain and patient satisfaction were also evaluated.

PATIENTS AND METHODS

A total of 438 adult patients were studied having excluded underweight patients, those requiring any additional intra-operative analgesia, multiple procedures, or records with incomplete data. Operative pain, patient satisfaction, LO and LA volume were retrospectively studied from the existing data from clinical and operative notes.

RESULTS

It was a predominantly male population (93.2% males) with an age range of 17-94 years peaking in the 60-69 years age group. BMI ranged 19-39 kg/m² with BMI above normal at 62.8%. LO was 13-100 minutes (average 37 mins {SD = 12}) utilising an average LA volume of 45 ml (SD = 11) per patient. Across BMI groups, no significant difference in LO (P = 0.168) or patient satisfaction (P = 0.388) was seen. Although LA volume (P = 0.011) and pain score (P<0.001) demonstrated statistically significant differences, these did not appear to be clinically relevant. Over 90% in each BMI group experienced mild or no pain and with severe pain reported in only one patient in the entire population. Overall, LA volume required per patient was low and dosage was safe in all BMI groups with significant proportion (89%) of patients evaluated for satisfaction rating their experience ≥ 90 out of 100.

CONCLUSION

LA repair is safe and well tolerated irrespective of BMI. BMI is not a viable reason for exclusion of obese/overweight individuals from LA repair.

Anesthesia for inguinal hernia repair: Experience with a tertiary hospital-based surgical outreach in a developing world

Background

The dearth of adequate facilities and anesthetists limits the number and extent of surgical cases that can be attended to in surgical outreach programs. Inguinal hernia remains a common health burden in the developing world. Tertiary hospitals provide good anesthetic complements to safe surgeries and will be a veritable tool in surgical outreaches.

Objectives

The objective of the study is to assess the types/techniques of anesthesia used in uncomplicated open inguinal hernia repair in a tertiary hospital-based surgical outreach program.

Materials and Methods

This study was a prospective analysis of anesthetic techniques used in all uncomplicated inguinal hernia repairs performed in outreach program over 1 week in May 2018. Data were collected with a pro forma, analyzed with SPSS, and presented in tables and figures.

Results

One hundred and ninety-five patients with uncomplicated inguinal hernias were recruited for the study. The patients' age ranged from 0 to 89 years, with a mean age of 33.62 ± 22.75 years. Most cases occurred in children. The male-to-female ratio was 7:1, and the majority were primary hernia repairs. Eighty-seven (44.6%) patients had local anesthesia (LA), 65 (33.3%) had general anesthesia (GA), while 43 (22.1%) had spinal anesthesia (SA). One hundred and sixty-two (83.1%) patients needed intraoperative analgesic augmentation. One hundred and sixty-nine (86.7%) patients were operated as day-case surgeries, while 26 (13.3%) patients were discharged the day after surgery. The failure rate of LA and SA put together was 74.6%, but there was no conversion to GA. Anesthetic complication was observed in 3.4% of cases.

Conclusion

Organizing inguinal hernia repair outreach in a tertiary hospital offers the benefit of a full complement of anesthesia, which ensures safe and smooth surgery with low anesthetic complications. Most cases were done as daycare surgeries despite the high failure rate of LA and SA.

Résumé

Contexte

Le manque d'installations adéquates et d'anesthésistes limite le nombre et l'étendue des cas chirurgicaux qui peuvent être traités dans les programmes de proximité chirurgicale. La hernie inguinale reste un fardeau de santé courant dans les pays en développement. Les hôpitaux tertiaires fournissent de bons compléments anesthésiques aux chirurgies sûres et seront un véritable outil dans les interventions chirurgicales.

Objectifs

Évaluer les types / techniques d'anesthésie utilisés dans la réparation de hernie inguinale ouverte non compliquée dans un programme de proximité chirurgicale en milieu hospitalier tertiaire.

Méthode

Une analyse prospective des techniques d'anesthésie utilisées dans toutes les réparations de hernie inguinale non compliquées effectuées dans le cadre d'un programme de sensibilisation sur une semaine en mai 2018. Les données ont été recueillies à l'aide d'un formulaire, analysées avec SPSS et présentées sous forme de tableaux et de figures.

Résultats

Cent quatre-vingt-quinze patients atteints de hernies inguinales non compliquées ont été recrutés pour l'étude. L'âge des patients variait de 0 à 89 ans avec un âge moyen de 33,62 + 22,75 ans. La plupart des cas sont survenus chez des enfants. Le ratio homme / femme était de 7: 1 et la majorité était des réparations primaires de hernie. Quatre-vingt-sept (44,6%) des patients ont eu une anesthésie locale (LA), 65 (33,3%) une anesthésie générale (AG), tandis que 43 (22,1%) une anesthésie rachidienne (SA). Cent soixante-deux (83,1%) patients ont eu besoin d'une augmentation analgésique peropératoire. Cent soixante-neuf (86,7%) patients ont été opérés en garderie tandis que 26 (13,3%) patients ont obtenu leur congé le lendemain de la chirurgie. Le taux d'échec de LA et SA réunis était de 74,6%, mais il n'y a pas eu de conversion en GA. Une complication anesthésique a été observée dans 3,4% des cas.

