|Year : 2022 | Volume
| Issue : 3 | Page : 122-128
To compare the outcome of inguinal hernia repair under local and spinal anesthesia
Naveen K Maurya, Shadab Asif, Saleem Tahir, Kumar Aishwarya, Swarnlata Shiromani
Department of Surgery, Era’s Lucknow Medical College, Lucknow, Uttar Pradesh, India
|Date of Submission||07-Mar-2022|
|Date of Decision||16-Apr-2022|
|Date of Acceptance||19-Apr-2022|
|Date of Web Publication||01-Sep-2022|
Naveen K Maurya
Department of Surgery, Era’s Lucknow Medical College, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
INTRODUCTION: The most frequent form of hernia is inguinal hernia, affecting around 15% of adult males. The optimal surgical anesthetic method for ambulatory inguinal hernia repair is unknown at the moment, and there is no consensus on the procedure. The goal of this study was to examine the outcome of inguinal hernia repair under local anesthesia compared with spinal anesthesia. MATERIALS AND METHODS: In this prospective observational study, 80 patients were randomly assigned into two groups by the SNOSE method with a different mode of anesthesia: group SA (n = 40) and group LA (n = 40). Lichtenstein tension-free hernioplasty was done in all patients. Pre- and post-OP clinical examinations (3rd day) were looked for complications. RESULTS: There were no significant demographic differences between the two groups. When compared with the SA group, the LA group experienced much less post-operative pain. With local anesthesia, post-operative ambulation was substantially faster. The use of a local anesthetic allowed for a shorter stay in the hospital and a speedy return to regular activity. In general, local anesthesia was linked to less post-operative complications in the early aftermath. CONCLUSION: Local anesthesia is a preferable choice to spinal anesthesia for short stay or daycare surgery, particularly for patients who are unable to tolerate spinal anesthesia. As a result, Lichtenstein’s hernioplasty performed under local anesthesia is attracting considerable interests in the field of groin hernia repair.
Keywords: Inguinal hernias, Lichtenstein’s hernioplasty, local anesthesia, spinal anesthesia
|How to cite this article:|
Maurya NK, Asif S, Tahir S, Aishwarya K, Shiromani S. To compare the outcome of inguinal hernia repair under local and spinal anesthesia. Int J Abdom Wall Hernia Surg 2022;5:122-8
| Introduction|| |
Inguinal hernia, which causes a bulge in the groin area, is one of mankind’s oldest ailments, with evidence reaching back to ancient Egypt and Greece. Inguinal hernias are the most common kind of hernia, affecting around 15% of adult males. Inguinal hernias are more common than other forms of hernias, accounting for about 80% of all cases. Males account for over 90% of instances, with the frequency increasing as people get older. According to the research, patients have a morbidity rate of 11 per 10,000 in the 16–24 year age group and 200 per 10,000 in the older age group (75 years and above) due to uncomplicated inguinal hernias. Shouldice and McVay, Bassini, and Lichtenstein are among the open methods for repairing the inguinal hernia that has been documented and practiced to date. The Lichtenstein mesh repair procedure is one of the most widely used therapies in the world.
In light of the historical backdrop, the Lichtenstein procedure of inguinal hernia repair was originally performed under local anesthesia at the Lichtenstein clinic, but is now a regular surgery in current practice under spinal anesthesia. General anesthesia, spinal or epidural anesthesia, paravertebral block, or local anesthesia are all options for inguinal hernia repair.
Patients’ safety should come first when deciding on the sort of anesthesia to utilize. General or spinal anesthesia is still the most often used in India. When the recovery qualities of local, general, and regional anesthesia are evaluated, local anesthesia is found to be the best choice for daycare surgery. There are various risks involved with spinal anesthesia, just as there are with any surgical treatment performed under general anesthesia. In the immediate and post-operative hours after spinal anesthesia administration, hypotension, nausea, vomiting, post-dural puncture headache, and urinary retention are all typical concerns. In the event of local anesthesia, however, the occurrence of all of the aforementioned issues is extremely low.
