Optimizing anesthesia for inguinal herniorrhaphy: general, regional, or local anesthesia?
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Anesthesia↗
Biomedical subjects
H Kehlet
Publications and source records attributed to H Kehlet.
One-thousand consecutive inguinal hernia repairs under unmonitored local anesthesia.
UNLABELLED: 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.
Adolescent↗
Pain and functional impairment 1 year after inguinal herniorrhaphy: a nationwide questionnaire study.
OBJECTIVE: To determine the incidence of groin pain 1 year after inguinal herniorrhaphy and to assess the influence of chronic groin pain on function. SUMMARY BACKGROUND DATA: The reported incidence of chronic pain after inguinal herniorrhaphy varies from 0% to 37%. No cross-sectional cohort studies with high follow-up rates have addressed this problem, and there is a lack of assessment of the functional consequences of chronic groin pain after herniorrhaphy. METHODS: Two sets of self-administered questionnaires were mailed 1 year after surgery. The first established the incidence of chronic groin pain. The second characterized the pain and the effect of the pain on the function of those reporting pain. The study population comprised patients older than age 18 years registered in the Danish Hernia Database who underwent surgery between February 1, 1998, and March 31, 1998. RESULTS: The response rate to the first questionnaire was 80.8%. Pain in the groin area was reported by 28.7%, and 11.0% reported that pain was interfering with work or leisure activity. Older patients had a lower incidence of pain. There were no differences in the incidence of pain with regard to the different types of hernia, the different types of surgical repairs, or the different types of anesthesia. The second questionnaire was returned by 83%. Of these, 46 (4%) reported constant pain. The intensity of pain while at rest was moderate or severe in 40 (3%); with physical activity, pain was moderate or severe in 91 (8%). Impairment of specific daily activities as a result of pain was reported by 194 (16.6%). Pain characteristics were predominantly sensory, with a low use of affective terms. CONCLUSION: One year after inguinal hernia repair, pain is common (28.7%) and is associated with functional impairment in more than half of those with pain. These factors should be addressed when discussing the need for surgical intervention for an inguinal hernia.
Adult↗
Perioperative medicine. The surgeons point of view.
A satisfactory postoperative outcome goes through the control of several factors, to ensure well-being and free-pain state. A multi-disciplinary effort is necessary to achieve this goal, and the adjustment of postoperative surgical care is as important as the supply of anesthesiological techniques.
Analgesia↗
Substantial variability in postoperative treatment, and convalescence recommendations following vaginal repair. A nationwide questionnaire study.
BACKGROUND: Postoperative care and convalescence recommendations following vaginal surgery are generally not evidence based. The aim of this study was to describe pre and postoperative treatment, and advice and restrictions for the convalescence period, given by Danish hospital-employed gynecologists, and gynecologists in private practice, to patients undergoing vaginal repair. METHOD: In 1999 all Danish gynecologists (n=433) received a tested questionnaire about postoperative treatment and convalescence recommendations following vaginal repair. Non-responders received one reminder. OUTCOME MEASURES: Pre and postoperative treatment, and expected hospital stay. Furthermore, lifting restrictions, sick leave, and convalescence before resumption of defined activities. RESULTS: The overall response rate was 82%. The expected postoperative hospital stay was median 3 days (range, 1-7) following anterior repair, and 2 days (range, 1-7) following posterior repair. The recommended sick leave was median 6 weeks (range, 2-12) for patients with work with heavy lifts. There were substantial differences in recommendations. Recommended lifting restrictions were median 3 kg (range, 0-20) for median 4 weeks (range, 1-12), and the recommended time till recommencement of sexual intercourse was median 4 weeks (range, 0-12). The recommended convalescence was median 4-5 weeks for strenuous activities, and median 1-2 weeks for non-strenuous activities, with ranges from 0-24 weeks. The overall, great variance could not be explained by demographic differences between gynecologists. CONCLUSION: Postoperative treatment, and convalescence recommendations given by Danish gynecologists following vaginal repair, show substantial variability and are based on individual viewpoints. Evidence based guidelines and consensus are desirable.
