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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_842_Библиотеки_им_академика_М_И_Перельмана.pdf
Perioperative Management ofLaparoscopic Inguinal Hernia Repair
In male patients, the vertical and longitudinal examination of the testicles completes the
procedure.
z
e criterion standard for hernia diagnosis is CE
of the groin with a sensitivity of 0.745 and a specicity of 0.963 reported in a prospective cohort
Results
Material and Methods
z
In order to nd out the number of inguinal or
femoral hernia diagnoses that were sonographically conrmed and to also consider the cases, in
which a sonographical examination led to the
detection of an inguinal or a femoral hernia, where
as a clinical examination neglected this diagnosis,
the ultrasound examinations of the groin area
executed in a 5-year period between 2010 and
study from 1999 [119]. ree consensus guidelines have been published on groin hernia treatment [13, 92, 111]. All published statements on
diagnostic work-up are weak, mainly focusing on
CE alone. Only groin pain that is obscure or groin
swelling of unclear origin (possible occult hernia)
is noted to require further diagnostic investigation [26, 65, 70, 75]. No consensus exists presently
on the best imaging modality for these diagnostic
dilemmas.
2015 were analyzed retrospectively. e results
were compared to the intraoperative ndings.
that are small, e.g., femoral hernias in obese
women and men and multiple hernias where only
Material
z
Between July 2010 and June 2015, 4951 ultrasound examinations of the groin area were executed in the Hanse Hernia Center Hamburg.
some of hernias are apparent with physical examination [119]. US, MRI, CT, and herniography
have all been studied in various settings in an
attempt to close this “diagnostic gap” [2, 3, 21, 26,
33, 39, 50, 53, 57, 58, 64, 67, 71, 77, 83, 100].
Results and Conclusion
z
e results show that standardized ultrasound
examinations of the groin area with high- frequency
small part linear transducers also serve to display
femoral and other small groin hernias accurately.
that US is highly sensitive and a useful way to
identify hernias [26, 32, 57]. Several other studies
have echoed this nding [67, 70, 71, 83, 90]
. Figs.8.2, 8.3, and 8.4.
e high-level specicity (0.9980) and sensitivity
(known to be strongly dependent on the exam-
cept can be provided/established.
iner) (0.9758) are proof of the procedure quality.
e recent international guideline (Herniasurge)
is recommending the combined use of a clinical
examination (CE) and DIUS:
e key question: “Which diagnostic modality
is the most suitable for diagnosing patients with
obscure pain or doubtful swelling?” lead to the
following statement and recommendation:
ther consultations and examinations should
depending on the dierential diagnostic assumptions be undertaken:
5 Radiology ->CT MRI [11]
5 Neurology
5 Orthopedy
5 Urology
5 Gynecology
Statement: QoE Recommendation
63
Discussion
CE alone can miss hernias, especially those
Two RCTs with a total of 510 patients showed
If a nal diagnosis is certain, a treatment con-
When no nal diagnosis can be achieved, fur-
8
CE and US combined is
recommended as most
suitable for diagnosing
patients with vague
groin swelling or
possible occult groin
hernias. Dynamic MRI
or CT can be consid-
ered for further
evaluation if US is
negative or non-
diagnostic
+++ Strong
(upgraded by
Herniasurge)
8.1.3 Treatment Plan
In case of a clear hernia diagnosis, dierent proposals for an individualized treatment in terms
of a tailored approach should be considered.
e patient must be oered a nal treatment
concept.
(For treatment options, see related 7 Chap. 5.)
Concerning the schedule for treatment, three
questions have to be answered: Where? When?
How?
64
H. Niebuhr et al.
. Fig.8.2 a Longitudi-
nal section (moderately
diagonal transducer
position) above the
inguinal canal showing
the spermatic cord and
the surrounding tissue.
b Longitudinal section
over a medium size
inguinal hernia during
the Valsalva maneuver
(blue mark)
8
a
b
“Where” indicates the institution when dier-
ent options are possible.
