(Acta Anaesth. Belg., 2020, 7], 45-56)

Pain management after open inguinal hernia repair: an updated1 systematic review and procedure-specific postoperative pain

1 management (PROSPECT/ESRA) recommendations

S. COPPENS’ (j, J. GTDTS (*), P. HUYNEN Ci. M. VAN DE VELDE (°), G. P. JOSHI (‘j. on behalf of thePROSPECT Working Group collaboration 0. P. Josin, E. POGATZKI-ZAH\, M. VAN DE VELDE. S.

:; SCE-ItJO, H. KEULET, F. BONNET, N. RAWAL, A. DELBOS, P. LAVAND’HOMME, H. BELOEIL, J. RAEDER, A.SAUTER, E. ALURECHT. P. LIRK. D. LoBo, S. FREYS

Abstract : Backgiound: Open inguinal hernia repaircan he associated wilh moderate-to-severe postoperativepain. w]iich can delay return to activities of daily living.The ainl of this systematic review was to update theavailable lilerature and develop recommendations foroptimal pain management after open inguinal herniarepair. A syslematic review utilizing PROcedure

r SPECiflcPostoperativePainManagemenT(PROSPECT)k* methodology was tindertaken.

‘v[ethods Randomised controlled trials published inthe English language between January Ist 2009 andAugust 3lst 2019, evaluating the effects of analgesic,anesthetic, and surgical interventions were retrieved fromMEDLINE, EMBASE and Cochrane Databases. Of 203eligible studies ideritifted, 37 studies met the inelusioncriteria.Resnils lnterventions that improved postoperativepain relief ineluded paraeetarnol and nonsteroidal antiaflamtnatory drugs or eyclooxygenase-2 seleetiveinhihitors, as well as local anesthetie infiltration and:egional analgesia teehniques such as ilio-hypogaslrie/ilio-inguinal nerve bloeks and transversus abdominis

lane bloeks. Although effeetive, epidural analgesia orparavertehral hlocks are considered invasive and harrnful.and thus not recommeoded. Insufficient evidence wasfound for psoas black, extended release local anesthetics.wound infiltration using non-steroidal anti-infianirnatorydrugs. elonidine or opioids, topical conventional non-steroidal anti-infiammatory drugs, systemic clonidine,corticosteroids and ketamine, otravenous lidocaine

1- inftision, cryoanalgesia techniques, and nerve section.Inconsistent evidenee was found for the use ofgabapentinoids.Conclusion The analgesic regimen for open inguinalhernia repair should inelude paracetarnol and nonsteroidalanti-inflarnmatory drug or cyclooxygenase-2 selectiveinhibitor administered pre-operatively or intraoperatively and continued post-operatively. In addition,local anesthetic infiltration and/or a regional analgesiatechnique (ilio-inguinal nerve blocks or transversusabdominis plane bloeks), with opioids used as rescueanalgesies. Further studies are required to assess the

role of navel regional analgesic techniques such aserector spinae blocks and to cunfirni the influence of therecommended analgesic regimen on postoperalive painrelief in an enhanced recovery setting.

Key words Open inguinal hernia repair ; pain ; analgesia ; systematie review evidence-based medicine.

Recommen4ations

1. Systemic analgesia should include paracetatnoland a non-steroidal anti-infiammatory drug or cyclooxygenase-2 selective inhibitor administered preoperatively or intra-operatively and continued postoperatively2. Local anesthetic infiltration and/or regional analgesiatechniquc (ilio-hypogastric/ilio-inguinal nerve bloeks or

S. Coass’, MD; 3. GDTS’. MD: R HcYNEN. MD; M. V,s 0EVELDE. MD, PhD : G. P. Josu’. MD. PhD on hehalfoftliePROSPECT Working Group collahoration.

S. Coppens and 3. Gidis equally share first auihorshipf9 Depariment of Cardiovascuiar Sciences, Section

Anesthesio’.ogy. KU Leuver. and L’niversHy HespitalLeuven, Belgium

(*9 Deparitnent of Anesthesiology and Pain Management,Llniversity of Texas Southwestem Medical Center. Dallas,Texas, LSA

Corresponding author Mate Van de Veide, Departmentof Cardiovascular Sciences. Section Anesthesiolugy, KLLeuven and Universiry Hospital Leuven, Belgium

E-rnail niarc.-andeveideïcuzleuven,be

Peper s,,b,,,itted en Mây 25, 2020 end accepted ei, 2,1ev 26,2020.

Conflict ofinterest PROSPECT1s srcpported hv cm ,,nresr,-icledg;znt from the Eutvpean Society of Regional Anesihesiaand Pain Therapy (ESRA,). In the past, PROSPECT hetreceived imrestricled grants from Pfizer mc. New York. NUSA and Grunenthal, Aachen, Gertnany GPJ has ,-eceivedhonorariafivm Boxter and Pacira Pharmaceuticc.Lv. MVdVher ,-eceived honoraria fivm Sintetica, Grunenthal, VforPharma, MSD, Nordic Pharma, Janssen Pharmaceuticals,He,vn Therapeutics and Aquettant. EP-Z has teceivedhonoraria from Mimdipharma, Gr,menthal, MSD, JanssenCilag GmbJ-J, Freseniz,s Kabi andAceiRs,

© Acte Ancrsthesiologtca Betgica. 2020,71, Spplement 1

46

transversus abdominis plane hlocks) is recommended.

3. A single dose of intravenous dexarnethasone is

recommended for its ability to increase the analgesic

duration of the block, decrease analgesic use, and

antiemetic effects.

4. Opioids should be reserved as rescue analgesics in the

post-Operative period.

Why was this guideline developed?

Open inguinal hernia repair is associated with moderate

to-severe postoperative pain which may influence

recovery. The aim ofthis guideline is to provide clinicians

with an updated evidence for optinial pain management

aller open inguinal henna repair.

What other guidelines are available on this topic?

The PROSPECT recommendations for pain managementafter open inguinal hernia repair have been published

previously, however, an update assessing analgesic

interventions was necessarv.

How doos this guideline differ from other guidelines?

The updated systematic review further confirnis

the previous recommendations. Also, an updated

PROSPECT approach was used to develop the culTent

recomniendations such thai the available evidence

is criicallv assessed for current clinical relevance

and the use of simple. non-opioid analgesic such as

paracetamol and non-steroidal anti-infiammatory drugs

as baseline analgesics. This approach reports true

clinical effectiveness by balancing the invasiveness of

the analgesic interventions and the degree of pain after

surgery, as well as balancing efficacy and adverse effects.

