Herniorraphy 2004

HERNIORRAPHY-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments against…

• Clonidine significantly increased VAS pain scores compared with placebo at rest at 24 h (p<0.05), and there was no significant benefit in the PACU or at 6 h, or on coughing at any time (n=31) Elliott et al 1997
• Intra-operative systemic clonidine was of no significant benefit over placebo for reducing postoperative analgesic requirements (n=31) Elliott et al 1997

CLINICAL PRACTICE

Arguments against…

• Clonidine is associated with side-effects, including hypotension, sedation, dizziness and bradycardia

PROSPECT RECOMMENDATIONS

• Intra-operative clonidine is not recommended due to limited procedure-specific evidence and potential side-effects, which may delay early ambulation (Grade D)

TRANSFERABLE EVIDENCE FROM OTHER PROCEDURES

Arguments for…

• Studies of gabapentin and pregabalin in mastectomy, abdominal surgery, laparoscopic cholecystectomy and spinal surgery showed reductions in postoperative pain and supplementary analgesic requirements for at least 24 h Dahl et al 2004

TRANSFERABLE EVIDENCE FROM OTHER PROCEDURES

Arguments for…

• Studies of ketamine in abdominal, orthopaedic, gastric, hepatic and renal surgery showed a reduction in postoperative pain and opioid use when used as an adjuvant to morphine, either epidurally or intravenously Subramaniam et al 2004

CLINICAL PRACTICE

Arguments for…

• Ketamine is associated with a risk of adverse effects on the central nervous system

PROSPECT RECOMMENDATIONS

• Intra-operative ketamine cannot be recommended at this time (Grade D) due to a lack of procedure-specific evidence, and due to associated side-effects that may hinder early ambulation, despite some evidence of analgesic efficacy in other procedures

HERNIORRAPHY-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

• Inguinal nerve block/field block was superior to placebo for reducing postoperative pain scores during the early postoperative period and the use of supplementary analgesics Bugedo et al 1990 Click here for more information
• Infiltration/field block was superior to placebo for reducing postoperative pain scores and the use of supplementary analgesics and for extending the time to firstanalgesic request Dierking et al 1994 Click here for more information
• Inguinal nerve block/field block/infiltration reduced postoperative pain scores and supplementary analgesic requirements, and increased the time to first analgesic request, compared with no treatment or placebo Fischer et al 2000 Click here for more information
• Group analysis of all pre-operative local anaesthetic injection techniques (inguinal nerve block/field block/infiltration) showed that they were superior to no treatment or placebo for reducing postoperative pain scores and supplementary analgesic requirements Bugedo et al 1990 Click here for more information
• Group analysis of all intra-operative (± pre-operative) local anaesthetic injection techniques (inguinal nerve block/field block/infiltration) showed that they were more effective than placebo for reducing pain scores during the early postoperative period and supplementary analgesic requirements Dierking et al 1994 Click here for more information
• Pre- plus intra- plus postoperative inguinal nerve block/field block/infiltration was superior to placebo for reducing pain scores and the proportion of patients requiring supplementary analgesia Fischer et al 2000 Click here for more information
• Group analysis of all local anaesthetic injection techniques (inguinal nerve block/field block/infiltration) showed that they are superior to placebo or no treatment for reducing postoperative pain scores Bugedo et al 1990 Click here for more information
• Group analysis of all local anaesthetic injection techniques (inguinal nerve block/field block/infiltration) showed that they reduced supplementary analgesic requirements compared with control Bugedo et al 1990 Click here for more information
• Pre-operative local anaesthetic injection was similar to the same regimen given at-closure for pain scores and analgesic use Dierking et al 1992 Click here for more information
• Local anaesthetic instillation, at closure, reduced pain scores compared with placebo or no treatment controls during the first day after surgery Bays et al 1991 Click here for more information
• Local anaesthetic instillation, at closure, reduced the requirement for supplementary analgesics compared with placebo or no treatment controls during the first day after surgery Bays et al 1991 Click here for more information
• Pre-operative local anaesthetic injection was similar to at-closure local anaesthetic instillation for pain scores and supplementary analgesic use Spittal et al 1992 Click here for more information
• Pre-operative inguinal nerve block/field block/infiltration was similar to postoperative papaveretum/aspirin, and the combination was superior to placebo for reducing pain scores and supplementary analgesic requirements Nehra et al 1995 Click here for more information
• A multi-analgesic regimen, including pre-operative local anaesthetic injection, showed significant analgesic benefits over pre-operative systemic strong opioid but did not reduce the incidence of PONV Pavlin et al 2003 Click here for more information
• Local injection of ropivacaine 0.5% had a greater analgesic efficacy than ropivacaine 0.25% and 0.125% Johansson et al 1997 Click here for more information
• Local injection of ropivacaine and bupivacaine was equally effective for analgesia, and there was no significant difference in the incidence of PONV Erichsen et al 1995 Click here for more information