“When” xes the date of the procedure.
“How” discusses the options “day case surgery
(DCS)” or “short-stay treatment (SST).”
See also 7 Sect. 8.3 Day Care (DC) or Short-
Stay Treatment (SST).
When antithrombotic medications for factor
X or thrombocyte inhibition are in use, a clear
plan on how to act prior to the scheduled procedure has to be handed out to the patient. is plan
must be part of the informed consent. It must be
clear who is responsible for the practical procedure to stop or/and bridge the drug in correct
time before the operation.
See also 7
Sect. 8.3.3 romboembolic
Prophylaxis.
e informed consent must be discussed and
signed.
An individualized standard report and a rereferral to GP consultation for blood sample and
ECG ndings are handed out to the patients and
sent to the GP. e patient receives a folder to
attach all necessary documents.
e documentation of the consultation and
the data input to the registry (Herniamed) are
nalizing the preoperative surgical consultation.
en the patient is referred to the anesthesia
and admission consultation.
Perioperative Management ofLaparoscopic Inguinal Hernia Repair
65
8
. Fig.8.3 Femoral hernia
(echo density) in projection
on the femoral vein
(background echo-free)
during the Valsalva
maneuver (blue mark)
a
b
8.2 Anesthesia andAdmission
Consultation at Clinic
While in this consultation, the technique of anesthesia is discussed and dened/appointed.
(For anesthesia options, see related 7 Chap. 46.)
e nal schedule of date and time of admis-
sion and operation is arranged.
A nursery consultation including MRSA
check and discharge planning is included.
See also 7 Sect. 8.3.9 Discharge Management.
e informed consent must be discussed and
signed.
8.3 Day Care (DC) or Short-Stay
Treatment (SST)
In case of a necessary surgical repair of an inguinal hernia, the question whether the patient can
be treated under day care (DC) conditions or
preferably as inpatient (SST) must be considered.
Day care surgery for inguinal hernia repair has
become increasingly common over the past several decades. Synonyms for “day surgery” include
outpatient surgery, ambulatory surgery, same-day
surgery, and day case and indicate that patient discharge occurs the day of operation. It is commonly
66
H. Niebuhr et al.
. Fig.8.4 a, b Femoral
hernia (echo density) in
projection on the femoral
vein (background echo-free)
during the Valsava
maneuver (blue mark)
a
8
b
known that day surgery is safe and feasible for many
inguinal hernia repairs. Several studies prove that
day surgery is cost-eective when compared with
inpatient treatment. However, it is unclear which
complex inguinal hernias should not be repaired
as day cases.
In the guidelines, “complex cases” include:
1. Groin hernias with signs of incarceration,
strangulation, infection, and relevant preop-
erative chronic pain, dicult local ndings in
the groin such as large (irreducible) scrotal
hernias, (multiple) recurrence(s), recurrence
Perioperative Management ofLaparoscopic Inguinal Hernia Repair
67
8
with previous mesh repair, and a relevant
history of lower abdominal surgery, radiation,
and comparable problems
2. Groin hernias in patients with relevant
comorbidities (cardiovascular/pulmonary/
endocrine/immune deciency/hepatic/renal/
gastrointestinal/mental disorders/anxiety,
immune deciencies, posttransplantation
status, coagulopathies, antithrombotic
medications)
3. Dicult intraoperative ndings (severe
adhesions, abnormal anatomy, excessive
bleeding) and intraoperative complications
such as damage to viscera, blood vessels,
nerves, and genitals
4. Symptoms and signs of postoperative local
complications (bleeding, hematoma, thromboembolism, urinary retention, bowel
obstruction, peritonitis, sepsis, infection,
orchitis) and or general complications
(cardiovascular, respiratory, renal, hepatic,
gastrointestinal, cerebral organ failure,
anxiety, psychic, mental distress)
e recent international guideline (Herniasurge)
[14] is recommending to consider day surgery
even for laparoscopic repair of simple inguinal
hernias.
