Feasibility of Umbilical Hernia Repair Under Local Anesthesia and Monitored Anesthesia Care at a Veteran Affairs Hospital.

BACKGROUND: Local anesthesia (LA) for open umbilical hernia tissue repair (OUHTR) is not widely utilized in academic centers in the United States. We hypothesize that LA for OUHTR is feasible in a veteran patient population. METHODS: From 2015 to 2019, 449 umbilical hernias were repaired at our institution utilizing a standardized technique in veteran patients. OUHTR was included in this analysis (n = 283). Since 2017, 18.7% (n = 53) UH were repaired under LA. We compared outcomes and operative times between general anesthesia and LA in patients undergoing OUHTR. Univariable and multivariable analyses were performed to determine significance. RESULTS: The entire cohort was composed of older (56.3 ± 12.1 years), White (75.5%), obese (body mass index [BMI] = 32.3 ± 4.6 kg/m2) men (98.0%). The average hernia size for the entire cohort was 2.42 ± 1.2 cm. The groups were similar in age and BMI. Patients with higher American Society of Anesthesiologists (ASA) (Odds ratio [OR] 3.1; 95% CI 1.5-6.8) and cardiovascular disease (OR 2.7; 95% CI 1.0-7.2) were more likely to receive LA. Recurrence (0.0% vs 6.0%; P = .9) and 30-day complications (6.0% vs 13%; P = .9) were similar between LA and GA after correcting for hernia size. Operating room times were reduced in the LA group (17.7 minutes; P < .05). None of the patients with LA required postanesthesia care unit for recovery. The patients who received LA reported being comfortable (78.9% of patients), with the worst reported pain being 2.4 ± 2.4 (out of a scale of 10), and 94.7% would elect to receive LA if they had another hernia repair. CONCLUSION: Patients who received LA had more cardiac disease and a higher ASA. Complications were similar between both groups. LA reduced operating room times. Patients were satisfied with LA.

Racial and Ethnic Disparities in Access to Local Anesthesia for Inguinal Hernia Repair.

BACKGROUND: Many studies have identified racial disparities in healthcare, but few have described disparities in the use of anesthesia modalities. We examined racial disparities in the use of local versus general anesthesia for inguinal hernia repair. We hypothesized that African American and Hispanic patients would be less likely than Caucasians to receive local anesthesia for inguinal hernia repair. MATERIALS AND METHODS: We included 78,766 patients aged ≥ 18 years in the Veterans Affairs Surgical Quality Improvement Program database who underwent elective, unilateral, open inguinal hernia repair under general or local anesthesia from 1998-2018. We used multiple logistic regression to compare use of local versus general anesthesia and 30-day postoperative complications by race/ethnicity. RESULTS: In total, 17,892 (23%) patients received local anesthesia. Caucasian patients more frequently received local anesthesia (15,009; 24%), compared to African Americans (2353; 17%) and Hispanics (530; 19%), P < 0.05. After adjusting for covariates, we found that African Americans (OR 0.82, 95% CI 0.77-0.86) and Hispanics (OR 0.77, 95% CI 0.69-0.87) were significantly less likely to have hernia surgery under local anesthesia compared to Caucasians. Additionally, local anesthesia was associated with fewer postoperative complications for African American patients (OR 0.46, 95% CI 0.27-0.77). CONCLUSIONS: Although local anesthesia was associated with enhanced recovery for African American patients, they were less likely to have inguinal hernias repaired under local than Caucasians. Addressing this disparity requires a better understanding of how surgeons, anesthesiologists, and patient-related factors may affect the choice of anesthesia modality for hernia repair.

Using Local Anesthesia for Inguinal Hernia Repair Reduces Complications in Older Patients.