Conclusion

l'organisation de soins de proximité pour la réparation de la hernie inguinale dans un hôpital tertiaire offre l'avantage d'un complément complet d'anesthésie qui garantit une chirurgie sûre et en douceur avec de faibles complications anesthésiques. La plupart des cas ont été pratiqués en garderie malgré le taux d'échec élevé de l'anesthésie locale et rachidienne.

Mots-clés

Réparation de hernie inguinale, chirurgie de jour, anesthésie générale, anesthésie locale, anesthésie rachidienne.

Comparative benefits of local anesthesia and spinal anesthesia in adult open inguinal hernia: a meta-analysis of clinical randomized controlled trials

INTRODUCTION

To systematically evaluate the clinical effects of local anesthesia and spinal anesthesia in the treatment of open inguinal hernia in adults, and provide theoretical evidence for clinical choice.

EVIDENCE ACQUISITION

We searched the PubMed, Embase and The Cochrane Library, and collected published clinical randomized controlled trials (RCTs) on the efficacy and safety of local anesthesia and spinal anesthesia for open inguinal hernia surgery in adults. According to the inclusion and exclusion criteria, the literature was screened and the data was analyzed by using Review Manager.

EVIDENCE SYNTHESIS

A total of 11 RCT studies were included in the meta-analysis, with 591 cases in the local anesthesia group and 584 cases in the spinal anesthesia group. Our results showed that compared with the spinal hernia repair group, the hernia repair group under local anesthesia had a lower incidence of headache (RR=0.11, 95% CI (0.03, 0.46)) , urinary retention (RR=0.13, 95% CI（0.05,0.32)) and postoperative pain score at 12 hours (SMD=-1.09, 95% CI (-1.41, -0.76)), and a higher anesthesia efficiency (RR=1.09, 95% CI （1.03,1.16)) and satisfaction rate (RR=1.12, 95% CI (1.01, 1.24)). There was no statistically significant difference between the two groups in operation time, the incidence of intraoperative pain, hematoma, infection, postoperative chronic pain in the groin area, and testicular pain/swelling.

CONCLUSIONS

In open inguinal hernia surgery for adults, local anesthesia is better than spinal anesthesia with lower incidence of adverse events, higher efficacy and satisfaction.

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.

Safety of Inguinal Hernia Repair in the Elderly with Perioperative Continuation of Antithrombotic Therapy

Introduction

This study aimed to evaluate the safety of an inguinal hernia repair (IHR) under local anesthesia (LA) in the elderly with a perioperative continuation of antithrombotic therapy (AT).

Methods

A total of 120 patients undergoing elective primary IHR between August 2018 and August 2019 at the West China Hospital of China were prospectively studied, among which 60 patients also had coexisting cardiovascular diseases and had a continuation of AT perioperatively (antithrombotic group); the other 60 patients were not on any prior AT (control group). The primary endpoints were intra- and postoperative hemorrhagic complications, the required interventions for complications based on the Clavien-Dindo classification, and postoperative thromboembolic complications. The secondary endpoints were nonhemorrhagic complications, intraoperative duration, and postoperative length of stay (LOS).

Results

None of the patients in both groups had significant intraoperative bleeding >10 mL, and there were no significant differences between the 2 groups in terms of the postoperative hemorrhagic complications: bruising (2 vs. 0%, p = 1.000), serosanguinous soakage (7 vs. 3%, p = 0.679), and no hematoma was observed. Interventions required for encountered complications based on the Clavien-Dindo classification grade I (7 vs. 5%, p = 1.000) were assessed. There were no episodes of postoperative thromboembolic complications within 60 days in both groups. There were also no significant differences between the 2 groups in terms of nonhemorrhagic complications, intraoperative duration, and postoperative LOS (p > 0.05 in all).

Conclusions

The perioperative continuation of AT did not increase the risk of intra- and postoperative hemorrhagic complications following IHR in the elderly. Thus, IHR under LA seems to be safe and feasible in this setting.

Three-step tumescent local anesthesia technique for inguinal hernia repair

The optimal method of anesthesia for inguinal hernia repair is still controversial. We have developed "three-step tumescent local anesthesia (TLA) technique" for inguinal hernia repair, and recently showed that this technique is acceptable in view of short- and long-term clinical outcomes. Our study included 273 consecutive cases (290 sides) of elective inguinal hernia repair performed under the newly developed technique between September 2003 and May 2019, and overall clinical outcomes were considered to be safe and feasible. Herein, we report the surgical procedure of "three-step TLA technique." Briefly, we rapidly inject the diluted solution of local anesthetic and epinephrine step-by-step into the three following closed tissue space. Initially, 80 mL injection into the subcutaneous tissue before skin incision (Step 1). After the external oblique fascia is exposed, injection of 20 mL into the inguinal canal before the external oblique fascia is incised and opened (Step 2). The hernia sac and spermatic cord are then dissected, and the blunt dissection of the preperitoneal space is made by injecting 20 mL under the internal inguinal ring (Step 3), followed by placing a gauze into the preperitoneal space, creating the space for mesh placement. We consider that the most important point of this technique is achieved through the rapid injection of TLA solution into each closed tissue space, which makes for easier dissection, hemostasis, and good pain control.