INTRODUCTION

OpenlnguinalHerniaRepair(IHR) isassociated

with moderate-to-severe postoperative pain, which

may delay recovery and return to activities of daily

living (1). In addition, inadequate pain control canincrease unplanned admission rate and readmission

after discharge home (1). Furthermore, inadequate

post-operalive pain relief may lead to hyperalgesiaand persistent postoperative pain (2).

Based on a systernatic review performedin 2009, the PRDSPECT (PROcedure SPECific

Postoperative Pain ManagemenT) Working Group

(3,4), which is a collaboration of surgeons andanesthetists, previously provided recommendationsfor pain management in patients undergoing IHR(5). A recent hitemational guideline for groin herniasurgery provided non-specific statements regardingpain management recommending perioperativefield blocks and/or subfascjalJsubcutaneous ïniil

© Acra A,;asrhesiologica Beigicu. 2020. 71. Spplenienr 1

trations and use of paracetamol and non-steroidal

anti-infiammatory drugs (NSA 1 Ds) or cyclo-oxy

genase (COX)-2 selective inhihitors (1). Therefore,

an updated systematic review on analgesie

interventions for pain management in JHR was

perfonned. In addition. It was deerned necessary to

reassess the recomniendations to align them with

the updated PROSPECT approach that considers

current clinical relevance and clinical effectiveness

by balancing the invasiveness of the analgesic

interventions and the degree of pain after surgery, as

well as balancing efficaey and adverse effects (6,7).

The aim of this update was to systematically

review the available literature assessing the anal

gesic, anesthetic. and surgical interventions on pain

after open 11-IR. Postoperative pain scores were

the primary outcome measures. Other recovery

outcomes assessed inciuded cumulative opioid

requirements and adverse effects, when reported,

and the limitations of the data were reviewed. The

ultirnate abn was to develop recommendations for

pain management after IHR.

METII0D0L0GY

The methods of this review adhered to the

PROSPECT inethodology as previously reported

(7). Specific to this study, the EM BASE, MEDLTNE,

PubMed and Cochrane Databases (Cochrane Central

Register of Controlled Trials, Cochrane Database ofAbstracts or Reviews of Effects, Cochrane Data-

base of Systematic Reviews) were searched for

randomized controlled trials (RCTs) publishedbetween Januarv ist 2009 and August 3lst 2019.

The search terms used was (hernia OR inguinal

OR inguinal hernia repair OR herniorrhaphv OR

herniorraphy) AND (pain OR postoperative painOR analgesia DR anesthesia DR anesthetic) AND(anesthetics neuraxial OR intrathecal OR spinal

DR epidural analgesia DR paravertebral blocks DRperipheral nerve DR peripheral block DR regional

nerve DR transversus abdominis plane block DR

infiltration DR instillation DR NSAID DR CDX-2

OR paracetamol DR acetaminophen DR gabapentin

DR pregabalin DR clonidine DR opioid DR

ketamine DR corticosteroid DR dexamethasone DR

heavyweight mesh DR polypropylene mesh).Quality assessment. data extraction and data

analysis adhered to the PRDSPECT methodology

[7]. Pain intensity scores were used as the primaryoutcome rneasure. In this study, we defined a changeof more than 10 mm on the visual analogue scale

(VAS) or numerical rating score (NRS) as clinically

relevant (8). The effectiveness of each intervention

S. COPPENS t al.

tt.

t’

PAIN MANAGEMENT AFTER OPEN INGUINAL HERNIA REPAIR 47

1

Ei

Rtu’ 1 litut f tij LecijI, ddt,e;pnr,tlnr

In özol

sacci In:Indd fcç t_It-Jt.varnr;In

1

pj-ç; tij.I&4ç 1± ,I s i16cc at4ttct rpeçw

1nU))

A.Irr çti,:,,r’

Ir- t6I

• u. !,Ç!t prccnd±’r [r_49)- nfl .1 flfl crnni rN tIl lc,t (r24Pçdat ‘t pcpubtcn Ir— s

- V l?r. .ç 1W çi’ ;n’’ç Ir— Ir.:

Fig. 1. PRISMA How diagram of studies

for each outcome was evaluated qualitatively byassessing the number of studies showing a significant difference between treatment arrns (p <

0.05 as reported in the study publication). A metaanalysis was not performed due to heterogeneity inSttldy design and result reporting, restricting pooiedana ly si s.

Recomtnendations were made accordingto PROSPECT melhodology (7). In brieL thisinvoived a grading of A—D according to the overallle ei of evidence, as determined by the quaiity ofstudies inciuded. consistency ofevidence and studydesign. The proposed recommendations were seinto the PROSPECT Working Group for review andcomrnents and a modified Deiphi approach wasutiiised as previously described. Once a consensuswas achieved the lead authors drafted the finaldocument, which was ultimately approved by theWorking Group.

RLULT5

PRISMA flow chart demonstrating the searchdata are presented in Figure 1. The methodologicalquahty assessments of the 38 RCTs inciuded for thefinal qualitative analysis are summarized in Table51. The characteristics of the inciuded studies are

shown in Table 52 and Tahie 53.Systenile non-opioid analgesies

One placebo-controlled RCT (n50) reportedgabapentin (400 mg) prior to surgery reduced painscores and postoperative morphine requirementsin the immediate postoperative period. No obviousside-effects vere reported (9). Another placebocontroiled RCT (n=60) reported that preoperativegabapentin (1200 mg) signiflcantly reduced painscores (at rest and on sitting) and reduced the totaltramadol consurnption at 8. 12. 16.20 and 24 hoursafter surgery (10). Pain scores at 1, 3 and 6 monthsafter surgery were lower in the gabapenttn group thanin the placebo group (10). A Iarge placebo-controlledRCT (n425) found that preoperative pregabalin(50, 150, or 300 mg/day) as adjuvant analgesic didnot influence the intensity of postoperative pain at24 hours (Ii). Of note, there was a wide variabilityin the anestbetic and analgesic techniques.

One placebo-controlled RCT (n77) found nostatistica] significant difference in pain during thefirst 24 hours. postoperatively with aTNF-rtinhibitor,etanercept 50 mg, administered subcutaneously 90min before incision (12).

