Page 30 - World Journal of Laparoscopic Surgery

Open vs Laparoscopic Inguinal Hernia Repair
Table 2: Medication data for patients who underwent open and overweight patients (87%) stayed 2 days, and all obese patients
laparoscopic surgery methods of inguinal hernia repair. Mean ± standard stayed at least 2 days.
deviation with range in parentheses. Between-group comparisons:
Student’s unpaired t tests dIscussIon
Open Laparoscopic Between- Just over one-third (38%) of inguinal hernia repairs in the current
surgery surgery group
(n = 39) (n = 24) comparison study were conducted using laparoscopic surgery, which is
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Length of hospital stay 2.2 ± 0.8 2.0 ± 0.8 p = 0.496 similar to the overall Australian rate for the 15 years prior, of 43%.
Overall, there were no significant differences between patients
(days) (1–5) (1–5) who underwent open vs laparoscopic surgery for inguinal hernia
Medication dose (mg) repair in terms of type and dose of analgesic medications given
Recovery Opioid 3.7 ± 5.9 4.7 ± 6.2 p = 0.553 during the immediate postoperative period or the hospital stay, or
equivalents (0–25) (0–20) the duration of the hospital stay. However, there was an influence
Opioid 0.05 ± 0.08 0.05 ± 0.07 p = 0.703 of BMI on several measures, with increased BMI associated with
equivalents/ (0–0.35) (0–0.24) requiring a combination of opioids with NSAIDs or paracetamol
kg body rather than none of, or any of these alone, and with a longer hospital
weight stay, which is clinically relevant. Patients in the open surgery group
Hospital Opioid 17.3 ± 17.7 15.2 ± 21.6 p = 0.675 were significantly older, which reflects Australian epidemiological
stay equivalents (0–55) (0–75) data that elderly patients are less likely to undergo laparoscopic
Paracetamol 5.7 ± 3.7 4.8 ± 3.9 p = 0.344 surgical repair of groin hernias. Further, age was significantly
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(g) (0–1.6) (0–1.6) correlated with hospital stay duration, and almost significantly
NSAID 112 ± 275 209 ± 601 p = 0.394 (p = 0.055) inversely correlated with equivalent morphine dose in
(0–1200) (0–2800) the postoperative period, so this is a confounding factor. Patients
Opioid 0.22 ± 0.23 0.19 ± 0.26 p = 0.259 who underwent laparoscopic surgery and patients with a direct
equivalents/ (0–0.75) (0–0.76) hernia were significantly more likely to have had a previous hernia
kg body repair. Overall, there was large variation in the total dose of all
weight medications given.
Paracetamol 0.07 ± 0.05 0.06 ± 0.05 p = 0.583 The current finding of no difference in analgesic consumption
(g)/kg body (0–0.17) (0–0.24) after open vs laparoscopic surgery during the immediate
weight
postoperative period and hospital stay is in contrast with much
previous research. 5,10–12,14,20,21 These studies all reported significantly
any medication. There were no significant difference between lower pain medication requirements after laparoscopic compared
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surgery groups for medication type (χ = 1.993, p = 0.574), for with open surgery for inguinal hernia repair. Notably, in the current
equivalent morphine dose total or per kg body weight (Table 2), study, patients who underwent open surgery were significantly older,
or for equivalent morphine dose when only those who received and there was an inverse correlation, close to significant, between
opioid analgesic were included in analysis (p = 0.88). There was age and equivalent morphine dose in the postoperative period. This
no correlation between age and equivalent morphine dose (R = is in line with previous reports that younger age is associated with
0.025, p = 0.844). increased perception of chronic pain, 15,23 but may have masked any
between groups difference in analgesic medication administration
Influences of BMI because of the confounding effects of age and pain. In the case of
The BMI group (15 healthy weight, 37 overweight, and 11 age-matched groups, analgesic requirements may have been less
obese patients) had no significant effect on the distribution of after laparoscopic vs open surgery, as per the above-mentioned
medication type received during the immediate postoperative previously reported findings. Interactions between surgery mode
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period (χ = 1.508; p = 0.471), but did have a significant influence and age should be included in comparisons of different surgical
on category of pain medication required during the hospital methods for more accurate results.
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stay (χ = 12.783; p = 0.047). During this time, the majority of A limitation of previous research examining analgesic doses
overweight and obese patients (62 and 60%, respectively) but after inguinal hernia repair is that opioid medications were not
less than half (43%) of healthy patients required a combination of included in analyzes. In the current study, the majority of patients
opioids with either NSAID or paracetamol. Among healthy-weight (62%) received opioid medication (mean of 16.5 ± 2.4 mg) during
patients, equivalent proportions (21% each) required just opioids their hospital stay. The proportion of patients receiving opioid
or NSAIDs and/or paracetamol, and 14% did not receive any pain medication in the current study was higher than, but the dose was
medication. In contrast, among overweight and obese patients, similar to, a comparable study that reported 40% of patients took
none received opioids alone; 33 and 30%, respectively, required opioid analgesics (most common total intake of 10–20 mg) for up
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only NSAIDs and/or paracetamol; and only 5 and 10%, respectively, to 1 week post-surgery. Given the widespread opioid tolerance
did not require any medication. There was no influence of BMI on and abuse and the increasing move to avoid opioids for surgical
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dose per kg body weight for opioid analgesics received during the pain, including after inguinal hernia repair, it is crucial that opioid
immediate postoperative period, or for opioids or paracetamol consumption is assessed, particularly when comparing surgical
during the hospital stay (F 2,60 = 1.216, p = 0.304; F 2,60 = 0.042, modalities. Further, in the current study there was a significant
p = 0.959; F 2,60 = 0.546, p = 0.582, respectively). The BMI also effect of BMI on the analgesic profile during the hospital stay,
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significantly influenced hospital stay duration (χ = 20.74; p = with overweight and obese participants more likely to require
0.008): the majority of healthy patients (72%) stayed 1–2 days, and a combination of opioid and NSAIDs, rather than just NSAIDs or

28 World Journal of Laparoscopic Surgery, Volume 13 Issue 1 (January–April 2020)