Page 52 - International guidelines for groin hernia management

Hernia

When compared with general anesthesia, local anes- database analysis found lower reoperation rates following
thesia is more cost effective when hospital and total hernia repair by private hernia surgeons with uniform use
healthcare costs are considered 632 and provides earlier of local anesthesia when compared with primary IH repair
patient mobilization and hospital discharge 614 Although by general surgeons (possibly due to inexperience). They
perioperative pain sensation is reported and can sometimes concluded that local anesthesia use in a general hospital
be a reason for conversion to general anesthesia, 619 early might be a direct hernia recurrence risk factor, stressing the
postoperative pain seems less in the local anesthesia importance of experience in the administration of local
614
group. Some randomized studies report no inter-group anesthesia.
difference in satisfaction or quality of life with respect to Cardiovascular disease accounts for most of the mor-
614, 615, 617
the operation and the first postoperative week. tality associated with elective hernia repair (see Chap-
Others report higher patient satisfaction with the anesthetic ter 18). 243 Therefore, correctly performed local anesthesia
technique for patients randomized to local might be preferable to regional and general anesthesia in
anesthesia. 618, 620 frail patients with severe systemic diseases (ASA class III).
We identified five reviews 609, 611–614 and 11 randomized An RCT has demonstrated that local anesthesia is associ-
trials 618, 620, 624, 625, 629, 633–638 comparing local to spinal ated with a superior ventilation and oxygenation pattern
anesthesia. The most recent meta-analysis, published in when compared with general and regional anesthesia. 635
2012, 614 did not include one randomized trial of spinal
versus local anesthesia. 634 The authors of this meta-anal- Discussion, consensus, clarification of grading
ysis performed an analysis with respect to urinary retention
and found a lower incidence of urinary retention in local Evidence strongly supports the idea that local anesthesia
614
anesthesia patients. The incidence of reported postop- has several advantages over general or regional anesthesia
erative pain varies, ranging from no difference to less early in elective reducible IH repairs. As suggested by hernia
postoperative pain after local anesthesia. 614 Two random- database analysis, hernia recurrence may be more common
ized trials reported no differences in postoperative nau- following operation employing local anesthesia. Experi-
sea. 618, 620 However, the largest randomized trial (with ence in local anesthetic administration might negate this
more subjects than the other two trials combined) reported downside risk.
less postoperative nausea in the local anesthetic group. 629 ASA class III patients undergoing IH repairs may ben-
The majority of studies report faster hospital discharge efit by the administration of local anesthetic over regional
after local anesthesia. 614 Local is more cost effective than or general anesthetic. However, the evidence for this
spinal anesthesia when hospital and total healthcare potential benefit is weak.
expenditures are compared. 632 Crossover rates from local
and regional anesthesia to general anesthesia strongly favor Key question
local anesthesia (1.9 versus 9.6%, respectively). 629
Hernia registries provide insights into IH recurrence KQ13.b Are outcomes different when open inguinal hernia
risks with different anesthetic modalities. A Swedish Her- repairs are performed with regional versus general or local
nia Registry analysis of 59,823 patients found that local anesthesia?
anesthesia is associated with an increased risk of reopera-
tion for recurrence after primary IH repair. 50 Using local Introduction
anesthesia as a reference, they reported reoperation relative
risks of 0.76 and 0.79 for regional and general anesthesia, The EHS Guidelines recommend against the use of spinal
3
respectively. A Danish Hernia Database analysis of 43,123 anesthesia in open anterior IH repairs in adults. They also
patients reported an increased reoperation rate after local cite general anesthesia with short-acting agents combined
anesthesia versus general or regional anesthesia after with local infiltration anesthesia as a valid alternative to
direct—but not indirect—hernia repair. 77 The same local anesthesia alone. 3

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