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LETTER TO THE EDITOR

Paravertebral Block: The Holy Grail of Anesthesia for Hernia Surgery?

Professor and Holder of the Margaret Milam McDermott Distinguished, Chair of Anesthesiology, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, paul.white{at}utsouthwestern.edu

In Response:

Baumgarten et al. (1) have apparently missed the essential point of my editorial (2). The purpose of the editorial was not to criticize the otherwise excellent comparative study performed by Hadzic et al. (3), but rather to question whether the same outcome advantages over general anesthesia could be achieved with local anesthetic infiltration and/or a simpler and more widely used peripheral nerve block technique (e.g., an ilioinguinal-hypogastric nerve block) (4).

Obviously, in the hands of experts in regional blocks, the risks of complications with a paravertebral nerve block (PVB) are small. Unfortunately, the "average" anesthesia provider may not possess the necessary expertise to successfully perform PVB in a safe and timely fashion for a straightforward inguinal hernia repair operation. In my recent conversations with Dr. Hadzic regarding this issue, he agreed that PVB should not be considered the "anesthetic technique of choice" for routine inguinal hernia repair procedures. In addition, it should be pointed out that nowhere in my editorial did I state that "PVB for hernia should be avoided because of the risk of pneumothorax."

The authors’ assertion that the "predominant modes" of anesthesia delivery in the United States are by Certified Registered Nurse Anesthetists or residents is an insult to our colleagues in both private practice and academic centers where many anesthetics are, in fact, still given by board-certified (or board-eligible) anesthesiologists! While the so-called "parallel processing" approach advocated by Baumgarten et al. may work well in their current practice models, many anesthesiologists would find it extremely difficult to routinely "perform PVB in a preoperative holding area 30–40 min before (hernia) surgery."

The criticism or the comparative general anesthetic technique was simply intended to point out that tracheal intubation is no longer a standard practice when inguinal hernia repairs are performed under general anesthesia. In fact, the "best outcomes" with respect to patient satisfaction and speed of recovery, typically use a facemask or laryngeal mask airway device in combination with short-acting general anesthetics (e.g., propofol, sevoflurane, desflurane, nitrous oxide) and local anesthesia (5). Alternatively, local infiltration analgesia combined with an ilioinguinal block (4) as part of a monitored anesthesia care technique (6,7), is another highly viable approach in providing anesthesia for inguinal hernia repair.

In my recent discussions with Dr. Baumgarten, I have provided him with a straightforward protocol design for a well-controlled clinical study, which would provide an answer to the real question raised in my editorial. Hopefully, he and his colleagues in Detroit (and Jacksonville) will follow through in performing this clinical trial which would provide the information needed to resolve this question for the readership of this journal.

REFERENCES

1. Baumgarten RK, Greengrass RA, Wesen CA. Paravertebral block: the holy grail of anesthesia for hernia surgery? Anesth Analg 2007;104:207.[Free Full Text]
2. White PF. Choice of peripheral nerve block for inguinal herniorrhaphy: is better the enemy of good? Anesth Analg 2006;102:1073–5.[Free Full Text]
3. Hadzic A, Kerimoglu B, Loreio D, et al. Paravertebral blocks provide superior same-day recovery over general anesthesia for patients undergoing inguinal hernia repair. Anesth Analg 2006;102:1076–81.[Abstract/Free Full Text]
4. Andersen FH, Nielsen K, Kehlet H. Combined ilioinguinal blockade and local infiltration anaesthesia for groin hernia repair–a double-blind randomized study. Br J Anaesth 2005;94:520–3.[Abstract/Free Full Text]
5. Tang J, White PF, Wender RH, et al. Fast-track office-based anesthesia: a comparison of propofol versus desflurane with antiemetic prophylaxis in spontaneously breathing patients. Anesth Analg 2001;92:95–9.[Abstract/Free Full Text]
6. Song D, Greilich NB, White PF, et al. Recovery profiles and costs of anesthesia for outpatient unilateral inguinal herniorrhaphy. Anesth Analg 2000;91:876–81.[Abstract/Free Full Text]
7. SaRego MM, Watcha MF, White PF. The changing role of monitored anesthesia care in the ambulatory setting. Anesth Analg 1997;85:1020–36.[Web of Science][Medline]

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