Inguinal Hernia Repair 2019

Open inguinal hernia repair-specific evidence

Data table: Paracetamol and NSAIDs/COX-2-selective inhibitors for pain management after open inguinal hernia repair

Arguments for…

• A placebo-controlled RCT evaluated the effects of rofecoxib 50 mg given one hour pre-operatively followed by once daily for 4 days after surgery (Schurr 2009; n=55). Rofecoxib reduced pain scores on the first postoperative day, but opioid requirements remained similar to placebo. Note: rofecoxib is a COX-2-selective inhibitor that has been withdrawn from the market due to potential cardiac complications.
• A placebo-controlled RCT evaluated the effects of oral etoricoxib 120 mg given 1 hour pre-operatively (Somri 2017; n=60). Pain scores at rest and on straight leg raise were significantly lower in the etoricoxib group at 16 and 24 hours, and on discharge.
• One RCT reported no difference in pain scores 12 and 24 hours after surgery, between lornoxicam (an NSAID administered at the end of the operation and 12 hours post-operatively) and tramadol (Mentes 2009; n=160). However, the tramadol group experienced more nausea.

PROSPECT Recommendations

• Systemic analgesia should include paracetamol (Grade D) and NSAID or COX-2-selective inhibitor (Grade D) administered pre-operatively or intra-operatively and continued post-operatively.
• Paracetamol, NSAIDs and COX-2-selective inhibitors have been shown to provide excellent analgesia and reduce opioid requirements (Joshi 2019).

Open inguinal hernia repair-specific evidence

Data table: Gabapentinoids for pain management after open inguinal hernia repair

Arguments for…

• One placebo-controlled RCT reported gabapentin (400 mg) prior to surgery reduced pain scores and postoperative morphine requirements in the immediate postoperative period. No obvious side-effects were reported (Mahoori 2014; n=50).
• Another placebo-controlled RCT reported that pre-operative gabapentin (1200 mg) significantly reduced pain scores (at rest and on sitting) and reduced total tramadol consumption at 8, 12, 16, 20 and 24 hours after surgery (Sen 2009; n=60). Pain scores at 1, 3 and 6 months after surgery were lower in the gabapentin group than in the placebo group.

Arguments against…

• A large placebo-controlled RCT found that pre-operative pregabalin (50, 150, or 300 mg/day) as adjuvant analgesic did not influence the intensity of postoperative pain at 24 hours (Singla 2014; n=425).
• There was a wide variability in the anaesthetic and analgesic techniques used in the studies of gabapentinoids.

PROSPECT Recommendations

• Gabapentinoids are not recommended due to inconsistent procedure-specific evidence.

Open inguinal hernia repair-specific evidence

Data table: IV lidocaine for pain management after open inguinal hernia repair

Arguments for…

• A placebo-controlled RCT assessed the effects of intra-operative IV bolus injection of 1.5 mg/kg lidocaine followed by a continuous infusion (2 mg/kg/h) (Kang 2011; n=64). Fentanyl consumption was significantly lower in the lidocaine group until 12 hours after surgery, after which the difference became insignificant.

PROSPECT Recommendations

• IV lidocaine infusion is not recommended due to limited procedure-specific evidence.

Open inguinal hernia repair-specific evidence

Data table: TNF-α inhibitor for pain management after open inguinal hernia repair

Arguments against…

• One placebo-controlled RCT found no statistically significant difference in pain during the first 24 hours postoperatively with a TNF-α inhibitor, etanercept 50 mg, administered SC 90 min before incision (Cohen 2013; n=77).

PROSPECT Recommendations

• Etanercept is not recommended due to limited procedure-specific evidence.

Open inguinal hernia repair-specific evidence

Data table: Dipyrone for pain management after open inguinal hernia repair

Arguments against…

• One RCT evaluated the effects of intra-operative dipyrone 15 mg/kg or 40 mg/kg IV during the operation (Chaparro 2012; n=162). A statistically significant difference was only found during the first 30 minutes in the PACU.

PROSPECT Recommendations

• Dipyrone is not recommended due to limited procedure-specific evidence.

Open inguinal hernia repair-specific evidence

• No new evidence was identified in the current review.
• The previous reviews found limited procedure-specific evidence (Joshi 2012; Archive: Herniorraphy 2004).