Groin Hernia Surgery in Uganda: Caseloads and Practices at Hospitals Operating Within the Publicly Funded Healthcare Sector

Background

Groin hernia is a major public health problem with over 200 million people affected. The unmet need for surgery is greatest in Sub-Saharan Africa where specialist surgeons are few. This study was carried out in Uganda to investigate caseloads and practices of groin hernia surgery at publicly funded hospitals.

Methods

The study employed mixed methods covering 29 hospitals: the National Referral Hospital (NRH), 14 Regional Referral Hospitals (RRH) and 14 General Hospitals (GH). In part one of the study, surgeons and medical doctors performing hernia repair were interviewed about their practices and experiences of groin hernia surgery. In part two, operating theater records from 2013 to 2014 from the participating hospitals were reviewed and information about groin hernia operations collected.

Results

All respondents reported that sutured repair was the first-choice method. A total of 5518 groin hernia repairs were performed at the participating hospitals, i.e., an annual hernia repair rate of 7/100 000 population. Of the patients operated, almost 16% were women and 24% were children. Local anesthesia (LA) was used in 40% of the cases, and non-surgeon physicians performed 70.3% of the groin hernia repairs.

Conclusion

Groin hernia repair outputs need to increase along with the training of surgical providers in modern hernia repair methods. Methods and outcomes for hernia repair in women and children should be investigated to improve the quality of care.

Tailored Surgery in Inguinal Hernia Repair. The Role of Subarachnoid Anesthesia: A Retrospective Study

Safety and effectiveness evaluation of subarachnoid anesthesia implemented with hyperbaric Prilocaine in reduced dose (30mg) in combination with Fentanyl (20mcg), for the purpose of ensuring an optimal analgesia in open inguinal hernia repair. Although the local anesthesia is the first line treatment for open inguinal hernia repair, a minority of patients is not eligible because of obesity or big groin hernia, requiring a high dose of local anesthetic. Subarachnoid anesthesia implemented with hyperbaric Prilocaine in reduced dose in combination with Fentanyl may be a good alternative. Thirty patients were treated with intrathecal association of Prilocaine 30 mg and Fentanyl 20 mcg (group PF); they were compared to a group of fifty three ones, previously treated with a classic procedure with intrathecal Prilocaine 60 mg (group P). The sensitive blockage remained within an higher limit at T12 level in the patients of PF group, and a lower limit at S1 level 50 minutes after the anesthesia, while in the P group the anesthetic tended to migrate (p<0.0001). In PF group 70 minutes after the anesthesia 21 patients had a Bromage score equal to 0 and 9 patients equal to 9 (in P group, 19 patients had a score equal to 3, 8 to 2 and 3 to 1, p<0.0001). Subarachnoid anesthesia using Prilocaine 30 mg + Fentanyl 20 mcg could be stated as a viable alternative to local anesthesia in selected patients.

Improving patient outcomes with inguinal hernioplasty-local anaesthesia versus local anaesthesia and conscious sedation: a randomized controlled trial

PURPOSE

Conscious sedation is regularly used in ambulatory surgery to improve patient outcomes, in particular patient satisfaction. We hypothesized that the addition of conscious sedation would provide greater patient satisfaction with inguinal hernioplasty compared to local anesthesia alone.

METHODS

This trial was a single-centre, randomized, placebo-controlled, double-blinded trial where patients undergoing inguinal hernioplasty using local anaesthesia were randomized to receive local anaesthesia alone versus local anaesthesia and conscious sedation. The primary outcome of patient satisfaction was assessed using the Iowa Satisfaction with Anesthesia Scale (ISAS). The study was powered to detect a significant difference in ISAS scores between groups. Comparisons were made using T test and Chi square tests. A p value of less than 0.05 was considered significant.

RESULTS

There were 149 patients randomized: 78 to the local anesthesia (LA) group and 71 to the local anaesthesia and conscious sedation (LACS) group. For the primary outcome measure of patient satisfaction, the mean ISAS score was significantly greater in the LACS group (p = 0.009). The experience of pain and pain severity was greater in the LA group (p = 0.016; p = 0.0162 respectively). No statistically significant difference was found between groups with respect to operative time, time to discharge or postoperative complications.

CONCLUSION

The use of conscious sedation with local anesthesia for inguinal hernioplasty is safe, results in less pain experience and severity and is associated with better patient satisfaction. The use of conscious sedation does not delay patient discharge.

Regional anesthesia to ameliorate postoperative analgesia outcomes in pediatric surgical patients: an updated systematic review of randomized controlled trials

Regional anesthesia is becoming increasingly popular among anesthesiologists in the management of postoperative analgesia following pediatric surgery. The main objective of this review was to systematically evaluate the last 5 years of randomized controlled trials on the role of regional anesthesia techniques in alleviating postoperative pain associated with various pediatric surgical procedures. Forty studies on 2,408 pediatric patients were evaluated. The majority of the articles published from 2013 to 2017 reported that the use of regional anesthesia minimized postoperative pain and reduced opioid consumption. Only a few surgical procedures (cholecystectomy, inguinal hernia repair, and non-laparoscopic major abdominal surgery) reported no significant difference in the postoperative pain relief compared with the standard anesthetic management. The growing number of randomized controlled trials in the pediatric literature is very promising; however, additional confirmation is needed to reinforce the use of specific regional anesthesia techniques to provide optimal postoperative pain relief for a few surgical procedures (reconstructive ear surgery, chest wall deformity, hypospadias, umbilical hernia, cleft palate repair) in pediatric patients. More randomized controlled trials are needed to establish regional anesthesia as an essential component of postoperative analgesia management in children.