BACKGROUND: Inguinal hernia repair is the most common general surgery operation in the United States. Nearly 80% of inguinal hernia operations are performed under general anesthesia versus 15%-20% using local anesthesia, despite the absence of evidence for the superiority of the former. Although patients aged 65 y and older are expected to benefit from avoiding general anesthesia, this presumed benefit has not been adequately studied. We hypothesized that the benefits of local over general anesthesia for inguinal hernia repair would increase with age. MATERIALS AND METHODS: We analyzed 87,794 patients in the American College of Surgeons National Surgical Quality Improvement Project who had elective inguinal hernia repair under local or general anesthesia from 2014 to 2018, and we used propensity scores to adjust for known confounding. We compared postoperative complications, 30-day readmissions, and operative time for patients aged <55 y, 55-64 y, 65-74 y, and ≥75 y. RESULTS: Using local rather than general anesthesia was associated with a 0.6% reduction in postoperative complications in patients aged 75+ y (95% CI -0.11 to -1.13) but not in younger patients. Local anesthesia was associated with faster operative time (2.5 min - 4.7 min) in patients <75 y but not in patients aged 75+ y. Readmissions did not differ by anesthesia modality in any age group. Projected national cost savings for greater use of local anesthesia ranged from $9 million to $45 million annually. CONCLUSIONS: Surgeons should strongly consider using local anesthesia for inguinal hernia repair in older patients and in younger patients because it is associated with significantly reduced complications and substantial cost savings.

Systemic immune response after open tension-free inguinal hernia repair under different anesthetic alternatives: a prospective comparative study.

PURPOSE: The purpose of the present study was a comparison of the systemic inflammatory response intensity through the estimation of C- reactive protein and albumin levels before and after open tension free inguinal hernia repair performed under different anesthetic alternatives. PATIENTS AND METHODS: Totally, 125 inguinal hernia patients scheduled for unilateral primary open tension free inguinal repair unRomader local (50 patients), spinal (50 patients) and general anesthesia (25 patients) have been included in this prospective study. RESULTS: The group of local anesthesia was associated with the higher postoperative serum levels of albumin compared to the group of general anesthesia (P 0.013). Local anesthesia was also associated with higher postoperative serum albumin levels compared to regional anesthesia but however the difference was not statistically significant (P 0.282). The group of local anesthesia was also associated with the lower postoperative levels of CRP compared to the regional (P 0.0094) and general anesthesia (P 0.0009) groups. CONCLUSION: Local anesthesia proved superior to regional or general anesthesia for open tension free inguinal hernia repair in the given patient sample from the standpoint of the inflammatory and acute phase response.

[Comparative analysis of efficiency indicators in ambulatory surgery]. / Análisis comparativo de indicadores de eficiencia en cirugía mayor ambulatoria.

OBJECTIVE: To find comparative elements for quality control in major ambulatory surgery (MAS) units. METHOD: Descriptive and comparative study of the Ambulatory Care Index (AI) and Substitution Index (SI) in the Santa Cristina Hospital Surgery Service (Madrid, Spain) compared to Key Indicators (KI) of the National Health Service (NHS). RESULTS: 7,817 MAS procedures (between 2006 and 2014) were analysed. The average annual AI was 54%, higher (p <0.0001) than «ambulatory surgery¼ KI. The hernia outpatient procedures (average 72%) were also superior to the national KI (p <0.0001), but ambulatory haemorrhoidectomy (average 33.6%) was clearly lower (p <0.0001). CONCLUSIONS: KI of the NHS are useful and allow to establish a proper development in the global AI and hernia outpatient surgery with opportunities for improvement in haemorrhoidectomy. Their collection should be careful, not including minor surgeries. Also, their usefulness could be increased if data was broken down by speciality and by complexity.

Long-term quality of life and outcomes following robotic assisted TAPP inguinal hernia repair.

Laparoscopic TAPP inguinal hernia repair is an established alternative to open hernia repair, which offers equivalent outcomes with less postoperative pain and faster recovery. Unfortunately, it remains technically challenging, requiring advanced laparoscopic skills which have limited its popularity among surgeons. The robotic platform has the potential to overcome these challenges. The objective of this study was to examine the long-term quality of life and outcomes following robotic assisted TAPP inguinal hernia repair, since these data have not been reported up to now. From October 2012 to October 2015, 159 inguinal hernias in 82 consecutive patients were repaired with 3D mesh (BARD) using da Vinci Si Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). The patients' demographics and intraoperative data were documented. Patients were seen 2 and 6 weeks after the surgery and the complications were recorded. Patients were assessed 6 weeks after the surgery by a survey using a universal pain assessment tool to document their post-operative pain, narcotic use and time of return to work and exercise. A modified short form 12 (SF 12) was also sent out to the patients 12-36 months after the surgery to measure their health-related quality of life prior to surgery and at the 12- to 36-month follow-up, and to document any evidence of recurrence. Postoperative health-related quality of life scores were compared to the pre-operative baseline quality of life scores using the unpaired t test. Over the course of 3 years, 159 robotic assisted TAPP inguinal hernia repair were performed in 82 patients, 73 men and 9 women by one surgeon as an outpatient basis. The mean age was 53 and mean body mass index was 26. There were no intraoperative complications or conversions. The average operative time was 99 min. Four patients developed urinary retention post-operatively and one patient developed postoperative bowel obstruction requiring laparoscopic lysis of adhesion with no long-term complications. All patients completed the pain assessment survey and the median pain score, 3 days after the surgery was 3. Narcotics were used for an average of 3.1 days. The modified SF 12 survey assessing for quality of life before and 12-36 months after surgery was completed and returned by 29 patients (response rate of 35.4% and median follow-up of 32 months). Only one recurrence was reported which was repaired with open technique. The analysis of the SF 12 survey that evaluated patient's quality of life, pain score and the ability to perform activities of daily living before and after surgery revealed a significant improvement in those measures 12-36 months after the surgery compare to their baseline. Hernia recurrence, chronic pain and physical impairment are the major long-term concerns after any type of inguinal hernia repair. Our results demonstrate that robotic assisted TAPP inguinal hernia repair appears to be a technically feasible, reproducible and safe minimally invasive alternative with low recurrence, low chronic pain and high health-related quality of life in the long term.