Lichtenstein mesh repair for inguinal hernias can be done as a day-case surgery under local anesthesia, which is ideal for the elderly and medically fragile. There is a low risk of morbidity and recurrence with this technique. It reduces post-operative pain, facilitates mobilization and discharge, and reduces the risk of complications. The choice of anesthetic approach for inguinal hernia repair is arbitrary because there is presently no consensus on the best surgical anesthetic strategy for ambulatory inguinal hernia repair. The use of a local anesthetic has boosted interests in inguinal hernia repair, allowing it to be performed as a day-case surgery. Numerous randomized controlled studies comparing spinal anesthesia vs. local anesthesia have been done, but with small sample numbers. The advantages of local anesthesia have been shown, and inguinal hernia repair under local anesthesia is advised as the preferred method. Despite the apparent benefits of local anesthesia, the majority of hernia repairs are still performed under general or spinal anesthesia, with the exception of those performed at specialty centers.
The introduction of “daycare surgery” for inguinal hernia repair has resulted in considerable cost and length of stay savings. Hospital wait times are significantly decreased. Additionally, it provides economical and social advantages to the patient. With over 20 million groin hernia repairs performed annually, even a little change in procedure can have significant social consequences. Local anesthesia has a number of advantages, including simplicity, safety, prolonged post-operative analgesia, early mobilization, the absence of post-operative side effects, and cheap cost. According to specialists, the type of anesthesia used has a minimal effect on the long-term outcome of hernia surgery.
The goal of this research was to evaluate the outcome of inguinal hernia repair under local vs. spinal anesthesia. This research might help shorten operating times, reduce post-operative discomfort, lower operating room expenses, and shorten hospital stays.
| Materials and Methods|| |
The current prospective observational study was conducted during 2019–2021, in the Department of General Surgery, Era’s Lucknow Medical College, Lucknow, Uttar Pradesh, India. Following clearance from the Institutional Ethical Committee (ELMC&H/R Cell/EC/2020/67) and informed consent, a total of 80 patients under the age of 18 who presented with an uncomplicated inguinal hernia were included in the study. Patients with chronic constipation, portal hypertension, bleeding disorders, psychological issues, obesity (body mass index > 30), benign prostatic hyperplasia, anal stenosis, uncontrolled diabetes, and hypertension, as well as hypersensitivity to lignocaine or bupivacaine in the past were excluded. The patients were divided into two groups: group SA using the SNOSE technique (spinal anesthesia) (n = 40) and group LA (local anesthesia) (n = 40).
All patients underwent a Lichtenstein tension-free hernioplasty. The surgeries were carried out by the same surgeon with the assistance of two scrub nurses. Before local anesthesia, each patient received a wide spectrum intravenous antibiotic (inj. Cefoperazone 30 mg/kg body weight), analgesics (inj. Diclofenac sodium 1 mg/kg body weight), inj. Metoclopramide 0.5 mg/kg body weight, and inj. Pantoprazole 40 mg.
An aliquot of 10 ml of local anesthesia is injected under the external oblique in a fan-wise way from a location about 2 cm medial to the anterior superior iliac spine. A further 10 ml of the medication is injected into the subcutaneous tissue at the same location, this time closer to the pubic tubercle along the anticipated incision line. To counteract innervation from the contralateral side, 10 ml of local anesthetic is injected into the pubic tubercle and along the rectus sheath toward the umbilicus. An additional 10 ml of local anesthetic is injected in a fan-like pattern in the suprapubic area, both superficially and deeply, closer to the anticipated incision line. An aliquot of 10 ml of the medication is injected deep at the mid-inguinal location, with another 10 ml administered subcutaneously in the line of the anticipated skin crease incision to complete the block. About 15 ml of the solution remains, which can be used as needed for infiltration of the spermatic cord and around the neck of the hernial sac, or for wound top-up at the end of the surgery. Before beginning the procedure, the anesthesia is given a brief time to take effect.