Arguments against…

• Local anaesthetic injection techniques were not significantly different from placebo for the incidence of PONV (all groups received general anaesthetic) Ding et al 1995 Click here for more information
• Addition of corticosteroid to local anaesthetic injection was of no benefit for reducing postoperative pain scores or supplementary analgesic requirements McCleane et al 1994 Click here for more information
• Addition of dextran to local bupivacaine injection showed no significant benefit for reducing pain or supplementary analgesic requirements Armstrong et al 1986 Click here for more information

TRANSFERABLE EVIDENCE FROM OTHER PROCEDURES

Arguments for…

• A systematic review of local anaesthesia infiltration showed inconclusive evidence of analgesic efficacy in hysterectomy, open cholecystectomy and a variety of other surgical procedures, but consistent and clinically relevant pain relief in herniorraphy Møiniche et al 1998
• There is evidence from a variety of surgical procedures that the efficacy of local anaesthetics for postoperative analgesia is similar following pre-operative or post-incisional administration Møiniche et al 1998

CLINICAL PRACTICE

Arguments for…

• Long-acting local anaesthetics are preferred to short-acting local anaesthetics for analgesia by local injection

Arguments for…

• In herniorraphy studies of local anaesthetic injection techniques, methodology is inconsistently described, and terminology is inconsistently used. In addition, studies directly comparing one local anaesthetic injection technique with another are lacking. For these reasons, no conclusion about the relative benefits of one technique, or combination of techniques (inguinal nerve block/field block/infiltration), can be made at this time

PROSPECT RECOMMENDATIONS

• Local anaesthetic injection techniques (inguinal nerve block/field block/infiltration), administered pre-operatively or intra-operatively, or both, are recommended (Grade A) because they reduce early postoperative pain and supplementary analgesic use compared with placebo. The effect of pre-operative administration is comparable to post-incisional administration
• There are insufficient data to recommend (Grade D) one injection technique (inguinal nerve block/field block/infiltration), or combination, in preference to another
• Local anaesthetic instillation administered at closure cannot be recommended at this time, despite some evidence for its analgesic efficacy, because of limited data (Grade D)
• Long-acting local anaesthetics are recommended in preference to short-acting local anaesthetics (Grade D)
• Addition of dextran or corticosteroid to local anaesthetic solution is not recommended (Grade D) because of limited procedure-specific evidence

HERNIORRAPHY-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments against…

• Intra-operative wound instillation with epinephrine and local anaesthetic was of no significant benefit over local anaesthetic alone for reducing postoperative pain scores during 1–20 h, for reducing analgesic requirements, or for increasing the time to first analgesic request (n=17) Bays et al 1991

TRANSFERABLE EVIDENCE FROM OTHER PROCEDURES – STUDY INFORMATION

Arguments against…

• Addition of epinephrine to local anaesthetic solution for extraperitoneal instillation did not reduce pain scores or analgesic requirements Deans et al 1998 Click here for more information