Local Anesthesia Versus Local Anesthesia and Conscious Sedation for Inguinal Hernioplasty: Protocol of a Randomized Controlled Trial

Background

Conscious sedation is regularly used in ambulatory surgery to improve patient outcomes, in particular patient satisfaction. Reports suggest that the addition of conscious sedation to local anesthesia for inguinal hernioplasty is safe and effective in improving patient satisfaction. No previous randomized controlled trial has assessed the benefit of conscious sedation in this regard.

Objective

To determine whether the addition of conscious sedation to local anesthesia improves patient satisfaction with inguinal hernioplasty.

Methods

This trial is designed as a single-center, randomized, placebo-controlled, blinded trial of 148 patients. Adult patients diagnosed with a reducible, unilateral inguinal hernia eligible for hernioplasty using local anesthesia will be recruited. The intervention will be the use of intravenous midazolam for conscious sedation. Normal saline will be used as placebo in the control group. The primary outcome will be patient satisfaction, measured using the validated Iowa Satisfaction with Anesthesia Scale. Secondary outcomes will include intra- and postoperative pain, operative time, volumes of sedative agent and local anesthetic used, time to discharge, early and late complications, and postoperative functional status.

Results

To date, 171 patients have been recruited. Surgery has been performed on 149 patients, meeting the sample size requirements. Follow-up assessments are still ongoing. Trial completion is expected in August 2017.

Conclusions

This randomized controlled trial is the first to assess the effectiveness of conscious sedation in improving patient satisfaction with inguinal hernioplasty using local anesthesia. If the results demonstrate improved patient satisfaction with conscious sedation, this would support routine incorporation of conscious sedation in local inguinal hernioplasty and potentially influence national and international hernia surgery guidelines.

Trial registration

Clinicaltrials.gov NCT02444260; https://clinicaltrials.gov/ct2/show/NCT02444260 (Archived by WebCite at http://www.webcitation.org/6no8Dprp4)

Postoperative urinary retention in patients undergoing elective spinal surgery

OBJECTIVE

Postoperative urinary retention (POUR) is a common problem leading to morbidity and an increased hospital stay. There are limited data regarding its baseline incidence in patients undergoing spinal surgery and the risk factors with which it may be associated. The purpose of this study was to evaluate the incidence of POUR in elective spine surgery patients and determine the factors associated with its occurrence.

METHODS

The authors retrospectively reviewed the records of patients who had undergone elective spine surgery and had been prospectively monitored for POUR during an 18-month period. Collected data included operative positioning, surgery duration, volume of intraoperative fluid, length of hospital stay, and patient characteristics such as age, sex, and medical comorbidities. Dialysis patients or those with complete urinary retention preoperatively were excluded from analysis.

RESULTS

Of the 397 patients meeting the study inclusion criteria, 35 (8.8%) developed POUR. An increased incidence of POUR was noted in those who underwent posterior lumbar surgery, those with benign prostatic hypertrophy (BPH), those with chronic constipation or prior urinary retention, and those using a patient-controlled analgesia pump postoperatively. An increased incidence of POUR was seen with a longer operative time but not with intraoperative intravenous fluid administration. A significant relationship between the female sex and POUR was noted after controlling for BPH, yet there was no association between POUR and diabetes or intraoperative instrumentation. Postoperative retention significantly prolonged the hospital stay. Three patients developed epidural hematomas necessitating operative reexploration, and while they experienced POUR, they also developed the full constellation of cauda equina syndrome.

CONCLUSIONS

Awareness of the risk factors for POUR may be useful in perioperative Foley catheter management and in identifying patients who need particular vigilance when they are due to void postprocedure. A greater understanding of POUR may also prevent longer hospital stays in select at-risk patients. Postoperative retention is rarely caused by a postoperative cauda equina syndrome due to epidural hematoma, which is also associated with saddle anesthesia, leg pain, and weakness, yet the delineation of isolated POUR from this urgent complication is necessary for optimal patient care.

Postoperative urinary retention in patients undergoing elective spinal surgery

OBJECTIVE Postoperative urinary retention (POUR) is a common problem leading to morbidity and an increased hospital stay. There are limited data regarding its baseline incidence in patients undergoing spinal surgery and the risk factors with which it may be associated. The purpose of this study was to evaluate the incidence of POUR in elective spine surgery patients and determine the factors associated with its occurrence. METHODS The authors retrospectively reviewed the records of patients who had undergone elective spine surgery and had been prospectively monitored for POUR during an 18-month period. Collected data included operative positioning, surgery duration, volume of intraoperative fluid, length of hospital stay, and patient characteristics such as age, sex, and medical comorbidities. Dialysis patients or those with complete urinary retention preoperatively were excluded from analysis. RESULTS Of the 397 patients meeting the study inclusion criteria, 35 (8.8%) developed POUR. An increased incidence of POUR was noted in those who underwent posterior lumbar surgery, those with benign prostatic hypertrophy (BPH), those with chronic constipation or prior urinary retention, and those using a patient-controlled analgesia pump postoperatively. An increased incidence of POUR was seen with a longer operative time but not with intraoperative intravenous fluid administration. A significant relationship between the female sex and POUR was noted after controlling for BPH, yet there was no association between POUR and diabetes or intraoperative instrumentation. Postoperative retention significantly prolonged the hospital stay. Three patients developed epidural hematomas necessitating operative reexploration, and while they experienced POUR, they also developed the full constellation of cauda equina syndrome. CONCLUSIONS Awareness of the risk factors for POUR may be useful in perioperative Foley catheter management and in identifying patients who need particular vigilance when they are due to void postprocedure. A greater understanding of POUR may also prevent longer hospital stays in select at-risk patients. Postoperative retention is rarely caused by a postoperative cauda equina syndrome due to epidural hematoma, which is also associated with saddle anesthesia, leg pain, and weakness, yet the delineation of isolated POUR from this urgent complication is necessary for optimal patient care.