In group B, 0.5% bupivacaine was used to provide regional anesthesia in the form of spinal anesthesia. After obtaining free flow of cerebrospinal fluid, 2.5 cc of 0.5% bupivacaine was injected into the subarachnoid space using a 26-gage spinal needle in the L3–L4 interspace. Local or spinal anesthesia was switched to general anesthesia if it had insufficient or no effect, and the patient was not included in the trial.
In both groups, tension-free hernioplasty was performed. The prosthetic mesh was made of polypropylene (ETHICON). Any discomfort during the surgery was noted, as well as post-operative pain, pain at the incision site, urine retention, wound hematoma, sepsis, headache, and testicular pain/swelling. At the third post-operative day, the patient was checked for wound infections, discomfort at the incision site, and other problems.
The patient was taken to the ward and given analgesics and antibiotics. Antibiotics were used for 3 days in spinal anesthesia and 1–2 days in local anesthesia, depending on surgical site infection (SSI). In the event of spinal anesthesia, oral fluids were started after 8 h, and in the case of local anesthesia, after 2 h. Patients who underwent surgery under local anesthesia were released on the first post-operative day if they were hemodynamically stable and clinically normal. Patients were urged to return after 1 week if they were still experiencing symptoms like SSI related to operation. They were followed up on a regular basis for 1 month for SSI according to the CDC guidelines.
SPSS (Statistical Package for Social Sciences) Version 21.0 or higher statistical analysis software was used for the statistical analysis. Number (percentage) and mean±SD or median have been used to represent the data. The data were analyzed using χ2 and independent samples t-tests. Significance was defined as a P-value of less than 0.05.
| Results|| |
The patients in this research (n = 80) varied in age from 18 to 70 years. Group LA had a mean age of 44.08 ± 18.22 years, whereas group SA had a mean age of 43.95 ± 13.04. In both groups, the incidence of indirect inguinal hernia was higher than that of direct hernia. In group LA, 30 patients (75.0%) had an indirect inguinal hernia, whereas 10 (25.0%) had a direct hernia. In group SA, 25 patients (62.5%) had an indirect inguinal hernia, and 15 patients (37.5%) had a direct inguinal hernia. The time taken to complete the surgery was calculated from the time of draping for surgery till dressing. The difference between the median time to complete hernioplasty under local anesthesia (range 40–90 min) and the median time to complete hernioplasty under spinal anesthesia (range 40–90 min) was not statistically significant (P > 0.05) [Table 1]. In all groups, post-operative pain was measured using the Visual Analog Scale (VAS) pain score system at 6, 12, and 24 h following surgery. At 6, 12, and 24 h, the mean VAS score for group LA was 3.18, 1.43, and 0.45, respectively, whereas the mean VAS score for group SA was 2.78, 2.83, and 0.99, which was statistically significant for the first 12 h (P = 0.05). However, there was no statistically significant difference between the two groups after 6 and 24 h (P > 0.05) [Figure 1] and [Table 2].
|Table 1: Intergroup comparison of demographical parameters between both groups|
Click here to view
Patients who had spinal anesthesia had greater post-operative problems such urine retention and post-spinal headache. When compared with spinal anesthesia, those who had local anesthesia experienced far less problems. When compared with group SA, group LA had considerably less post-operative problems (P < 0.05) [Figure 2] and [Table 3]. The mean hospital stay in the LA group was 2.75 ± 1.50 days, whereas the mean stay in the SA group was 3.60 ± 0.98 days in this study. When compared with group SA, it was statistically considerably lower in group LA (P = 0.05) [Figure 3] and [Table 4].
|Table 3: Intergroup comparison of post-op complications between both groups|
Click here to view
| Discussion|| |
In terms of age, gender, type, and side of inguinal hernia, the findings of this study are similar with previous research, like most of the patients had right-sided inguinal hernia with indirect type.,,,,,, In both groups, the time gap between draping for the surgery and dressing was determined. The LA group’s mean operational time was 61.50 min, whereas the SA group’s was 61.25 min. No statistically significant difference (P-value > 0.05) was found in mean operational time. According to Jain et al., the median time required to complete hernioplasty under local anesthesia was 70.26 minutes (range: 40–90 min) and under spinal anesthesia was 72.46 min (range: 46–94 min). However, the difference (P > 0.05) was not statistically significant.
