(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) recommendations 1 (*), 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. 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 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 Key words 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-inguinal nerve bloeks or 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, 2,1ev 26, gabapentinoids. 2020. Conclusion The analgesic regimen for open inguinal Conflict ofinterest PROSPECT1s srcpported hv cm ,,nresr,-icled hernia repair should 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 used as 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, Spplement 1 46 S. COPPENS t al. transversus abdominis plane hlocks) is recommended. trations and use of paracetamol and non-steroidal 3. A single dose of intravenous dexarnethasone is anti-infiammatory drugs (NSA 1 Ds) or cyclo-oxy recommended for ability its to increase the analgesic genase (COX)-2 selective inhihitors (1). Therefore, duration of the block, decrease analgesic use, and an updated systematic review on analgesie antiemetic effects. interventions for pain management in JHR was 4. Opioids should be reserved as rescue analgesics in the post-Operative period. perfonned. In addition. It was deerned necessary to reassess the recomniendations to align them with Why was this guideline developed? the updated PROSPECT approach that considers t current clinical relevance and clinical effectiveness t. Open inguinal hernia repair is associated moderate with by balancing the invasiveness of the analgesic to-severe postoperative pain which may influence interventions and the degree of pain after surgery, as recovery. The aim ofthis guideline is to provide clinicians well as balancing efficaey and adverse effects with an updated evidence for optinial pain management (6,7). aller open inguinal henna repair. The aim of this update was to systematically review the available literature assessing the anal What other guidelines are available on this topic? gesic, anesthetic. and surgical interventions on pain after open 11-IR. Postoperative pain scores were The PROSPECT recommendations for pain management the primary outcome measures. Other recovery after open inguinal hernia repair have been published outcomes assessed inciuded previously, however, an update assessing analgesic cumulative opioid interventions was necessarv. requirements and adverse effects, when reported, and the limitations of the data were reviewed. The How doos this guideline differ from other guidelines? ultirnate abn was to develop recommendations for pain management after IHR. The updated systematic review further confirnis the previous recommendations. Also, an updated METII0D0L0GY PROSPECT approach was used to develop the culTent recomniendations such thai the available evidence is criicallv assessed for current clinical relevance The methods of this review adhered to the and the use of simple. non-opioid analgesic such as PROSPECT inethodology as previously reported paracetamol and non-steroidal anti-infiammatory drugs (7). Specific to this study, the EM BASE, MEDLTNE, as baseline analgesics. This approach reports true PubMed and Cochrane Databases (Cochrane Central clinical effectiveness by balancing the invasiveness of Register of Controlled Trials, Cochrane Database of the analgesic interventions and the degree of pain after Abstracts or Reviews of Effects, Cochrane Data- surgery, as balancing as well efficacy and adverse effects. base of Systematic Reviews) were searched for randomized controlled trials (RCTs) published between Januarv ist and t’ 2009 August 3lst 2019. INTRODUCTION The search terms used was (hernia OR inguinal OR inguinal hernia repair OR herniorrhaphv OR OpenlnguinalHerniaRepair(IHR) isassociated herniorraphy) AND (pain OR postoperative pain with moderate-to-severe postoperative pain, which OR analgesia DR anesthesia DR anesthetic) AND may delay recovery and return to activities of daily (anesthetics neuraxial OR intrathecal OR spinal living (1). In addition, inadequate pain control can DR epidural analgesia DR paravertebral blocks DR increase unplanned admission rate and readmission peripheral nerve DR peripheral block DR regional after discharge home (1). Furthermore, inadequate nerve DR transversus abdominis plane block DR post-operalive pain relief may lead to hyperalgesia infiltration DR instillation DR NSAID DR CDX-2 and persistent postoperative pain (2). OR paracetamol DR acetaminophen DR gabapentin Based on a systernatic review performed DR pregabalin DR clonidine DR opioid DR in 2009, the PRDSPECT (PROcedure SPECific ketamine DR corticosteroid DR dexamethasone DR Postoperative Pain ManagemenT) Working Group heavyweight mesh DR polypropylene mesh). (3,4), which is a collaboration of surgeons and Quality assessment. data extraction and data anesthetists, previously provided recommendations analysis adhered to the PRDSPECT methodology for pain management in patients undergoing IHR [7]. Pain intensity scores were used as the primary (5). A recent hitemational guideline for groin hernia outcome rneasure. In this study, we defined a change surgery provided non-specific statements regarding of more than 10 mm on the visual analogue scale pain management recommending perioperative (VAS) or numerical rating score (NRS) as clinically field blocks and/or subfascjalJsubcutaneous ïniil relevant (8). The effectiveness of each intervention © Acra A,;asrhesiologica Beigicu. 2020. 71. Spplenienr 1 PAIN MANAGEMENT AFTER OPEN INGUINAL