spinal vs local anesthesia on hernia repair

spinal vs local anesthesia on hernia repair

1. DEPARTMENT OF SURGERY POKHARA ACADEMY OF HEALTH SCIENCES SPINAL ANAESTHESIA VERSUS LOCAL ANAESTHESIA FOR INGUINAL HERNIA REPAIR JOURNAL CLUB PRESENTER: DR PRAKASH KHANAL MODERATOR: DR SUNIL JWARCHAN 1 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow 2082/05/01

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3. CONTENTS: Introduction Methods Results Discussion Critical Analysis Conclusion Other similar studies References 3 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

4. INTRODUCTION: Hernia word derived from Greek meaning an offshoot, a budding, or bulg. Inguinal hernia, presenting as a bulge in the groin, is one of the oldest recorded surgical conditions, with evidence dating back to ancient Egypt and Greece. It is the most common type of hernia, affecting approximately 15% of adult males and accounting for around 80% of all hernia cases. Men are predominantly affected, with incidence increasing with age. Morbidity rates range from 11 per 10,000 in young adults (16–24 years) to 200 per 10,000 in elderly patients (≥75 years). 4 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

5. INTRODUCTION Various open repair techniques, including Shouldice , McVay , Bassini , and Lichtenstein, have been developed, with the Lichtenstein tension-free mesh repair being the most widely used worldwide can be performed under general, spinal, or local anesthesia. Local anesthesia offers advantages for day-case surgery, including reduced postoperative pain, fewer complications, early mobilization, shorter hospital stay, and lower costs, especially in elderly or medically fragile patients. 5 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

6. INTRODUCTION Despite these benefits, most hernia repairs are still performed under general or spinal anesthesia. This study aims to compare outcomes of inguinal hernia repair under local versus spinal anesthesia to optimize recovery, reduce pain, and decrease hospital stay. © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow 6

7. METHODS STUDY DESIGN AND SETTINGS: Prospective observational study Study site: Department of General Surgery, Era’s Lucknow Medical College, Lucknow , Uttar Pradesh, India. Study time: 2019–2021 7 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

8. METHODS STUDY DESIGN AND SETTINGS: Total participants: A total of 80 patients who were randomly assigned by the SNOSE method (Sequentially Numbered, Opaque, Sealed Envelopes) into two groups. Study groups: Group A – Hernia repair under local anesthesia (n=40) Group B – Hernia repair under spinal anesthesia (n=40) A written informed consent was obtained from all patients. Confidentially was maintained. 8 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

9. METHODS STUDY DESIGN AND SETTINGS: Inclusion criteria: Above the age of 18 who presented with uncomplicated inguinal hernia. 9 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

10. METHODS STUDY DESIGN AND SETTINGS: Exclusion criteria: Chronic constipation, portal hypertension, Bleeding disorders, Psychological issues, Obesity (BMI > 30), Benign prostatic hyperplasia, Anal stenosis, Uncontrolled diabetes, hypertension, and Hypersensitivity to lignocaine or bupivacaine. If local or spinal anesthesia was inadequate, switched to general anesthesia (patient excluded from trial (conversion criteria) © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow 10

11. METHODS SURGICAL PROTOCOL Lichtenstein tension-free hernioplasty with single surgeon with assistance from two scrub nurses. Preoperative medications: IV cefoperazone 30 mg/kg IV diclofenac sodium 1 mg/kg IV metoclopramide 0.5 mg/kg IV pantoprazole 40 mg 11 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

12. METHODS SURGICAL PROTOCOL LOCAL ANESTHESIA TECHNIQUE (GROUP LA): Injection sites & volumes: 10 ml under the external oblique, fan-wise, ~2 cm medial to the anterior superior iliac spine. 10 ml subcutaneous at same location toward pubic tubercle along incision line. 10 ml at pubic tubercle and along rectus sheath toward umbilicus (to block contralateral innervation ). 10 ml in suprapubic area (superficially and deeply) near incision line, fan-like pattern. 10 ml deep at mid-inguinal location. 10 ml subcutaneous along anticipated skin crease incision. Additional as needed for spermatic cord and neck of hernial sac. 12 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

