INGUINAL HERNIOTOMY Updated by Narinder Rawal

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1 Sistla SC, Sibal AK, Ravishankar M. Intermittent wound perfusion for postoperative pain relief following upper abdominal surgery: a surgeon s perspective. Pain Practice 2009;9: Sorbello M, Paratore A, Morello G, et al. Wound levobupivacaine continuous infusion for postoperative analgesia in living kidney donors: case-control study. Transplant Proc 2009;41: Thomas D, Lambert W, William K. The direct perfusion of surgical wounds with local anaesthetic solution: an approach to postoperative pain? Ann R Coll Surg Engl 1983;65: Utvoll J, Beausang-Linder M, Mesic H, Raeder J. Brief report: improved pain relief using intermittent bupivacaine injections at the donor site after breast reconstruction with deep inferior epigastric perforator flap. Anesth Analg 2010;110: Wang LW, Wong SW, Crowe PJ, et al. Wound infusion with local anaesthesia after laparotomy: a randomized controlled trial. ANZ J Surg 2010;80: Yoost TR, McIntyre M, Savage SJ. Continuous infusion of local anesthetic decreases narcotic use and length of hospitalization after laparoscopic renal surgery. J Endourol 2009;23(4): INGUINAL HERNIOTOMY Updated by Narinder Rawal The authors would like to acknowledge Professor Henrik Kehlet, Professor of perioperative therapy and Head of Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Denmark, for his original work in the first edition of this booklet Wound Catheter Techniques for Postoperative Analgesia Review of evidence No new studies of surgical site local anaesthetic continuous infusion for inguinal herniotomy, eligible for inclusion in this booklet, have been published since However, a recent systematic review of the literature on behalf of the PROcedure-SPECific postoperative pain management (PROSPECT) Working Group concluded that regional anaesthesia was superior to general anaesthesia for reducing postoperative pain (Joshi et al. 2012). Furthermore, the review found that continuous local anaesthetic infusion of a surgical site provides a Chapter 2 Abdominal surgery

2 longer duration of analgesia. This finding supports the evidence presented here: continuous postoperative local anaesthetic surgical site infusion provides effective postoperative analgesia in this setting. A number of studies have also reported the effectiveness of surgical site infiltration in this setting (reviewed by Joshi et al. 2012), but the studies do not use a catheter for continuous infusion and therefore have not been included in this evaluation. There are six procedure-specific randomized studies of continuous surgical site infusion: five placebo-controlled (saline) (Le Blanc 2005, Oakley et al. 1998, Sanchez et al. 2004, Schurr et al. 2004, Stewart et al. 2004) and one comparing infusion with no infusion (Lau et al. 2003). All studies show significant reductions in pain and/or opioid requirements. The analgesic effect, although statistically significant, was only moderate, and no data are available on convalescence for this relatively small, outpatient operation. A 1-year follow-up assessment from the study by Schurr et al. (2004) was published in 2011 but showed no difference in the incidence, severity or functional interference of pain between the study groups (Russ et al. 2011). No data suggest any side effects. Continuous subfascial infusion of local anaesthetics after open inguinal herniotomy provides additional analgesia without side effects. Infusion time ranged between 48 and 60 h, except in one 24-h study (Stewart et al. 2004). Most studies used bupivacaine 0.25% or 0.5% with a subfascial catheter (Lau et al. 2003, Le Blanc, 2005, Oakley et al. 1998, Schurr et al. 2004)

3 Publication Lau et al. Dig Surg 2003 Le Blanc J Am Coll Surg 2005 Oakley et al. Br J Surg 1998 Sanchez et al. Am Surg 2004 Grade* (1 13) Number of patients Catheter type and location 4 44 Multiholed 4 52 Multiholed 3 72 Epidural 4 45 Multiholed Subcutaneous Preclosure bolus 0.5%, 10 ml 0.5%, 10 ml 0.5%, 10 ml 0.25%, 20 ml Postoperative administration 0.5%, 2 ml/h for 48 h 0.5%, 2 ml/h for 48 h 0.5%, 2 ml/h for 50 h 0.25%, 2 ml/h for 48 h Outcomes at rest and during coughing Opioid consumption on days 2 5 Chapter 2 Abdominal surgery Schurr et al. Surgery Multiholed 0.25%, 10 ml 0.25%, 2 ml/h for 60 h = Pain on days 2 5 Stewart et al. ANZ J Surg No information on catheter type Subcutaneous Not used Ropivacaine 0.75%, 4 ml/h for 24 h Opioid consumption Table 16. Summary of literature for inguinal herniotomy. *see page 15 for grading of publications.