CLINICAL PRACTICE

Arguments against…

• Epinephrine may result in undesirable cardiovascular side-effects

PROSPECT RECOMMENDATIONS

• Addition of epinephrine to local anaesthetic solution is not recommended because of a lack of additional or prolonged analgesic effect from limited procedure-specific data (Grade A)

HERNIORRAPHY-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

• Paravertebral nerve block was superior to peripheral nerve block for reducing the proportion of patients requiring supplementary analgesia in the PACU (p=0.002; n=46) Klein et al 2002
• Paravertebral nerve block was associated with a lower incidence of PONV in the PACU compared with peripheral nerve block (p<0.001; n=46) Klein et al 2002

Arguments against…

• Paravertebral nerve block and peripheral nerve block were not significantly different for VAS pain scores at rest, on movement and on coughing in the PACU, or at 2, 6, 12, 18, 24 and 48 h (n=46) Klein et al 2002
• There was no significant difference between paravertebral nerve block and peripheral nerve block for the proportion of patients requiring supplementary analgesics in the 72-h follow-up period, or the time to first analgesic request (n=46) Klein et al 2002

CLINICAL PRACTICE

Arguments against…

• Clinical experience with the paravertebral nerve block is not widespread. This technique is considered to be more complex, and thus it may be associated with a higher incidence of complications than other local anaesthetic techniques (nerve block/field block/infiltration)

PROSPECT RECOMMENDATIONS

• Paravertebral nerve block is not recommended (Grade D) because it has only a marginal analgesic benefit over other local anaesthetic techniques (nerve block/field block/infiltration) and is a more complex technique

TRANSFERABLE EVIDENCE FROM OTHER PROCEDURES – STUDY INFORMATION

Arguments against…

• Two of three studies showed no significant benefit of extraperitoneal instillation of local anaesthetic over placebo for reducing postoperative pain scores Deans et al 1998 Click here for more information
• Extraperitoneal instillation of local anaesthetic showed no significant benefit over placebo for reducing supplementary analgesic requirements   Deans et al 1998 Click here for more information

CLINICAL PRACTICE

Arguments against…

• There is little clinical experience with extraperitoneal instillation and the technique is poorly defined

PROSPECT RECOMMENDATIONS

• Extraperitoneal instillation with local anaesthetic is not relevant for open herniorraphy
• Extraperitoneal instillation with local anaesthetic is not recommended in laparoscopic herniorraphy because of a lack of analgesic effect (Grade A)

HERNIORRAPHY-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

• Wound infiltration with clonidine was superior to intramuscular clonidine for reducing pain scores, but a significant benefit was only evident at 24 h; there was no significant benefit for reducing supplementary analgesic requirements Elliott et al 1997 Click here for more information

Arguments against…

• Wound infiltration with clonidine showed no significant benefit compared with placebo for reducing VAS pain scores at rest and on coughing in recovery, at 6 h and at 24 h (n=31) Elliott et al 1997
• Wound infiltration with clonidine showed no significant benefit compared with placebo for reducing supplementary analgesic requirements (n=31) Elliott et al 1997

CLINICAL PRACTICE

Arguments against…

• Clonidine is associated with side-effects, including hypotension, sedation, dizziness and bradycardia

PROSPECT RECOMMENDATIONS

• Wound infiltration with clonidine is not recommended due to limited procedure-specific data and potential side-effects that can delay early ambulation (Grade D)

HERNIORRAPHY-SPECIFIC EVIDENCE -STUDY INFORMATION

Arguments against…

• Intra-operative wound infiltration with conventional NSAIDs was of no analgesic benefit over systemic administration Rømsing et al 2001 Click here for more information

TRANSFERABLE EVIDENCE FROM OTHER PROCEDURES

Arguments for…

• One randomised trial in patients undergoing transurethral prostatectomy showed that diclofenac did not affect total blood loss compared with placebo Bricker et al 1987