13. METHODS SURGICAL PROTOCOL ANESTHETIC DETAIL Group B (Spinal anesthesia) 0.5% bupivacaine with dose of 2.5 cc injected into subarachnoid space via 26-gauge spinal needle at the level L3–L4 interspace . 13 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

14. METHODS SURGICAL PROTOCOL Surgical procedure (both groups): Tension-free Lichtenstein hernioplasty . Prosthetic mesh: Polypropylene (ETHICON). 14 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

15. METHODS SURGICAL PROTOCOL Outcome measures : Intraoperative : Discomfort during surgery. Postoperative: Pain (overall and at incision site). Urine retention. Wound hematoma. Sepsis. Headache. Testicular pain/swelling. Third postoperative day assessment: Wound infections. Incision site discomfort. Other complications. 15 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

16. METHODS SURGICAL PROTOCOL Follow-up and postoperative care Postoperative ward care: Analgesics and antibiotics administered to all patients. Antibiotic duration: Spinal anesthesia: 3 days. Local anesthesia: 1–2 days (based on surgical site infection [SSI] status). Oral fluids initiation: Spinal anesthesia: After 8 hours. Local anesthesia: After 2 hours. 16 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

17. METHODS SURGICAL PROTOCOL Follow-up and postoperative care Discharge criteria: Local anesthesia patients discharged on first postoperative day if hemodynamically stable and clinically normal. Follow-up schedule: Return after 1 week if symptoms such as SSI persisted. Regular follow-up for 1 month for SSI monitoring. SSI assessment followed CDC guidelines. 17 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

18. METHODS SAMPLE SIZE AND STATISTICAL ANALYSIS Software used: SPSS (Statistical Package for Social Sciences) Version 21.0 or higher. Data presentation: Number (percentage). Mean ± standard deviation (SD). Median (where applicable). Statistical tests applied: Chi-square test ( χ²). Independent samples t-test. Significance threshold: P-value < 0.05. 18 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

19. RESULTS STUDY POPULATION Total patients: 40 in each arm of age (18-70 years) Group A (LA): Mean age 44.08 ± 18.22 years. Group B (SA): Mean age43.95 ± 13.04 years. Group LA: Indirect inguinal hernia: 30 patients (75.0%). Direct inguinal hernia: 10 patients (25.0%). Group SA: Indirect inguinal hernia: 25 patients (62.5%). Direct inguinal hernia: 15 patients (37.5%). 19 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

20. RESULTS STUDY POPULATION Operative time results: Local anesthesia: median time range 40–90 minutes. Spinal anesthesia: median time range 40–90 minutes. No statistically significant difference between groups Pain assessment tool: Visual Analog Scale (VAS) at 6, 12, and 24 hours postoperatively. Mean VAS scores: Group LA: 6 h (3.18), 12 h (1.43), 24 h (0.45). Group SA: 6 h (2.78), 12 h (2.83), 24 h (0.99). 20 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

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22. RESULTS STATISTICAL FINDINGS: At 12 hours: Statistically significant difference between groups (P = 0.05) — lower pain in LA group. At 6 and 24 hours: No statistically significant difference (P > 0.05). Overall observation: Group LA showed better pain control in the first 12 hours postoperatively compared to Group SA. 22 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

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25. RESULTS Post-op complications: Higher in SA (urine retention, post-spinal headache); LA had significantly fewer (P < 0.05). 25 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

26. METHODS Mean hospital stay: LA: 2.75 ± 1.50 days. SA: 3.60 ± 0.98 days. Significantly shorter in LA (P = 0.05). 26 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