The patients’ post-operative discomfort was measured using the VAS. In our study, group LA experienced significantly less post-operative discomfort than group SA. According to Nordin et al., patients who received local anesthesia had much less post-operative pain than the other groups.
According to Van Veen, patients who received local anesthesia experienced significantly reduced post-operative discomfort (P = 0.021). According to Jethva et al., 64% of patients in the LA group experienced mild pain, whereas 38% experienced severe pain. None of the patients belonged to the chronic pain category. In South Africa, 6% of patients reported severe pain, 22% reported mild pain, and 2% reported moderate pain.
Zamani-Ranani et al. found that the pain score in the LA group was considerably lower 3, 6, and 12 h after surgery (P = 0.0001). However, 24 h after surgery, there was no significant difference in pain levels across groups (P = 0.24).
Micturition problems were noted in seven patients in the spinal anesthesia group but not in any of the patients in the local anesthesia group. Following spinal anesthesia, Van Veen, Sanjay and Woodward, and Young, all observed a significant rate of urine retention. It is thought to be caused by the suppression of bladder autonomic innervation for a long time. It might also be linked to the patient’s age and the amount of liquids given to them. In 3,175 primary inguinal hernia operations conducted under local anesthesia, Kark et al. found no post-operative instances of urine retention. These findings suggest that using a local anesthetic can assist to minimize the cost and complications of catheterization.
Two patients in the SA group (5%), but none in the LA group, experienced post-operative headache. The incidence of post-operative headache was 7% in the LA group and 8% in the SA group, according to Young. In a study of 50 hernioplasty patients, Goyal et al. found no single case of post-operative headache. In the LA group, four patients (10%) had seroma, whereas in the SA group, three patients (7.5%) acquired seroma. Sakorafas et al. observed two patients experienced hematomas that needed drainage and six patients had seroma in their 2001 analysis of 540 tension-free inguinal hernia surgeries.
Six of 40 inguinal hernia operations performed under local anesthesia and 5 of 40 inguinal hernia repairs performed under spinal anesthesia resulted in wound infection in the current research. Antibiotics and standard bandages were used to treat infections. In comparison to earlier studies, such as Van Veen and Gultekin et al., delayed post-operative sequelae such as scrotal edema, hematoma, seroma, and SSIs were not statistically significantly different between the two groups.
In inguinal hernia repair under local anesthesia, Shrestha et al. found a 1.6% infection rate at the superficial surgical site. According to Khurram Niaz et al., wound infections developed at a rate of 2% in the local anesthetic group and 5% in the spinal anesthetic group. Gao et al. investigated all 110 patients who had mesh-based inguinal hernia repair under local anesthesia and found no evidence of wound infection. Following inguinal hernia surgery under local anesthesia, Shaikh et al. found a wound infection incidence of 2.7% in late phase patients. The LA group had a mean length of stay of 2.75 ± 1.50 days, whereas the SA group had a mean length of stay of 3.60 ± 0.98 days in the study. On a statistical basis, it was much lower in group LA than in group SA.
Our findings are in accordance with those of Goel et al., Nordin et al., and Subramaniam et al., who found that in their research that the mean post-operative hospital stay was shorter in the local anesthetic group than in the spinal anesthetic group.,,,,,,,,,,,,, According to Pradeep et al., 60% of patients in the LA group returned to work within 7 days, whereas the majority of patients in the SA group took longer. The average time it took to get back to work in the LA group was 5.6 ± 2.64 days, while it took 7.04 ± 3.51 days in the SA group. In 103 individuals, Teasdale et al. found that local anesthesia was quicker than general or spinal anesthesia in terms of recovery time.
