Intra-Operative

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PROSPECT Recommendations

  • Intra-operative clonidine is not recommended due to limited procedure-specific evidence and potential side-effects, which may delay early ambulation (Grade D)

Clinical Practice

  • Clonidine is associated with side-effects, including hypotension, sedation, dizziness and bradycardia

Transferable Evidence from Other Procedures

  • [None cited]

Herniorraphy-Specific Evidence - Study information

  • Clonidine significantly increased VAS pain scores compared with placebo at rest at 24 h (p<0.05), and there was no significant benefit in the PACU or at 6 h, or on coughing at any time (n=31) Elliott et al 1997
  • Intra-operative systemic clonidine was of no significant benefit over placebo for reducing postoperative analgesic requirements (n=31) Elliott et al 1997

PROSPECT Recommendations

  • Gabapentin/pregabalin cannot be recommended at this time due to the lack of procedure-specific evidence (Grade D), despite analgesic efficacy in other procedures

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • Studies of gabapentin and pregabalin in mastectomy, abdominal surgery, laparoscopic cholecystectomy and spinal surgery showed reductions in postoperative pain and supplementary analgesic requirements for at least 24 h Dahl et al 2004

Herniorraphy-Specific Evidence

  • [None cited]

PROSPECT Recommendations

  • Intra-operative ketamine cannot be recommended at this time (Grade D) due to a lack of procedure-specific evidence, and due to associated side-effects that may hinder early ambulation, despite some evidence of analgesic efficacy in other procedures

Clinical Practice

  • Ketamine is associated with a risk of adverse effects on the central nervous system

Transferable Evidence from Other Procedures

  • Studies of ketamine in abdominal, orthopaedic, gastric, hepatic and renal surgery showed a reduction in postoperative pain and opioid use when used as an adjuvant to morphine, either epidurally or intravenously Subramaniam et al 2004

Herniorraphy-Specific Evidence

  • [None cited]

Local Anaesthetic Techniques 

This section includes studies of local anaesthetics administered to provide postoperative analgesia (i.e. where each group received the same anaesthetic background). For studies of local anaesthesia versus other types of anaesthesia, see Intra-operative, Operative Anaesthetic Techniques 

PROSPECT Recommendations

  • Local anaesthetic injection techniques (inguinal nerve block/field block/infiltration), administered pre-operatively or intra-operatively, or both, are recommended (Grade A) because they reduce early postoperative pain and supplementary analgesic use compared with placebo. The effect of pre-operative administration is comparable to post-incisional administration
  • There are insufficient data to recommend (Grade D) one injection technique (inguinal nerve block/field block/infiltration), or combination, in preference to another
  • Local anaesthetic instillation administered at closure cannot be recommended at this time, despite some evidence for its analgesic efficacy, because of limited data (Grade D)
  • Long-acting local anaesthetics are recommended in preference to short-acting local anaesthetics (Grade D)
  • Addition of dextran or corticosteroid to local anaesthetic solution is not recommended (Grade D) because of limited procedure-specific evidence

Clinical Practice

  • Long-acting local anaesthetics are preferred to short-acting local anaesthetics for analgesia by local injection
  • In herniorraphy studies of local anaesthetic injection techniques, methodology is inconsistently described, and terminology is inconsistently used. In addition, studies directly comparing one local anaesthetic injection technique with another are lacking. For these reasons, no conclusion about the relative benefits of one technique, or combination of techniques (inguinal nerve block/field block/infiltration), can be made at this time

Transferable Evidence from Other Procedures

  • A systematic review of local anaesthesia infiltration showed inconclusive evidence of analgesic efficacy in hysterectomy, open cholecystectomy and a variety of other surgical procedures, but consistent and clinically relevant pain relief in herniorraphy Møiniche et al 1998
  • There is evidence from a variety of surgical procedures that the efficacy of local anaesthetics for postoperative analgesia is similar following pre-operative or post-incisional administration Møiniche et al 1998

Herniorraphy-Specific Evidence - Study information

PROSPECT Recommendations

  • Addition of epinephrine to local anaesthetic solution is not recommended because of a lack of additional or prolonged analgesic effect from limited procedure-specific data (Grade A)

Clinical Practice

  • Epinephrine may result in undesirable cardiovascular side-effects

Transferable Evidence from Other Procedures - Study information

Herniorraphy-Specific Evidence - Study information

  • Intra-operative wound instillation with epinephrine and local anaesthetic was of no significant benefit over local anaesthetic alone for reducing postoperative pain scores during 1–20 h, for reducing analgesic requirements, or for increasing the time to first analgesic request (n=17) Bays et al 1991

PROSPECT Recommendations

  • Paravertebral nerve block is not recommended (Grade D) because it has only a marginal analgesic benefit over other local anaesthetic techniques (nerve block/field block/infiltration) and is a more complex technique

