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367
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371
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_31,
© Springer Science+Business Media New York 2013
31. Drains, Pain Pumps,
and Abdominal Binders
Chris Edwards
Some aspects of surgery rely heavily on science to tell the surgeon
how to perform a certain procedure or determine which adjunctive
modality should be used at a certain time. Some aspects of surgery rely
on surgical science to develop algorithms of patient care and to standardize
best practices. Some aspects of surgery rely more heavily on tradition
than on hard scienti fi c fact usually in areas where surgical science is hard
to produce or inconsistent. Some areas are a true blend of the science of
surgery and the art of surgery. This is certainly true when discussing
current strategies regarding drains, pain pumps, and abdominal binders
for the laparoscopic treatment of hernia.
This is certainly one area where surgical science is lacking. There
simply is a paucity of true surgical research in this area of hernia repair.
Many surgeons rely on the advice of others and the traditions that have
been passed down from their mentors as to when these adjuncts to hernia
repair are used. This chapter is an attempt to consolidate what little
research is available and to provide the author’s current practice regarding
the use of drains, pain pumps, and abdominal binders for laparoscopic
hernia repair.
Drains
There are many types of drains available for surgical practice today.
Open or closed drainage of hernia repair has been described. The scope
of this writing is not to describe the types of drains available but to
describe the use during laparoscopic hernia repair.
372
C. Edwards
The primary purpose of the use of any drain is to be able to evacuate
blood, pus, or fl uid from a surgical site. The bene fi ts of this in hernia
repair may be to decrease seroma formation, to remove infected material
from a surgical site, or to allow more rapid healing of wounds by the use
of negative pressure. Drains used for open treatment of hernia are often
used to evacuate the accumulation of seroma fl uid.
The use of drains during laparoscopic hernia repair is often
controversial. There truly is minimal data published on this topic. The
use of drains for laparoscopic hernia repair should be balanced by the
possibility of introducing an outside contaminant with the bene fi t of
removing seroma fl uid. Closed suction drains placed over a permanent
prosthetic material should be avoided as the author feels this can lead to
a portal of infection to the mesh often used for laparoscopic hernia repair.
One of the key bene fi ts of laparoscopic hernia repair is the decreased risk
of wound infection and mesh infection [
1, 2 ] . It simply does not make
sense to leave a tract for the possible contamination of a mesh material
by the use of a drain.
However, the data on the use of drains during laparoscopic mesh
hernia repair is minimal. In fact, Kaafarani et al. list the placement of a
surgical drain as an independent risk factor for the development of
surgical site infection after laparoscopic ventral hernia repair [ 3 ] . Other
studies have found inconclusive evidence on whether the use of a drain
over mesh hernia repairs yields an increase in surgical site infections or
not during incisional hernia repair [ 4 ] .
One recent study is worth looking into that advocates the use of
closed suction drainage during laparoscopic total extraperitoneal (TEP)
inguinal hernia repair. This study by Ismail et al. reviewed 929 patients
(1,753) hernias where laparoscopic TEP hernia repair was performed.
Eight hundred forty-nine (1,607) patients had drains placed where 80
(146) patients did not. Seroma formation was signi fi cantly less in the
drain group (0.75 %) compared to the open group (15.1 %). No infections
were identi fi ed in either group supporting the use of drains in this
procedure [ 5 ] . Still, the data suggesting routine drainage for mesh hernia
repair is sparse, and the author does not recommend the use of drains in
this setting. Furthermore, the author feels that the risk of even one mesh
infection during laparoscopic repair outweighs the bene fi ts of decreased
seroma formation that typically clears spontaneously without
complication.
However, one example where drains should be used liberally is in
abdominal wall reconstruction. Drains should be used during component’s
release incisional hernia repair in the submuscular spaces that are created
373
31. Drains, Pain Pumps, and Abdominal Binders
during this particular type of procedure. Drains used in this fashion will
help reduce seroma formation and allow the negative pressure to help
“seal” these spaces and improve healing. Furthermore, the evacuation of
this fl uid can certainly help limit the accumulation of old hematoma and
seroma that can predispose to abscess formation in the often medically
complex patients where this procedure is performed. The technique
should attempt to separate any prosthetic with drains to limit contamination
of the mesh. These drains left in the submuscular spaces should be left
longer than most other procedures where mesh is used typically. Most
surgeons remove drains when the volume of fl uid being drained reaches
a certain minimal amount. However, with components release where
large sub- or intramuscular fl aps are created, the author feels it is useful
to leave these drains in for 2–3 weeks sometimes for the negative pressure
to help close these spaces and speed healing.