27. DISCUSSION Local anaesthesia is safe, simple, effective, and economical for reducible inguinal hernia repairs. It blocks the iliohypogastric, ilioinguinal, and genitofemoral nerves, which supply sensation to the inguinal region. Local anaesthesia provides longer postoperative pain relief by inhibiting nociceptive molecule buildup, offering better pain control after surgery. Although patients under local anaesthesia (LA) may experience more intraoperative pain than those under spinal anaesthesia (SA), especially with large hernias, this pain is manageable. 27 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

28. DISCUSSION STUDY SHOWS: The demographic and hernia characteristics in this study align with previous research, with most patients having right-sided indirect inguinal hernias. Operative times were similar between groups (LA: 61.50 min, SA: 61.25 min), showing no significant difference. Postoperative pain was lower in the LA group. No significant difference was observed at 24 hours. Urinary retention occurred in seven SA patients but none in LA, Postoperative headache affected two SA patients, none in LA. 28 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

29. DISCUSSION STUDY SHOWS: Other complications such as seroma (LA: 10%, SA: 7.5%) and wound infection (LA: 6, SA: 5) were comparable between groups, and multiple other studies. Hospital stay was significantly shorter in the LA group (2.75 ± 1.50 days) compared to SA (3.60 ± 0.98 days), highlighting the clinical and economic advantages of local anesthesia. 29 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

30. Critical analysis: Strength Topic of the study clearly mentions the surgical procedure and the study groups. Introduction reviews existing literatures and explains the rationale for this study. Objective of the study is clearly mentioned. Results justifying the study question and its objectives. Conclusion is made upon the result produced. © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow 30

31. Critical analysis: Strength Results applicable in clinical practice. Hernia surgeries under local anesthesia is safe, effective, and economical in our setting too. It will be a good alternative to the patient with cardiovascular/respiratory comorbidities. The duration of hospital stay can be shorter to prevent hospital acquired infections © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow 31

32. Critical analysis: limitations Small Sample size Single-center study Age range variability Short follow-up Single surgeon Non-blinded design Postoperative care variability . 32 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

33. CONCLUSION Local anaesthesia is a safe, effective, and economical alternative to spinal anaesthesia for reducible inguinal hernia repair. It offers comparable operative times, better postoperative pain control, and significantly fewer complications such as urinary retention. Additionally, local anaesthesia facilitates faster postoperative mobilization and avoids sedation-related side effects, making it particularly suitable for patients with cardiovascular or respiratory comorbidities. 33 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

34. OTHER SIMILAR STUDIES Local anesthesia as an alternative option in repair of recurrent groin hernias : An outcome study from the American College of Surgeons(retrospective, cohort study using the 2017,national database including 23,342 patients, concluded LA being safer and economical yet underutilized alternative to other methods of anesthesia) Spinal Anaesthesia Versus Local Anaesthesia for Inguinal Hernia Repair : A Comparative Study.(Prospective follow up study including 110 patients in Janaki Medical College and Teaching Hospital in July 2020 to July 2022 concluded Local anaesthesia is a safe, effective, and economical alternative to spinal anaesthesia for reducible inguinal hernia repair. 34 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

35. OTHER SIMILAR STUDIES Spinal or local anesthesia in lichtenstein hernia repair: a randomized controlled trial Between August 2004 and June 2006, a multicenter prospective clinical trial conducted by Department of Surgery, Erasmus University Medical Center Rotterdam, The Netherlands evidence that local anesthesia is superior to spinal anesthesia in inguinal hernia repair. Local anesthesia in primary, inguinal hernia repairs should be the method of choice. © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow 35

36. REFERENCES Maurya NK, Asif S, Tahir S, Aishwarya K, Shiromani S. To compare the outcome of inguinal hernia repair under local and spinal anesthesia. International Journal of Abdominal Wall and Hernia Surgery. 2022 Jul 1;5(3):122-8. 36 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow

37. THANK YOU!!! 37 © 2022 International Journal of Abdominal Wall and Hernia Surgery | Published by Wolters Kluwer - Medknow