Page 56 - International guidelines for groin hernia management

Hernia

abdominal-surgery patients including those undergoing Discussion and grading clarification
groin hernia repair. A PVB has the potential to offer sus- Inguinal hernia repair results in pain postoperatively and
tained pain relief with minimal side effects. One systematic the optimal method(s) to treat this pain remain(s) contro-
review 674 and three randomized studies 675–677 found a versial. However, it is clear that local anesthetic field
tendency to less postoperative pain in PVB-patients when blocks and subfascial and/or subcutaneous local infiltration
compared with general-anesthesia and spinal-anesthesia reduces early postoperative pain scores and the need for
patients. supplemental analgesics. Therefore, when general or
The transversus abdominis plane (TAP) block is a rel- regional anesthesia is used, local anesthetic field blocks and
atively new regional anesthetic technique developed in an infiltration is recommended in all open groin hernia surg-
attempt to reduce postoperative pain. It has evolved from a eries. Additionally, the combination of a conventional
landmark technique to an ultrasound-guided one. Four NSAID or a selective COX-2 inhibitor plus paracetamol
randomized studies comparing TAP blocks with either reduces postoperative pain and is also recommended.
placebo, local anesthetic infiltration, or no treatment A weakness in the review presented in this chapter stems
reported conflicting results with respect to early postoper- from the variation in quality of the available randomized
ative pain and analgesic use. 123, 654, 678, 679 A 2010 trials. Although postoperative pain was our focus, it was
Cochrane Database Systematic Review found only limited not always the primary endpoint of the included studies.
evidence to suggest that the use of perioperative TAP There is strong evidence for preoperative and intraop-
blocks is opioid sparing or reduces pain scores after erative inguinal field blocks and wound infiltration with
680
abdominal surgery. seven randomized studies showing superiority to no treat-
In addition to the preoperative and intraoperative pain ment or to placebo. Four randomized trials found wound
prevention and treatment methods above, non-opioid and infiltration superior to placebo. Provided that there is no
non-steroidal anti-inflammatory medications (ac- contraindication, the use of a conventional NSAID or a
etaminophen, NSAIDs and selective COX-2 inhibitors) selective COX-2 inhibitor is also recommended with four
should be used for postoperative pain management. 681–685 randomized trials and one review showing reduced post-
Paracetamol (acetaminophen) has insufficient effect as operative pain when compared to placebo. There is also
single-agent therapy for moderate-to-severe pain. How- strong evidence to support the use of paracetamol in
ever, the combination of paracetamol and a non-steroidal combination with conventional NSAIDs/selective COX-2
anti-inflammatory drug, given in a timely manner, seems to inhibitors. Opioids are recommended in limited circum-
be optimal and provides sufficient analgesic during the stances as described above.
early recovery phase provided that there is no
contraindication. 614, 686
Opioids may cause adverse effects such as nausea,
vomiting, and constipation, amongst others which may Chapter 15
delay postoperative recovery. Therefore, non-opioid anal-
gesics should be used whenever possible. However, opioids
can be used for moderate- or high-intensity pain, in addi- Convalescence
tion to non-opioid analgesia or when the combination of an
NSAID and paracetamol is not sufficient or is T. Bisgaard and L. N. Jorgensen
contraindicated. 687
Several small studies of varying quality seem to indicate Introduction
that local anesthetic administration via intra-wound
catheters by repeat bolus or continuous infusion is more Convalescence duration—defined as sick leave from work
efficacious than placebo at reducing postoperative and time away from leisure—is an important feature of the
pain. 688–693 Potential benefits and risks of this technique recovery phase following IH surgery. However, most
need further study with RCTs and other means. studies have not investigated the impact of recommenda-
tions on short duration convalescence.

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