Discussion
z
Day surgery for inguinal hernia repair involves
patient discharge the same day of surgery aer a
period of medically supervised recovery [42].
In a rst publication on the subject in 1955, the
advantages of outpatient inguinal hernia surgery
are mentioned for the rst time: faster mobilization, lower costs and positive patient acceptance
[37]. Subsequently, several retrospective case
series and three small randomized studies were
published comparing inguinal hernia repair day
surgery with inpatient treatment [43, 82, 91, 94].
Another randomized study surveyed patient preference for site (inpatient or outpatient) of surgery
[97]. ese studies all concluded that day surgery
is cheaper than, and as safe and eective as, inpatient repair of selected inguinal hernias.
A 2006 Danish study of nearly 19,000day sur-
gery patients noted a 0.8% hospital readmission
rate [35]. A 2012 Danish multicenter study of over
57,700day surgeries found a 1.1% complication
rate leading to hospital readmission following day
surgery for inguinal hernias [76].
Although tension-free repair under local
anesthetic seems most suitable for day surgery,
published series support the use of other surgical and anesthetic techniques in this setting [5].
Day surgery should be considered for all simple
inguinal hernia repairs (both open and endoscopic) provided adequate aercare is organized
[68, 76, 79]. However, aer laparoscopic repair
(TAPP/TEP) and posterior open mesh repair,
severe pre-/retroperitoneal aerbleed may occur
in rare circumstances. In most of the cases, this
infrequent complication occurs within the rst
24–48 h postoperatively. Since the laparoscopic
management of large hematoma is oen only possible aer immediate diagnosis, short stay inpatient treatment (SST) of these patients should be
considered.
ere are insucient data to routinely recommend outpatient repair of complex inguinal hernias (see above). However, if adequate aercare is
arranged, some of these cases may be suitable for
ambulatory surgery. Operations on strangulated
and acutely incarcerated hernias should not be
performed as day cases. Barring the exclusions
cited above, inguinal hernia day surgery can be
considered for every patient with satisfactory care
at home, including stable ASA III patients [31, 54,
78, 93, 101, 103].
A recent publication based on data of 82,911
patients with inguinal hernia operations which
were documented in the German hernia registry
“Herniamed” revealed that patients with prophylactic or therapeutic use of platelet aggregation
inhibitors and oral anticoagulants had a signicant higher risk of bleeding complications (3.9%
vs. 1.1%; p < 0.001) compared to those patients
without such a medication [61]. ese data suggest that inguinal hernia day care surgery of
patients under anticoagulants cannot be recommended.
A number of additional factors will either
encourage or discourage day surgery. e anesthesiologist’s preoperative assessment is extremely
important, because he has primary responsibility
for the perioperative and immediately postoperative phase [93]. Other hospital-, physician-, and
patient-related factors must be considered also
[42]. In a facility with considerable day surgery
experience and a good infrastructure (i.e., easy
availability of pre-assessment consultation and
a smoothly functioning day surgery center), a
large percentage of inguinal hernia repairs may
68
H. Niebuhr et al.
take place in day surgery. Surgical factors (quick
operations and few complications) and anesthetic
factors (eective pain and nausea control making
rapid patient discharge possible) may inuence
the decision to proceed with day surgery.
In the literature, very heterogeneous information about postoperative rate of wound infections
are given, ranging from 0% to 8.8% with antibiotic
prophylaxis and from 0% to 8.9% without prophylaxis [15]. In an updated Cochrane review of 2012,
a group of authors came to the conclusion that a
general antibiotic prophylaxis in inguinal surgery
8.3.1 Preoperative Admission
totheClinic
cannot be recommended [102]. Publications that
are explicitly emphasizing the dierence between
open and laparoscopic technology are rare. In
Prior to the operation, the patient comes to the
clinic at the scheduled date and time. Administrative
procedures are passed through. Following the
patient will be prepared for the operation.
the laparoscopic surgery, the infection rate varies from 0% to 2.8%. In the open surgery, it varies
from 0.7% to 3.1% [15].
