(Acta Anaesth. Belg., 2020, 7], 45-56) Pain management after open inguinal hernia repair: an updated 1 systematic review and procedure-specific postoperative pain management (PROSPECT/ESRA) 1 recommendations (*), S. COPPENS’ (j, J. GTDTS P. HUYNEN Ci. M. VAN DE VELDE (°), G. P. JOSHI (‘j. on behalf of the PROSPECT Working Group collaboration 0. P. Josin, E. POGATZKI-ZAH\, M. VANDE 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 repair role of navel regional analgesic techniques such as can he associated wilh moderate-to-severe postoperative erector spinae blocks and to cunfirni the influence of the pain. w]iich can delay return to activities of daily living. recommended analgesic regimen on postoperalive pain The ainl of this systematic review was to update the relief in an enhanced recovery setting. available lilerature and develop recommendations for
optimal pain management after open inguinal hernia Keywords Open inguinal hernia repair ; pain ; analge
repair. A syslematic review utilizing PROcedure sia ; systematie review evidence-based medicine. r SPECiflcPostoperativePainManagemenT(PROSPECT) k* methodology was tindertaken. ‘v[ethods Randomised controlled trials published in Recommen4ations the English language between January Ist 2009 and August 3lst 2019, evaluating the effects of analgesic, 1. Systemic analgesia should include paracetatnol anesthetic, and surgical interventions were retrieved from and a non-steroidal anti-infiammatory drug or cyclo MEDLINE, EMBASE and Cochrane Databases. Of 203 oxygenase-2 selective inhibitor administered pre eligible studies ideritifted, 37 studies met the inelusion operatively or intra-operatively and continued post criteria. operatively Resnils lnterventions that improved postoperative 2. Local anesthetic infiltration and/or regional analgesia pain relief ineluded paraeetarnol and nonsteroidal anti techniquc(ilio-hypogastric/ilio-inguinalnervebloeksor aflamtnatory drugs or eyclooxygenase-2 seleetive inhihitors, as well as local anesthetie infiltration and S. Coass’, MD; 3. GDTS’.MD: R HcYNEN. MD; M. V,s 0E VELDE. MD, PhD : G. P. Josu’. MD. PhD on hehalfoftlie :egional analgesia teehniques such as ilio-hypogaslrie/ PROSPECT Working Group collahoration. ilio-inguinal nerve bloeks and transversus abdominis S. Coppens and 3. Gidis equally share first auihorship lane bloeks. Although effeetive, epidural analgesia or f9 Depariment of Cardiovascuiar Sciences, Section paravertehral hlocks are considered invasive and harrnful. Anesthesio’.ogy. KU Leuver. and L’niversHy Hespital and thus not recommeoded. Insufficient evidence was Leuven, Belgium (*9 Deparitnent of Anesthesiology and Pain Management, found for psoas black, extended release local anesthetics. Llniversity of Texas Southwestem Medical Center. Dallas, wound infiltration using non-steroidal anti-infianirnatory Texas, LSA drugs. elonidine or opioids, topical conventional non- Corresponding author Mate Van de Veide, Department steroidal anti-infiammatory drugs, systemic clonidine, of Cardiovascular Sciences. Section Anesthesiolugy, KL corticosteroids and ketamine, otravenous lidocaine Leuven and Universiry Hospital Leuven, Belgium E-rnail niarc.-andeveideïcuzleuven,be 1- inftision, cryoanalgesia techniques, and nerve section. Inconsistent evidenee was found for the use of Peper s,,b,,,itted en Mây 25, 2020 end accepted ei, 2,1ev26, gabapentinoids. 2020. Conclusion The analgesic regimen for open inguinal Conflict of interest PROSPECT1s srcpportedhv cm,,nresr,-icled herniarepairshould inelude paracetarnol and nonsteroidal g;znt from the Eutvpean Society of Regional Anesihesia and Pain Therapy (ESRA,).In the past, PROSPECT het anti-inflarnmatory drug or cyclooxygenase-2 selective received imrestricled grants from Pfizer mc. New York.N inhibitor administered pre-operatively or intra USA and Grunenthal, Aachen, Gertnany GPJ has ,-eceived operatively and continued post-operatively. In addition, honorariafivm Boxter and Pacira Pharmaceuticc.Lv.MVdV local anesthetic infiltration and/or a regional analgesia her ,-eceived honoraria fivm Sintetica, Grunenthal, Vfor technique (ilio-inguinal nerve blocks or transversus Pharma, MSD, Nordic Pharma, Janssen Pharmaceuticals, He,vn Therapeutics and Aquettant. EP-Z has teceived abdominis plane bloeks), with opioids as used rescue honoraria from Mimdipharma, Gr,menthal, MSD, Janssen analgesies. Further studies are required to assess the Cilag GmbJ-J,Freseniz,s Kabi andAceiRs,
