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AMBULATORY ANESTHESIA

One-Thousand Consecutive Inguinal Hernia Repairs Under Unmonitored Local Anesthesia

Department of Surgical Gastroenterology, H:S Hvidovre University Hospital, Hvidovre, Denmark

Address correspondence and reprint requests to T. Callesen, MD, Department of Anesthesiology, 4132 (HovedOrtoCentret), Rigshospitalet, DK-2100 Copenhagen Ø, Denmark. Address e-mail to callesen{at}rh.dk

	Abstract

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To evaluate the feasibility and safety of unmonitored local anesthesia (ULA) for elective open inguinal hernia repair, we made a prospective, consecutive data collection from 1000 operations on primary and recurrent hernias. Follow-up consisted of a questionnaire 1 mo after surgery and retrieval from the electronic patient data management system. In 921 ASA Group I and II and 79 ASA Group III and IV patients, the median age was 60 yr (range, 18–95 yr). ULA was converted to general anesthesia in 5 of 1000 cases, and 961 patients were discharged on the day of surgery after 95 min (median; interquartile range, 75–150); 29 patients had complications requiring surgical intervention. Within the first month, three patients died of causes unrelated to hernia surgery, and six had cardiovascular or respiratory events. The questionnaire was returned by 940 patients; 124 were dissatisfied with local anesthesia, day-case setup, or both, primarily because of intraoperative pain (n = 74; 7.8%). We conclude that open inguinal hernia repair can be conducted under ULA, regardless of comorbidity, with a small rate of deviation from day-case setup and minimal morbidity. It provides a safe alternative to other anesthetic techniques with an acceptable rate of satisfaction, but intraoperative pain relief needs improvement.

IMPLICATIONS: Inguinal hernia repair can be safely performed under unmonitored local anesthesia with infrequent postoperative morbidity and acceptable satisfaction, but intraoperative pain may be a problem.

	Introduction

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In private, specialized hernia centers, local anesthesia (LA) is often preferred for day-case open hernia repair (1,2). This is in contrast to large epidemiologic surveys, in which LA is used in only 2%–15% of cases (3–5). Despite this, it represents a near-ideal technique because of its simplicity, low cost, and lack of potentially detrimental cardiovascular effects observed with regional or general anesthesia (GA). We present a prospective, consecutive series of 1000 open hernia repairs from a surgical department in a public service university hospital to discuss the feasibility, advantages, and shortcomings of unmonitored LA (ULA) for day-case open hernia surgery.

	Methods

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The department received unselected patients from a well defined district in Copenhagen. Between September 1, 1994, and December 3, 1998, all adult patients referred for elective surgical correction of an inguinal or femoral hernia were considered eligible for day-case surgery under ULA. Inclusion for ULA was consecutive except for 35 patients, excluded because of explicit patient refusal (3), incooperability caused by psychiatric disorder or language barriers (6), laparoscopic surgery for multirecurrent hernias (4), previous vaso-vagal episode or fainting during LA (2), GA planned before this project started (1), and irreducibility of the hernia (19).

Comorbidity, current medication, and level of function were recorded in a standardized file, allowing ASA classification of the patients (Table 1). No preoperative tests were ordered, except for selected patients with diabetes or continuing anticoagulant therapy. Hernia pathology, the surgical procedure, and the use of LAs or sedatives were recorded in the file.

Before surgery, oral methadone (5 or 10 mg, depending on age) and tenoxicam (40 mg twice, in the evening and 2 h before surgery) were prescribed until April 30, 1997, after which no premedication was used. Stepwise wound infiltration of bupivacaine 0.25% with the addition of 6 mL as an ilioinguinal block was provided by the surgeon (1,6). In the latter half of the study, however, the ilioinguinal block was abandoned. Small incremental doses of IV midazolam were used for sedation. Physiologic variables were not monitored, because the patients were monitored only by verbal contact with the staff. Equipment for resuscitation and relevant medicine were available in the room, and anesthesia equipment was immediately accessible. No anesthesia personnel were scheduled to be involved in the care of the patients but were readily available if necessary. After surgery, the patients went to the surgical ward for a short recovery stay before discharge. Until April 30, 1997, postoperative analgesia consisted of oral tenoxicam and paracetamol plus a single dose of methadone (5–10 mg). After May 1, 1997, only ibuprofen and paracetamol were prescribed.