Arguments against…

• A systematic review of the postoperative analgesic effect of local infiltration with conventional NSAIDs showed little difference between wound infiltration and systemic administration Rømsing et al 2000
• Randomised trials in healthy volunteers showed that conventional NSAIDs (ketorolac, naproxen or diclofenac) reduced the platelet aggregation response compared with placebo; ketorolac and naproxen also prolonged bleeding time compared with placebo Greer et al 1999
• Meta-analyses of randomised, controlled trials showed that peri-operative conventional NSAIDs increased the risk of postoperative bleeding requiring treatment and/or the risk of re-operation for haemostasis after tonsillectomy compared with controls Marret et al 2003
• A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused a reversible platelet dysfunction Niemi et al 1997
• A randomised controlled trial showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) were associated with a similar incidence of surgical site bleeding after elective surgery Forrest et al 2002
• A randomised clinical trial showed that the conventional NSAID diclofenac was associated with significantly greater intra-operative blood loss than the COX-2-selective inhibitor rofecoxib in patients undergoing abdominal or vaginal hysterectomy or breast surgery Hegi et al 2004

CLINICAL PRACTICE

Arguments against…

• The potential for conventional NSAIDs, administered by wound infiltration, to adversely affect platelet function and wound healing must be considered

PROSPECT RECOMMENDATIONS

• Intra-operative wound infiltration with conventional NSAIDs is not recommended (grade A) because of a limited analgesic benefit compared with systemic administration

HERNIORRAPHY-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments against…

• Wound infiltration with morphine was of no significant benefit over placebo for pain scores at rest or on mobilisation at 0, 2, 4, 6 h and days 2 or 7 (n=30) Rosenstock et al 1996
• Two studies comparing incisional morphine with placebo showed inconsistent results for supplementary analgesic requirements Rosenstock et al 1996 Click here for more information
• Two of three studies showed no significant benefit of wound infiltration with strong opioid compared with systemic strong opioid for reducing pain scores, or for reducing supplementary analgesic requirements Rosenstock et al 1996 Click here for more information

CLINICAL PRACTICE

Arguments against…

• Strong opioids are associated with adverse effects, including respiratory depression, nausea, vomiting, sedation, confusion, paralytic ileus and urinary retention

PROSPECT RECOMMENDATIONS

• Wound infiltration with strong opioids is not recommended because of conflicting procedure-specific evidence for its analgesic efficacy (Grade A). In addition, strong opioids are not recommended for routine analgesic treatment in herniorraphy because of potential side-effects (Grade D)

HERNIORRAPHY-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

• Local anaesthesia reduced pain scores at different times during the first postoperative week compared with general anaesthesia Aasbo et al 2002 Click here for more information
• Local anaesthesia significantly reduced PONV compared with general anaesthesia Özgün et al 2002 Click here for more information
• Local anaesthesia significantly reduced the incidence of sore throat compared with general anaesthesia Song et al 2000Click here for more information
• Local anaesthesia significantly reduced the duration of hospital stay compared with general anaesthesia Nordin et al 2003 Click here for more information
• Local anaesthesia significantly reduced the incidence of urinary retention compared with general anaesthesia Gönüllü et al 2002 Click here for more information
• Local anaesthesia was of significant benefit compared with spinal anaesthesia for reducing postoperative pain scores Malazgirt et al 2000 Click here for more information
• Local anaesthesia was associated with a significantly lower incidence of urinary retention compared with spinal anaesthesia Song et al 2000 Click here for more information
• Local anaesthesia significantly reduced the duration of hospital stay compared with spinal anaesthesia Song et al 2000Click here for more information
• Local anaesthesia was superior to spinal anaesthesia for reducing the proportion of patients converted to general anaesthesia (p=0.0001, n=412) Nordin et al 2003