Clinical Practice

  • Clinical experience with the paravertebral nerve block is not widespread. This technique is considered to be more complex, and thus it may be associated with a higher incidence of complications than other local anaesthetic techniques (nerve block/field block/infiltration)

Transferable Evidence from Other Procedures

  • [None cited]

Herniorraphy-Specific Evidence - Study information

  • Paravertebral nerve block was superior to peripheral nerve block for reducing the proportion of patients requiring supplementary analgesia in the PACU (p=0.002; n=46) Klein et al 2002
  • Paravertebral nerve block was associated with a lower incidence of PONV in the PACU compared with peripheral nerve block (p<0.001; n=46) Klein et al 2002
  • Paravertebral nerve block and peripheral nerve block were not significantly different for VAS pain scores at rest, on movement and on coughing in the PACU, or at 2, 6, 12, 18, 24 and 48 h (n=46) Klein et al 2002
  • There was no significant difference between paravertebral nerve block and peripheral nerve block for the proportion of patients requiring supplementary analgesics in the 72-h follow-up period, or the time to first analgesic request (n=46) Klein et al 2002

PROSPECT Recommendations

  • Extraperitoneal instillation with local anaesthetic is not relevant for open herniorraphy
  • Extraperitoneal instillation with local anaesthetic is not recommended in laparoscopic herniorraphy because of a lack of analgesic effect (Grade A)

Clinical Practice

  • There is little clinical experience with extraperitoneal instillation and the technique is poorly defined

Transferable Evidence from Other Procedures - study information

Herniorraphy-Specific Evidence

  • – None cited for open herniorraphy– For data in laparoscopic herniorraphy, see the transferable evidence below

PROSPECT Recommendations

  • Wound infiltration with clonidine is not recommended due to limited procedure-specific data and potential side-effects that can delay early ambulation (Grade D)

Clinical Practice

  • Clonidine is associated with side-effects, including hypotension, sedation, dizziness and bradycardia

Transferable Evidence from Other Procedures 

  • [None cited]

Herniorraphy-Specific Evidence - Study information

  • Wound infiltration with clonidine was superior to intramuscular clonidine for reducing pain scores, but a significant benefit was only evident at 24 h; there was no significant benefit for reducing supplementary analgesic requirements Elliott et al 1997 Click here for more information
  • Wound infiltration with clonidine showed no significant benefit compared with placebo for reducing VAS pain scores at rest and on coughing in recovery, at 6 h and at 24 h (n=31) Elliott et al 1997
  • Wound infiltration with clonidine showed no significant benefit compared with placebo for reducing supplementary analgesic requirements (n=31) Elliott et al 1997

PROSPECT Recommendations

  • Intra-operative wound infiltration with conventional NSAIDs is not recommended (grade A) because of a limited analgesic benefit compared with systemic administration

Clinical Practice

  • The potential for conventional NSAIDs, administered by wound infiltration, to adversely affect platelet function and wound healing must be considered

Transferable Evidence from Other Procedures

  • One randomised trial in patients undergoing transurethral prostatectomy showed that diclofenac did not affect total blood loss compared with placebo Bricker et al 1987
  • A systematic review of the postoperative analgesic effect of local infiltration with conventional NSAIDs showed little difference between wound infiltration and systemic administration Rømsing et al 2000
  • Randomised trials in healthy volunteers showed that conventional NSAIDs (ketorolac, naproxen or diclofenac) reduced the platelet aggregation response compared with placebo; ketorolac and naproxen also prolonged bleeding time compared with placebo Greer et al 1999
  • Meta-analyses of randomised, controlled trials showed that peri-operative conventional NSAIDs increased the risk of postoperative bleeding requiring treatment and/or the risk of re-operation for haemostasis after tonsillectomy compared with controls Marret et al 2003
  • A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused a reversible platelet dysfunction Niemi et al 1997
  • A randomised controlled trial showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) were associated with a similar incidence of surgical site bleeding after elective surgery Forrest et al 2002
  • A randomised clinical trial showed that the conventional NSAID diclofenac was associated with significantly greater intra-operative blood loss than the COX-2-selective inhibitor rofecoxib in patients undergoing abdominal or vaginal hysterectomy or breast surgery Hegi et al 2004

Herniorraphy-Specific Evidence -study information

PROSPECT Recommendations

  • Wound infiltration with strong opioids is not recommended because of conflicting procedure-specific evidence for its analgesic efficacy (Grade A). In addition, strong opioids are not recommended for routine analgesic treatment in herniorraphy because of potential side-effects (Grade D)

Clinical Practice

  • Strong opioids are associated with adverse effects, including respiratory depression, nausea, vomiting, sedation, confusion, paralytic ileus and urinary retention

Transferable Evidence from Other Procedures

  • [None cited]