Overall, minimal data supports the use of drains during laparoscopic
mesh hernia repair. Several studies emphasize the use of drains to
increase the incidence of surgical site and mesh infections when used in
this matter. Some studies may demonstrate the use of drains to decrease
seroma rates, but the author feels that the prevention of this relatively
benign complication not to be worth the risk of mesh infection that the
drain may cause. If the surgeon can separate the mesh from the site
needed for drainage however as in certain abdominal wall reconstruction
techniques, then drains may prove useful. More data needs to be
evaluated.
Binders
Many surgeons feel that the use of abdominal binders after
laparoscopic ventral hernia repair may have many advantages. The
possible advantages include less pain, possibility of lower recurrence,
and the possibility of fewer seromas. Like the use of drains after
laparoscopic hernia repair, there is a paucity of data for this.
The most common binders used in the United States are relatively
inexpensive elasticized products with Velcro fi xation. The bene fi ts of
these binders are that they are cheap and easy to place. They are also
readily available at any medical supply store. These are usually placed
immediately after the procedure. Many surgeons claim that these binders
add support to the repair; however, there is no clear evidence in the
literature to support this for laparoscopic repair.
374
C. Edwards
One of the most common fi ndings after laparoscopic incisional hernia
repair is postoperative seroma. These are all usually benign but can be
disconcerting to the patient and confused with early recurrence to the
inexperienced clinician. Dr. LeBlanc feels that the use of binders may
decrease the incidence of this common fi nding after surgery [ 6 ] . However,
this author could not fi nd any comparative analysis in the literature to
support this.
There does seem to be some support in the literature for the use of
binders to bene fi t postoperative pain after laparoscopic hernia repair.
Cheifetz et al. found a signi fi cant reduction in pain 1, 3, and 5 days after
surgery with the use of binders. They also found improvement in the ability
to ambulate afterward in a randomized control trial [ 7 ] . Larson et al. also
demonstrated an improvement in pain scores of about half that without
binders in a prospective randomized control study of 54 patients [ 8 ] .
A criticism of binders is that there may be a decrease in the patient’s
ability to breathe. This may lead to poor respiratory function and the
associated problems of atelectasis, postoperative fever, and pneumonia
following an especially painful procedure. Larson and Chei fi tz groups
both looked at this as well and found no reduction in pulmonary function
as measured by pulmonary function testing with the use of abdominal
binders after major abdominal surgery [ 7, 8 ] .
The author feels that binders can help with pain if the patient feels
that this will be the case. The authors do not routinely use binders after
laparoscopic ventral hernia repair unless asked by the patient. There is
no clear evidence that binders reduce the incidence of seroma formation
or reduce the recurrence rate. However, pain control does seem to be
improved. The drawback however is that many patients feel that the
binder is “prescribed” for them and they often wear it to excess, including
in the shower. The author has seen some very foul binders come back in
to the of fi ce raising the question of hygiene for these patients. Overall,
binders may have a utility for pain control but have not shown a clear cut
bene fi t in other postoperative improvements in laparoscopic incisional
hernia repair.
Pain Pumps
Pain control after laparoscopic surgery is a huge topic and best suited for
its own chapter. The general feeling that the laparoscopic approach is a less
painful approach should not mean to say that laparoscopic treatment of
375
31. Drains, Pain Pumps, and Abdominal Binders
hernia is a painless procedure. In fact, the author believes that the laparoscopic
approach provides access to perform a much more thorough dissection than
an open approach. The laparoscopic approach also allows for more broad
mesh placement which can irritate a very sensitive peritoneum and provide
signi fi cant postoperative pain. The use of postoperative pain pumps can be
one way to minimize this pain after surgery.
Pain control after laparoscopic surgery can consist of a variety of
modalities. Intravenous and oral narcotics, anti-in fl ammatory, epidural
catheter infusions, regional anesthetic blocks, and placement of pain
pumps are a few of these modalities. This discussion will center on what
the literature supports for the placement of pain pumps after laparoscopic
hernia repair.
Epidural catheter pumps have been demonstrated to be a successful
pain control strategy for a number of open procedures. However, the
routine use of epidural catheters for laparoscopic hernia repair is not
universally accepted or understood. There is minimal data supporting
this. This author feels however that a laparoscopic repair of a large
ventral hernia is a very painful procedure. This author also routinely uses
epidural catheter and patient-controlled pumps for its administration
after their repair. The data is not published yet, but this author has seen a
reduction in length of stay by 2 days as well as a faster recovery of
gastrointestinal function after the use of epidural catheters for laparoscopic
repair of ventral hernias over 30 cm
2
. In fact, an ad hoc analysis of the
authors’ data supported early closure of the trial due to favorable results.