A placebo-controlled RCT (n=55) evaluatedthe effects of rofecoxib 50 mg (a COX-2 selective

X:n is ,LT,cr,nd

1 uII-tt f tIen d.1tII [tn ,iwbi IV

© ,4cra Anwsrhesiologica Be/gica. 2020.71, Spplernent 1

48 S. COPPENS ei al.

Table S]

AllocationStudy

- concealroen: A-D

‘ A

A

A

Statistical analyses andJadad Score

patient fo)Iow-up

4

5

no

no

yes

inhibitor that has been withdrawn from the marketdue to potential cardiac complications) given onehour pre-operatively followed by once daily for 4days after surgery (13). Rofecoxib reduced painscores on the first postoperative day, but the opioidrequirements remained similar to the placebogroup. A placebo-controlled RCT (n=60) evaluatedthe effeets of oral etoricoxib 120 mg given 1 hoor

preoperatively (14). Painscores at restandon straight

leg raise were significantly lower in the etoricoxib

group at 16 and 24 hours, and on discharge.A placebo-colltrolled RCT (rr=64) assessed the

effects of intra-operative intravenous bolus injection

of 1.5 mg/kg lidocaine followed by a continuous

irtfüsion (2 mg/kg/h) (15). Fentanyl consumption

was significantly lower in the lidocaine group until

Quality assessrnent and level of evidence assigned to the randomised trials inciLided in the review for anatgesia after inguinal hernia

repair surgery

Sen f1 ei al 2009 (.0)

Singla NK et al 2014(11)

Cohen SP ei al 2013 (12)

Mahoori Act al 2014 (9) i A 3 1 no

Level of Evidence

Sclturr Nl eI al 2009 (13) A 3 no

Somri Met al 2017 (14) 1A, ves__

KaneHetaL2Oll(1S) 4 4 no

ChaparroLEetal2øt2(16) A .. 5 yes

Mentes 0 et al 2009 (17) A 4 00

Viscusi E et al 2019 (18) 4 5 yes

Velanov,ch Vet al 2019 (19) 5 1 es

Neisio.cnpour SH et al 2013 (20) A 1 no

Santos SC ei al., 2011 (21) C 3 no 2

SaeedMet al., 2015(22) C 4 00 2

Baerentzen F et al., 2012 (23) A 4 no

Vizcaino-Nlariinez Let al 2014_(2jj 3 Yes

Aveline C ct al 2011 (25) A 5 no

Okur Oct al 2017 (26) A 3 yes

Hosalli Vet al 20)9 (27) A 5 yes

Theodoraki K et al 2019 (28) A 5 yes

WvgncrRetal2ol7(29) A D no

Razavizadh MR eI al 2017 (30) B 41 no t

AkyolBCetal2OlS(3l) A 3 yes 2

Heil .1W et al 20t4 (32) A 4 no

Bhattacharva P ei al 2010 (33) A 4 no

Magnusson J etal 2016 (34) A 3 ves

Kingsnodh Act al 2012 (35) 4 3 no

Manyiiirah Wetal 20i2{36) 4 4 yes

Gundre NP ei al 2012 (37) A 2 no

Torcivia Act al 20) t (38) A 1 no

CanonicoSetal2û)3(39) 3 3 no

Fan 5KM ei al 2017 (40) A 5 1 yes

CarroJLPetal2Ol7(41) B 3 yes

Bracale Vet at 2014 (42) A 2 110

ShenYMetal2Ol2(43) A 2 no

BonaSetai20l8(44) A 3 yes 2

f{oyuela C et al 2016 (45) A 5 yes

© 4cm Anesthesioioçica Belçica. 2020.71, Spplement

PAIN MANAGEMENT AFTER OPEN INGUINAL HERNIA REPA1R 49

Tahie S2

SummarY of key resuits from studies evaluating systemic analgesics, analgesics adjuncls, regional anesthesia, and surgical proceduresused to support the recommended interventions in patients afler open inguinal hernia repair

Etoricoc,b ‘20 Ing or ptaceho 1 hoor

preoperalt’e

rceei’ cd t 1 ml of bnpivacaine 0.5%and the control gt otip placeho 110 mlnormal nat mc).

gas ‘fl511 Clie bErk

signiflcanlly lower pais scores inpaltenls with COX-2 ishibitor at16. 24 t and ets discharge, in restand wilt active atraighl leg raisc.

Cumulative opioid done

Amount of rescue analgesic

dosca ofmorphine(mg) within 24 h “ere

signiflcantly lower in COX-2

inhibitor group.

\Vhen VA5ESI at PACU l-Smgboluses of morphine eere itseduntil a response of t en a verbat

• tAS > 4 rcecs ed inrras-edrpvronc 2.0 g). In case

- ite0ècttvc, in travc noas Lctoroiac(30 net and, whencvcr tieressa 0,

intras enoos tialbuphmne (3 mg),“ere added.

Nledian \‘AS “-as lo;n er in the Not nsentior:ed. only ttrne for VAS>3, on dentand paracetatnol

tntene;ttton group. - dcrnand first done aatalgesia I000nag and if necessarv 75 mg

-dirlofcnae sodiuttt.

Soidy 1 Study denEn

p,-e.ope-otil-e

______________

SvsÎetltiC atolt’Opiold ottet!gesics

Schnrr Met al. 2009 (13)

Pain Scores

SL’rnri 7n1 et al. 2017 (14)

Rascline Analgeaia

Roferosib 50 nsg or placeho 1 hoor Signiflcantly lower ratings for No dinèrence in milligrams Palients were gi’enprior to suegery and oncc daily on east pain in patients vith COX-2 hydrocodotte bitartrate hydrocodone bitartrate as neededpostoperato e day -4. inhibitor intake os the opeestive eonsnmed. postoperative.

day.