IS SAME-DAY INGUINAL HERNIA SURGERY POSSIBLE?

1-INTRODUCTION: The Lichtenstein hernia repair is associated with low recurrence rates and short operation times, and can be performed under local anaesthesia. Thus, this is among the most-preferred methods used in recent years. Our objective was to explore the same-day discharge rates, and the causes of delayed discharge and re-admission to hospital, of patients treated using the Lichtenstein repair method, to evaluate the feasibility of performing same-day hernia surgery in clinical practice. 2.

MATERIALS AND METHODS

. One hundredof a total of 236 patients diagnosed with unilateral inguinal or femoral hernias, who required surgical treatment, and who agreed with the conditions of the study, were prospectively included. All patients were treated using the Lichtenstein mesh repair method, under local anaesthesia between June 2006 and January 2008. We investigated the types and locations of hernias, duration of surgery, seniority of the surgeon, the feasibility of same-day surgery in subgroups stratified by ASA risk scores, and postoperative complication rates, in patients who underwent inguinal surgery under local anaesthesia 3. RESULTS , DISCUSSION AND CONCLUSIONS:. The rates of pain and post-operative complications were very low in hernia patients who underwent same-day surgery under local anaesthesia. The operation reduces the length of hospital stay and helps patients mobilise earlier. Both the literature, and our data, indicate that inguinal hernia repair under local anaesthesia is safe and effective, reducing anaesthesia-related complications and the length of hospital stay; is cost-effective; and is applicable in all patients.

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.

Local anaesthesia versus spinal anaesthesia in inguinal hernia repair: A systematic review and meta-analysis

BACKGROUND

Inguinal hernias are a significant cause of morbidity. The purpose of this systematic review and meta-analysis is to determine the totality of evidence regarding the effectiveness of local anaesthesia when compared to spinal anaesthesia in individuals undergoing open inguinal hernia repair.

METHODS

A systematic literature search was conducted. Inclusion criteria were randomised controlled trials (RCTs) comparing spinal and local anaesthesia on clinical and self-reported outcomes, in patients undergoing open inguinal hernia repairs. The methodological quality was assessed using the Cochrane risk of bias tool. The mode of analysis used was the difference in outcomes between the groups post-surgery and at follow-up time points. Statistical heterogeneity was assessed using the I² statistic.

RESULTS

Ten original RCTs were included, with a total of 1379 patients. There was no significant difference in operative time between the groups [Random Effects Model, MD -0.70 min (95% CI, -5.80 to 4.40 min), p = 0.79, I² = 84%]. Patients in the local anaesthetic group experienced significantly less pain than those in the spinal group [Fixed Effects Model, SMD -0.63 (95% CI, -0.81 to -0.46), p < 0.01, I² = 49%], lower rates of urinary retention [FEM, RR 0.03 (95% CI 0.01-0.08), p < 0.01, I² = 0%], decreased rates of anaesthetic failure [FEM, OR 0.17 (95% CI 0.06-0.45), p < 0.01, I² = 0%], and increased satisfaction with the anaesthetic [FEM, OR 3.40 (95% CI 2.09-5.52), p < 0.01, I² = 0%]. The methodological quality of studies was variable.

CONCLUSION

Our findings support the use of local anaesthetic in adult patients undergoing open repair for a primary inguinal hernia.

Tumescent local anesthetic technique for inguinal hernia repairs

Purpose

We evaluated the adequacy and feasibility of a tumescent solution containing lidocaine and bupivacaine for inguinal hernia repairs.

Methods

The medical records of 146 consecutive inguinal hernia patients with 157 hernia repairs using the tumescent local anesthesia technique performed by a single surgeon between September 2009 and December 2013 were retrospectively reviewed.

Results

The mean operation time (±standard deviation) and hospital stay were 64.5 ± 17.6 minutes and 2.7 ± 1.5 days. The postoperative complication rate was 17.8%. There were four cases of recurrences (2.5%) at a mean follow-up of 24 ± 14 months.

Conclusion

Our results suggest that local anesthesia with the tumescent technique is an effective and safe modality for inguinal hernia repairs.