Herniorraphy-Specific Evidence - study information

PROSPECT Recommendations

  • Local anaesthesia (inguinal nerve block/field block/infiltration techniques), with or without intravenous sedation, is recommended (Grade A) because it decreases postoperative pain and provides additional recovery benefits compared with spinal anaesthesia or general anaesthesia
  • Long-acting local anaesthetics are recommended (Grade D) in preference to short-acting local anaesthetics

Clinical Practice

  • Long-acting local anaesthetics are preferred to short-acting local anaesthetics
  • For all regional anaesthesia techniques, there are procedure-specific failure rates between 2 and 10%, and conversion to general anaesthesia may be required
  • Local practices and cultural differences influence the choice of anaesthetic technique for herniorraphy

Transferable Evidence from Other Procedures

  • [None cited]

Herniorraphy-Specific Evidence - study information

PROSPECT Recommendations

  • When general anaesthesia is used, its combination with local anaesthetic techniques is recommended to decrease postoperative pain (Grade A)
  • Spinal anaesthesia provides good anaesthesia and early postoperative analgesia. Spinal anaesthesia cannot be recommended for routine use (Grade D - majority vote from the prospect Working Group) because of postoperative side-effects that can delay early ambulation, such as urinary retention and hypotension
  • Epidural anaesthesia is not recommended (Grade D)
  • Local anaesthetic techniques (inguinal nerve block/field block/infiltration) are recommended (Grade A) because they provide good postoperative analgesia, rapid recovery, and few side-effects, but the need for intravenous sedation has to be considered (see Intra-operative anaesthetic techniques, Local anaesthesia)
  • Addition of clonidine or neostigmine to local anaesthetic solution for spinal anaesthesia is not recommended due to limited procedure-specific evidence. In addition, potential side-effects of clonidine (Grade D) and neostigmine (Grade A) may hinder early ambulation

Clinical Practice

  • For all regional anaesthesia techniques, there are procedure-specific failure rates between 2 and 10%, and conversion to general anaesthesia may be required
  • Local practices and cultural differences influence the choice of anaesthetic technique for herniorraphy
  • Clonidine is associated with side-effects, including hypotension, sedation, dizziness and bradycardia

Transferable Evidence from Other Procedures

  • [None cited]

Herniorraphy-Specific Evidence -study information

  • Spinal anaesthesia reduced pain scores compared with epidural anaesthesia, but did not reduce analgesic requirements during 0–24 h or the incidence of PONV Günal et al 2002 Click here for more information
  • Spinal anaesthesia (local anaesthetic) reduced the use of supplementary analgesics and the incidence of nausea compared with general anaesthesia, but data for a reduction in pain scores was inconclusive Tverskoy et al 1990 Click here for more information
  • Spinal anaesthesia (local anaesthetic plus strong opioid) significantly reduced supplementary opioid requirements and the incidence of PONV, compared with general anaesthesia, but there was no significant difference for pain scores or oral analgesic use Song et al 2000 Click here for more information
  • General anaesthesia was similar to epidural or spinal anaesthesia (mixed population) for VAS pain scores during the early postoperative period, at 8 days and at 30 days, for the duration of analgesic requirement but was associated with higher VAS nausea scores (n=407) Nordin et al 2003
  • General anaesthesia plus wound infiltration was superior to spinal anaesthesia for reducing dynamic pain scores, but not resting pain scores, and for increasing the time to first analgesic request Tverskoy et al 1990 Click here for more information
  • For spinal anaesthesia, bupivacaine 7.5 mg significantly reduced the proportion of patients requiring intra-operative fentanyl compared with bupivacaine 6 mg, but there was no significant difference in pain scores, supplementary analgesic requirements or the incidence of PONV Gupta et al 2003 Click here for more information
  • For spinal anaesthesia, local anaesthetic plus clonidine was of significant analgesic benefit compared with local anaesthetic alone during the early postoperative period, but did not reduce the risk of PONV Dobrydnjov et al 2003 Click here for more information
  • For spinal anaesthesia, local anaesthetic plus neostigmine showed significant benefit compared with local anaesthetic alone for reducing pain scores and increasing time to first analgesia  Tan et al 2000 Click here for more information
  • For spinal anaesthesia, neostigmine 50 µg and 100 µg were not significantly different for reducing VAS pain scores over 24 h, for reducing supplementary analgesic requirements, and for increasing the time to first analgesic request (n=40) Tan et al 2000
  • Tetracaine plus neostigmine caused a significantly higher rate of PONV than tetracaine alone (p<0.05) (two arms, n=60) Tan et al 2000
  • Pre- plus intra-operative epidural morphine plus postoperative naloxone did not significantly reduce postoperative analgesic requirements or VAS pain scores at rest at 6, 12, 24 or 48 h compared with placebo (n=36) Aida et al 1999