,,-a- opeWire

________________________________________________________________________ _______________________________________________________________

Jhpica/ottdnIltgICO/ tilt’ ofihrtsaoost si,Ü eelenclrd—rrijceue’ /oco! eittca(/te/tcs

cs]oonpottr 5H ei al - \Vostnd inflltration phor to inetsion Mean pain score at all titnc The amount of opioid one for IfNRS pais score >4 ntravenous

20 3 21’) infiltrated kr the sutgcotr One group points (eveo’ 4 Ii during 24 the bupivacaine grottp ons admission of IS me pethidmne nar

/1 ;—;ognlnnl oitd llto—litpes

S.trt:.rsScetat20tt (2!;

poi os descripttve sea te of 5 was

achie’ed,

postopera t ive) “ere t ower t t the

treatttirnt grottp80% lens in the first 24 Is. mi cc t cd

Sa:ed?,tetat.2015 f22)

lt:oinguinal and ltioh2 pogastrr \‘taua astalog’ae scale al rest “-as Not nieestionedeer’ c bloek ei 1h tO rr,L of 0 755i a,sniftcar.t os er 3 h after surgerv.rop:t aeatne. end ssouad mnfiltiatior. No difterenee ar 6 and 12 h after

-

oOit 10 nL of 075% ropis aaine aurserv and” ith inoventent.versos no bik nar wo:tnd infiltratiur.

tIiohpoeastrie and lioingtttttai bbck12nt 0.75% ropivacainel and incision -

i rifiltrat ior. er ior to mci don -

Baare n:zen F er ah 2012 Ilro-hypogastric and ilio’ ingutnat Significarst lower pEn scores at No smgnificant ditferenee j /

25; black wit) 20 tttL bupiveeatne 05% ntobiltzation and rest upon arri al betweer, the two groups. tora plareho block nOh 20 ml oaline in RACE and after 30 minutes.

UP-Hoek

.-\ e;nie eet aL 2011 (25) Uitras ound-gaided TAP bErk 1 e-o- \‘as paas scores at rest “-ere losser No significant ditTerenee. Paracetamol 1000 nut and ketohttpt acaine 05%, t Smg5)g) ‘-cr5115 in the US-gttided TAP group at profen 100 rng i.’e. duritag sttr-ety

blind 1H bloek Ilevobitpivacaine 0.5%. 4h. 12h and 24h. At PACU 3 mg io. moeptttne1 .Smsfsg) before eurgerv- , boluses al 5 min inten Es, unri

. VAS<3.

Okur Oct al. 2017 (26) TAP block serstis ilio-hypogastrie and Pain scores “ere s ignifleantly No significant diftèrenee Aceratramnoptren 10—15 tttg

tt:o-tngurtral nen e hork erstts no Io»-er al Ei time poinls of the in additicoal anaigesie i kg onee ever 6 t and salvage

bloek- R:oekç ere done w th 20 nat study groups ‘erarts placcbo. Only reqttiretaent was foorrd anaigesia of intravenous tramadol

of 0.25% tsoharic hatpi aeattae. al 21 h tisere was a aigniflear.lly betwcen study groups- hydrochioride 50 me.dtfTeretrce hertveen TAP and HIN

in 0-er olTAP.

Mosaili V ei al. 20:927, Dust TAP-block and \.1S at 12 1 and 45 h were A higher nunber of parierts Fenrarryt 0.5 reAg and, r1er 2itiohvpogasrrie bloek veralla stsnitiearativ los er is Duat TAP- cecuired resetre anEgesies in h if the pain pers:sls tAS score

- itioinrauinal: it;ohrposastrte bleek. groep eompttred to IL-IH group - IL’IH group. of P4 al rest) esen afler gising1 aletre. fentanyt intra’ er.ous trarnadoi 5(3

- mgadded.

heodoraki K cl al. 2019 flP-btock ropiaacaine 1)75% 20mb Significant different pion scores [otter ttsedian rnorphine con- Paraeeiaitsot le and pareconibc 28) versus placebo (sEine SOtiti) in fa’ our uflAP-bloek in rest al 6 sumption via the PCA deviee lÜmg intra-enotisty 3ümitt

and al 24 h. For ntos-ement at 2.6 forthe tirst24 h in cottipari-son approximatety hefore the end of

and 24 h poslopcratively. to the placebo group. surgery.

Razavizadeh MR et al . Additionof desamethasone S mg to Onsetfdurslton of aneslhesia Not mentioned. Not mentioned.2017 (30) eptdur-at block into epidural space “-as aigni0çantly more espid and

versus ptaeebo (satinc 2m11. longer in the desamethasonegrOnp.

Poat-operative

U-1P-bloek

.Akyol BC er al. 2018(31) ltttrasenous anatgesie regimen Pain scores signifieantly lower in NRS-aeore >4 reeeived as During close-up ofthe surgery,(group II sersus aubeostal TAP- group II eompared with group Ir additional dose of 1 mglkg patients II bolh groupa werebloek poaloperativcly in addition to poatoperative 151h-minute; Ist-, Irarnadol IV. given tOOmg tramadol andan intrasenous anatgcsie regimen 6th-, 121h-, and 24th-hour; lSth- l000mg paraeetamol IV.(group II) day and lst’month NRS values.

NS no signifleant differenee between groups. on = Poatoperstive Day.

© Actea Asicesrhesiologiccs Be/gica, 2020,71. Spplernent t

50 S. COPPENS et al.

Table S3

.Surnmary of key resuits from studies evaluating systemic analgesics, analgesics adjuncis, regional aneslhesla, and surgical procedures

used to support the NOT recomniended interventions in patients open inguinal hernia repair surgery

!

Scuds ‘Stad. design Pairt Scores Cjtr.ttlatis apioid dose 0e1irte azalgesia

Pie.opeiïiore

S_,s:essCr s,asr—opioid iasscaigesic,

Gabapenliitoicls

Mahoorp A er al. Gabapenun 400 me versus placebo 2 LReduccd pain scores possoperative al Reduced postoperative rnor-Morphine 005 mgkg inlra

2014 9) priojjgmiorraphy_,___j,4.l2 h and 24 h pliine requiremeists venously on deniand

Sen El er cl. 2009 Gahane:i:in 1200 ma er pIsccbo 1 tiror Gahapen:in group had sigaift-cantlv îra:ncdc.l eens .unpliori “as PCA desice postopcralls e 1’

t) 0) prior ie surgery ower \‘AS scores al lime 1 - 4. 8, one r St nrc 8, 12, 16. 20 boi.is of traitadol 20 me (1ockout

12. IS, 20 and 24 h posi.nperativeand2-ihooslopera:ivc. ir.Ienal 15 mia and a 4 haur

stopernni

‘

Singla NL et30I4 pregahalin 50. 50 er 300 me/day or No sialistically significant dif- Derreased h 41% and hy 500 iiag naprosen (bid) for 3 daya.

