Herniorraphy 2004

The recommendations of the PROSPECT Working Group are graded A-D, based on the level of evidence from the studies, which .. 

The recommendations of the PROSPECT Working Group are graded A–D, based on the level of evidence from the studies, which is in accordance with the Oxford Centre for Evidence-Based Medicine (CEBM website accessed Dec 2003, Sackett 2000). In the context of PROSPECT, recommendations based on procedure-specific evidence are grade A (randomised clinical trials), those based on transferable evidence are grade B (randomised clinical trials) or grade C (retrospective studies or case series) and those based on clinical practice are grade D (Click here for further information on levels of evidence and grades of recommendation).

PROSPECT provides clinicians with supporting arguments for and against the use of various interventions in postoperative pain based on published evidence and expert opinion. Clinicians must make judgements based upon the clinical circumstances and local regulations. At all times, local prescribing information for the drugs referred to must be consulted.

The following pre-, intra- and postoperative interventions have been evaluated for the management of postoperative pain following herniorraphy:

Pre-operative

Recommended

Systemic 

• Conventional NSAIDs (Grade A) or COX-2-selective inhibitors (Grade A) 

Local anaesthetic techniques

• Inguinal nerve block/field block/infiltration, pre-operatively and/or intra-operatively (Grade A)
• Long-acting local anaesthetics (Grade D)

Not recommended

Systemic

• Clonidine (Grade D)
• Corticosteroid (Grade D)
• Gabapentin/pregabalin (Grade D)
• Ketamine (Grade D)

Local anaesthetic techniques

• Epinephrine (Grade A), dextran (Grade D) or corticosteroid (Grade D) as part of a local anaesthetic solution
• Paravertebral nerve block (Grade D)

Other local analgesics

• Wound infiltration with clonidine (Grade D)
• Wound infiltration with conventional NSAIDs (Grade A)
• Topical conventional NSAIDs (Grade D)

Intra-operative

Recommended 

Local anaesthetic techniques

• Inguinal nerve block/field block/infiltration, pre-operatively and/or intra-operatively (Grade A)
• Long-acting local anaesthetics (Grade D)

Operative anaesthetic techniques

• Local anaesthesia ± sedation OR general anaesthesia in combination with local anaesthetic techniques (inguinal nerve block/field block/infiltration) (Grade A)
• Long-acting local anaesthetics (Grade D)

Operative techniques

• Open or laparoscopic surgery (Grade D)
• Mesh techniques (Grade A) – no recommendations for one particular open mesh technique, prosthesis type or mesh fixation technique over another due to limited available pain data

Not recommended 

Systemic

• Clonidine (Grade D)
• Gabapentin/pregabalin (Grade D)
• Ketamine (Grade D)

Local anaesthetic techniques

• Epinephrine (Grade A), dextran (Grade D) or corticosteroid (Grade D) as part of a local anaesthetic solution
• Local anaesthetic instillation (no needles) at closure (Grade D)
• Extraperitoneal instillation of local anaesthetic during laparoscopic surgery (Grade A)
• Paravertebral nerve block (Grade D)

Other local analgesics

• Wound infiltration with clonidine (Grade D)
• Wound infiltration with conventional NSAIDs (Grade A)
• Wound infiltration with strong opioid (Grade A)

Operative anaesthetic techniques

• Epidural anaesthesia (Grade D)
• Spinal anaesthesia (Grade D)

Operative techniques

• Open non-mesh surgery (Grade A)

Nerve section/cryoanalgesia techniques

• Surgical division of the ilioinguinal nerve (Grade A)
• Cryoanalgesia (Grade A)

Postoperative

Recommended 

Systemic

• Conventional NSAIDs (grade A) or COX-2-selective inhibitors (grade A)
• Paracetamol, for routine pain therapy in combination with conventional NSAIDs/COX-2-selective inhibitors (Grade B)
• Weak opioids for moderate-intensity pain when conventional NSAIDs/COX-2-selective inhibitors plus paracetamol are not sufficient or are contraindicated (Grade B)
• Strong opioids as rescue analgesia only (for high-intensity pain), in addition to non-opioid analgesia (Grade B)

Not recommended 

Systemic

• Gabapentin/pregabalin (Grade D)
• Ketamine (Grade D)

Local anaesthetic techniques

• Continuous infusion with local anaesthetic by a catheter in the wound (Grade D)
• Single/repeat dose of local anaesthetic by a catheter in the wound (Grade A)
• Postoperative subcutaneous infiltration with local anaesthetic (Grade D)

Non-pharmacological techniques

• TENS (Grade A)

See Overall PROSPECT recommendations for the overall strategy for managing pain after herniorraphy