Estudo comparativo entre anestesia local e raquianestesia na herniorrafia inguinal / Comparative study between local and spinal anesthesia in inguinal herniorraphy

Objetivo: Apesar das vantagens da anestesia local para o reparo de hérnias inguinais já estarem bem estabelecidas, a técnica anestésica mais utilizada em nosso meio é a raquidiana. O objetivo deste estudo é investigar os benefícios do emprego da anestesia local nas herniorrafias inguinais, comparando aspectos relacionados a dor, consumo de analgésicos, encargos hospitalares e satisfação do paciente. Métodos: Foram analisados prospectivamente 105 pacientes submetidos a herniorrafias inguinais eletivas no período de janeiro a outubro de 2002, no Complexo Hospitalar Santa Casa de Porto Alegre. Quatorze pacientes foram excluídos. A amostra final foi dividida em dois grupos: um submetido à anestesia raquidiana (69 pacientes) e o outro à anestesia local com sedação endovenosa (22 pacientes). Resultados: O grupo da anestesia local teve maior incidência de dor no transoperatório (p<0,05). No entanto, durante a internação hospitalar este grupo apresentou menor incidência e intensidade de dor (p<0,05), consumindo quantidades semelhantes de analgésicos (p>0,05). Além disso, encontramos no grupo da anestesia local menor tempo de permanência na sala de recuperação (p<0,05) e custos anestésicos 62,45% menores em cada procedimento. A dor no transoperatório, na anestesia local, não prejudicou a satisfação do paciente em relação à técnica anestésica (p>0,05). Conclusões: A anestesia local com sedação mostrou-se adequada para ser utilizada nas herniorrafias inguinais primárias. Ela apresentou vantagens em relação à anestesia raquidiana: menor intensidade de dor, menor tempo de recuperação anestésica e menores custos hospitalares (AU)

Background: Advantages of local anesthesia for inguinal hernia repair are well established. Even though, the spinal anesthetic technique is still the routine in our hospitals. The objective of this study is to compare the use of local and spinal anesthetic techniques for inguinal herniorraphies. We evaluated the repercussion of these anesthetic techniques in pain, use of analgesic medications, hospital discharges and satisfaction with the procedure. Methods: One hundred and five patients who underwent elective inguinal herniorraphy between January and October, 2002, were prospectively analyzed. Fourteen patients were excluded. The amount of patients was divided in two groups: spinal anesthesia (69 patients) and local anesthesia with sedation (22 patients). Results: Local anesthesia group presented greater pain incidence during the transoperative period (p<0.05). Despite this, while in hospital, these patients referred minor incidence and intensity of pain (p<0.05), with comparable consuming of analgesics (p>0.05). Besides, the local anesthesia group had a minor anesthesia recovery time (p<0.05) and an expense of 62,45% minor in each procedure. Pain related in the local anesthesia group during the surgery did not influence the grade of satisfaction with the procedure (p>0.05). Conclusions: Local anesthesia with sedation is an adequate anesthetic technique to be used in primary inguinal herniorraphies. It showed advantages over spinal anesthesia: lower incidence and intensity of pain during hospital staying, shorter anesthesia recovery time and minor hospitals expenses (AU)