1 1 piacebo -ferenec in paul scores betsseen 300 59% in palicals rece’ tip 50 mg trannsdol and 500—650

2 and 2 h riot to surger’ and 011cr nag’dav prcgsbalin and placeho 50 and 300 rsg day pl’s- ma aeeIansinophen eser> 4 Ii, as

da;ly 1 week fosepesalis e gabalir.. respeelt’ e}V, scheI; rireded. if stiO llladecalr. 5 ma

eompared whplacebo[2codoneeser’4h,aanceded.

TA’F.ealp?ao mhibiror

Cohen SP er al. 2013 Etanercept 50 naR subcs,igneous Dr The Nl? S witt scores ware losser Etanercepl aroup required Morphinc as teeded post-opa-

t 12) placeho 90 rnhllalei prior Ie surser,. ei the etarercepi group I!iough less opio:ds (rllorptline) ralit e.

1 these tcaul Is “ere not s taiisiicall’1

Iiough fl01 slatisl icaLy

signt5rant stanifrens.

fatrse’-opeiaa!ise

Syslesiic a,oss-opioid anolgesics

L idocoioe-

Kang ‘t ct aL 201h Irtravenoas bellis injeetlot; of L5 Ing’ VAS pein scores in the lidocaine Tolal fenlanyl eonsa:ltpl:oll PCA ,stfusion of 0.1 pg’kg’h

(15) kg Isdocaine folhowed by S continuoiis . group wrre signiticantlv loss-er al 2. 1 PCA and rcscsie admi-nsstration fenranyt and ora-demand

lidocair,e ir.fiision of 2 nas kel:. 4. S and 12 Ii afTer s;irgery. ssas sieniftcaiatly 0w er in the recase ol a 0 1 iag bolus.

lidocaine group. \Vhcn V-’sS>J 50 pa of

fenianyl 55 as adnainsstered.

Diptsoaleos cd.

2012(163 srnousiy after indiclion a lower ir.eideiaee of moderale to consump:lon in theO S group.

1 arvere pain onty in the first 30

minutes

Topica) end s,sagicol sla istfi/na!icsisariei, exeended-releose /oco? eaa,eseheeies

HTXO II

\‘iselssi E ei al. 2019 Near conaphetios, stuaey local infil- HTX-0l 1 stenlficansly redueed Opioid consslmplion os er 72 As nerded: oral ocycodone

(IS) tration with El 1 X.0l 1 300 mg9 me mear. pan ia:ens:ty by 23% versus Ii was reduced bs 38% versus-(t Ome nu’ 4h:, alad.’or IV

(bsspis acaine nacosican:lor bupivazaine placebo p plarebo and 25% versus bupi- morsahine as needed( 1 Ome

035%. 75 na ore cplscebo Ed ht0t srlCl fl).(LO00mgntaV6

i’sL-OOi

________

Velailos-ich 5- et al. Consparisora 0: [NL-GO) (in:planI Patietils “ho received NL .s.xil [ras opio:e analgcssc us age nl . Poslariers:is e para 1:1cm

2019(19) designed to provide extended delisc0 reporled losser pais intensir’ sltrough the INL-0Ol group compared niorphine as reedcd

- of biipivacaine to lIre area arourd lIre 72 t. Itrronito:sI the rsr 24 Ir inbolh

surgica 1 svoulld) ss uh placehu 5 rnphaisi. sltldies

Jlio.ia’giiinol asie/ ilio—hspogaso-ic bloc/e

izcainr.Martincz L General anesthesia ssilh ilioineuinaTe Only signifleani 2 h afler ad- Not mentioned. Paracetansol (1 g/8 h). meta

er ai. 2014 (24) - black ‘ersas spirtal a:sesihcsia alone misslon wad iaefore discharee. nsizo1 (2 g’S h). dertkeloprofen

.

Analgesic dn:g siar.ificantly bigger (50 me 8 Ii) and aèmanvl

-

in spinal anestbesta group fboua of 25 pgl5 min iv.)

until VAS<3.

TAP-black

Wegner R et al. 2017 Dexarnethasone mgadded 0 ropivacaine The dexamethasone had a greater Not mentioned. Not menilioned.

(29) TAP-blork. change in pain score lhough no- stasislical sla ralficant difïerence was

noted.

1-kil 1W ei al. 2014 Coni,nuous TAP-bloot (calhetee 2 da; s No: sinatficanl No: significant Intravenons fenianyi was

(32) posloperatis e) with administered at PACU at

Ropivacaine 0.5% 20m1 bolus initislly need.

versus saline injrrlion.

.4nestbeeio !echoiqsie

Bhattaclsana Per al. 1 Unihateral lumbar PVB versus con- No statisrical significant dif- Orly the linie to first post- VAS scores of 4 or more

2010(33) ventional spina! snesthesia ference. -

ooerctive anaigesic reetilre-meni w ere trealed wilh rescue

“as langer in the PVB group. analgesic tramadol in bolusesof Sünag t.;.

C Aow .Amrsthesiologic-a 8e/pico, 2020.7), Spplement 1

PATN NIANAGENIENT AFTER OPEN INGU1NAL HERNIA REPAIR 51

al iechowjue

_______________________________________________________ ____________ ____________

\ft,&flnaSOit J ei al. UltraPro Hernia System, serstta Pro- NS. Not mentioned. Not mentioned.201634) riter.Sn

versus Lich-tetistein

Isriorttt A cl al. Stittirelesa ParietexCt Prooriptu mesh Pain score “as tower in the Not tnentiorted. Net toentioned‘1’ 35) repa* ‘ets-ja iraditional Ltehiens:ejn parielesTSi group al diseltaree and al

repairssith iielits’eight polvpropyene 7 das posloperalive.rnesh secured w rIt Sutures.

N{;!r ,Erah W ci al. Cr’rnpxrieor. ol no n-mes: (Des.arda) and There WJS no signifteant diftrencc Not a:enlio:,ed. Net tentioned.2012 361 rnesh (Liclslenslein) teehtaique for open 1-2 h postoperalis e and not after 3

insttiinal hernia repair da.