Data from the Herniamed registry study could
show that only the positive inuence of the endoscopic or laparoscopic technique is enough on
8.3.2 Perioperative Antibiotics
8
Perioperative antibiotic prophylaxis in hernia surgery is still controversial. e aim of antibiotic
prophylaxis is to reduce surgical site infections.
By prophylaxis, a multiplication of pathogens that
contaminate the surgical eld should be prevented. is must be evaluated by the toxicity,
allergic reactions, development of resistance, and
higher perioperative costs. Antibiotic prophylaxis
cannot replace evidence-based hygiene measures
for the prevention of postoperative infections, but
it can only complement [120].
Hernia operations are by denition “clean
procedures” [52]. In contrast, there are also a signicant number of patients associated with risk
factors that may promote an increased rate of surgical site infections [1, 4].
postoperative infection rate, and an additional
benet is not reached by perioperative antibiotics.
At the same time, these data show a benet of
perioperative eect of antibiotics in open inguinal
hernia procedures [62].
A general antibiotic prophylaxis cannot be
recommended, therefore, in endoscopic routine
inguinal hernia repair [92]. Existence of additional risk factors should evaluate in each case the
decision in favor of an antibiotic. Risk factors are
listed in . Table8.4.
e optimal time of antibiotics, depending on
the half-life of the antibiotic, should be within a
period of 60min before cutting, ideally at the time
of anesthetic induction [48, 122]. A single dose of
PAP is preferred [127].
In our facility, an antibiotic is introduced
30min before incision in all open inguinal hernia.
. Table8.4 Individual risk factors mod [1]
Patients factors Surgical skills Intraoperative Postoperative
Age Emergency Time<2h Revision
Diabetes mellitus Contaminated More than one procedure Drainage more than 3days
Immunodeciency Complication Reoperation
Adipositas
MRSA
Dialysis
Drug abuse
ASA-Score>3
Perioperative Management ofLaparoscopic Inguinal Hernia Repair
69
8
. Table8.5 Standards in the Hernia Center
Cologne
Procedure Generic Single
shot
TEP – –
TEP+Umbilicus Cefuroxim 1.5g X
TEP+Risk factors Cefuroxim 1.5g X
Lichtenstein Cefuroxim 1.5g X
Shouldice Cefuroxim 1.5g X
TIPP Cefuroxim 1.5g X
e endoscopic surgery without additional risk
situation such as diabetes mellitus no routine
antibiotic prophylaxis is carried out.
. Table 8.5 shows an overview of the stan-
dards in the Hernia Center Cologne.
Selection of the appropriate antibiotic is carried out primarily by the expected spectrum of
pathogens, resulting from the normal or pathological colonization of the surgical eld and its
immediate cutaneous and mucosal environment.
In addition, care must be taken individually for
each patient on a possible antibiotic allergy [60].
Deciding which antibiotic is used depends
primarily on the expected range of bacteria
specific to operating region. Microbiological
results of the specific region should be considered. The antibiotic should have few side
effects, be little allergenic and inexpensive. For
groin ampicillin is recommended with sulbactam and cephalosporins group one and two
[120]. There is no advantage in multidose anti-
biotic prophylaxis [88].
8.3.3 Thromboembolic Prophylaxis
e annual incidence of DVT in the general population is between 0.05% and 0.1 without any surgical treatment [6]. According to the American
College of Chest Physicians, the prevalence of
DVT is in general surgery at 15–40% [6, 40].
romboembolic events in inguinal hernia
repair are very rare. According to the most existing guidelines worldwide, unilateral inguinal hernia repair is a low-risk procedure [15, 40].
