Anesthesia in Open Inguinal Hernia Repair: The History, Progression, and Current Status




Argo, Madison Bailey

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BACKGROUND: The benefits of local anesthesia in open inguinal hernia repairs was first noticed in the second half of the 20th century, however, for unknown reasons, this practice has nearly been entirely replaced with other anesthetic techniques. In fact, in the United States and globally, the predominant anesthetic techniques employed include general and regional anesthesia leaving local anesthesia immensely underutilized. It was only after implementing local anesthesia at the North Texas Veterans Affairs Health Care System (VANTHCS) in 2015, driven by the increasing amount of patient comorbidities, that this underutilization was recognized. This infrequency and variation in the choice of anesthetic technique for open inguinal hernia repair (OIHR) worldwide, seems to be guided primarily by surgeon preference. The factors determining the use of local anesthesia compared to spinal and general anesthesia (all other forms of anesthesia) remains equivocal as previous data has compared individually spinal anesthesia or general anesthesia to local anesthesia. In the present study: (1) the experience implementing an LA program for OIHR at the VA North Texas Health Care System is described, (2) we present data regarding the underutilization of LA in the USA and underdeveloped countries, (3) and we present an analysis of all randomized controlled trials (RCTs) in patients undergoing open inguinal hernia repair comparing local anesthesia to all other forms of anesthesia to objectively assess the respective outcomes. OBJECTIVE: We hypothesize the use of LA in OIHR is: a) underutilized, b) readily implementable in an academic center with minimal training, and c) advantageous and provides benefit to the patient over other anesthetic techniques in terms of outcomes and operative room times. METHODS: I. We retrospectively analyzed a prospectively collected database at the VANTHCS to determine the implementation of a LA program for OIHR. II. We interrogated a database from a third world country in Guatemala, Hospital Nacional de San Benito (HNSB) to determine current practices at that hospital with regards to the choice of anesthesia for OIHR. We also collected data on other developing countries to determine current practices as well. III. PubMed, MEDLINE, Ovid Syntax from 1976 to May 2018, the Cochrane Library, Google, and Google Scholar were reviewed by two independent reviewers following PRISMA guidelines. We identified 83 potential manuscripts, following exclusion of papers that were not OIHR, did not include anesthesia type, and non-randomized trials, 18 RCT's were available for inclusion. The parameters evaluated were short-term complications (urinary retention, wound infections, and hematomas), patient satisfaction, length of hospital stay (LOS), total surgical time, total operating room time, and postoperative pain. Review Manager 5.3 was used to test for overall effect between the included studies. RESULTS: Data obtained from the VANTHCS showed there was a rapid implementation of LA for OIHR. Data from HNSB showed that 95% of OIHR are performed under regional anesthesia and the rest via GA. A study in Ghana showed a substantial underutilization of local anesthesia. A meta-analysis showed that LA was favored in many analyses and weighed statistical significance was notable for several important outcomes. Overall complication rate was similar in LA vs. AO (p=0.06). Wound infection and hematoma were similar between LA vs. OA (p=0.17 and p=0.62; respectively). Urinary retention was significantly decreased in LA (p=0.0002). Collectively, patient satisfaction was not inferior and tended to favor the use of LA vs. OA (p=0.11). Total surgical time was similar in LA vs. AO (p=0.86), but operating room time was significantly decreased when LA was used (p<0.0001; 95% CI [-16.6 to -5.9]). Seven of the ten studies that recorded LOS reported a significant decrease when LA was used. Four separate studies reported cost. LA was less expensive than AO in all aspects (costs of anesthetic materials, intraoperative and early postoperative costs, and in total healthcare costs). CONCLUSION: The use of LA can be easily implemented at a VA hospital. LA is substantially underutilized in the US and around the world. Our meta-analysis demonstrated that LA is a well-tolerated anesthetic approach for OIHR and ought to be utilized more in the United States and globally. Specifically, OR times and urinary retention were significantly improved with LA vs. AO. Additionally, LA improves the economic burden by decreasing operating room time and decreasing overall intraoperative and early postoperative costs, which is significant for a procedure performed so frequently. LA underutilization is quite apparent and significant future research should be focused on education and implementation of this technique globally.

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