C.ndre NP ei al. Polyethylene vi polypropylene ntesh The mean averane post-operative Not nentioned. Not mentioned,2012 137) pain ‘sas sirnilar he me en groups

T ss .5 Act al. 2011 Gltieamnesh vs Polypropyletme On the es enina of the intervenlioti Not nientioned Nol menlioned.çSt lhe pair sas Iets intense in Le

Glucansesls 8 group.1 :JiieoS Tal. Lightwc-igiat. aree-pore mcdi vs heavv Paiien:s wida light” eight. large- 1 Not metilior.ed. Not nienlioiied

23 13 t r9 ss eiglt tnaes Ii svs ih small porea pore n:eah reported Iets pain 1p os top er a live

Pan 1KM ei al. 2017 Self gripping semi reabaorbahle nseah No significant pamn ditYerences at Not mettmioned Nol mentioned.($0) (Progrip) va polvpropylene mnesh. any linie point.

-

Larro ILP et al. 2017 Low density s s high denaity Mesti Only 0fl Ihe Ist poatoperalis’e day Not mentioned. Not menlioned.)4[ 4 and the 7tli postoperatire day). -

:5. , \‘ ei al. 2014 Fibrin altie t Lichterstein fsaion of PesIoierat:ve puin w as loss er ie the Pafenta reqainino analgesies \‘oI mcm ioned.1slesli fibriii alue cup al 1 week aiad 1 in the darm nIce grottpwere

[__ naonth. sienificantlv leo.1 She:: ‘\Ï ei al. 2011 NOCA i:-bctyl-2-cyanc-aetylate )rtme dical . 24 Ii after aurgerv \‘AS n as Not ineetioned. Not inentioned.

434 aditesis e s traditional suture sigmaifleant boer in the NBCAgroup ssten eompared with tlarconirol group.

ltona S eI al. 2018 Lightweight ntesh (UltraproT) va A atalistically aignifleant differenee NS, NS.(44) he,sv ysse inkt ntesh (ProleneT) in patients in favour of light” eighl mesla for

ss ith prirnary ingainal hernia repair pain at 1 week and 6 months aller(Licbatensiein tee:sniqt:ei surgcre

Ei .s. ::el.s C eI al. Glue (Histoaer P) or non-absorbable PoatoperamEs e pain st S It, 24k. . Not ineetiorted All pal:eiata rereiveti para2016 (45) polvprony ene stimatres for ûxaiota of Jdavs and 3üdays ‘tas leas “hen eetamnol 000 mg every 8h

- iigisiweishm pulvrnropylene neah. eltie was used inalead ofstiturea for and dexketeprofen 25 ingall naeasures. J j e eiy 8h for 7 days.

Prast-operoore

:etetoie itofl-opioid aoolge.sicsMentes 0 et al. 2009 Loeaoxieana 8 ma al the end of surgery amad 12 No staliatical signifleani Patienls “ere not reeeivifltt Slsidy protocol.II?) h alter serstis tr.smadol 1 nsglkst al the end of difference in the effect of pain resetie anatgesia protocol.

surgers and esery 6h up to 24 h poslop.aralis e. 2 h and 24 h aller surgery.

NS = no signiflearat dt0renee belueen grotips. POD Postoperative Day.

12 hours after surgery after which the difference use of 1-ITX-011 (a novel, extended release, fixedbecame insignificant. Another RCT (n= 1 62) dose combination local anesthetic comprisingevaluated the effects of intra-operative dipyrone 15 bupivacaine and low-dose meLoxicam, incorporatedrng/kg or 40 mg/kg IV during the operation (16). in a proprietary Biochronomer® polyrne’-) (18). ItA statistically significant difference was only found showed a 23% reduction in niean pain intensitv overduring the first 30 minutes in the PACU. One RCT 72 hours compared to placebo. At all timepoints(nl60) reported no difference in pain scores 12 through 72 hoi.ws, the mean pain scores were lowerand 24 hours after surgery. between lornoxicam (an in the 1-ITX-01 1 group. A reduction of 21% for painNSAID administered at the end of the operation intensity over 72 hours was observed when HTXand 12 hours post-operatively) and tramadol (17). 011 was compared to plain bupivacaine. Of note,However, the tramadol group experienced more hasic anaLgesics — paracetamol and/or NSAIDsnause-a. were not used.

One study, which consisted of two RCTsLoca//RegionalAnalgesia Techniques (n=417), compared the effect of INL-001 (an

implant designed to provide extended delivery ofTopical and surgical site infiltration with extended- bupivacaine to the area around the surgical wound)release local anesthetics with placebo implant (19). Patients who received

INL-00l reported lower pain intensity through 72 hOne placebo-controlled RCT (n=418) for the two pooled studies. One placeho-controlled

showed a significant reduction in pain with the RCT(n=60) in patients receiving spinal anesthesia

rAcen A,mtramliesiologico Belgicei, 2020.7 i - Spplemenl 1

52

examined the effects of wound infiltration with

bupivacaine 0.05% 10 mL prior to incision (20).

Early postoperative paul was signiflcantly lower at

all timepoints in favour of the bupivacaine group.

Ilio-inguinal and ilio-hypogastric block

A placebo-controlled RCT (n=34) investigated

the possible beneflis of an additional ilio-ingirnal,

ilio-hypogastric block (lOrnL 075% ropivacaine)

and surgical xvound infiltration (1 OrnL 0.75%

ropivacaine) (21). Pain scores were lower in the

control group 3 hours post-surgery. There was no

difference in pain scores at 6 and 12 hours post

surgery. Another placebo controlled RCT (n60)

found that an iho-mguinal and ilio-hypogastric block

(I2mL 0.75% ropivacaine) and wound infiltration

prior to incision provided significantly lower

median AS scores compared vith placebo (22).A

placebo-controlled RCT (n=60) also investigated the

effects of ultrasound-guided ilioinguinal and ilio

hypogastric nerve blocks. A significant reduction in

pain scores at mohilization and rest was recorded

in the bupivacaine group vs placebo upon arrival

in the post anestbesia care unit (PACU) and again

after 30 minutes. Flowever, opioid consumption was

not significantly different between groups (23). Yet

another RCT (n=32) investigated general anesihesia

combined with ilio-inguinal nerve black vs spinal

anesthesia alone. Except for the first 2 h after

surgery, there was no difference in pain scores for

the 24 h study period (24).

TransVersus abdominis plane (TAP) blocks

A RCT (n=273) compared ultrasound-guided

TAP block (levohupivacaine 0.5%. 1 .5mg/kg)

with blind ilio-hypogastric and ilio-inguinal block

(levohupivacaine 05%, 1 .Smg/kg) performed he

fore surgery. Pain at rest was lower during the first

24h after ultrasound-guided TAP block, but this

difference was not observed during movenient (25).