Inguinal hernias in patients of 50 years and above. Pattern and outcome

OBJECTIVE: to evaluate a one year experience with inguinal hernia repair, in patients of > 50years, with respect to the type of inguinal hernia, type of surgery, postoperative complications and recurrence. METHODS: a prospective descriptive study of patients (n=57) > 50 years operated for inguinal hernia during a one year period. Tension-free meshplasty and herniorrhaphy, using 3"x6" polypropylene mesh and 2-0 polypropylene suture, were performed in elective and emergency surgery respectively. Follow-up visits were scheduled at six weeks, three and six months postoperatively. RESULTS: the most representative age group was 61-70 years, and all patients were male. 52 (91.22%) patients had unilateral inguinal hernias, while five (8.77%) had bilateral hernias. In 50 (87.71%) patients, the hernia was uncomplicated, while seven (12.28%) patients presented with some complication such as obstruction or strangulation. Elective surgery was performed in 50 (87.71%) patients while seven (12.28%) patients were operated in emergency. Postoperatively, 50 (87.7%) patients had uneventful recovery, while seven (12.28%) patients developed some complications which were treated conservatively. Mean hospital stay was six days. One recurrence was observed and there was no peri/postoperative death. CONCLUSION: tension-free meshplasty and herniorrhaphy are safe, simple and applicable even in elderly patients after adequate pre-operative assessment and optimization. Although associated with longer hospital stay, the mortality rate is nil and complication as well as recurrence rate is low. Hence, timely repair is necessary in elderly patients even in those with comorbid conditions.

Increased rate of day surgery use for inguinal and femoral hernia repair in a decade of hospital admissions in the Veneto Region (north-east Italy): a record linkage study

BACKGROUND

Worldwide, there has been a marked increase in the number of inguinal and femoral hernia repairs performed as day surgery procedures. This study aimed to outline the epidemiology of the procedures for repairing unilateral inguinal and femoral hernia in the Veneto Region, and to analyze the time trends and organizational appropriateness of these procedures.

METHODS

Drawing from the anonymous computerized database of hospital discharge records for the Veneto Region, we identified all unilateral groin hernia repair procedures completed in Veneto residents between 2000 and 2009 at both public and accredited private hospitals.

RESULTS

A total 141,329 hernias were repaired in the Veneto Region during the decade considered, with an annual rate of 291.2 per 100,000 population for inguinal hernia (IH) repairs and 11.2 per 100,000 population for femoral hernia (FH) repairs. Day surgery was used more for inguinal than for femoral hernia repairs, accounting for 76% and 43% (p< 0.05), respectively, of all hernia repair procedures completed during the period. The % of other than surgery hospital ordinary admissions (day surgery or ambulatory surgery) during the decade considered rose from 61.7% to 86.7% for IH and from 33.0% to 61.8% for FH.

CONCLUSIONS

In the last decade, the Veneto Region has reduced the rate of ordinary hospital admissions for groin hernia repair with a view to improving the efficiency of the hospital network.

Open preperitoneal versus anterior approach for recurrent inguinal hernia: a randomized study

BACKGROUND

Inguinal herniorrhaphy remains one of the most common general surgical operations, with approximately 15% performed for recurrence. The repair of the resulting recurrent hernia is a daunting task because of already weakened tissues and obscured and distorted anatomy. The aim of this study is to compare the posterior preperitoneal versus anterior tension-free approach for repair of unilateral recurrent inguinal hernia regarding complications and early recurrence.

METHODS

120 Patients in this study were divided randomly into 2 main groups; Group A patients were subjected to posterior preperitoneal approach and those of group B were subjected to conventional anterior tension-free repair. The primary end point was recurrence and the secondary end points were time off from work, postoperative pain, scrotal swelling and wound infections.

RESULTS

The mean hospital stay was 1.2 days and 4.7, the mean time to return work was 8.2 and 11.2 days and the mean time off from work was 9.4 and 15.9 days in group A and B respectively. The maximum follow-up period was 48 months and the minimum was 14 months with a mean value as 37.11 ± 5.14 months. Only 2 recurrences (3.3%) in group A and 4 cases (6.25%) in group B were seen. The final pain score per patient and the overall complication rate were higher in group B.

CONCLUSIONS

The open preperitoneal repair offers the advantages of low recurrence rate and allows covering all potential defects with one piece of mesh and is far superior to the anterior approach.

TRIAL REGISTRATION

ACTRN12611000337976.

Surgical management of inguinal hernias at Bugando Medical Centre in northwestern Tanzania: our experiences in a resource-limited setting

BACKGROUND

Inguinal hernia repair remains the commonest operation performed by general surgeons all over the world. There is paucity of published data on surgical management of inguinal hernias in our environment. This study is intended to describe our own experiences in the surgical management of inguinal hernias and compare our results with that reported in literature.

METHODS

A descriptive prospective study was conducted at Bugando Medical Centre in northwestern Tanzania. Ethical approval to conduct the study was obtained from relevant authorities before the commencement of the study. Statistical data analysis was done using SPSS software version 17.0.