Convalescence↗
Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials.
OBJECTIVES: To obtain reliable estimates of the effects of neuraxial blockade with epidural or spinal anaesthesia on postoperative morbidity and mortality. DESIGN: Systematic review of all trials with randomisation to intraoperative neuraxial blockade or not. STUDIES: 141 trials including 9559 patients for which data were available before 1 January 1997. Trials were eligible irrespective of their primary aims, concomitant use of general anaesthesia, publication status, or language. Trials were identified by extensive search methods, and substantial amounts of data were obtained or confirmed by correspondence with trialists. MAIN OUTCOME MEASURES: All cause mortality, deep vein thrombosis, pulmonary embolism, myocardial infarction, transfusion requirements, pneumonia, other infections, respiratory depression, and renal failure. RESULTS: Overall mortality was reduced by about a third in patients allocated to neuraxial blockade (103 deaths/4871 patients versus 144/4688 patients, odds ratio=0.70, 95% confidence interval 0.54 to 0.90, P=0. 006). Neuraxial blockade reduced the odds of deep vein thrombosis by 44%, pulmonary embolism by 55%, transfusion requirements by 50%, pneumonia by 39%, and respiratory depression by 59% (all P<0.001). There were also reductions in myocardial infarction and renal failure. Although there was limited power to assess subgroup effects, the proportional reductions in mortality did not clearly differ by surgical group, type of blockade (epidural or spinal), or in those trials in which neuraxial blockade was combined with general anaesthesia compared with trials in which neuraxial blockade was used alone. CONCLUSIONS: Neuraxial blockade reduces postoperative mortality and other serious complications. The size of some of these benefits remains uncertain, and further research is required to determine whether these effects are due solely to benefits of neuraxial blockade or partly to avoidance of general anaesthesia. Nevertheless, these findings support more widespread use of neuraxial blockade.
Anesthesia, Epidural↗
Risks of interrupting drug treatment before surgery.
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Drug Administration Schedule↗
[Diagnosis of common bile duct stones in symptomatic gallstone disease].
It is unclear which diagnostic procedure is optimal for the detection of common bile duct stones prior to laparoscopic cholecystectomy. It is routine to use blood tests for liver function and transabdominal ultrasound, and the best method is currently to continue evaluation with other methods when one or more blood tests for liver function are elevated and/or the diameter of the common bile duct is > or = 10 mm on transabdominal ultrasound. Magnetic resonance cholangiography, endoscopic ultrasound, laparoscopic ultrasound, intraoperative cholangiography and endoscopic retrograde cholangiography are all accurate in the detection of common bile duct stones. Intravenous cholangiography and computer tomography needs further evaluation before final recommendations can be made. Intraoperative cholangiography and endoscopic retrograde cholangiography have the best documentation available in the literature. Intraoperative cholangiography is easy, cheap and without significant complications, whereas endoscopic retrograde cholangiography has a high morbidity and mortality rate. Endoscopic retrograde cholangiography is therefore not suitable as a diagnostic test and should be abandoned as such in the future. Patients with cholangitis, jaundice and common bile duct stones visualised by transabdominal ultrasound have a high risk of common bile duct stones, and these patients can therefore undergo endoscopic retrograde cholangiography directly. Other patients should have a magnetic resonance cholangiography or endoscopic ultrasound preoperatively, or intraoperative cholangiography or laparoscopic ultrasound depending on local factors such as available equipment and surgical expertise.
Cholangiography↗
Manipulation of the metabolic response in clinical practice.