These fi ndings are to be presented later this year.
There are problems associated with epidural catheters however.
Weakness and numbness are some common side effects. Urinary retention
is also common. A lot of these factors are technique driven and depend
on the anesthetists’ skill at placing the catheter. In summary, it is
reasonable to consider an epidural catheter for pain control after any
large laparoscopic ventral hernia repair.
The uses of regional anesthetic pumps are commonplace as well. The
most common is a Silastic-type catheter attached to a continuously
infusing reservoir of local anesthetic designed to administer a set amount
of local anesthesia to the surgery site. The use for open inguinal hernia
repair is present with Stewart et al. and Sanchez et al. presenting their
data in 2004 demonstrating lower mean pain scores and less rescue
aesthesia with the use of these pumps in open inguinal hernia repair. This
difference persisted even after removal of the pump [ 9, 10 ] . However,
Rosen et al. did not see a difference in pain scores with the use of these
pumps after laparoscopic ventral hernia repairs in 73 patients [ 11 ] .
376
C. Edwards
An interesting corollary of this is the use of regional block anesthesia
with or without the use of pumps. There has been interest in the
administration of local anesthetic to the preperitoneal space for the use
of both open and laparoscopic procedures. This is commonly called
transversus abdominis plane (TAP) block. Heil et al. reported a bene fi t in
pain scores when used for outpatient open inguinal hernia repair [ 12 ] ,
while Ahmed et al. reported a bene fi t with laparoscopic incisional hernia
repair [ 13 ] . Data on this technique is sparse but carries the bene fi t of no
additional short-term catheter.
Conclusion
The use of drains, binders, and pain pumps is largely driven by anecdotal
evidence only. Few studies really support or disprove these techniques in
regard to laparoscopic hernia repair. However, these techniques may prove
bene fi cial in the long run and require further study.
References
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hernia. World J Surg. 2006;30(11):2056–64.
2. Sauerland S, et al. Laparoscopic versus open surgical techniques for ventral or
incisional hernia repair. Cochrane Database Syst Rev. 2011;3:CD007781.
3. Kaafarani HMA, et al. Predictors of surgical site infection in laparoscopic and open
ventral incisional herniorrhaphy. J Surg Res. 2010;163(2):229–34.
4. Gurusamy KS (2007) Wound drains after incisional hernia repair. Cochrane Database
Syst Rev. 2007; (1):CD005570.
5. Ismail M, et al. Impact of closed-suction drain in preperitoneal space on the incidence
of seroma formation after laparoscopic total extraperitoneal inguinal hernia repair.
Surg Laparosc Endosc Percutan Tech. 2009;19(3):263–6.
6. LeBlanc KA. Laparoscopic incisional and ventral hernia repair: complications—how
to avoid and handle. Hernia. 2004;8(4):323–31.
7. Cheifetz O, et al. The effect of abdominal support on functional outcomes inpatients
following major abdominal surgery: a randomized controlled trial. Physiother Can.
2010;62(3):242–53.
8. Larson CM, et al. The effect of abdominal binders on postoperative pulmonary
function. Am Surg. 2009;75(2):169–71.
377
31. Drains, Pain Pumps, and Abdominal Binders
9. Stewart A, et al. Randomized trial of a pain control infusion pump following inguinal
hernia repair. ANZ J Surg. 2004;4(10):873–6.
10. Sanchez B, et al. Local anesthetic infusion pumps improve postoperative pain after
inguinal hernia repair: a randomized trial. Am Surg. 2004;70(11):1002–6.
11. Rosen MJ, et al. Prospective randomized double-blind placebo-controlled trial of
postoperative elastomeric pain pump devices used after laparoscopic ventral hernia
repair. Surg Endosc. 2009;23(12):2637–43.
12. Heil JW, et al. Ultrasound-guided transversus abdominis plane catheters and ambulatory
perineural infusions for outpatient hernia repair. Reg Anesth Pain Med.
2010;35(6):556–8.
13. Ahmed M, et al. A simple technique of regional anesthesia to reduce opioid
requirements postoperatively in laparoscopic incisional hernia repairs. Surg Laparosc
Endosc Percutan Tech. 2011;21(2):e70–1.