RESULTS

A total of 452 patients with inguinal hernias were enrolled in the study. The median age of patients was 36 years (range 3 months to 78 years). Males outnumbered females by a ratio of 36.7:1. This gender deference was statistically significant (P=0.003). Most patients (44.7%) presented late (more than five years of onset of hernia). Inguinoscrotal hernia (66.8%) was the commonest presentation. At presentation, 208 (46.0%) patients had reducible hernia, 110 (24.3%) had irreducible hernia, 84 (18.6%) and 50(11.1%) patients had obstructed and strangulated hernias respectively. The majority of patients (53.1%) had right sided inguinal hernia with a right-to-left ratio of 2.1: 1. Ninety-two (20.4%) patients had bilateral inguinal hernias. 296 (65.5%) patients had indirect hernia, 102 (22.6%) had direct hernia and 54 (11.9%) had both indirect and direct types (pantaloon hernia). All patients in this study underwent open herniorrhaphy. The majority of patients (61.5%) underwent elective herniorrhaphy under spinal anaesthesia (69.2%). Local anaesthesia was used in only 1.1% of cases. Bowel resection was required in 15.9% of patients. Modified Bassini's repair (79.9%) was the most common technique of posterior wall repair of the inguinal canal. Lichtenstein mesh repair was used in only one (0.2%) patient. Complication rate was 12.4% and it was significantly higher in emergency herniorrhaphy than in elective herniorrhaphy (P=0.002). The median length of hospital stay was 8 days and it was significantly longer in patients with advanced age, delayed admission, concomitant medical illness, high ASA class, the need for bowel resection and in those with surgical repair performed under general anesthesia (P<0.001). Mortality rate was 9.7%. Longer duration of symptoms, late hospitalization, coexisting disease, high ASA class, delayed operation, the need for bowel resection and presence of complications were found to be predictors of mortality (P<0.001).

CONCLUSION

Inguinal hernias continue to be a source of morbidity and mortality in our centre. Early presentation and elective repair of inguinal hernias is pivotal in order to eliminate the morbidity and mortality associated with this very common problem.

Local anaesthetic inguinal hernia repair performed under supervision: early and long-term outcomes

INTRODUCTION

Local anaesthetic inguinal hernia repair may be technically demanding. There are minimal data regarding the outcomes of local anaesthetic hernia repair by trainees in comparison with consultants.

PATIENTS AND METHODS

All consecutive local anaesthetic repairs performed by trainees and one consultant over a 9-year period were reviewed. Operation time, volume of local anaesthetic used, early and long-term complications were assessed. A postal survey was conducted to assess chronic groin pain and satisfaction rates.

RESULTS

A total of 369 repairs were reviewed of which 265 repairs were performed by the consultant and 104 by trainees. The male-to-female ratio was 25:1 and the median age of the study group was 61 years (range, 18-93 years). The volume of local anaesthetic used was significantly higher for trainees than the consultant (42 ml versus 69 ml; P = 0.03). The operative time for the consultant and the trainees was 35 min and 40 min (P = 0.8). The day-case rate was higher for the consultant than the trainees (84% versus 69%; P = 0.02). Three patients operated by trainees required conversion to a general anaesthetic repair. No difference was noted in chronic groin pain (consultant 28% versus trainees 32%; P = 0.52) on the postal survey. The median follow-up was 5 years (range, 2-7 years).

CONCLUSIONS

Local anaesthetic inguinal hernia repair can be performed safely by surgical trainees under consultant supervision with minimal short- and long-term morbidity. A large volume dilute solution of Lignocaine and Marcaine is recommended when hernia repair is undertaken by trainees.

Local anesthetic hernia repair in overweight and obese patients

BACKGROUND

Inguinal hernia repair under local anesthesia (LA) has many advantages and is associated with high patient satisfaction. However, there are concerns of exceeding the maximum safe dose of LA agents in overweight and obese patients. The aim of the present study was to establish whether inguinal hernia repair could be safely performed under LA in overweight and obese patients.

METHODS

Patients who underwent elective LA hernia repair under a single consultant surgeon were studied retrospectively. Each patient received the same LA mixture developed at our hospital specifically for hernia repair. The mixture includes lignocaine and bupivocaine, both with adrenaline, made up to a volume of 100 ml with saline. Data were collected by case note review, and by postal and telephone surveys.

RESULTS

A total of 125 patients who underwent LA hernia repair, in whom body mass index (BMI) was measured, were studied. Based on the World Health Organization (WHO) classification, there were 35 (28%) normal weight patients and 63 (72%) overweight (BMI>or=25<30) or obese (BMI>or=30) patients. The median BMI was 27 (range 19-38). The mean volumes of LA mixture used for each group were 58 ml and 62 ml, respectively. High day case rates of 91% and 84% were obtained for the two groups, respectively. Complications included three wound hematomas and three simple wound infections, with no significant differences between groups. One patient developed a recurrent hernia (<1%).

CONCLUSIONS

Local anesthetic inguinal hernia repair in the obese is safe and well tolerated. Use of a large volume local anesthetic mixture is recommended in overweight and obese patients.

Factors determining the doses of local anesthetic agents in unilateral inguinal hernia repair

BACKGROUND

Today, local anesthesia is used in specialized hernia clinics in most cases. The technique for establishing local anesthesia for inguinal surgery may differ among surgeons. Few articles to date have mentioned the exact doses of local agents. This prospective study aimed to research the doses of local anesthetic agents needed in practice and determine the patient-related and other factors which affected those doses.