On the basis of our observations, we concur with O’Dwyer et al., Kark et al., and Behnia et al., about the economic benefits associated with low morbidity, minimum catheter use, and shorter recovery, room, and post-operative ward stays during local anesthesia.
| Conclusion|| |
While both local and spinal anesthesia can be used for hernia repair, spinal anesthesia has a higher risk of complications, such as headache and urinary retention. With spinal anesthesia, general issues such as hypotension, bradycardia, urine retention, vomiting, and headache are considerably enhanced. The LA group had a much lower rate of post-operative pain than the SA group, according to our findings.
The use of a local anesthetic considerably expedited post-operative ambulation. The use of a local anesthetic resulted in a shorter stay in the hospital and a quicker return to regular activity. In general, local anesthesia was linked to a decreased rate of immediate post-operative problems. The study shows that local anesthesia is a better alternative for short-stay or day-care surgery than spinal anesthesia, especially for individuals who cannot tolerate spinal anesthesia. Short-stay services will result in considerable cost reductions for both the hospital and its patients. Therefore, Lichtenstein’s hernioplasty under local anesthesia is gaining immense attention currently among the groin hernia repairs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Johnson J, Roth JS, Hazey JW, Pofahl WE The history of open inguinal hernia repair. Curr Surg 2004;61:49-52.
Purkayastha S, Chow A, Athanasiou T, Tekkis P, Darzi A Inguinal hernia. BMJ Clin Evid 2008;2008:0412. Published July 16, 2008.
Zogbi L An easier Lichtenstein hernioplasty. Hernia 2018;22:555-7.
Langesæter E, Dyer RA Maternal haemodynamic changes during spinal anaesthesia for caesarean section. Curr Opin Anaesthesiol 2011;24:242-8.
Amado WJ Anesthesia for groin hernia surgery. Surg Clin North Am 2003;83:1065-77.
Callesen T, Bech K, Kehlet H One-thousand consecutive inguinal hernia repairs under unmonitored local anesthesia. Anesth Analg 2001;93:1373-6, table of contents.
Kaban OG, Yazicioglu D, Akkaya T, Sayin MM, Seker D, Gumus H Spinal anaesthesia with hyperbaric prilocaine in day-case perianal surgery: Randomised controlled trial. Scientific World J 2014;2014:608372.
Atta-ur-Rehman, et al
. Lichtenstein mesh repair under local anesthesia. J Med Sci 2009;17:103-5.
Akcaboy EY, Akcaboy ZN, Gogus N Ambulatory inguinal herniorrhaphy: Paravertebral block versus spinal anesthesia. Minerva Anestesiol 2009;75:684-91.
Bhattacharya P, Mandal MC, Mukhopadhyay S, Das S, Pal PP, Basu SR Unilateral paravertebral block: An alternative to conventional spinal anaesthesia for inguinal hernia repair. Acta Anaesthesiol Scand 2010;54:246-51.
Van Veen RN New clinical concepts in inguinal hernia, spinal or local anesthesia in Lichtenstein hernia repair: Randomized controlled trial. Br J Surg 2007;94:17-22.
Fischer Josef E. Fischer’s Mastery of Surgery, 7th ed. Wolters Kluwer; 2018. p. 2220.
Goyal P, Sharma SK, Jaswal KS, Goyal S, Ahmed M, Sharma G, et al
. Comparison of inguinal hernia repair under local anesthesia and spinal anesthesia. IOSR J Dent Med Sci (IOSR-JDMS) 2014;13:54-9.
O’Dwyer PJ, Serpell MG, Millar K, Paterson C, Young D, Hair A, et al
. Local or general anaesthesia for open tension-free hernioplasty: A randomized trial. Ann Surg 2002;237: 574-79.