Despite the low risk is a prophylaxis against
DVT in view of the potentially fatal risk of a pulmonary embolism useful and is done by the most
surgeons [4]. ese results in the need for a prophylaxis, as a thrombosis can throw just in the
early stages clots in the blood stream without
clinically tangible symptoms. A reliable test for
determining the individual risk of thrombosis is
currently not available [40]. Hence the need for a
general thromboembolic prophylaxis in the repair
of inguinal hernia arises, even for ambulatory surgery, although this is not explicitly required in the
international guidelines.
e indication and the choice of prophylaxis
should be carried out individually and risk adapted.
e risk of developing a VTE is inuenced by two
dierent factors: on the one hand the risk that is
caused by the exposition in the kind and duration
of operation and the risk at the patient’s disposition to develop a VTE on the other. A special role
is played by the patient’s medical history with
regard to previous thromboembolism.
All data about inguinal hernia repair is
counted in the group of general surgical operations. Individual studies on the risk of DVT or
VTE in inguinal hernia repair are not available.
A recent study showed a slower ow in the femoral vein aer implantation of a mesh but with no
inuence on the development of thrombosis [15].
Laparoscopic procedures considering to the positioning of the patient and intra-abdominal pressure may have a higher risk for the occurrence
of DVT [7, 51]. e thromboembolism must be
weighed against the risk of increased bleeding
tendency and thus increased postoperative complications. Patient-related risk factors are [116]:
5 Active cancer or cancer treatment
5 Age over 60years
5 Critical care admission
5 Dehydration
5 Known thrombophilias:
5 Inherited thrombophilias, for example:
Ȥ High levels of coagulation factors (e.g.,
factor VIII)
Ȥ Hyperhomocysteinemia
Ȥ Low-activated protein C resistance (e.g.,
factor V disease)
Ȥ Protein C, S, and antithrombin deciencies
Ȥ Prothrombin 2021A gene mutation
5 Obesity (body mass index [BMI] over
2
30kg/m
)
70
H. Niebuhr et al.
5 One or more signicant medical comorbidi-
ties (e.g., heart disease; metabolic, endocrine,
or respiratory pathologies; acute infectious
diseases; inammatory conditions)
5 Personal history or rst-degree relative with a
history of VTE
5 Use of hormone replacement therapy
5 Use of estrogen-containing contraceptive
therapy
5 Varicose veins with phlebitis
5 Women who are pregnant or have given birth
within the previous 6weeks
increase in the exibility of its reactive site loop.
e activated AT then inactivates thrombin and
other proteases involved in blood clotting, most
notably factor Xa. e rate of inactivation of these
proteases by AT can increase by up to 1000-fold
due to the binding of heparin [19, 27, 47].
A serious side eect of heparin is heparininduced thrombocytopenia (HIT), caused by an
allergic reaction of the body. HIT is caused by the
formation of abnormal antibodies that activate
platelets. HIT antibodies have been found in individuals with thrombocytopenia and thrombosis
who had no prior exposure to heparin, but the
Therapeutic Approach
majority are found in people who are receiving
heparin [121]. Frequencies for HIT are given with
Physical Activities
5 Early mobilization
8
5 Compression stockings
5 Intermittent pneumatic compression
2.6% for unfractionated heparin and 0.2% for
low-molecular-weight heparin [73].
e common application for heparin has
become the low-molecular-weight fractionated
form. ere is no sure medical benet to low-
e early mobilization in hernia surgery is a standard. In an age increasingly outpatient operations
performed, it is a conditio sine qua non. Only disabled patients represent a high-risk group. e
discussion about compression stockings is still
controversial, although no study shows a clear
molecular- weight heparin comparing to unfractionated heparin, except for the once-daily
administration form [22, 30].
. Table8.6 shows an overview of the approved
LMWH and pentasaccharide in the prophylaxis
of VTE [6].
benet was observed, also there is no evidence
that they harm [56, 105]. But without accompanying pharmacological thromboprophylaxis, they
are not suitable alone. Intermittent pneumatic
compression is not an option for inguinal hernia
Other Medicaments Used
forThromboembolic Prophylaxis
Indication may be a HIT or other intolerances to
heparin or derivates.
repair patients.