4 Practical details for inguinal herniotomy Catheter type Four studies used a multiholed catheter (Lau et al. 2003; Le Blanc 2005, Sanchez et al. 2004, Schurr et al. 2004). No specific information was given in the two remaining studies (Oakley et al. 1998, Stewart et al. 2004). The limited data do not allow a separate analysis of efficiency between multiholed vs single-holed catheters. There are no comparative studies of different catheter types. With the small incision used for inguinal herniotomy, the data are too limited to allow assessment of potential differences between the analgesic effects from multiholed vs single-holed catheter infusions. Evidence grade: Low Catheter placement Four studies (Lau et al. 2003, Le Blanc 2005, Oakley et al. 1998, Schurr et al. 2004) used a subfascial placement and two (Sanchez et al. 2004, Stewart et al. 2004) used subcutaneous placement. No comparative studies exist, and the data from the six studies do not allow analyses of differences in efficacy in relation to catheter placement, since all studies were positive. However, data on single-dose administration of local anaesthetic suggest better efficacy from subfascial administration. catheter placement is suggested. Evidence grade: Moderate Preclosure bolus administration Five studies (Lau et al. 2003, Le Blanc 2005, Oakley et al. 1998, Sanchez et al. 2004, Schurr et al. 2004) used a preincisional ilioinguinal block or pre-closure infiltration with bupivacaine (variable concentration and volume ml of 0.25% or 0.5%), in accordance with existing literature on this procedure (

5 Preclosure bolus infiltration (incisional or ilioinguinal block) is suggested based on the evidence, but its role when combined with a continuous surgical site infusion has not been specifically evaluated. Evidence grade: High Drug and dosing regimen The six available studies used variable concentrations of bupivacaine or ropivacaine (2 4 ml/h, %), but most used a fixed rate of 2 ml/h, 0.5% bupivacaine (Lau et al. 2003, Le Blanc 2005, Oakley et al. 1998). There are no comparative data of different local anaesthetics and the data do not allow dose-response evaluation. The limited data suggest the use of 2 ml/h bupivacaine 0.5%. Evidence grade: Low Duration of infusion Durations of infusion of between 48 and 60 h have been used. Since the pain after inguinal herniotomy is most severe during the first 48 h, this is the recommended duration of infusion, even though there are insufficient data to document any possible gains from prolonged infusion. Duration should be tailored to the patient s needs. Evidence grade: Moderate Key messages for inguinal herniotomy The herniotomy model provides proof of concept of the analgesic efficacy of continuous postoperative local anaesthetic surgical site infusion. There is a need for further studies on catheter type, catheter placement and dose/volume relationships, and cost-effectiveness when compared with multimodal analgesic techniques. Chapter 2 Abdominal surgery

6 References For a list of additional references and suggestions for further reading, see Appendix 4. Joshi GP, Rawal N, Kehlet H, on behalf of the PROSPECT collaboration. Evidence-based management of postoperative pain in adults undergoing open inguinal hernia surgery. Br J Surg 2012;99: Lau H, Patil NG, Lee F. Randomized clinical trial of postoperative subfascial infusion with bupivacaine following ambulatory open mesh repair of inguinal hernia. Dig Surg 2003;20: LeBlanc K, Bellanger D, Rhynes VK, Hausmann M. Evaluation of continuous infusion of 0.5% bupivacaine by elastomeric pump for postoperative pain management after open inguinal hernia repair. J Am Coll Surg 2005;200: Oakley MJ, Smith JS, Anderson JR, Fenton-Lee D. Randomized placebo-controlled trial of local anaesthetic infusion in day-case inguinal hernia repair. Br J Surg 1998;85: Procedure-specific postoperative pain relief ( Russ AJ, Faucher LD, Gordon DB, et al. Functional implications of long-term pain following outpatient inguinal herniorrhaphy a prospective evaluation. J Sur Res 2011;169: Sanchez B, Waxman K, Tatevossian R, et al. Local anesthetic infusion pumps improve postoperative pain after inguinal hernia repair: a randomized trial. Am Surg 2004;70: Schurr MJ, Gordon DB, Pellino TA, Scanlon TA. Continuous local anesthetic infusion for pain management after outpatient inguinal herniorrhaphy. Surgery 2004;136: Stewart A, Fan MM, Fong MJ, et al. Randomized trial of pain control infusion pump following inguinal hernia repair. ANZ J Surg 2004;74: