Page 41 - Journal of World Association of Laparoscopic Surgeons

REVIEW ARTICLE
Local Anesthetic Use for Pain Relief Following Laparoscopic

Ventral Hernia Repair: A Systematic Review

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Vaaiga Autagavaia , Jamie-Lee Rahiri , Melanie Lauti , Lydia Poole , Garth Poole , Andrew G Hill 6
AbstrAct
Aim: To assess the effectiveness of the addition of local anesthetic (LA) techniques in reducing pain and morphine consumption in the first 24
hours following laparoscopic ventral hernia repair (LVHR) in adults.
Background: Ventral hernias (VH) are a common condition; with risk factors (including obesity), the incidence of VH is projected to increase.
Surgical VH repair is required for symptom relief and to prevent related complications. LVHR has significant advantages over open repair, with
reduced infectious complications, shorter hospital stays, and more favorable outcomes in obese patients. However, in comparisonto open repair
LVHR patients often experience severe pain post-LVHR. LA is an important part of multimodal analgesia regimes and their use in the context
of post-operative LVHR pain management is growing in importance.
Review results: A systematic review was performed according to PRISMA using search terms related to LA, LVHR post-operative pain, and
morphine consumption; studies were limited to adults (>18 years) and randomized control trials (RCT). Four RCT met the inclusion criteria.
All studies compared bupivacaine with normal saline, one also used bupivacaine with epinephrine; varying LA interventions were used. One
study showed a statistically significant, but small (0.08 mg) reduction in pain scores at 24 hours, which is likely to be clinically insignificant.
Three studies showed an overall reduction in morphine consumption at 24 hours, with only one reaching statistical and clinical significance.
Conclusion: Bupivicaine LA interventions post-LVHR did not reduce pain scores at 24 hours, but morphine consumption appeared to have
been reduced.
Clinical significance: Despite some evidence of reduction in morphine consumption in the first 24 hours post-LVHR, further investigation is
required regarding post-operative LVHR pain management using LA, including agent and mode of delivery.
Keywords: Analgesia, Laparoscopy, Outcomes, Ventral hernia.
World Journal of Laparoscopic Surgery (2019): 10.5005/jp-journals-10033-1349

bAckground 1–6 Department of Surgery, South Auckland Clinical Campus, The
A ventral hernia (VH) is a fascial defect in the anterior abdominal wall. University of Auckland, Auckland, New Zealand
Primary VH includes epigastric, umbilical, and spigelian hernias. A Corresponding Author: Vaaiga Autagavaia, Department of Surgery,
secondary defect, or incisional hernia, is one that develops at a previous South Auckland Clinical Campus, The University of Auckland,
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surgical incision site. VH are a common condition and risk factors Auckland, New Zealand, Phone: +64 92760000, e-mail: v.autagavaia@
include obesity, previous abdominal surgery, and chronic elevated auckland.ac.nz
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intra-abdominal pressure. With the current obesity epidemic, the How to cite this article: Autagavaia V, Rahiri J-L, Lauti M, et al. Local

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incidence of VH formation is projected to increase. Consequently, Anesthetic Use for Pain Relief Following Laparoscopic Ventral Hernia
the optimization of postoperative care following VH repair is critical Repair: A Systematic Review. World J Lap Surg 2019;12(1):33–38.
to the effective management of this increasingly significant issue. Source of support: The University of Auckland, Auckland, New Zealand

VH require surgical repair to relieve symptoms and prevent Conflict of interest: None

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complications, such as uncontrolled pain and hernia strangulation.
Open mesh repair has been the gold standard since it has significant abdominal wall pain impacting on short- and long-term
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been provedto be superior to open suture repair owing to patient wellbeing, recovery, and satisfaction.
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significantly lower recurrence rates. However, LVHR has grown Local anesthesia has become an important addition to
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in popularity since its introduction in 1993. Multiple studies have multimodal analgesia regimens for postoperative pain. Local
demonstrated a number of advantages of LVHR over open repair, anesthesia prevents afferent nociceptive nerve transmission from
including decreased infectious complications and shorter hospital the surgical site to the spinal cord, reducing the local inflammatory
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admissions. Furthermore, LVHR appears to be favorable in obese response and pain perception. This is clinically achieved by
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patients owing to lower complication rates. neuraxial blockade with epidural anesthesia, wound instillation,
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Laparoscopic surgery has long been considered less painful or compartment blocks. The objective of this systematic review

in comparison with open surgery, yet trials have reported no was to assess the effectiveness of the addition of LA techniques
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difference in acute or chronic pain between open and LVHR. In in reducing pain and morphine consumption in the first 24 hours
fact, patients often experience severe pain following LVHR and this following LVHR in adults.
remains a significant clinical problem. It is hypothesized that this
severe pain is attributable to techniques of mesh fixation during
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ventral herniorrhaphy. Mesh may be secured with sutures or Methods

tacks, which pass through the peritoneum, fascia, and muscle of A systematic review was performed in accordance with the preferred
the anterior abdominal wall. Both techniques are associated with reporting items for systematic reviews and meta-analyses (PRISMA)
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
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