Heparin
Heparin is a naturally occurring anticoagulant
produced by basophils and mast cells. Heparin
acts as an anticoagulant, preventing the formation
of clots and extension of existing clots within the
blood. While heparin does not break down clots
that have already formed, it allows the body’s
natural clot lysis mechanisms to work normally to
break down clots that have formed. Heparin and
its low-molecular-weight derivatives (e.g., enoxaparin, dalteparin, tinzaparin) are eective at preventing deep vein thrombosis and pulmonary
emboli in patients at risk, but no evidence indicates any one is more eective than the other in
preventing mortality.
Heparin binds to the enzyme inhibitor antithrombin III (AT), causing a conformational
change that results in its activation through an
. Table8.6 Approved LMWH and pentasaccha-
ride in the prophylaxis of VTE
Generic Trade name Dosage
Certoparin Mono
Embolex NM
Dalteparin Fragmin P 2500I.E. anti Xa
Enoxaparin Clexane 20 20mg/40mg
Nadroparin Fraxiparin
0,2–1,0
Reviparin Clivarin 13,8mg/25ml
Tinzaparin Innohep 3500I.E.
Fondaparinux Arixtra 2,5mg
Danaparoid Orgaran 2×750I.E.
3.000I.E. anti-Xa
1900I.E.–
9500I.E. anti-Xa
anti-Xa
Perioperative Management ofLaparoscopic Inguinal Hernia Repair
71
8
Not Vitamin K-Dependent Oral Factor Xa
Inhibitors [97, 98] . Table8.7
. Table8.7 Not vitamin K-dependent oral factor
Xa inhibitors
Generic Trade name Dosage
Rivaroxaban Xarelto 10mg (oral)
Apixaban Eliquis 2,5mg (oral)
Direct Thrombin Inhibitors [9, 125]
. Table8.8
. Table8.8 Direct Thrombin inhibitors
Generic Trade
name
Argatroban Argatra 2μ g/kg/min. i.v.
Dabigatran
etexilate
Pradaxa 75mg up to
Dosage
150mg
of the issues is the surgical site hair removal. It is
performed as electric clipping. According to the
planned procedure, the area of hair removal is determined: for laparoscopic TAPP or TEP repair, a bigger area is requested than for open inguinal repair.
In three reviews [59, 112, 113] and one RCT
[84], no strong evidence was found to advocate
against preoperative hair removal. Furthermore,
there was strong evidence to recommend that
when hair removal is considered necessary, shaving should not be performed. Instead, a depilatory
or electric clipping, preferably immediately before
surgery, should be used [8].
8.3.5 Intraoperative Procedures:
Anesthesia andOperation
(For anesthesia and surgical treatment options,
see related 7 Chap. 46.)
8.3.6 Postoperative Documentation
andData Input toRegistry
Vitamin K Antagonists . Table8.9
. Table8.9 Vitamin K Antagonists
Generic Trade name Dosage
Warfarin Coumadin,
Jantoven
Phenprocoumon Marcumar,
Falithrom
Individ.
Individ.
Duration of VTE-Prophylaxis
e duration of the VTE-prophylaxis depends and
orientates on the individual risk of the patient. In
inguinal hernia, it’s only necessary if there are risk
factors on patient, e.g., inherited thrombophilias.
8.3.4 Preoperative Hair Removal
of the Operation Field
In the Hanse-Hernia Center Hamburg, the following procedure is used: Aer informing the sta of
the ward to prepare the next patient for surgery, one
Immediately aer the procedure, the documentation is done and a report sent to the GP. e
related data have to be put in to the registry.
8.3.7 Postoperative Readmission
totheWard
Aer the stay in the anesthetic recovery room, the
patient is readmitted to the ward in case of shortstay treatment where the postoperative treatment
follows nursery standards. In case of day case surgery, the patient can be discharged directly from
the anesthetic recovery room or from the ward.