Ryan JA Jr, Adye BA, Jolly PC, Mulroy MF II. Outpatient inguinal herniorrhaphy with both regional and local anesthesia. Am J Surg 1984;148:313-6.
Kark AE, Kurzer MN, Belsham PA Three thousand one hundred seventy five primary inguinal hernia repairs: Advantages of ambulatory open mesh repair using local anaesthesia. Am J Coll Surg 1998;186:1541-7.
Wantz GE Ambulatory hernia surgery. Br J Surg 1989;76:1228-9.
Stobie B Shouldice hospital: Dedicated to the repair of hernias. Can Oper Room Nurs J 1999;17:30-2.
Glassow F Inguinal hernia repair using local anaesthesia. Ann R Coll Surg Engl 1984;66:382-7.
Nordin P, Zetterström H, Gunnarsson U, Nilsson E Local, regional, or general anaesthesia in groin hernia repair: Multicentre randomised trial. Lancet 2003;362:853-8.
Jain A, Jain R, Choudhrie A. Local anaesthesia versus spinal anaesthesia in inguinal hernia surgery - An evidence based approach. Int J Anat Radiol Surg 2019;8:SOO1-4.
Jethva J, Gadhavi J, Patel P, Parmar H. Comparison of hernioplasty under local anesthesia v/s spinal anesthesia. Int Arch Integr Med 2015;2.
Zamani-Ranani MS, Moghaddam NG, Firouzian A, Fazli M, Hashemi SA. A comparison between local and spinal anesthesia in inguinal hernia repair. Int J Clin Anesthesiol 2015;3:1041.
Sanjay P, Woodward A Inguinal hernia repair: Local or general anaesthesia? Ann R Coll Surg Engl 2007;89:497-503.
Young DV Comparison of local, spinal, and general anesthesia for inguinal herniorrhaphy. Am J Surg 1987;153:560-3.
Sakorafas GH, Halikias I, Nissotakis C, Kotsifopoulos N, Stavrou A, Antonopoulos C, et al
. Open tension free repair of inguinal hernias: The Lichenstein technique. BMC Surg 2001;1:3. http://www.biomedcentral.com/1471–2482/1/3
Gultekin FA, Kurukahvecioglu O, Kuruahvecioglu O, Karamercan A, Ege B, Ersoy E, et al
. A prospective comparison of local and spinal anesthesia for inguinal hernia repair. Hernia 2007;11: 153-6.
Shrestha SK, Sharma VK. Outcome of Lichenstein operation: A prospective evaluation of sixty four patients. Nepal Med Coll J 2006;8:230-3.
Gao J-S, Wang ZJ, Zhao B, Ma SZ, Pang GY, Na DM, et al
. Inguinal hernia repair with tension free hernioplasty under local anesthesia. Saudi Med J 2009;30: 534-6.
Shaikh AR, Rao AM, Muneer A, et al
. Inguinal mesh hernioplasty under local anesthesia. J Pak Med Assoc 2012;62:566-9.
Niaz KH, Iqbal JA, Khan MI, Sarfraz M, et al
. Comparison of inguinal herniorrhaphy under local and spinal anesthesia. Pak J Med Health Sci 2010;4:259-62.
Goel A, Bansal JA, Singh A. Comparison of local versus spinal anaesthesia in long standing open inguinal hernia repair. Int Surg J 2017;4:3701-4.
Teasdale C, McCrum AM, Williams NB, Horton RE A randomised controlled trial to compare local with general anaesthesia for short-stay inguinal hernia repair. Ann R Coll Surg Engl 1982;64:238-42.
Behnia R, Hashemi F, Stryker SJ, Ujiki GT, Poticha SM A comparison of general versus local anesthesia during inguinal herniorrhaphy. Surg Gynecol Obstet 1992;174:277-80.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]