Arguments against…

• Studies comparing local anaesthesia with general anaesthesia showed no consistent benefit for a reduction in supplementary analgesic requirements Aasbo et al 2002 Click here for more information
• Local anaesthesia was not superior to spinal anaesthesia for reducing supplementary analgesic requirements Nordin et al 2003 Click here for more information
• Local anaesthesia was similar to spinal anaesthesia for the incidence of PONV in two of three studies (n=50, n=56) Nordin et al 2003
• Studies of racemic bupivacaine versus levobupivacaine for local anaesthesia gave inconsistent results [popup num="23"]Kingsnorth et al 2002a Click here for more information
• Dextran with local anaesthetic for local anaesthesia was not significantly different from local anaesthetic alone for reducing pain scores, reducing analgesic use, or for increasing the time to first analgesic request (n=40) Kingsnorth et al 1979

CLINICAL PRACTICE

Arguments for…

• Long-acting local anaesthetics are preferred to short-acting local anaesthetics

Arguments against…

• For all regional anaesthesia techniques, there are procedure-specific failure rates between 2 and 10%, and conversion to general anaesthesia may be required
• Local practices and cultural differences influence the choice of anaesthetic technique for herniorraphy

PROSPECT RECOMMENDATIONS

• Local anaesthesia (inguinal nerve block/field block/infiltration techniques), with or without intravenous sedation, is recommended (Grade A) because it decreases postoperative pain and provides additional recovery benefits compared with spinal anaesthesia or general anaesthesia
• Long-acting local anaesthetics are recommended (Grade D) in preference to short-acting local anaesthetics

HERNIORRAPHY-SPECIFIC EVIDENCE -STUDY INFORMATION

Arguments for…

• Spinal anaesthesia reduced pain scores compared with epidural anaesthesia, but did not reduce analgesic requirements during 0–24 h or the incidence of PONV Günal et al 2002 Click here for more information
• Spinal anaesthesia (local anaesthetic) reduced the use of supplementary analgesics and the incidence of nausea compared with general anaesthesia, but data for a reduction in pain scores was inconclusive Tverskoy et al 1990 Click here for more information
• Spinal anaesthesia (local anaesthetic plus strong opioid) significantly reduced supplementary opioid requirements and the incidence of PONV, compared with general anaesthesia, but there was no significant difference for pain scores or oral analgesic use Song et al 2000 Click here for more information
• General anaesthesia was similar to epidural or spinal anaesthesia (mixed population) for VAS pain scores during the early postoperative period, at 8 days and at 30 days, for the duration of analgesic requirement but was associated with higher VAS nausea scores (n=407) Nordin et al 2003
• General anaesthesia plus wound infiltration was superior to spinal anaesthesia for reducing dynamic pain scores, but not resting pain scores, and for increasing the time to first analgesic request Tverskoy et al 1990 Click here for more information
• For spinal anaesthesia, bupivacaine 7.5 mg significantly reduced the proportion of patients requiring intra-operative fentanyl compared with bupivacaine 6 mg, but there was no significant difference in pain scores, supplementary analgesic requirements or the incidence of PONV Gupta et al 2003 Click here for more information
• For spinal anaesthesia, local anaesthetic plus clonidine was of significant analgesic benefit compared with local anaesthetic alone during the early postoperative period, but did not reduce the risk of PONV Dobrydnjov et al 2003 Click here for more information
• For spinal anaesthesia, local anaesthetic plus neostigmine showed significant benefit compared with local anaesthetic alone for reducing pain scores and increasing time to first analgesia  Tan et al 2000 Click here for more information
• For spinal anaesthesia, neostigmine 50 µg and 100 µg were not significantly different for reducing VAS pain scores over 24 h, for reducing supplementary analgesic requirements, and for increasing the time to first analgesic request (n=40) Tan et al 2000