See also 7 Sect. 8.3.9 Discharge Management.
8.3.8 Postoperative Pain Control
One of the most important treatments immediately aer the surgical procedure is an eective
pain control. Early pain within the rst week aer
TAPP and TEP is most severe on the rst postoperative day, and the pain pattern is dominated by
deep abdominal pain [114]. e pain control
treatment should always follow a clearly dened
standard procedure.
72
H. Niebuhr et al.
. Table8.10 Concept of postoperative pain control [63]
Concept 1 Concept 2
Basic pain value acc. NRS NRS value >4->Step 1
NRS value >8
Inform doctor in charge
Step 1 Paracetamol p.o. 4×1g /24h
or
Paracetamol i.v. 4×1g/24h
and
Ibuprofen p.o. 3×600mg
PPI 20mg/24h when indicated
Control pain value acc. NRS NRS value >4->Step 2
NRS value >8
Inform doctor in charge
Step 2 Pitriamid 7.5mg s.c. Up to 4×/24h
or
8
Control pain value acc. NRS NRS value >4->evaluate repeated
It is evidence based that laparoscopic inguinal
hernia repair leads to less postoperative pain as
well for the early postoperative period as for the
time up to 3months aer surgery (chronic inguinal pain/CIP).
e use of regional anesthesia instead of the
traditional general anesthesia does not seem to
adversely aect the quality of repair. Whether it
oers the patient an anesthetic alternative leading
to less postoperative pain remains unclear [118].
Nevertheless, a postoperative pain control
treatment is necessary which should be started
already intraoperatively.
For the Hanse-Hernia Center Hamburg, the
following ow sheet/treatment instruction is
actually in practical use
Hereby, a sucient postoperative pain control
is provided as well aer laparoscopic hernia repair
as aer open procedures.
Pitriamid 7.5mg i.v. Up to 4×/24h
Otime always 4h
When indicated
Oxycodon 10/5mg p.o. 2×/24h
drug administration (regard o times)
NRS value >8
Inform doctor in charge
. Table8.10:
mendation says that an endoscopic technique is
considered if a quick postoperative recovery is
particularly important [111].
Dierent meta-analyses revealed that aer an
open mesh procedure, patients recovered 4days
earlier on average than aer a conventional repair
and recovered 7days earlier on average following
an endoscopic operation than aer an open technique with mesh [17, 18, 23, 28, 45, 49, 66, 68, 80,
104, 107]. e main cause of prolonged recovery
is predominantly pain [24].
e use of a titanized ELW mesh for laparoscopic hernia repair did not aect the rate of
chronic pain, but it seems to improve early postoperative convalescence [16].
In addition to the pre- and intraoperative pain
prevention and treatment methods (above), nonopioid and nonsteroidal anti-inammatory medications (acetaminophen, NSAIDs, and selective
NRS value >4->Step 1
NRS value >8
Inform doctor in charge
Metamicol p.o. 4×1g/24h
or
Metamicol i.v. 4×1g/24h
NRS value >4->Step 2
NRS value >8
Inform doctor in charge
Pitriamid 7.5mg s.c. Up to 4×/24h
or
Pitriamid 7.5mg i.v. Up to 4×/24h
Otime always 4h
When indicated
Oxycodon 10/5mg p.o. 2×/24h
NRS value >4->evaluate repeated drug
administration (regard o times)
NRS value >8
Inform doctor in charge
COX-2 inhibitors) should be used for postopera-
Discussion
z
e EHS Guidelines conclude (Level 1A) that
endoscopic inguinal hernia techniques result in
an earlier return to normal activities or work than
the Lichtenstein technique. e Grade A recom-
tive pain management [12, 25, 34, 106, 109, 117].
Paracetamol (acetaminophen) has insucient
eect as single-agent therapy for moderate to
severe pain. However, the combination of
paracetamol and a nonsteroidal anti- inammatory