950 Experience of Inguinal Mesh Hernioplasty Under Local Anaesthesia: A 3-Year Experience in A Teaching Hospital

Background: The cost effective and less pain caused after the operation, local anesthesia has been considered as the appropriate option for repair of open hernia inguinal repairs as it helps in swift healing. However, less attention was given to explain the effectiveness and safety of LA in the context of elective inguinal hernia repair. The current study had aimed to scrutinize the effectiveness and safety in elective inguinal repair of LA. Methods: In order to perform the analysis, by the usage of mesh a retrospective analysis was performed in the hospital which also served the teaching purpose and data used was of the last 3 years. The result measured remained ASA grade of patients, age group, postoperative (late and early) recurrence and complications. Results: During the course of study, the number of hernia repair performed were 260 ASA grade for all patients ranged between I-IV. The mean age was 37 (20 to 65). Intraoperatively 9 patients (3.5%) had problems such as pain, hypotension or sweating. About 224 (86.3%) patients were dispensed home the sidereal day and 36 patients admitted for a night for less than 24 h. Hematoma was seen in 5 patients (1.92%), Urinary retention in 2 patients (0.7%), Wound infection seen in 24 patients (9.2%), Readmission in 10 patients (3.8%). Chronic groin pain was seen in 10 patients (3.9%) and no recurrence in 6 months follow up. Conclusion: The results of the study indicated that this procedure is feasible under L/A and can be performed safely. It showed satisfactory acceptance by the operating surgeon and patient, without significant perioperative issues. It is reliable and shows a shorter hospital stay. Zeeshan Hashmi, Rizwan Ahmed, Tehreem Zafar, Masood Ahmed, Nizam Yousaf, Kamran Chaudhary and Mansoor Madanur* Department of Surgical Gastroenterology, Lewisham and Greenwich NHS Trust, UK Introduction Globally, the commonly conducted general surgery probably is the Inguinal Hernia (IH) repair. Till now several techniques for repair have been identified. Despite the selection or preference of anesthesia among surgeons have not been found to have any mutual ground. In the context of best clinical outcome, LA has been found to be the best choice which was identified through various retrospective and randomized control trials [1-5]. Despite having remarkable outcomes in IH using LA, it is not preferred by patients and surgeons globally. The study aimed to analyze the consequences of Inguinal mesh hernioplasty with emphasis on use of LA, day case rates, short and time taking complications and patient experience (Table 1). Methods We performed a retrospective review of all adult inguinal hernia repairs in a tertiary teaching hospital in the last three years. The data were collected retrospectively from medical records and reviewing case notes after approval from the hospital Ethics Committee. The demographics, ASA grade, repair technique, early complications were noted. These patients were followed for 6 months to measure inguinodynia and recurrence. Patients with complex or irreducible hernia, recurrent hernia, obesity (BMI greater than 30 Kg/m2), patient refusal and patients of psychiatric problems were excluded from the study. The suggestions for the surgery were due to indirect IH and direct symptomatic IH. In the situation where it was difficult to identify the direct or indirect hernia, surgery was offered to the patient. The surgeon who was going to perform the operation explained to the patient about the procedure Mansoor Madanur, et al., Clinics in Surgery General Surgery Remedy Publications LLC., | http://clinicsinsurgery.com/ 2021 | Volume 6 | Article 3131 2 of LA. In the supervision of pulse oximetry, patients of grade 1 and 2 of ASA went through the surgery. Under the circumstance where the patient was of grade 3 and 4, the presence of an anesthetist was required. Surgical technique At the time of induction all patients were given a single dose of I/V antibiotics. Our choice for field block was 50:50 mixture of 1% Lidocaine and 0.5% bupivacaine, with 1/200,000 epinephrine. 45 mL as an average of this solution was administered in the standard fashion as mentioned in Mastery of Surgery for a field block. The sequence was subdermal infiltration followed by intradermal injection, deep subcutaneous injection and lastly sub-aponeurotic injection. To buffer the lignocaine, 6 ml of sodium bicarbonate (8.4%) (Fresenius, UK) was mixed, indicating 7.0 on the pH scale. Option of intravenous benzodiazepine/opioid to help in procedure was also considered. For the first 1 to 2 postoperative periods strong analgesic was considered in conjunction with paracetamol. Mesh plug and patch repair, Lichtenstein repair [6] were the two surgical techniques used. The combinations of mesh plug and mesh as used when the defect was comparatively large in the patient, and had large internal ring. By the utilization of (6 by 11 cm) flat polypropylene mesh, the mesh plug was created; the form of the mesh plug was conserved by a 1 single nylon suture positioned by the mesh about 1 cm away from the mesh plug’s apex. Through usage of 1 single nylon stitch, in plug was then positioned in the internal ring. Irrespective of the cases, the mesh was saturated in antiseptic before the repair of mesh. All patients were followed up in our clinic (Day 7, 30, 60, 90 and 180 postoperatively) to record early and late complications. Statistical analysis SMSS was used to perform the statistical analysis (SPSS, Chicago, IL, USA). To compare the rate of early, late and day case complications, Chi-square was used. Fischer’s exact test was utilized to match discomfort and chronic groin pain. Results A total of 260 hernia repairs were performed in study duration time. The mean age was 37 years-of-age (20 to 65 years-of-age). The maximum number of patients were from the classification of ASA grade 1 and 2 (78%), followed by grade 3 and 4 (22%). Lichtenstein mesh hernioplasty was performed in all patients using PHS mesh (Prolene hernia system). All the operations were done under LA as planned and none required conversion from LA to GA. Intraoperatively, 9 patients had problems, 5 experienced some painful sensation, 3 developed hypotension with sweating. They were managed accordingly by the anesthetist with analgesic and benzodiazepine. Rates of the day case and complications are demonstrated in Table 2. About 224 out of 260 valetudinarians were discharged the same day and 36 stayed overnight for less than 24 h. The reason for overnight stay is summarized in Table 3. Readmission within 48 h was seen in 10 patients out of which 2 presented with hematoma, 7 with pain and one with urinary retention. Patients were followed up in the clinic post operatively, hematoma was seen in 3 patients, and wound infection was seen in 24 patients on the 7th postoperative day. 8 patients were admitted for IV antibiotics and no patient was found obligatory to remove mesh (Table 4). Chronic groin pain was seen in 10 patients (3.9%) and no recurrence was seen at 6 months follow up. The main symptom of chronic groin pain was mild chronic groin pain/discomfort in 7 patients ranging from ache, numbness and burning. Only 3 patients reported moderate to severe chronic groin pain which required specialist pain team input. A questionnaire was given to all patients on their experience of groin hernia surgery under LA at their follow up appointment. 96% were satisfied with the procedure under local anesthesia and opted to undergo the procedure on the opposite side if required. Discussion In case of emergency or elective, for the repair of hernia, general Centre % of LA No. of Cases Day-Cases British Hernia Centre 100.00% >4000 100.00% Lichtenstein Hernia Institute 100.00% >5000 99.00% Plymouth Hernia Centre 88.00% 1000 81.00% Shouldice Hospital 97.00% >25000 (0.0 % in-patients) The Hernia Centre New Jersey 0.00% >6000 NA Table 1: Usage of LA in various specialist centers for IH. Age (Years) 37 (20-65)