A questionnaire about complications was mailed to the patients 4 wk after surgery. In addition, the patients were asked: "If you should need surgical correction for another hernia would you prefer the same treatment, including local anesthesia? If not, why?" A prestamped envelope was enclosed, and if the patients did not return the questionnaire, they were reminded by letter and telephone. The electronic patient data management system in Copenhagen was used to monitor mortality and readmissions to Hvidovre or other Copenhagen Hospitals within 30 days after the operation. In such cases patient files were checked for a possible relation to the hernia operation. The study was approved by the local ethical committee, and the patients gave written informed consent for their participation.

	Results

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One-thousand consecutive elective inguinal hernia repairs were performed under ULA in 912 patients. Eight-hundred-thirty patients were operated on once, 76 twice, and 6 three times during the study period. Multiple operations were caused by recurrence during the study period (n = 36) or an independent contralateral hernia (n = 52). In 225 cases (23%) the surgery was performed for a recurrent hernia. Thirty-nine patients were not discharged on the day of surgery (Table 2), and five patients had their LA converted to GA, four because of pain during dissection or reposition of the hernia and one because of a preoperatively unobserved irreducible hernia. Two patients required anesthesia monitored care (AMC), one because of a familial disposition to malignant hyperthermia and one because deeper sedation was needed because of pain during dissection. Surgery was thus completed under ULA in 993 cases (99.3%). Age, duration of surgery, time to discharge, and dosage of bupivacaine and midazolam are summarized in Table 3.

Three patients with an otherwise uneventful postoperative course died within 30 days of surgery. An 84-yr-old man with known pulmonary impairment, ASA Group III, died suddenly at home 6 days after surgery, probably from a heart attack; a 68-yr-old man with known cardiac symptoms, ASA Group II, died at home, probably from a myocardial infarction, 26 days after surgery; and an 81-yr-old man died 29 days after surgery in the hospital because of widespread preexisting malignant disease.

Cardiovascular events were recorded in three patients: one patient had a transitory cerebral ischemic attack 3 h after surgery (the attack resolved completely but required a 1-wk stay in the hospital), one patient was readmitted on Day 8 because of preexisting paroxysmal atrial fibrillation, and one patient with well known ischemic heart disease had a nonlethal subendocardial infarction on Day 24. Pulmonary events were recorded in three patients with chronic obstructive lung disease: one was readmitted on Day 4 with pneumonia, with complete response to antibiotic treatment, and two were readmitted because of exacerbation on Day 8 and Day 11. Five patients were readmitted during the first 30 postoperative days of causes unrelated to hernia surgery or cardiopulmonary events. No case of urinary retention was recorded.

Of 1000 questionnaires, 940 were returned (94%). Of these, 755 patients (80.3%) would have a similar procedure performed under similar conditions, 61 (6.5%) were indecisive, and 124 (13.2%) would not. The reasons were intraoperative discomfort or pain (74 patients, 7.9%), the wish for inpatient setup or other type of surgery or anesthesia (23 patients, 2.4%), postoperative discomfort or complications (10 patients, 1.1%), or no reason given (17 patients, 1.8%). The rate of dissatisfaction from our preliminary report on the subject (6) did not differ significantly from the rate of the last 600 patients (41 of 400 vs 83 of 600; ²₁ = 2.84, P > 0.05). The rate of dissatisfaction, however, was significantly increased after May 1, 1997, when the change in premedication and postoperative analgesia occurred (61 of 611 vs 63 of 389; ²₁ = 8.44, P < 0.01).

	Discussion

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The main criteria for success of day-case surgery are reliability, feasibility, and patient safety and satisfaction. Regardless of the anesthetic technique, the main reasons for deviation from a planned day-case setup would be related to anesthesia, surgery, and patient factors.

We experienced a small rate of conversion to GA or AMC (7 in 1000), and such cases are probably best managed by an infusion of propofol with incremental doses of a short-acting opioid with standard anesthesia monitoring. For these rare cases, the flexibility of the anesthetic department to assist was already agreed upon at the initiation the hernia service at the hospital. The need for conversion to GA is not described in other reports. The residual effects of anesthesia may lead to a number of overnight stays because of urinary retention, nausea, vomiting, or sedation. In accordance with results from another large-scale study on LA (2), no case of urinary retention was reported in this study. Rates of urinary retention after GA vary from 0% to 2.3% in large descriptive reviews (2,5,7) and from 0.5% to 4% in large randomized, controlled studies on surgical techniques (8,9), but more frequent rates after spinal and GA with unrestricted fluid load have been reported (10,11). Seven patients stayed overnight because of anesthesia-related residual effects (transient femoral nerve block [n = 2], postanesthetic care [n = 4], and nausea [n = 1]).

