Network meta-analysis of urinary retention and mortality after Lichtenstein repair of inguinal hernia under local, regional or general anaesthesia.

BACKGROUND: Urinary retention and mortality after open repair of inguinal hernia may depend on the type of anaesthesia. The aim of this study was to investigate possible differences in urinary retention and mortality in adults after Lichtenstein repair under different types of anaesthesia. METHODS: Systematic searches were conducted in the Cochrane, PubMed and Embase databases, with the last search on 1 August 2018. Eligible studies included adult patients having elective unilateral inguinal hernia repair by the Lichtenstein technique under local, regional or general anaesthesia. Outcomes were urinary retention and mortality, which were compared between the three types of anaesthesia using meta-analyses and a network meta-analysis. RESULTS: In total, 53 studies covering 11 683 patients were included. Crude rates of urinary retention were 0·1 (95 per cent c.i. 0 to 0·2) per cent for local anaesthesia, 8·6 (6·6 to 10·5) per cent for regional anaesthesia and 1·4 (0·6 to 2·2) per cent for general anaesthesia. No death related to the type of anaesthesia was reported. The network meta-analysis showed a higher risk of urinary retention after both regional (odds ratio (OR) 15·73, 95 per cent c.i. 5·85 to 42·32; P < 0·001) and general (OR 4·07, 1·07 to 15·48; P = 0·040) anaesthesia compared with local anaesthesia, and a higher risk after regional compared with general anaesthesia (OR 3·87, 1·10 to 13·60; P = 0·035). Meta-analyses showed a higher risk of urinary retention after regional compared with local anaesthesia (P < 0·001), but no difference between general and local anaesthesia (P = 0·08). CONCLUSION: Local or general anaesthesia had significantly lower risks of urinary retention than regional anaesthesia. Differences in mortality could not be assessed as there were no deaths after elective Lichtenstein repair. Registration number: CRD42018087115 ( https://www.crd.york.ac.uk/prospero).

ANTECEDENTES: La retención de orina y la mortalidad tras la reparación abierta de las hernias inguinales puede depender del tipo de anestesia. El objetivo de este estudio fue investigar posibles diferencias en la retención de orina y mortalidad en adultos tras reparación de Lichtenstein bajo diferentes métodos anestésicos. MÉTODOS: Se efectuaron búsquedas sistemáticas en las bases de datos Cochrane, PubMed y Embase con la última revisión el 1 de agosto de 2018. Los estudios elegibles incluyeron pacientes adultos sometidos a reparación electiva de hernia inguinal unilateral mediante la técnica de Lichtenstein bajo anestesia local, regional o general. Las variables de resultados fueron la retención de orina y la mortalidad, comparándose los tres tipos de anestesia con metaanálisis y un metaanálisis en red. RESULTADOS: En total se incluyeron 53 estudios con un total de 11.683 pacientes. Las tasas crudas de retención de orina fueron del 0,1% (i.c. del 95% 0,0-0,2%) para la anestesia local, del 8,6% (i.c. del 95% 6,6-10,5%) para la anestesia regional y del 1,4% (i.c. del 95% 0,6-2,2%) para la anestesia general. No se observó mortalidad relacionada con el tipo de anestesia. El metaanálisis en red mostró un riesgo más elevado de retención de orina tras la anestesia regional (razón de oportunidades, odds ratio, OR 15,73 (i.c. del 95% 5,85-42,32), P < 0,001) y anestesia general (OR 4,07 (i.c. del 95% 1,07-15,48), P = 0,040) en comparación con la anestesia local y un riesgo más alto tras la regional en comparación con la anestesia general (OR 3,87 (i.c. del 95% 1,10-13,60), P = 0,035). Los metaanálisis mostraron un riesgo más alto de retención de orina tras la anestesia regional en comparación con la anestesia local (P < 0,001), pero sin diferencias entre anestesia general y local (P = 0,08). CONCLUSIÓN: La anestesia local o general presentaba un riesgo significativo menor de retención urinaria en comparación con la anestesia regional. Las diferencias en mortalidad no pudieron ser evaluadas ya ningún paciente falleció tras la reparación electiva de Lichtenstein.

Limited use of local anesthesia for open inguinal hernia repair: a qualitative study.

PURPOSE: Local anesthesia for open inguinal hernia repair is recommended by guidelines but is rarely used in clinical practice in several countries. This study aimed to explore physician's considerations in choosing type of anesthesia and barriers for implementing local anesthesia for open hernia repair in clinical practice. METHODS: We performed individual semi-structured interviews of surgeons and anesthesiologists. Transcribed data were condensed, coded, categorized, and formulated into themes in an inductive qualitative content analysis. RESULTS: Twenty two participants from seven public hospitals were included in the study. Participants described a standardized setup for general anesthesia with use of intravenous propofol/remifentanil and a laryngeal mask and were generally satisfied with this setup. Their considerations in choosing anesthesia could be described in four themes: (1) Intraoperative pain and quality of surgical technique, (2) Communication and teaching, (3) Logistics, and (4) Clinical routines. CONCLUSION: Participants considered intraoperative pain and quality of surgical technique, communication and teaching, logistics, and clinical routines as important factors when choosing anesthesia for open inguinal hernia repair and these factors acted as barriers for implementing of local anesthesia in Danish public hospitals. In this setting, implementation strategies should, therefore, be multimodal to address these barriers. The potential workload in such an effort should be justified by evidence supporting specific types of local anesthesia comapared with general anesthesia with use of propofol/remifentanil and a laryngeal mask.

Mortality and Urological Complications After Open Groin Hernia Repair in Local, General, and Regional Anesthesia: A Nationwide Linked Register Study.

BACKGROUND AND AIMS: The choice of anesthesia method may influence mortality and postoperative urological complications after open groin hernia repair. We aimed to investigate the association between type of anesthesia and incidence of urinary retention, urethral stricture, prostate surgery, and 1-year mortality after open groin hernia repair. MATERIALS AND METHODS: Data were linked from the Danish Hernia Database, the national patient register, and the register of causes of death. We investigated data on male adult patients receiving open groin hernia repair from 1999 to 2013 with either local anesthesia, regional anesthesia, or general anesthesia. In relation to the type of anesthesia, we compared mortality and urological complications up to 1 year postoperatively. We adjusted for covariates in a logistic regression assessing urological complications and with the Cox regression assessing mortality. RESULTS: We included 113,069 open groin hernia repairs in local anesthesia, regional anesthesia, or general anesthesia. The risk of urinary retention adjusted for covariates was higher after both general anesthesia (adjusted odds ratio = 1.64, 95% confidence interval = 1.05-2.57, p = 0.031) and regional anesthesia (odds ratio = 2.99, 95% confidence interval = 1.67-5.34, p < 0.0005) compared with local anesthesia. The adjusted risk of prostate surgery was also higher for both general anesthesia (odds ratio = 1.58, 95% confidence interval = 1.23-2.03, p < 0.0005) and regional anesthesia (odds ratio = 1.90, 95% confidence interval = 1.40-2.58, p < 0.0005) compared with local anesthesia. Type of anesthesia did not influence 1-year mortality or the risk for urethral stricture. CONCLUSION: Patients undergoing open groin hernia repair in local anesthesia experience the lowest rate of urological complications and have equally low mortality compared with patients undergoing repair in general anesthesia or regional anesthesia.