METHODS

Three hundred consecutive patients who underwent an elective unilateral inguinal hernia repair were planned to be included in the study. Lidocaine as a short-acting, medium-lasting agent and bupivacaine 0.5% as a long-acting agent were chosen. Gender, age, body mass index (BMI), side of hernia (right/left), concomitant disease, history of hernia (primary/recurrent), type of hernia (indirect/direct), Gilbert class of hernia (1-6), size of hernia (small or medium/large or massive), hernia sac content (omentum/intestine), time shift (8 am to 4 pm/later than 4 pm), duration of operation, and institutional experience (first 150 cases vs. latter 150 cases) were recorded.

RESULTS

There were 277 male and 23 female patients. The mean age was 49.73 years (range 16-83; median 50.00). The mean volume of total anesthetic agents (lidocaine + bupivacaine) was 19.79 ml (range 5.5-40; median 19.5). The mean volumes separately were 101.79 mg for lidocaine (range 30-200; median 100) and 48.12 mg for bupivacaine (range 12.5-110; median 50). The patients were discharged after a median time of 2 h postoperatively. Univariate analysis for the total dose of the two agents showed that younger age (< or =60 vs. > or =61 years), larger size of hernia, longer duration of operation (> or =61 vs. < or =60 min), recurrent hernia, hernia sac content (omentum > intestine), and higher BMI (> or =25.1 vs. < or =25.0) were significant parameters. On the other hand, BMI, recurrent hernia, size of hernia, and omentum in the hernia sac were factors that significantly affected the mean lidocaine dose. Higher BMI and recurrent hernia also caused a higher need for bupivacaine. In addition, significantly lower doses of bupivacaine was used in older patients. The significant independent parameters in the multivariate analysis were duration of operation, sac content, and BMI for lidocaine dose, whereas the duration of operation and sac content were determinative for the sum volume of the two agents. None of the recorded parameters were found to be significant for bupivacaine dose in the logistic regression.

CONCLUSIONS

This prospective study showed, again, the feasibility of local anesthesia in elective inguinal hernia repair in all patient groups with different characteristics. The mean and maximum doses of local anesthetic agents were well within safety limits, even in recurrent and large hernias. Younger age, large hernias, recurrent hernias, omental mass in the hernia sac, high BMI, and duration of operation might be the factors affecting local anesthetic doses. The significant independent parameters in the multivariate analysis were duration of operation, sac content, and BMI for lidocaine dose, whereas the duration of operation and sac content were determinative for the sum volume of lidocaine and bupivacaine.

Day-case neurosurgery for brain tumours: the early United Kingdom experience

Day-case biopsy and craniotomy for brain tumours have been reported as safe and feasible options for selected patients. The incidence and timing of complications after such procedures has also been characterized in recent publications. However, more widespread adoption of day-case cranial neurosurgery has not taken place. We report the first UK series of day-case surgery for intra-axial tumours, consisting of 30 image-guided biopsies and 11 craniotomies, taking place over 1 year from October 2006. Patients were studied prospectively and 27/30 biopsy and 9/11 craniotomy patients were discharged 6 h postoperatively. One biopsy case was admitted due to increased headache postoperatively, but with a normal CT and one craniotomy case had transient worsening of lower limb paresis requiring overnight admission. The three other overnight admissions were for patient preference. One biopsy patient was readmitted 30 h postoperatively with a seizure and discharged the following day. No patients suffered an adverse outcome. The results are presented together with the Toronto series of 284 cases over 11 years, also with no patients suffering an adverse outcome because of planned early discharge. These results suggest that day-case surgery for brain tumours is a safe and feasible option for patients in the UK.

A survey of inguinal hernia repair in Wales with special emphasis on laparoscopic repair

BACKGROUND

The National Institute of Clinical Excellence (NICE) recently published its guidance on the use of laparoscopic repair for inguinal hernias. This study aimed to assess the likely uptake of laparoscopic surgery for inguinal hernias in Wales. In addition the current practice with regards to day case surgery, use of local anaesthesia, antibiotic prophylaxis, thromboembolic prophylaxis and advice regarding convalescence was assessed.

METHODS

A postal questionnaire survey of all consultant surgeons (n = 91) in Wales was performed.

RESULTS

There was a 70% (n = 67) response to the questionnaire. Fifteen percent of surgeons (n = 9) perform laparoscopic inguinal hernia repair in Wales; 10% of surgeons in Wales agreed with the NICE guidance. Lichtenstein hernia repair was the most commonly used the technique to repair primary inguinal hernias in Wales (82%). No surgeon currently is using a laparoscopic repair as the technique of choice for repair of primary inguinal hernias. Eighteen percent of surgeons perform all the procedures as day cases; 15% of surgeons perform more than 90% of the procedures under local anaesthesia; 44% of surgeons do not use any form of thromboprophylaxis for elective inguinal hernia repair, while 78% of the surgeons used routine antibiotic prophylaxis. Post-operative advice regarding return to sedentary work and driving was highly variable (1-4 weeks), as was advice regarding heavy work and sport (2-12 weeks).

CONCLUSIONS

The uptake of laparoscopic surgery for inguinal hernia repair in Wales is low. Only a minority of surgeons agree with the NICE guidance. Similarly the uptake of day case repair and the use of local anaesthesia are minimal. The use of antibiotic and thromboembolic prophylaxis is empirical and inconsistent. There is a need for evidence-based guidelines to standardise the antibiotic prophylaxis, TE prophylaxis and advice regarding post-operative advice.