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Optimizing Anesthesia for Inguinal Herniorrhaphy: General, Regional, or Local Anesthesia?

White, Paul F. PhD, MD

doi: 10.1097/00000539-200112000-00001
Editorials: Editorial

*Department of Surgical Gastroenterology, Hvidovre University Hospital, Hvidovre, Denmark; and †Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas

August 21, 2001.

Address correspondence to Paul F. White, PhD, MD, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390–9068. Address e-mail to

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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1. Bay-Nielsen M, Kehlet H. Prospective nation-wide quality assessment of 26,304 herniorrhaphy in Denmark. Lancet 2001; 358: 1124–8.
2. Hair A, Duffy K, Mclean J, et al. Groin hernia repair in Scotland. Br J Surg 2000; 87: 1722–6.
3. Nilsson E, Kald A, Anderberg B, et al. Hernia surgery in a defined population: a prospective three year audit. Eur J Surg 1997; 163: 823–9.
4. Song D, Greilich NB, White PF, et al. Recovery profiles and costs of anesthesia for outpatient unilateral inguinal herniorrhaphy. Anesth Analg 2000; 91: 876–81.
5. Glassow F. Short-stay surgery (Shouldice technique) for repair of inguinal hernia. Ann R Coll Surg Engl 1976; 58: 133–9.
6. Amid PK, Schulman AG, Lichtenstein IL. Local anesthesia for inguinal hernia repair: step-by-step procedure. Ann Surg 1994; 220: 735–7.
7. Kark AE, Kurzer MN, Belsham PA. 3175 primary inguinal hernia repairs: advantages of ambulatory open mesh repair using local anesthesia. J Am Coll Surg 1998; 186: 447–55.
8. Callesen T, Bech K, Kehlet H. One-thousand consecutive inguinal hernia repairs under unmonitored local anesthesia. Anesth Analg 2001; 93: 1373–6.
9. White PF. Ambulatory anesthesia advances into the new millennium. Anesth Analg 2000; 90: 1234–5.
10. Li S, Coloma M, White PF, et al. Comparison of the costs and recovery profiles of three anesthetic techniques for ambulatory anorectal surgery. Anesthesiology 2000; 93: 1225–30.
11. Callesen T, Kehlet H. Postherniorrhaphy pain. Anesthesiology 1997; 87: 1219–30.
12. Ding Y, White PF. Post-herniorrhaphy pain in outpatients after pre-incision ilioinguinal-hypogastric nerve block during monitored anesthesia care. Can J Anaesth 1995; 42: 12–5.
13. Yndgaard S, Holst P, Bjerre-Jepsen K, et al. Subcutaneously versus subfascially administered lidocaine in pain treatment after inguinal herniotomy. Anesth Analg 1994; 79: 324–7.
14. Møiniche S, Mikkelsen S, Wtterslev J, Dahl JB. A qualitative systematic review of incisional local anaesthesia for postoperative pain relief after abdominal operations. Br J Anaesth 1998; 81: 377–83.
15. Klein SM, Grant SA, Greengrass RA, et al. Interscalene brachial plexus block with a continuous catheter insertion system and a disposable infusion pump. Anesth Analg 2000; 91: 1473–8.
16. Møiniche S, Kehlet H, Dahl JB. A qualitative and quantitative systematic review of pre-emptive analgesia for postoperative pain relief—the role of timing of analgesia. Anesthesiology, In Press.
17. Bay-Nielsen M, Perkins FM, Kehlet H. Pain and functional impairment 1 year after inguinal herniorrhaphy: a nationwide questionnaire study. Ann Surg 2001; 223: 1–7.
18. Young DV. Comparison of local, spinal and general anesthesia for inguinal herniorrhaphy. Am J Surg 1987; 153: 560–3.
19. van Vlymen JM, Sá Rêgo MM, White PF. Benzodiazepine premedication: can it improve outcome in patients undergoing breast biopsy? Anesthesiology 1999; 90: 740–7.
20. Kehlet H. Modification of responses to surgery by neural blockade: clinical implications. In: Cousins M, Bridenbaugh P, eds. Neural blockade in clinical anesthesia and management of pain. 2nd ed. Philadelphia: JB Lippincott, 1988: 145–88.
21. Peiper C, Töns C, Schippers E, et al. Local versus general anesthesia for Shouldice repair of the inguinal hernia. World J Surg 1994; 18: 912–6.
22. Pavlin DJ, Pavlin EG, Fitzgibbon DR, et al. Management of bladder function after outpatient surgery. Anesthesiology 1999; 91: 42–50.
23. Kozol RA, Mason K, McGee RN. Post-herniorrhaphy urinary retention: a randomised prospective study. J Surg Res 1992; 52: 111–2.
24. Hirano T, Yoshioka H. Post-operative urinary retention after inguinal herniorrhaphy with spinal anaesthesia. Med Sci Res 1993; 21: 693–4.
25. Millat B, Fingerhut A, Gignoux M, Hay J-M. Factors associated with early discharge after inguinal hernia repair in 500 consecutive unselected patients. Br J Surg 1993; 80: 1158–60.
26. Kendell J, Wildsmith JAW, Gray IG. Costing anaesthetic practice. An economic comparison of regional and general anaesthesia for varicose vein and inguinal hernia surgery. Anaesthesia 2000; 55: 1106–26.
© 2001 International Anesthesia Research Society