Inguinal herniorrhaphy is one of the most frequent operations and can be successfully performed using general, regional, or local anesthesia. Epidemiological data from both nationwide (1) and large regional (2,3) databases have found that general anesthesia is used in 60%–70% of cases, central neuraxis blockade in 10%–20%, and local infiltration anesthesia in only 5%–15% of cases. Even though local anesthesia with sedation (so-called monitored anesthesia care) is a more cost-effective anesthetic technique for inguinal hernia repair (4), general and spinal anesthesia remain the most popular anesthetic techniques at university-based teaching programs. Interestingly, specialized hernia centers use local infiltration anesthesia in more than 95% of these cases (5–8).
Why does this variability exist in the choice of the anesthetic technique for this commonly performed surgical procedure, and what is the optimal anesthetic technique for inguinal hernia repair in the current healthcare environment? The choice of anesthesia depends on several factors, including patient and surgeon preferences, feasibility of the technique in a given patient, intra- and postoperative pain control, early recovery and monitoring requirements (e.g., ability to fast-track), postoperative morbidity, and perioperative costs. Given the recent studies confirming the benefits of local anesthetic-based techniques over both general and spinal anesthesia (4,8), it is surprising that these techniques are so rarely used outside dedicated hernia centers.
Local anesthesia-based techniques fulfill all the requirements for the ideal ambulatory anesthetic (9). Furthermore, the feasibility of routinely using local infiltration anesthesia for inguinal hernia repair has been convincingly demonstrated (4–8). Exclusionary criteria are rare (<5%) and include patients with large irreducible hernias, patients with psychiatric disease, and those who refuse to cooperate. The technique used for local infiltration anesthesia has been extensively described in the surgical literature (6) and can be performed by the surgeon and/or the anesthesiologist.
A potential advantage of local infiltration anesthesia is that it can be performed using so-called unmonitored anesthesia (8), although most centers prefer to use sedation as a part of a monitored anesthesia care technique to increase acceptance by patients and surgeons (4–7). Despite the fact that it is safe, simple, and cost-effective, there is a lack of acceptance of local infiltration anesthesia within the surgical community. It has been suggested that the use of local anesthetic techniques requires greater surgical skill in the handling of tissues and that, therefore, less-skilled surgeons find it more convenient to operate under general or spinal anesthesia.
Postoperative recovery is definitely faster with local anesthesia compared with general and regional anesthetic techniques. In addition, it can obviate the need for admitting these patients to the postanesthesia care unit (PACU). The ability to “bypass the PACU” can facilitate an earlier discharge home after surgery (i.e., ability to fast-track) (4,8,10). Postoperative pain is ideally treated with a multimodal approach involving both opioid and nonopioid analgesics (11). Local anesthetics are highly effective in alleviating postoperative pain when administered using both a peripheral nerve block technique (e.g., ilioinguinal-hypogastric nerve block) (12) and local wound infiltration at the fascial level (13). However, the duration of local analgesia after a single injection typically lasts <8 h (14). Although the local anesthetic effect can be extended using a disposable elastomeric infusion pump (15), the cost effectiveness of this approach has not been studied in patients undergoing inguinal hernia repair.
Preincisional administration of local anesthesia is recommended to minimize intraoperative opioid use; however, preemptive analgesia with local anesthesia has not proven to be more effective in preventing postoperative pain than postincisional administration (16). Interestingly, the anesthetic technique does not appear to have a significant effect on the occurrence of chronic postherniorrhaphy pain (17). Furthermore, patient satisfaction appears to be similar with local, regional, and general anesthetic techniques (18). However, use of local anesthesia with sedation may be associated with increased patient satisfaction compared with local anesthesia alone (“unmonitored anesthesia”) (4,8,10,19). With minimal sedation and unmonitored anesthesia care, optimization of intraoperative local anesthesia is required (8).
Nonsurgical postoperative morbidity is extremely infrequent after inguinal herniorrhaphy. The predominant side effects are related to the effects of general and regional anesthesia on gastrointestinal and urinary bladder function, and the occurrence of postural hypotension (e.g., dizziness, nausea, and vomiting). In contrast, local infiltration anesthesia provides adequate surgical conditions without inducing major organ dysfunction (20). Data obtained from prospectively randomized series have uniformly found that urinary retention is virtually eliminated with local infiltration compared with other commonly used anesthetic techniques (4,7,8,21). However, the use of fluid restriction during general and spinal anesthesia can reduce the risk of urinary retention with these techniques (22–24). Although there are insufficient data to directly compare postoperative cardiopulmonary morbidity when using different anesthetic techniques for inguinal hernia repair, large databases from specialty centers using exclusively local anesthesia have reported very infrequent morbidity (even in high-risk patients) (7,8) compared with series using general or regional anesthesia (25). Additional data from large-scale, nationwide or regional databases comparing postoperative morbidity with local, regional, and general anesthetic techniques are eagerly awaited.
Finally, the direct and indirect costs of anesthesia for inguinal hernia repair are lowest when using local anesthesia with or without sedation (4,8,26). The recent study by Callesen et al. (8) suggests that the low costs associated with unmonitored anesthesia care are related, in part, to the infrequent incidence of postoperative morbidity (e.g., urinary retention), reduced need for intra- and postoperative monitoring, and a shorter hospital stay. The ability to perform inguinal herniorrhaphy on a day-case (or ambulatory) basis is largely dependent on organizational issues. It is therefore surprising that recent nationwide and regional databases from Europe have suggested that “only” about 60% of patients undergo this procedure in the ambulatory setting (1–3). In North America, inguinal herniorrhaphy is routinely performed on an ambulatory basis, even in high-risk patients.
In conclusion, there is a surprising discrepancy between the documented benefits of local anesthesia in reducing postoperative pain and anesthetic-related morbidity (as well as perioperative costs) in patients undergoing inguinal herniorrhaphy and the frequency with which this technique is used for this operation. Despite being a simple operation with a very infrequent overall morbidity, this surgical procedure is an example of the difficulty in integrating recent scientific data into clinical practice. Considering the potential benefits to patients and third-party payers, it would behoove anesthesiologists and surgeons to reexamine their current clinical practices for inguinal hernia repair in light of these recent data.
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