Local Anesthesia in Outpatient Herniotomy

Letters to the Editor regarding the article Pain After Outpatient Surgical Procedures A Survey of 330 000 Patients by Dr. phil. Philipp Baumbach; Dr. med. Johannes Dreiling; Dr. rer. nat. Christin Arnold; Claudia Weinmann, MA; Dr.-Ing. Marcus Komann; Dr. med. Klaus Bäcker; Dr. med. Axel Neumann; Dr. med. Jörg Karst; and Prof. Dr. med. Winfried Meißner in issue 3/2024

The authors reported (1) that one in every three patients in Germany complained of more severe pain after an outpatient herniotomy, with 71.1% of procedures carried out under general anesthesia and only 19.7% under regional/local anesthesia. The causes of pain may be multifarious and should be considered. Preoperative pain, for example, can be triggered by ilioinguinal nerve entrapment syndrome and postoperative pain can be associated with the surgical technique and/or mesh fixation technique, or chronic postoperative inguinal pain may develop. Further factors of influence may be:

• General anesthesia
• Waiving preoperative local pain prophylaxis
• Intraoperative neurectomy
• Age
• Sex
• Outpatient postoperative aftercare/follow-up
• Soft tissue treatment, and
• The treating surgeon’s experience in outpatient herniotomy.

In Denmark, an effective and efficient outpatient follow-up system for inguinal hernia surgery (>80% outpatient 2000/2016 OECD Health Statistics 2018) helps prevent postoperative complications and pain, even though surgery in specialized hernia centers is 100% carried out under local anesthesia.

With regard to the surgery, Danish patients have a choice between outpatient, open, under local anesthesia, and with or without mesh (2). Local anesthesia is associated with less analgesia, less pain, and fewer complications (3)—an opinion shared by German expert groups. Usually, however, barriers exist vis-à-vis the use of local anesthesia.

In Germany (0.3% outpatient surgical procedures 2000/2016 OECD Health Statistics 2018), no option for choice exists and experience with outpatient herniotomy is at a low level by comparison/comparatively speaking. The specialist professional scientific societies for hernia in Germany, Austria, and Switzerland [DACH] note that an outpatient system that is comparable to Scandinavia does not exist in Germany (4). Creating a system of outpatient surgical procedures such as in Denmark constitutes a health political challenge.

DOI: 10.3238/arztebl.m2024.0105

Prof. Dr. med. René Gordon Holzheimer

Facharzt für Chirurgie, Sportmedizin, Spezialist für Hernien und Venen

Straßlach-Dingharting

Conflict of interest statement

RGH received consultancy fees and is an advisory board member of the start-up company Titanium Textiles. He is a delegate of the German Hernia Society in the European Hernia Society.

References

1. Baumbach P, Dreiling J, Arnold C, et al.: Pain after outpatient surgical procedures—a survey of 330 000 patients. Dtsch Arztebl Int 2024; 121: 71–8

2. Callesen T: Inguinal hernia repair: anaesthesia, pain and convalescence. Dan Med Bull 2003; 50: 203–18

3. Holzheimer RG, Gaschütz N: Prophylaxis and treatment of acute and chronic postoperative inguinal pain (CPIP)—association of pain with compression neuropathy. J Surg Case Rep 2020; 14: rjaa143

4. DACH-Konsensusgruppe ambulante Leistenhernienchirurgie; Niebuhr H, Köckerling F, Fortelny R, et al.: [Inguinal hernia operations—always outpatient?]. Chirurgie 2023; 94: 230–6