© Acte Ancrsthesiologtca Betgica. 2020,71, Spplement1 t. t
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46 transversus 3. recommended
4. post-Operative duration antiemetic to-severe Why Open recovery. The with aller What after previously, The How interventions the PROSPECT recomniendations and
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INTRODUCTION
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of PAIN MANAGEMENT AFTER OPEN INGUINAL HERNIA REPAIR 47
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Ei Fig. 1. PRISMA How diagram of studies for each outcome was evaluated qualitatively by shown in Table 52 and Tahie 53. assessing the number of studies showing a signi Systenile non-opioid analgesies ficant difference between treatment arrns (p < 0.05 as reported in the study publication). A meta One placebo-controlled RCT (n50) reported analysis was not performed due to heterogeneity in gabapentin (400 mg) prior to surgery reduced pain Sttldy design and result reporting, restricting pooied scores and postoperative morphine requirements analysis. in the immediate postoperative period. No obvious Recomtnendations were made according side-effects vere reported (9). Another placebo to PROSPECT melhodology (7). In brieL this controiled RCT (n=60) reported that preoperative invoived a grading of A—Daccording to the overall gabapentin (1200 mg) signiflcantly reduced pain le ei of evidence, as determined by the quaiity of scores (at rest and on sitting) and reduced the total studies inciuded. consistency ofevidence and study tramadol consurnption at 8. 12. 16.20 and 24 hours design. The proposed recommendations were sein after surgery (10). Pain scores at 1, 3 and 6 months to the PROSPECT Working Group for review and after surgery were lower inthe gabapenttn group than comrnents and a modified Deiphi approach was in the placebo group (10). AIargeplacebo-controlled utiiised as previously described. Once a consensus RCT (n425) found that preoperative pregabalin was achieved the lead authors drafted the final (50, 150, or 300 mg/day) as adjuvant analgesic did document, which was ultimately approved by the not influence the intensity of postoperative pain at WorkingGroup. 24 hours (Ii). Of note, there was a wide variability in the anestbetic and analgesic techniques. RLULT5 One placebo-controlled RCT (n77) found no statistica] significant difference in pain during the PRISMA flow chart demonstrating the search first24 hours. postoperatively withaTNF-rtinhibitor, data are presented in Figure 1. The methodological etanercept 50 mg, administered subcutaneously 90 quahty assessments of the 38 RCTs inciuded for the min before incision (12). final qualitative analysis are summarized in Table A placebo-controlled RCT (n=55) evaluated 51. The characteristics of the inciuded studies are the effects of rofecoxib 50 mg (a COX-2 selective
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PAIN MANAGEMENT AFTER OPEN INGUINAL HERNIA REPA1R 49
TahieS2 SummarYof key resuits from studies evaluating systemic analgesics, analgesics adjuncls, regional anesthesia, and surgical procedures used to support the recommended interventions in patients afler open inguinal hernia repair
Soidy Study denEn Pain Scores Cumulative opioid done Rascline Analgeaia 1 p,-e.ope-otil-e SvsÎetltiCatolt’Opioldottet!gesics
Schnrr Met al. 2009 (13) Roferosib 50 nsg or placeho 1 hoor Signiflcantly lower ratings for No dinèrence in milligrams Palients were gi’en prior to suegery and oncc daily on east pain in patients vith COX-2 hydrocodotte bitartrate hydrocodone bitartrate as needed postoperato e day -4. inhibitor intake os the opeestive eonsnmed. postoperative. day.