PROSPECT Recommendations

• Clonidine is not recommended due to limited procedure-specific evidence.

Open inguinal hernia repair-specific evidence

• No new evidence of systemic corticosteroids was identified in the current review.
• Limited procedure-specific evidence was found in the previous review (Joshi 2012).

PROSPECT Recommendations

• A single dose of IV dexamethasone is recommended (Grade B) for its ability to increase the analgesic duration of the block (see Anaesthetic technique), decrease analgesic use, and for antiemetic effects.

Open inguinal hernia repair-specific evidence

Data table: Topical and surgical site infiltration for pain management after open inguinal hernia repair

Arguments for…

• One placebo-controlled RCT in patients receiving spinal anaesthesia examined the effects of wound infiltration with bupivacaine 0.05% 10 mL prior to incision (Neisioonpour 2013; n=60). Early postoperative pain was significantly lower at all timepoints in favour of the bupivacaine group.
• One placebo-controlled RCT showed a significant reduction in pain with the use of HTX-011 (a novel, extended release, fixed-dose combination local anaesthetic comprising bupivacaine and low-dose meloxicam, incorporated in a proprietary Biochronomer® polymer) (Viscusi 2019; n=418). It showed a 23% reduction in mean pain intensity over 72 hours compared to placebo. At all timepoints through 72 hours, the mean pain scores were lower in the HTX-011 group. A reduction of 21% for pain intensity over 72 hours was observed when HTX-011 was compared to plain bupivacaine. Of note, basic analgesics – paracetamol and/or NSAIDs – were not used.
• One study, which consisted of two RCTs, compared the effect of INL-001 (an implant designed to provide extended delivery of bupivacaine to the area around the surgical wound) with placebo implant (Velanovich 2019; n=417). Patients who received INL-001 reported lower pain intensity through 72 h for the two pooled studies.
• No new evidence was identified for topical NSAIDs or wound infiltration with NSAIDs, ketamine, clonidine or opioids. The previous review found limited procedure-specific evidence showing little evidence of benefit for these interventions (Joshi 2012).

PROSPECT Recommendations

• Local anaesthetic infiltration is recommended to provide regional analgesia.
• A field block (e.g. ilio-inguinal/ilio-hypogastric block) with or without wound infiltration is recommended as a sole anaesthetic or as an adjunct to general anaesthesia (Grade A).
• There is limited procedure-specific evidence for topical administration or surgical site infiltration with extended-release local anaesthetics, topical NSAIDs, and wound infiltration with NSAIDs, ketamine, clonidine, or opioids.

Open inguinal hernia repair-specific evidence

Data table: Ilio-inguinal and ilio-hypogastric nerve block for pain management after open inguinal hernia repair

Arguments for…

• A placebo-controlled RCT investigated the possible benefits of an additional ilio-inguinal, ilio-hypogastric block (10mL 0.75% ropivacaine) and surgical wound infiltration (10mL 0.75% ropivacaine) (Santos 2011; n=34). Pain scores were lower in the intervention group 3 hours post-surgery. There was no difference in pain scores at 6 and 12 hours post-surgery.
• Another placebo-controlled RCT found that an ilio-inguinal and ilio-hypogastric block (12mL 0.75% ropivacaine) and wound infiltration prior to incision provided significantly lower median VAS scores compared with placebo (Saeed 2015; n=60).
• A placebo-controlled RCT also investigated the effects of ultrasound-guided ilio-inguinal and ilio-hypogastric nerve blocks. A significant reduction in pain scores at mobilisation and rest was recorded in the bupivacaine group vs placebo upon arrival in the PACU and again after 30 minutes. However, opioid consumption was not significantly different between groups (Baerentzen 2012; n=60).
• Another RCT investigated general anaesthesia combined with ilio-inguinal nerve block vs spinal anaesthesia alone. Except for the first 2 h after surgery, there was no difference in pain scores for the 24 h study period (Vizcaino-Martinez 2014; n=32).

