Mersadies Martin, MS, MD1, Amy Banks-Venegoni, MD2, Erica Kane, MD1, Alexander Knee, MS1, John Romanelli, MD1, David Earle, MD1. 1Baystate Medical Center, Tufts University, 2Spectrum Health Medical Group, Department of Surgery
INTRODUCTION: Literature supporting laparoscopic herniorrhaphy without general anesthesia is almost nonexistent. We believe that in addition to operation type, anesthesia type can also be patient specific. We therefore offered patients the option of choosing local anesthesia with sedation for totally extraperitoneal (TEP) laparoscopic inguinal hernia repair. The purpose of this study was to analyze our experience and describe the lessons learned.
METHODS: We performed a retrospective, IRB approved study analyzing the experience and outcomes associated with the use of local anesthesia and sedation for laparoscopic TEP repair from 2000-2015. The preperitoneal space was opened with a round balloon dissector placed through an infraumbilical incision with two 5-mm midline ports. A standard CO2 insufflator was used with a set pressure of 10 mmHg. Local anesthetic was used at the incision sites and in the preperitoneal space. Intravenous sedation was controlled by the anesthesia team. All repairs utilized a 10x15cm mesh selectively anchored with permanent spiral tacks. No bladder catheter was utilized.
RESULTS: 38 TEP repairs were performed in 33 (86.8%) males, and 5 (13.2%) females, age 36-84 (mean 59.79) years. Mean BMI was 26.4 (range: 20.8-35.2). All patients had small hernias on exam (H1-H2; Kingsnorth classification). Permanent spiral tacks were used in 21 (55.3%) patients, and 23 (60.5%) repairs were bilateral. Co-morbidities such as cirrhosis, diabetes, hypertension, asthma, obstructive sleep apnea, angina, coronary artery disease, and or COPD were present in 89.5% of the patients. Median operating time was 73 minutes (range: 40-202) and performed on an elective, outpatient basis. One case was converted to an open approach due to central obesity and intolerance of local anesthesia likely secondary to COPD. No patients required admittance or excessive use of pain medications within the perioperative period. There were no deaths, and one minor complication (hematoma) that required no intervention. Follow up was conducted on 74% (28/38) of the patients for a mean of 30.5 months (range: 0.3-106.9). There was one recurrence (10x15cm PTFE mesh without fixation), and revision was performed with a TAPP technique using a larger PTFE mesh with fixation.
CONCLUSIONS: TEP repair with local anesthesia and varying amounts of sedation decreases general anesthesia concerns in those patients with significant co-morbidities that would otherwise need an open inguinal hernia repair. Appropriate patient selection based on motivation to avoid general anesthesia, low BMI body habitus, and small hernia size seems to be the primary reasons for success in this group.
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