SL’rnri7n1et al. 2017 (14) Etoricoc,b ‘20 Ing or ptaceho 1 hoor signiflcanlly lower pais scores in Amount of rescue analgesic \Vhen VA5ESIat PACU l-Smg preoperalt’e paltenls with COX-2 ishibitor at dosca ofmorphine boluses of morphine eere itsed
16. 24 t and ets discharge, in rest (mg) within 24 h “ere until a response of t en a verbat and wilt active atraighl leg raisc. signiflcantly lower in COX-2 poiosdescripttve seate of 5 was inhibitor group. achie’ed, ,,-a- opeWire Jhpica/ottdnIltgICO/ tilt’ ofihrtsaoostsi,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 pethidmnenar
1 t t t rceei’ cd t ml of bnpivacaine 0.5% postoperative) “ere ower t the 80% lens in the first 24 Is. micc cd and the control gtotip placeho 110 ml treatttirnt grottp normal natmc).
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S.trt:.rsScetat20tt (2!; lt:oinguinal and ltioh2pogastrr \‘taua astalog’aescale al rest “-as Not nieestioned • tAS > 4 rcecs ed inrras-e eer’ c bloek ei 1h tO rr,L of 0 755i a,sniftcar.t os er 3 h after surgerv. drpvronc 2.0 g). In case
rop:t aeatne. end ssouad mnfiltiatior. No difterenee ar 6 and 12 h after - ite0ècttvc, intravcnoas Lctoroiac oOit 10 nL of 075% ropis aaine aurserv and” ith inoventent. (30 net and, whencvcr tieressa 0, versos no bik nar wo:tnd infiltratiur. intrasenoos tialbuphmne (3 mg), “ere added. Sa:ed?,tetat.2015 f22) tIiohpoeastrie and lioingtttttai bbck Nledian \‘AS “-as lo;ner in the Not nsentior:ed. only ttrne for VAS>3, on dentand paracetatnol
12nt 0.75% ropivacainel and incision - tntene;ttton group. - dcrnand first done aatalgesia I000nag and if necessarv 75 mg
irifiltratior. erior to mcidon - dirlofcnae sodiuttt. - Baaren:zen F er ah 2012 Ilro-hypogastric and ilio’ingutnat Significarst lower pEn scores at No smgnificant ditferenee /
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25; black wit) 20 tttL bupiveeatne 05% ntobiltzation and rest upon arri al betweer, the two groups. t ora plareho block nOh 20 ml oaline in RACE and after 30 minutes.
UP-Hoek
.-\ e;nie eet aL 2011 (25) Uitrasound-gaided TAP bErk 1 e-o- \‘as paas scores at rest “-ere losser No significant ditTerenee. Paracetamol 1000 nut and keto
httpt acaine 05%, t Smg5)g) ‘-cr5115in the US-gttided TAP group at profen 100 rng i.’e.duritagsttr-ety blind 1Hbloek Ilevobitpivacaine 0.5%. 4h. 12h and 24h. At PACU 3 mg io. moeptttne
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Okur Oct al. 2017 (26) TAP block serstis ilio-hypogastrie and Pain scores “ere signifleantly No significant diftèrenee Aceratramnoptren 10—15 tttg e erstts in additicoal anaigesie kg onee ever 6 t and salvage tt:o-tngurtral nen hork no Io»-er al Ei time poinls of the i 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. dtfTeretrcehertveen TAP and HIN in 0-er olTAP.
MosailiV 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 2 itiohvpogasrrie bloek veralla stsnitiearativ los er is Duat TAP- cecuired resetre anEgesies in h if the pain pers:sls tAS score
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1 aletre. fentanyt intra’ er.ous trarnadoi 5(3
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c28) 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-atblock into epidural space “-as aigni0çantly more espid and versus ptaeebo (satinc 2m11. longer in the desamethasone grOnp. Poat-operative U-1P-bloek .AkyolBC 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 were bloek poaloperativcly in addition to poatoperative 151h-minute; Ist-, Irarnadol IV. given tOOmgtramadol and an 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.
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to PAIN MANAGEMENT AETER OPEN INGIjINAL HERNIA REPAIR 55
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