Arguments against…

• Tetracaine plus neostigmine caused a significantly higher rate of PONV than tetracaine alone (p<0.05) (two arms, n=60) Tan et al 2000
• Pre- plus intra-operative epidural morphine plus postoperative naloxone did not significantly reduce postoperative analgesic requirements or VAS pain scores at rest at 6, 12, 24 or 48 h compared with placebo (n=36) Aida et al 1999

CLINICAL PRACTICE

Arguments against…

• For all regional anaesthesia techniques, there are procedure-specific failure rates between 2 and 10%, and conversion to general anaesthesia may be required
• Local practices and cultural differences influence the choice of anaesthetic technique for herniorraphy
• Clonidine is associated with side-effects, including hypotension, sedation, dizziness and bradycardia

PROSPECT RECOMMENDATIONS

• When general anaesthesia is used, its combination with local anaesthetic techniques is recommended to decrease postoperative pain (Grade A)
• Spinal anaesthesia provides good anaesthesia and early postoperative analgesia. Spinal anaesthesia cannot be recommended for routine use (Grade D – majority vote from the prospect Working Group) because of postoperative side-effects that can delay early ambulation, such as urinary retention and hypotension
• Epidural anaesthesia is not recommended (Grade D)
• Local anaesthetic techniques (inguinal nerve block/field block/infiltration) are recommended (Grade A) because they provide good postoperative analgesia, rapid recovery, and few side-effects, but the need for intravenous sedation has to be considered (see Intra-operative anaesthetic techniques, Local anaesthesia)
• Addition of clonidine or neostigmine to local anaesthetic solution for spinal anaesthesia is not recommended due to limited procedure-specific evidence. In addition, potential side-effects of clonidine (Grade D) and neostigmine (Grade A) may hinder early ambulation

HERNIORRAPHY-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

• Laparoscopic mesh procedures reduced pain scores compared with open non-mesh procedures and the benefits were more apparent for pain on movement and overall pain Berndsen et al 2002 Click here for more information
• Laparoscopic mesh procedures showed a significant benefit over the open non-mesh procedures in terms of lower supplementary analgesic use Berndsen et al 2002 Click here for more information
• Two studies showed that laparoscopic mesh procedures were superior to open procedures (mixed mesh/non-mesh group) for reducing pain scores and supplementary analgesic requirements Tanphiphat et al 1998 Click here for more information
• The transabdominal preperitoneal (TAPP) laparoscopic procedure was superior to the totally extraperitoneal (TEP) laparoscopic procedure for reducing pain scores on the day of operation and the proportion of patients requiring analgesics on day 1 Schrenk et al 1996b Click here for more information

Arguments against…

• Data are inconclusive for the relative effect on pain of laparoscopic mesh procedures and open mesh procedures Heikkinen et al 1997 Click here for more information
• Laparoscopic procedures were not associated with a consistent reduction in supplementary analgesic requirements compared with open mesh procedures Filipi et al 1996 Click here for more information

CLINICAL PRACTICE

• Meta-analysis of the analgesic data is associated with the following problems Click here for more information

PROSPECT RECOMMENDATIONS

• It is recommended (Grade D) that the choice of operative technique for herniorraphy (open versus laparoscopic) should be primarily based on factors other than the management of postoperative pain e.g. operative risk factors of the patient, risk of wound infection, availability of surgical expertise, risk of rare but serious complications, contraindications to general anaesthetic, recurrence rates, and cost
• Laparoscopic herniorraphy is associated with less postoperative pain than open non-mesh herniorraphy (Grade A), but data are inconclusive for the relative analgesic effects of laparoscopic herniorraphy and open mesh herniorraphy
• A recommendation for pain management following laparoscopic herniorraphy cannot be made until further data are available