Okur et al. (n=90) found that pain scores with TAP

b)ock were significantly lower at 24 h compared

with ilio-inguinal-ilio-hypogastric blocks in a post-

hoc analysis (26). A prospectiVe RCT (n=197)

compared the effects of ultrasound-guided TAP

block combined with Ilio-inguinal/Ilio-hypogastricnerve blocks vs llio-inguinal/flio-hypogastric nerve

blocks alone. Pain scores at 12, 24 and 48 hours

were signiflcantly lower in the TAP block and ilio

inguinaL/ilio-hypogastric block group compared to

Ilio-inguinal/Ilio-hypogastricnerveblock alone (27).Theodoraki et al. compared the effëcts of an

US-guided TAP block with ropiVacaine VS an US

guided TAP block with saline and conciuded that

pain was reduced with a ropivacaine TAP block

(28). Statistical significant differences were noted at

rest. at 6 and 24 hours and with moVement at 3. 6

and 24 hours. in favour of TAP block (28).A placebo-controlled RCT (n82) found no

significant difference between the adjuVant effect

of dexamethasone to ropiVacaine in TAP blocks

(29). Another placebo-controlled RCT (n44) in

vestigated the effect of adding dexamethasone

8 ing to a lumhar epidural anesthesia black. The

onset of epidural anesthesia, the primary outcome

of this study. was significaatly more rapid in the

dexamethasone group than in the control group. The

duration of analgesia was markedly prolonged in

the dexamethasone group than in the control group

(30).Another RCT (n=l00) compared the effect of

a post-operative subcostal TAP bloek to a standard

analgcsic reginlen. At different timepoints after

surgery (15 min, 1 h, 6h, 12 h, 24 h 15 days and

one rnonth) there was a signifleantly difference in

pain scores between the two groups in favour of the

TAP black group (31).One randomized triple-masked, placebo

controlled study (n=20) inVestigated the effects of

single injection TAP block ‘s a continuous TAP

black through a perineural catheter for 2 days post

operative (32). There were no differences between a

single injection and continuous infusion at 6, 24,48

and 72 hours after surgery. FloweVer, this study was

u nde rpove red.

A,,esthetic techniquc

One placebo-controlled RCT (n58) study

found no difference in pain scores at 2, 12 and 24

hours between spinal anesthesia and paraveitebralblock (PVB). Of note, these techniques had a 7%

failure rate (33).

8w gleuf technique

One placebo-controlled RCT (n=309) cornpared Lichtenstein technique with Prolene HerniaSyslem (PHS) and UltraPro Hernia System (UHS).There were no differences between groups regardingperioperative course, operating time, postoperatiVepain or rehabilitation (34). Pain was assessed dailyuntil 14 days postoperatiVely by a research nurseusing a telephone interview. Need time pointsfor pain assessments. A placebo-controlled RCT(n302) used Sutureless ParietexTM ProGripTt

5. COPPENS et (ii,

1

© Anti Arnrsrhesio/ogitv &4gJL1S, 2020. 7) Spplemeni t

MIN \IANAGEMENT AFTER OPEN INGUINAL HERNIA REPAIR 53

:ish repair vs traditional Lichtenstein repair with1 ightweight polypropylene mesh secured withsutures. The pain scores were significantly lowerin the sutureless rnesh group at discharge and at 7days, bot not at 1 rnonth after surgery (35). One RCT(n1 01) evaluated the effects of non-mesh (Desarda)vs rnesh (Lichtenstein) methods fbr inguinal herniarepair. No differences 1fl Lerms of postoperative painbetween the two techniques were noted (36). Therewas no signiflcant difference in païn scores at 1-2hours postoperative and after 3 days.

Another placebo-controlled RCT (n70) foundno significant differences in early postoperative

pain, infection. seroma. recurrence and other

complications between different types of mesh(37). However, this study rnight be underpowered.Another placebo-controlled RCT (n=50) cornpailngGlucamesh® VS Polypropylene® mesh found thatthe pain scores (measured twice daily for 7 postoperative days) were significantly lower beforedischarge in the glucamesh group (38).

A placebo-controlled study (n=80) evaluatedthe etTect of sutureless fixation with flbrin glue oflightxveight mesh in open inguinal hernia repair.Patients in the lightweight group reported lesspain during the first month after surgery (39).Another placebo-conirolled RCT (n=45) found nodifferences in pain scores between self-grippingmesh VS polypropylene mesh (40). In a comparisonhekveen low density vs high density rnesh, therevere differences in pain scores only on the Ist andthe 7th postoperative days in faVour of low densitymesh (41). One randornized controlled Ina! (n=102)compared the effect of fibrin glue vs Lichtensteinrnesh repair (42). The fibrin group had lowerpain scores and opioid requirements at 1 week.A randomized controlled trial (n= 110) companed9brin glue as medical adhesive NBCA (n-hutyl2-cyanoacrylate) vs sutnre for patch fixation inLichtenstein inguinal herniorrhaphy (43). The painscores in the fibnin group vere lower at 24 hours aftersurgery. One multicenter RCT (n808) coniparedthe effects of lightweight mesh (Ultrapro®) VS

heavyweight mesh (Prolene®), and reported lowerpostoperative pain scores in favour of lightweightmesh (44). One multicenter RCT (n=370) comparedthe effects of glue (Histoacryl®) or non-absorbablepolypropylene sutures for fixation of lightweightpolypropylene mesh (45). Postoperative pain wasless in the group where glue was used.

Postoperahve•

Paracclamol (Grade D)

____________ ________________

• cyclo-oxygenase-2 selective inhibitor or non-steroidal antinflatninatory drugs (Grade D)• Opinid Cor rescile (Grade OlAnesiltetic techniqoe

_____________

• Field block (ee., ilio-ingtiinnl/ilio-hypogastric block) with oruithout wound inOltration as a soe anest[etic Or as an adjunct togeneral aneatliesia (Grade -\

Surgical tcchniqne

• Mesh tcchniqiies in preference to non-mesh techniques (Grade A)

this systematic review were detennined to be ofhigh quality and all but three showed statisticullysigniflcant results. The updated literature strengthensthe previous PROSPECT recommendations for painmanagement in patients undergoing open IHR (5).The updated PROSPECT methodology furiherstrengthens the recommendations, because it goesbeyond assessment of the available evidence basedsolely on the simple statistical analysis (7).