Surgical injury is followed by profound changes in endocrine metabolic function and various host defense mechanisms leading to catabolism, immunosuppression, ileus, impaired pulmonary function, and hypoxemia. These physiologic changes are supposed to be involved in the pathogenesis of postoperative morbidity. Effective afferent neural blockade with continuous epidural local anesthetic techniques inhibits a major part of the endocrine metabolic response, leading to improved protein economy but without important effects on inflammatory or immunologic responses. In contrast, pain treatment with other modalities such as nonsteroidal antiinflammatory drugs (NSAIDs) and opioids has only a small inhibitory effect on endocrine metabolic responses. Preoperative high-dose glucocorticoid therapy provides additional pain relief and improves pulmonary function, but it reduces the inflammatory response (acute-phase proteins, cytokines, hyperthermia) and immune function. Minimally invasive surgery leaves the endocrine metabolic responses largely unaltered but reduces the inflammatory response and immune suppression. Thus several techniques are available to modify the stress responses in elective surgery patients. The effect of these techniques to alter endocrine metabolic and inflammatory responses during severe surgical illness has not been established. Neural blockade and minimally invasive surgery have improved outcome following elective surgery, especially when integrated into a multimodal postoperative rehabilitation program. Application of this knowledge from pathophysiologic responses to uncomplicated surgical injury should be explored in patients with severe surgical illness.
Anesthesia, General↗
Pain after microlaparoscopic cholecystectomy. A randomized double-blind controlled study.
BACKGROUND: Laparoscopic cholecystectomy (LC) is traditionally performed with two 10-mm and two 5-mm trocars. The effect of smaller port incisions on pain has not been established in controlled studies. METHODS: In a double-blind controlled study, patients were randomized to LC or cholecystectomy with three 2-mm trocars and one 10-mm trocar (micro-LC). All patients received a multimodal analgesic regimen, including incisional local anesthetics at the beginning of surgery, NSAID, and paracetamol. Pain was registered preoperatively, for the first 3 h postoperatively, and daily for the 1st week. RESULTS: The study was discontinued after inclusion of 26 patients because five of the 13 patients (38%) randomized to micro-LC were converted to LC. In the remaining 21 patients, overall pain and incisional pain intensity during the first 3 h postoperatively increased in the LC group (n = 13) compared with preoperative pain levels (p<0.01), whereas pain did not increase in the micro-LC group (n = 8). CONCLUSIONS: Micro-LC in combination with a prophylactic multimodal analgesic regimen reduced postoperative pain for the first 3 h postoperatively. However, the micro-LC led to an unacceptable rate of conversion to LC (38%). The micro-LC instruments therefore need further technical development before this surgical technique can be used on a routine basis for laparoscopic cholecystectomy.
Adult↗
Endogenous morphine--another component and biological modifier of the response to surgical injury?
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Animals↗
Randomized controlled trial to examine the influence of thoracic epidural analgesia on postoperative ileus after laparoscopic sigmoid resection.
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Analgesia, Epidural↗
Rapid rehabilitation in elderly patients after laparoscopic colonic resection.
BACKGROUND: Introduction of the laparoscopic surgical technique has reduced hospital stay after colonic resection from about 8-10 to 4-6 days. In most studies, however, specific attention has not been paid to changes in perioperative protocols required to maximize the advantages of the minimally invasive procedure. In the present study the laparoscopic approach was combined with a perioperative multimodal rehabilitation protocol. METHODS: After laparoscopically assisted colonic resection, patients were treated with epidural local anaesthesia for 2 days, early mobilization and enteral nutrition. Routine use of morphine and traditional tubes, drains and prolonged bladder catheterization was avoided. RESULTS: Laparoscopic resection was intended in 50 consecutive patients, of median age 81 years. The conversion rate to open resection was 22 per cent. In patients in whom the procedure was completed laparoscopically the median hospital stay was 2.5 days; defaecation occurred in 92 per cent of patients within 3 days. Patients were mobilized for more than 8 h daily from day 2. CONCLUSION: Recovery after colonic surgery was improved considerably by combining the use of a laparoscopic technique with a multimodal rehabilitation protocol of pain relief, early mobilization and oral nutrition.
Aged↗
Postoperative ileus: a preventable event.