PROSPECT Recommendations

• Ilio-hypogastric/ilio-inguinal nerve blocks are recommended (Grade A) to provide regional analgesia.
• A field block (e.g. ilio-inguinal/ilio-hypogastric block) with or without wound infiltration is recommended as a sole anaesthetic or as an adjunct to general anaesthesia (Grade A).
• Recent international guidelines recommend the use of local anaesthesia provided the surgeon is experienced in this technique (Simons 2018).
• Patient selection and acceptance to a sole regional/local anaesthetic is imperative.
• A recent meta-analysis of RCTs comparing local anaesthesia versus other forms of anaesthesia (including general anaesthesia) concluded that local anaesthesia allows shorter operating room times and is associated with a lower incidence of urinary retention (compared with neuraxial anaesthesia) (Argo 2019). Also, patient satisfaction with local anaesthesia was similar to that with other anaesthetic techniques.

Open inguinal hernia repair-specific evidence

Data table: TAP block for pain management after open inguinal hernia repair

Arguments for…

• An RCT compared ultrasound-guided TAP block (levobupivacaine 0.5%, 1.5mg/kg) with blind ilio-hypogastric and ilio-inguinal block (levobupivacaine 0.5%, 1.5mg/kg) performed before surgery. Pain at rest was lower during the first 24h after ultrasound-guided TAP block, but this difference was not observed during movement (Aveline 2011; n=273).
• One RCT found that pain scores with TAP block were significantly lower at 24 h compared with ilio-inguinal-ilio-hypogastric blocks in a post-hoc analysis (Okur 2017; n=90).
• A prospective RCT compared the effects of ultrasound‐guided TAP block combined with ilio-inguinal/ilio-hypogastric nerve blocks vs ilio-inguinal/ilio-hypogastric nerve blocks alone. Pain scores at 12, 24 and 48 hours were significantly lower in the TAP block and ilio-inguinal/ilio-hypogastric block group compared to ilio-inguinal/ilio-hypogastric nerve block alone (Hosalli 2019; n=197).
• An RCT compared the effects of ultrasound-guided TAP block with ropivacaine vs ultrasound-guided TAP block with saline and concluded that pain was reduced with a ropivacaine TAP block (Theodoraki 2019; n=60). Statistically significant differences were noted at rest, at 6 and 24 hours and with movement at 3, 6 and 24 hours, in favour of TAP block.
• Another RCT compared the effect of a post-operative subcostal TAP block to a standard analgesic regimen (Akyol Beyoğlu 2018; n=100). At different timepoints after surgery (15 min, 1 h, 6 h, 12 h, 24 h; 15 days and one month) there was a significant difference in pain scores between the two groups in favour of the TAP block group.

Arguments against…

• A placebo-controlled RCT found no significant difference in analgesic effect with addition of dexamethasone to ropivacaine in TAP blocks (Wegner 2017; n=82).
• One randomized triple-masked, placebo-controlled study investigated the effects of single injection TAP block vs a continuous TAP block through a perineural catheter for 2 days post-operative (Heil 2014; n=20). There were no differences between a single injection and continuous infusion at 6, 24, 48 and 72 hours after surgery. However, this study was underpowered.

PROSPECT Recommendations

• Transversus abdominis plane blocks are recommended to provide regional analgesia (Grade D).

Open inguinal hernia repair-specific evidence

Data table: Anaesthetic technique for pain management after open inguinal hernia repair

• One placebo-controlled RCT study found no difference in pain scores at 2, 12 and 24 hours between spinal anaesthesia and paravertebral block (Bhattacharya 2010; n=58). Of note, these techniques had a 7% failure rate.
• Another placebo-controlled RCT investigated the effect of adding dexamethasone 8 mg to a lumbar epidural anaesthesia block (Razavizadeh 2017; n=44). The onset of epidural anaesthesia, the primary outcome of this study, was significantly more rapid in the dexamethasone group than in the control group. The duration of analgesia was markedly prolonged in the dexamethasone group compared with the control group.

PROSPECT Recommendations

• A field block (e.g. ilio-inguinal/ilio-hypogastric block) with or without wound infiltration is recommended as a sole anaesthetic or as an adjunct to general anaesthesia (Grade A).
• Neuraxial analgesic techniques (epidural or paravertebral analgesia) are not recommended despite the fact that they provide excellent pain relief because they are invasive and have potential complications.
• Although in comparison with general anaesthesia, neuraxial blocks are associated with reduced pain scores and decreased post-operative analgesic requirement, their use is associated with side effects (e.g. postural hypotension) that might delay recovery and discharge home in a day care setting.
• Although dexamethasone extends the duration of epidural block, a single dose of IV dexamethasone is recommended (Grade B) for its ability to increase the analgesic duration of the block, decrease analgesic use, and for antiemetic effects.
• Psoas-block is not recommended as procedure-specific evidence is lacking.
• Newer interfascial plane blocks such as erector spinae blocks may provide pain relief and negate the concerns of neuraxial blocks (Abu Elyazed 2019). However, evidence is lacking for open inguinal hernia repair.

