Better hernia repair recovery with local anesthetic plus dexamethasone

Last Updated: 2016-09-29

By Marilynn Larkin

NEW YORK (Reuters Health) - Quality of recovery after bilateral total extraperitoneal inguinal hernia repair (TEP-IHR) is improved with preperitoneal instillation of local anesthetic (PILA) with dexamethasone, Indiana-based researchers say.

TEP-IHR "is typically performed on an outpatient basis. It is a relatively recent technique that has been reported to have a number of advantages over open hernia repair including less pain, fewer wound complications, excellent recovery, and a high degree of patient satisfaction," write Dr. Bryan Sakamoto of the Veterans Affairs Medical Center in Indianapolis and colleagues in JAMA Surgery, online September 21.

"Nevertheless," they add, "this surgical technique still can result in significant patient discomfort in the immediate postoperative period."

The authors note that results of studies on PILA following TEP-IHR have been "contradictory," and studies of transversus abdominis plane (TAP) blocks following TEP-IHR suggest "limited" analgesic benefits.

To investigate whether adding dexamethasone might be helpful, Dr. Sakamoto and colleagues randomized 19 patients to a TAP block with local anesthetics and dexamethasone, 24 patients to PILA with dexamethasone, and 23 patients to a control group that received standard anesthesia without regional anesthetics.

After surgery, on arrival in the postanesthesia care unit (PACU), the patients were asked to rate their pain at rest using numeric ratings of 0 to 10. Pain ratings were repeated at regular interviews during the PACU stay.

On the day after surgery, patients were contacted by phone and asked about their pain and analgesic use. They also responded to the QoR-40, a questionnaire that covers five domains of patient recovery (physical comfort, pain, physical independence, psychological support and emotional state) using the 5-point Likert scale (none of the time, some of the time, usually, most of the time, and all of the time).

The average global QoR-40 scores on the first postoperative day for the TAP block group (178) were comparable to those of the control group (174), whereas the PILA group had better scores, on average (184).

However, outcomes in the TAP block and PILA groups were not significantly different from the control group for pain in the PACU (1, 3.5 and 4, respectively); pain after discharge (3, 3 and 4), opiate use after discharge (6.7, 6.7 and 6.7), and incidence of nausea and vomiting in the PACU (21%, 25% and 26%).

There was a significant reduction of opioid use in the PACU in the TAP block group (0) but not in the PILA group (2) compared with the control group (4).

The authors conclude that that the study "demonstrates a better quality of recovery in patients receiving PILA with dexamethasone compared with control for a TEP-IHR surgery."

Dr. Sakamoto told Reuters Health, "While laparoscopic inguinal hernia repairs tend to be less painful than open repairs, this surgical technique can result in significant patient discomfort in the immediate postoperative period."

"Our study is the first to demonstrate that mixing local anesthetics with a steroid and instilling it in the preperitoneal space can provide patients with improved quality of recovery 24 hours postoperatively," he said by email. "This is an easy, cost-effective option for any surgeon performing laparoscopic totally extraperitoneal inguinal hernia surgeries, and may improve their patients' postoperative satisfaction."

Dr. Robert Rege of the University of Texas Southwestern Medical Center in Dallas, author of an accompanying editorial, commented to Reuters Health, "Sakamoto and colleagues demonstrate improved patient comfort on the first postoperative day after bilateral laparoscopic hernia repair when they instill local anesthetic and dexamethasone into the preperitoneal space at the end of the procedure. The technique is simple to use, does not significantly increase operative time, requires no special technique, and is free of complications."

"It is not clear whether the benefits persisted after the first day or whether they contribute to the overall recovery of the patient," he wrote in an email. "However, the benefit of improving patient comfort in the first 24 hours after hernia repair alone is significant, making this article of interest to surgeons who perform laparoscopic hernia repair."

SOURCE: http://bit.ly/2cNQmy5 and http://bit.ly/2doC1pj

JAMA Surg 2016.