BACKGROUND: Postoperative ileus has traditionally been accepted as a normal response to tissue injury. No data support any beneficial effect of ileus and indeed it may contribute to delayed recovery and prolonged hospital stay. Efforts should, therefore, be made to reduce such ileus. METHODS: Material was identified from a Medline search of the literature, previous review articles and references cited in original papers. This paper updates knowledge on the pathophysiology and treatment of postoperative ileus. RESULTS AND CONCLUSION: Pathogenesis mainly involves inhibitory neural reflexes and inflammatory mediators released from the site of injury. The most effective method of reducing ileus is thoracic epidural blockade with local anaesthetic. Opioid-sparing analgesic techniques and non-steroidal anti-inflammatory agents also reduce ileus, as does laparoscopic surgery. Of the prokinetic agents only cisapride is proven beneficial; the effect of early enteral feeding remains unclear. However, postoperative ileus may be greatly reduced when all of the above are combined in a multimodal rehabilitation strategy.
Forecasting↗
Intraarticular glucocorticoid, morphine and bupivacaine reduces pain and convalescence after arthroscopic ankle surgery: a randomized study of 36 patients.
In a double-blind randomized study, 36 patients undergoing arthroscopic removal of bony spurs and synovitis causing impingement of the ankle were allocated to intraarticular saline or bupivacaine 15 mg + morphine 5 mg + intraarticular methylprednisolone 40 mg. Combined methylprednisolone, bupivacaine and morphine reduced pain, joint swelling, time of immobilization, duration of sick leave and return to sports after the arthroscopic procedure. In the treatment group, 1 patient had transitory purulent arthritis requiring antibiotics and arthroscopic synovectomy occurred.
Adult↗
Effect of oxygen on postoperative cardiovascular response to exercise.
OBJECTIVE: To evaluate the effect of supplemental oxygen on postoperative cardiovascular response to submaximal exercise. DESIGN: Randomised, controlled study. SETTING: University hospital, Denmark. SUBJECTS: 16 patients having major abdominal operations. INTERVENTIONS: A submaximal exercise test (heart rate up to 120 min(-1)) done twice on the third day after operation. Patients were given either 100% oxygen (4 L min(-1)) or air (21% oxygen, 4 L min(-1)) 30 minutes before and during the test in randomised order. During the tests they were monitored with a Holter tape recorder and a pulse oximeter. MAIN OUTCOME MEASURES: Heart rate during exercise. RESULTS: At similar workloads there were significantly lower heart rates (median decrease 3 min(-1)) during exercise tests with oxygen compared with air (p < 0.05). Holter monitoring showed signs of myocardial ischaemia in 6 patients in relation to exercise testing, 4 of them related to both tests, 2 of them only when breathing air. Signs of myocardial ischaemia disappeared when the exercise ended. CONCLUSION: During the late postoperative period supplementary oxygen reduced heart rate in response to exercise to the same degree as observed previously in non-surgical patients and surgical patients not taking exercise. These findings do not suggest that decreased peripheral tissue oxygenation is responsible for the impaired cardiovascular response to exercise in postoperative patients.
Adult↗
Effect of peripheral morphine in a human model of acute inflammatory pain.
Several studies have demonstrated the presence of opioid inducible receptors on peripheral nerves and peripheral antinociceptive effects of opioids. However, the effects of peripheral opioid administration in man are controversial. Our study used a randomized, double-blind, placebo-controlled, three-way crossover design in a human model of acute inflammatory pain (heat injury). We studied 18 healthy volunteers who each received morphine locally (2 mg), morphine systemically (2 mg), or placebo on three separate study days. The subjects received morphine infiltration subcutaneously (s.c.). 1 h before heat injury (47 degrees C, 7 min) and naloxone infiltration s.c. (0.2 mg) 2.5 h after the heat injury. Hyperalgesia to mechanical and heat stimuli were examined using von Frey hairs and thermodes, and pain was rated using a visual analogue scale. The burns produced significant hyperalgesia, but local morphine infiltration neither reduced pain during the burn, nor primary or secondary hyperalgesia to mechanical and heat stimuli after the burn. In conclusion, peripherally applied morphine had no acute antinociceptive effects in this human model of acute inflammatory pain.
Administration, Cutaneous↗