Combination of basic analgesics such as paracetarnol and NSAID or COX-2 selective inhihitoralong with a local/regional analgesic techniques(eg., locaL infiltration with or without a field blockssuch as ilio-inguinal/ilio-hypogastric nerve blockor interfascial plane blocks such as TAP block) isrecommended pre-operatively and/or intra-operatively. Paracetamol and NSAID have been shownto provide excellent analgesia and reduce opioidrequirements, and should be continued in thepostoperative period, with opioids used as rescueanalgesics (Table 1). Although wound infiltrationis recommended, the ro]e of extended releaselocal anesthetics, topical NSAIDs, clonidine,dexamethasone, or opioids remain controversial.

With regards to the choice of anesthetictechniqtle, the current systematic review strengthensour previous recommendation of using a field block(eg., ilio-inguinal!ilio-hypogastric block) with orwithout wound infiltration as a sole anesthetic oras an adjunct to general anesthesia. In fact, eventhe recent International guidelines recommendthe use of local anesthesia provided the surgeon isexperienced in this technique (1). Obviously, patientselection and acceptance to a sole regional/local

Table /

Overall recommendations for pain management in patienleundergoing open inguinal hernia repair

___________

Pre-operative and inti-a-opei-ativc• Paracetamol_(Graden)• c\-c!o-oxrge;iase-2 setecilve nh:hiior Grade 0)• Intravenous tlexan’.ethasone (Grade B)

• Local anes:hetic infiltration anWor regional analgesia (ilio-inguinalrilic.liypogaslrlc nerve block or transversus ahdonsinis planeHoek)

DIscUsstoN AND coNcLusloN

The majority of the studies inciuded in

© Aria Amrsrhesivlogica Belgica. 2020.71, spplement 1

54 S. COPPENS er al,

Table 2

Anatgesic interventions that are not reconijuended for pain management in patients undergoing open inguinal hernia repair

cattecitnite

Zolpidern as a sleep aid

lENS

Reason for not recommending

‘ Coaflictine procedure-specific evidence

Limited procedure-specific evidence

lncnnclusive procediire-specilic evidence

anesthetic is imperative. A recent meta-analysis of

RCTs comparing loca’ ancsthesia vs other forms of

anesthesia (inciuding general anesihesia) conchided

that local anesthesia allows shorter operating

room times and is associated with lower inciclence

of urinary retention (compared with neuraxial

anesthesia) (46). Also, patient satisfaction with local

anesihesia was similar to that with other anesthetic

techniques (46). Although in comparison with

general anesthesia, neuraxial black is associated with

reduced pain scores and decreased post-operative

analgesic requirement, their use is associated with

side effects (eg., postural hypotension) that might

delay recovery and discharge home in a day care

setting.It is recommended that the surgical technique

should be based on surgeon’s expertise, hernia

relateci characteristics, and availability of local

resources (1). Nevertheless, as far as postoperative

pain is concerned, a mesh technique is in preference

to non-mesh techniques. This recommendation is

also validated by the International guidelines for

groin hernia management (1).-Several analgesic interventions are not recom

mended diLe to either conflicting data, insufficient

data, or lack of evidence (Table 2). These include

analgesic adjuncts such as gabapentinoids, clonidine,

corticosteroids, ketamine, intravenous lidocaine

infijsion, and etatilacept. Neuraxial analgesic

techniques (epidural or paravertebral analgesia) are

not recommended despite the fact that they provide

exeellent pain relief because they are invasive and

have potential complications. Psoas-block is not

recommended at the moment due to insufficient

evidence. However, newer interfascial plane blocks

such as erector spinae blocks may provide pain

relief and negate the concerns of neuraxial blocks

(47). However. evidence currently is lacking for

open inguinal hernia repair.The limitations ïn this review are related to

those ofthe ineluded studies. There was considerableheterogeneity between studies with regards to

dosing regimens and route ofadministration as well

as timing of pain assessments. The small size ofmast studies has the potential for estirnation effectand do not provide safety profile of the analgesicinterventions. In a majority of the studies theanalgesic intervention was not evaluated against anoptimized multimodal analgesic regimen.

In summary, this review has identified an

Iniervention

Gabapentinoids

Clanidine Insutlicient procedure-specihc evidence

Ketamine Insufficient procedure-specific evidence

Pre-o,erative aanercept fastifiucient procedure-specific evidence

.

Alrhouuh etEective these techniques are relativeiv invasiveEpidural analoesa - -

- - ,. -

th pLteniial for compiications

Although etïective these lechniques are relatively invasiveParavertebral blocks - -

vith potential for compl rcations

Psoas block Insufficient procedure-spccilic evidence

\Vaund infiltration vith exiended release bupi acaine tnsiifficient procedure-specific evidence

Wound riO itratinn usinu coirventional noti-steroidal anti- - -

.-

Insutficient procedure-specific e’tdence

Iiitrn-uperatire infiamriratory drugs clonidine or optoids

Topical non-stcrtidal anti-infiarnmatory dnigs Insufficient procedure-specific evidence

Intravenous lidocaine inftision Instifficient prccedure-spcclfic e idence

Topical extended-reiease local anesthelic Limi:ed procedure-specific n dence

Transcutanenus Electrical Nene Stimulation Limited procedure-specific evidence

Postoperative compressive crynlherapy or ice wrapping Lack of procedure-specific evidcnce

Nene seclion Limiled ofproccdure-specific evidence

Cryoanalgesia techniques tnsutficient procedure-specific evidence

© Acta Amz-rt]esioIogica BeJçico, 2020! 71 Spplement 1

PAIN MANAGEMENT AETER OPEN INGIjINAL HERNIA REPAIR 55

analgesic regimen that foroptimal pain managementafter open inguinal hernia repair as we]1 asinterventions that are not recommended for painmanagement in patients undergoing IHR. Futureadeqtiately powered studies should assess the effectsof analgesic intenentions not oniy on pain, opioidconsumption. opioid-related adverse events andcomplications associated with the intervention. butalso outcome measures such as time to ambulation,Ienglh ofhospilal stay, and the occun’ence ofchronicpain or chronic opioid consumption. Furthermore,the influence of analgesic intervention on patientspecific factors such as chronic pain and chronicopioid therapy need to be assessed.

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