Open inguinal hernia repair-specific evidence

Data table: Surgical technique for pain management after open inguinal hernia repair

Arguments for…

• One placebo-controlled RCT compared Lichtenstein technique with Prolene Hernia System (PHS) and UltraPro Hernia System (UHS) (Magnusson 2016; n=309). There were no differences between groups regarding perioperative course, operating time, postoperative pain or rehabilitation. Pain was assessed daily until 14 days postoperatively by a research nurse using a telephone interview.
• A placebo-controlled RCT used Sutureless Parietex™ ProGrip™ mesh repair vs traditional Lichtenstein repair with lightweight polypropylene mesh secured with sutures (Kingsnorth 2012; n=302). The pain scores were significantly lower in the sutureless mesh group at discharge and at 7 days, but not at 1 month after surgery.
• One RCT evaluated the effects of non-mesh (Desarda) vs mesh (Lichtenstein) methods for inguinal hernia repair (Manyilirah 2012; n=101). No differences in terms of postoperative pain between the two techniques were noted. There was no significant difference in pain scores at 1–2 hours postoperatively and after 3 days.
• Another placebo-controlled RCT found no significant differences in early postoperative pain, infection, seroma, recurrence and other complications between different types of mesh (Gundre 2012; n=70). However, this study might be underpowered.
• Another placebo-controlled RCT comparing Glucamesh® vs Polypropylene® mesh found that the pain scores (measured twice daily for 7 postoperative days) were significantly lower before discharge in the Glucamesh® group (Torcivia 2011; n=50).
• A placebo-controlled study evaluated the effect of sutureless fixation with fibrin glue of lightweight mesh in open inguinal hernia repair. Patients in the lightweight group reported less pain during the first month after surgery (Canonico 2013; n=80).
• Another placebo-controlled RCT found no differences in pain scores between self-gripping mesh vs polypropylene mesh (Fan 2017; n=45).
• In a comparison between low density vs high density mesh, there were differences in pain scores only on the 1st and the 7th postoperative days in favour of low density mesh (Carro 2017; n=67).
• One RCT compared the effect of fibrin glue vs Lichtenstein mesh repair (Bracale 2014; n=102). The fibrin group had lower pain scores and opioid requirements at 1 week.
• An RCT compared fibrin glue as medical adhesive NBCA (n-butyl-2-cyanoacrylate) vs suture for patch fixation in Lichtenstein inguinal herniorrhaphy (Shen 2012; n=110). The pain scores in the fibrin group were lower at 24 hours after surgery.
• One multicenter RCT compared the effects of lightweight mesh (Ultrapro®) vs heavyweight mesh (Prolene®), and reported lower postoperative pain scores in favour of lightweight mesh (Bona 2018; n=808).
• One multicenter RCT compared the effects of glue (Histoacryl®) or non-absorbable polypropylene sutures for fixation of lightweight polypropylene mesh (Hoyuela 2017; n=370). Postoperative pain was less in the group where glue was used.

PROSPECT Recommendations

• It is recommended that the surgical technique should be based on surgeon’s expertise, hernia-related characteristics, and availability of local resources (Simons 2018).
• As far as postoperative pain is concerned, mesh techniques are recommended in preference to non-mesh techniques (Grade A).
• This recommendation concurs with the international guidelines for groin hernia management (Simons 2018).

Open inguinal hernia repair-specific evidence

Arguments for…

• No new evidence was identified in the current review.
• A previous review found limited procedure-specific evidence showing a lack of benefit (Archive: Herniorraphy 2004).

PROSPECT Recommendations

• Cryoanalgesia is not recommended due to lack of procedure-specific evidence.

Open inguinal hernia repair-specific evidence

• No new evidence was identified in the current review.
• A previous review found limited procedure-specific evidence showing a lack of benefit (Archive: Herniorraphy 2004).

PROSPECT Recommendations

• Nerve section is not recommended due to lack of procedure-specific evidence.