TEP repair for inguinal hernia under CSEA vs GA: A RCT

Naveen Sharma, Amit K Kundu, Medha Mohta. UCMS Delhi

Introduction: Totally extraperitoneal repair (TEP) for inguinal hernia is usually performed under general anaesthesia (GA). Some reports have considered TEP to be feasible under locoregional anaesthesia.This study compared ease of surgery of performing TEP under GA versus combined spinal and epidural anaesthesia (CSEA).

Objectives: To compare ease of performing TEP under CSEA with that of performing TEP under GA.

Methods and procedures: This was a pilot study since ease of surgery had not been compared in a randomized controlled trial before. We took a sample size of 20 in each group.The trial was cleared by the Institutional Ethics Committee and was registred in the Clinical trials registry of India.The primary outcome measure was “ease of performing surgery” measured by NRS. Mann Whitney U test was used to compare the “ease of performing surgery”, patient’s satisfaction, and postoperative pain. Student t test was used to compare the duration of surgery.

Results:The basechine characteristics of the two groups were comparable.Of the 20 patients allocated to CSEA group,one was converted to open hernia repair and excluded from analysis.Of the 19 patients analyzed, 10 had to be converted to GA.

Pain scores and patient satisfaction scores were almost similar between the groups. TEP under CSEA took an average of 100 minutes compared to 71 minutes for TEP under GA.The median ease of surgery scores in GA was 10 (IQR 9.25-10) compared to 9 (IQR 6-10) in CSEA group (p=0.002).

Discussion:It was not easy to operate on a patient who was straining, agitated due to pain in shoulders and chest and at times complaining of breathing difficulties. All these factors lead to a comparatively more difficult surgery in the CSEA group. No study in the past has compared ease of performing TEP under the two groups. Though, some previous researchers found it convenient and even advocated that TEP should be routinely performed under locoregional anaesthesia. Difficulties were more frequently encountered during sac dissection and mesh placement.

Conclusion: CSEA is appropriate for performing TEP only in a limited subset of patients but in most of the cases it is associated with a difficult surgery with prolonged surgery duration. It should definitely be avoided during the learning curve of a surgeon.

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