HERNIORRAPHY-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments for…

• A systematic review reported that open mesh herniorraphy is associated with a 50–75% reduction in the risk of hernia recurrence compared with open non-mesh herniorraphy Grant 2002
• The Prolene Hernia System® procedure was superior to the Lichtenstein patch procedure for postoperative VAS pain scores at rest on day 0 (p<0.05) but there was no significant difference on days 1–14, or for the duration of requirement for postoperative analgesia (n=206) Kingsnorth et al 2002b
• Two of three studies showed a significant benefit of the plug-and-patch procedure over the Lichtenstein open mesh procedure for reducing postoperative pain scores, and in all studies there was no significant difference in analgesic use Abu-Own A et al 2000 Click here for more information
• The Stoppa procedure was not significantly different from the Lichtenstein patch procedure for VAS pain scores at rest on days 1, 2, 7 and 30, or on movement on days 7 and 30 (n=33) Malazgirt et al 2000
• The smooth polypropylene mesh was superior to the monofile, rigid mesh for reducing VAS pain scores on day 1 and at 2, 4, 8 and 12 weeks (p<0.05), but there was no significant difference at 3 days or at 1 week (n=40) Langenbach et al 2003
• A lightweight mesh was superior to a conventional mesh for reducing dynamic pain scores at 6 months but there was no significant difference in pain during the early postoperative period Post et al 2004 Click here for more information
• Fixation by sutures for hernia repair was similar to fixation with staples for postoperative pain and supplementary analgesic requirements Leibl et al 2002 Click here for more information

Arguments against…

• Six out of ten studies showed no significant benefit of open mesh procedures compared with open non-mesh procedures for reducing pain scores Barth et al 1998 Click here for more information
• Of eight studies that reported supplementary analgesic use, five showed no significant benefit for mesh procedures compared with non-mesh procedures for reducing analgesic requirements Barth et al 1998 Click here for more information

PROSPECT RECOMMENDATIONS

• Open mesh procedures are recommended in preference to non-mesh procedures because of lower recurrence rates (Grade A); the recommendation cannot be based on the inconclusive acute pain data (Grade A)
• There is not enough evidence, at this time, to recommend the following for the management of acute or chronic pain: – the plug-and-patch or the Prolene Hernia System® techniques in preference to the Lichtenstein patch technique (Grade D) – one type of mesh in preference to another (Grade D)  – one mesh fixation technique in preference to another (Grade D)

HERNIORRAPHY-SPECIFIC EVIDENCE

Arguments for…

• Suture repair and no suture repair were similar for cumulative pain scores during the first week and for analgesic requirements (n=84) Callesen et al 1999
• Moloney’s darn repair was superior to the Shouldice repair for reducing postoperative VAS pain scores at 6, 12 and 24 h (p<0.05) and for reducing postoperative requirement for analgesia on days 1, 2 and 3 (p<0.05) (n=50) Thapar et al 2000

Arguments against…

• A systematic review reported that open non-mesh herniorraphy is associated with a 50–75% increase in the risk of hernia recurrence compared with open mesh herniorraphy Grant 2002

PROSPECT RECOMMENDATIONS

• Open mesh procedures are recommended in preference to non-mesh procedures because of lower recurrence rates (Grade A); the recommendation cannot be based on the inconclusive acute pain data (Grade A, see Open Mesh Procedure)
• There is not enough evidence to recommend one non-mesh repair technique in preference to another for the management of acute or chronic pain (Grade D)

HERNIORRAPHY-SPECIFIC EVIDENCE – STUDY INFORMATION

Arguments against…

• Division of the ilioinguinal nerve was of no significant benefit over preservation of the nerve for VAS pain scores at 1 week, 1 or 6 months, 1 year or at telephone follow up (n=813) Picchio et al 2004
• Cryoanalgesia was of no benefit for reducing VAS pain scores compared with no treatment or sham treatment in two studies (n=36) Khiroya et al 1986

PROSPECT RECOMMENDATIONS

• Nerve section/cryoanalgesia techniques are not recommended because of a lack of analgesic benefit (Grade A)