Preoperative recognition of irreducibility is probably important, because two of the five conversions to GA in this study were caused by difficult reduction or unobserved irreducibility of the hernia. The rates of infection or hematoma requiring new surgical intervention in our study are similar to those from other large studies (9,11,12), although reported rates vary considerably. Definitions of complications are rarely mentioned, so most studies are not readily comparable.

This report is the only available large series of unselected, consecutive patients in whom the ASA classification of all patients is specified to the involved organ system, although data are available from smaller studies (13–15). No patients were excluded from planned day-case setup or LA because of comorbidity, and only in two cases could the overnight stay be related to preexisting illness (chronic obstructive lung disease and alcohol abuse).

From large, descriptive studies of enrolled unselected patients, the mortality rates at 0.2%–0.3% (5,12) and the rates of cardiovascular events at 0.4%, including deep vein thrombosis, myocardial infarction, and so on within 30 days of surgery (5), are similar to those of our study. Chest infection rates between 1% and 2.4% are reported from randomized and descriptive studies (5,8), compared with 0.3% from our data. The small nonsurgical morbidity in this high-risk material probably reflects spontaneous morbidity, because most cases occurred more than one week after surgery.

Old age does not exclude a day-case setup, but social factors may necessitate an overnight stay, although it was rare in our study. Successful use of LA in elderly patients has been described (14), but with a smaller rate of discharge on the day of operation than in this study: 46% vs 96%. The reported postoperative morbidity was small, but follow-up data are not convincingly presented.

Coexistent illness, old age, or unfitness for GA are often used as exclusion criteria in randomized studies on different surgical or anesthetic techniques (8,16,17), and these may therefore hinder relevant comparison of morbidity data to results from unselected materials such as these.

One randomized comparison of satisfaction with LA, GA, or regional anesthesia for primary hernia surgery has been conducted, with higher satisfaction scores for LA (16); these could be explained by extensive supplementary sedation. Our material seems comparable with that of the few other studies reporting data on satisfaction (16,18). Insufficiency of the LA, the main cause of dissatisfaction, was present in approximately 8% of the patients. Median doses of bupivacaine and midazolam in this group of dissatisfied patients were comparable to those of the satisfied patients, but underdosage in particularly nervous or pain-sensitive patients may be a reason for insufficient analgesia. The higher dissatisfaction scores after May 1, 1997, may be caused by the changes in anesthetic or analgesic technique during the study period. A potential improvement might be a large-dose ilioinguinal-iliohypogastrical block in combination with stepwise infiltration, although the block technique has not been compared with simple infiltration in randomized studies. Our results seem less optimal than those from the specialized, private hernia centers (19,20), with deviations from day-case setup, conversions to GA, a slightly larger number of complications, and dissatisfied patients. However, details of patient demographics, inclusion and exclusion criteria, and follow-up rates are often lacking from these reports, which also use LA with sedation and AMC or regional anesthesia in contrast to ULA.

Despite the fact that monitoring of physiologic variables has not been proved in randomized trials to reduce the number of serious events or complications, it is recommended by the ASA for patients receiving sedative and analgesic medications (21). As judged by the number of complications and cardiovascular and pulmonary events, patient safety was satisfactory with presence of relevant equipment and immediate access to anesthesia equipment and staffing. The choice between ULA and LA plus AMC, however, depends on the required degree of sedation, access to anesthesia staffing, and legal regulations (21).

In conclusion, day-case elective inguinal hernia surgery under ULA is a feasible and safe setup in unselected patients, provided that access to coverage for the rare GA conversion and overnight stay facilities are available. The LA technique should be refined and more widely adopted.

	Acknowledgments

 
Supported, in part, by a research grant from ASTRA Pain Control, Södertälje, Sweden, and grants from the quality assurance funds, Copenhagen Hospital Corporation (H:S).

	References

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Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999