PROSPECT Recommendations

  • It is recommended (Grade D) that the choice of operative technique for herniorraphy (open versus laparoscopic) should be primarily based on factors other than the management of postoperative pain e.g. operative risk factors of the patient, risk of wound infection, availability of surgical expertise, risk of rare but serious complications, contraindications to general anaesthetic, recurrence rates, and cost
  • Laparoscopic herniorraphy is associated with less postoperative pain than open non-mesh herniorraphy (Grade A), but data are inconclusive for the relative analgesic effects of laparoscopic herniorraphy and open mesh herniorraphy  
  • A recommendation for pain management following laparoscopic herniorraphy cannot be made until further data are available 

Clinical Practice

Transferable Evidence from Other Procedures

  • [None cited]

Herniorraphy-Specific Evidence - study information

PROSPECT Recommendations

  • Open mesh procedures are recommended in preference to non-mesh procedures because of lower recurrence rates (Grade A); the recommendation cannot be based on the inconclusive acute pain data (Grade A)
  • There is not enough evidence, at this time, to recommend the following for the management of acute or chronic pain: – the plug-and-patch or the Prolene Hernia System® techniques in preference to the Lichtenstein patch technique (Grade D) – one type of mesh in preference to another (Grade D)  – one mesh fixation technique in preference to another (Grade D)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • [None cited]

Herniorraphy-Specific Evidence - study information

  • A systematic review reported that open mesh herniorraphy is associated with a 50–75% reduction in the risk of hernia recurrence compared with open non-mesh herniorraphy Grant 2002
  • The Prolene Hernia System® procedure was superior to the Lichtenstein patch procedure for postoperative VAS pain scores at rest on day 0 (p<0.05) but there was no significant difference on days 1–14, or for the duration of requirement for postoperative analgesia (n=206) Kingsnorth et al 2002b
  • Two of three studies showed a significant benefit of the plug-and-patch procedure over the Lichtenstein open mesh procedure for reducing postoperative pain scores, and in all studies there was no significant difference in analgesic use Abu-Own A et al 2000 Click here for more information
  • The Stoppa procedure was not significantly different from the Lichtenstein patch procedure for VAS pain scores at rest on days 1, 2, 7 and 30, or on movement on days 7 and 30 (n=33) Malazgirt et al 2000
  • The smooth polypropylene mesh was superior to the monofile, rigid mesh for reducing VAS pain scores on day 1 and at 2, 4, 8 and 12 weeks (p<0.05), but there was no significant difference at 3 days or at 1 week (n=40) Langenbach et al 2003
  • A lightweight mesh was superior to a conventional mesh for reducing dynamic pain scores at 6 months but there was no significant difference in pain during the early postoperative period Post et al 2004 Click here for more information
  • Fixation by sutures for hernia repair was similar to fixation with staples for postoperative pain and supplementary analgesic requirements Leibl et al 2002 Click here for more information
  • Six out of ten studies showed no significant benefit of open mesh procedures compared with open non-mesh procedures for reducing pain scores Barth et al 1998 Click here for more information
  • Of eight studies that reported supplementary analgesic use, five showed no significant benefit for mesh procedures compared with non-mesh procedures for reducing analgesic requirements Barth et al 1998 Click here for more information

PROSPECT Recommendations

  • Open mesh procedures are recommended in preference to non-mesh procedures because of lower recurrence rates (Grade A); the recommendation cannot be based on the inconclusive acute pain data (Grade A, see Open Mesh Procedure)
  • There is not enough evidence to recommend one non-mesh repair technique in preference to another for the management of acute or chronic pain (Grade D)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • [None cited]

Herniorraphy-Specific Evidence

  • Suture repair and no suture repair were similar for cumulative pain scores during the first week and for analgesic requirements (n=84) Callesen et al 1999
  • Moloney's darn repair was superior to the Shouldice repair for reducing postoperative VAS pain scores at 6, 12 and 24 h (p<0.05) and for reducing postoperative requirement for analgesia on days 1, 2 and 3 (p<0.05) (n=50) Thapar et al 2000
  • A systematic review reported that open non-mesh herniorraphy is associated with a 50–75% increase in the risk of hernia recurrence compared with open mesh herniorraphy Grant 2002

PROSPECT Recommendations

  • Nerve section/cryoanalgesia techniques are not recommended because of a lack of analgesic benefit (Grade A)

Clinical Practice

  • [None cited]

Transferable Evidence from Other Procedures

  • [None cited]

Herniorraphy-Specific Evidence - Study information

  • Division of the ilioinguinal nerve was of no significant benefit over preservation of the nerve for VAS pain scores at 1 week, 1 or 6 months, 1 year or at telephone follow up (n=813) Picchio et al 2004
  • Cryoanalgesia was of no benefit for reducing VAS pain scores compared with no treatment or sham treatment in two studies (n=36) Khiroya et al 1986