Acta Anaesthesiol Scand 2001; 45: 603–607 Copyright C Acta Anaesthesiol Scand 2001Printed in Denmark. All rights reserved

ACTA ANAESTHESIOLOGICA SCANDINAVICA

ISSN 0001-5172

Effect of preincisional ilioinguinal andiliohypogastric nerve block on postoperative analgesicrequirement in day-surgery patients undergoingherniorrhaphy under spinal anaesthesia

J. TOIVONEN1, J. PERMI2 and P. H. ROSENBERG3

Departments of 1Anaesthesia and 2Surgery, South Carelian Central Hospital, Lappeenranta, and 3Department of Anaesthesiology and Intensive Care,Helsinki University Hospital, Helsinki, Finland

Background: By choosing spinal anaesthesia instead of generalanaesthesia, and by infiltrating the wound area with local anaes-thetic the need for postoperative analgesics may be reduced. Anilioinguinal and iliohypogastric nerve block (IINB) in inguinalherniorrhaphy was, therefore, studied in a day surgery settingin combination with a spinal block.Methods: One hundred ASA I–II adult patients scheduled foringuinal herniorrhaphy were given spinal anaesthesia withhyperbaric 0.5% bupivacaine. In a randomized and blindedfashion half of them received an IINB 5 min before the surgicalincision with 10 ml of 0.5% bupivacaine (B-IINB) and the otherhalf with saline (S-IINB). All patients received ketoprofen 100mg i.v. during surgery and another 100 mg 2–3 h postopera-tively. The patients were observed for about 6 h in the daysurgery unit before discharge.Results: The results showed that in comparison with the S-IINBgroup, significantly fewer patients in the B-IINB group neededanalgesics (P,0.01) and the amount required was also signifi-cantly less postoperatively, before discharge (about 6 h post-

IN RECENT YEARS day surgery has increased in popu-larity and volume because of the development of

less invasive surgical techniques, improved post-operative pain control methods and the need for gen-eral medical cost savings. Uncontrolled pain is one ofthe reasons for readmissions following day surgeryand, occasionally, prolonged postoperative pain maydelay the return to normal daily functions and towork. In fact, pain after day surgery may still be rela-tively strong on the seventh postoperative day (1). Ina recent follow-up study on orthopaedic patients, ap-proximately 7% of the patients reported strong painin the operative area one week after the operation (2).

Local anaesthetic nerve blocks of the operative area,before incision and/or after incision, have been foundto decrease the intensity of pain and the need for anal-gesics in the postoperative period (3–6). Most promis-

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operatively) (P,0.05). The latency to the need for the first post-operative analgesic was shorter in the S-IINB patients (P,0.01).At home the VAS scores and the need for analgesics (oral keto-profen 100 mg) were low with no differences between thegroups. No complications occurred.Conclusion: It is concluded that no long-term analgesia couldbe demonstrated by a preincisional IINB performed duringspinal anaesthesia in day-surgery inguinal herniorrhaphy pa-tients. Thus, reduced analgesic requirement was seen only forabout 6 h postoperatively.

Received 26 July, accepted for publication 29 November 2000

Key words: Anesthesia: day surgery; anesthetics, local: bupiva-caine; anesthetic techniques: subarachnoid, ilioinguinal-iliohy-pogastric nerve block; pain: postoperative; surgery: inguinalherniorrhaphy.

c Acta Anaesthesiologica Scandinavica 45 (2001)

ing results were reported by Bugedo et al. (6), whodemonstrated lower postoperative pain scores for upto 48 h after inguinal herniorrhaphy in in-hospital pa-tients when they performed an ilioinguinal andiliohypogastric nerve block (IINB) before incision.Other studies (3, 4) have shown only a short-lastingbenefit of local anaesthetic infiltration, and the choiceof anaesthetic technique (regional vs. general) mayalso play a role (7, 8).

With the use of bupivacaine and thin spinal needlesfor day-surgical lower body operations, the quality ofspinal anaesthesia is good and postanaesthetic ad-verse sequelae are rare (9, 10). We found it worthwhileto examine whether a supplemental IINB may futherprolong the painfree period provided by the spinalblock anaesthetic and, perhaps, also reduce the needfor analgesics in the patients’ home environment.

J. Toivonen et al.

Patients and methods

One hundred patients, ASA physical status I–II, un-dergoing elective open repair of a unilateral inguinalhernia (Lichtenstein) in the day-surgery unit (DSU)were studied. This randomised double-blind studywas approved by the Hospital Ethics Committee, andinformed written consent of each patient was ob-tained for the study.

Patients who were allergic to nonsteroidal antiin-flammatory drugs (NSAIDs) or local anaesthetics orin whom NSAIDs were contraindicated, those knownto be using analgesics regularly for other reasons, andthose aged less than 15 yr were excluded.

No premedication was given but all of the patientsreceived the antibiotic ciprofloxacin 750 mg p.o. onehour before the surgery because the surgical tech-nique involved the use of nonabsorbable mesh graft.All patients had spinal anaesthesia (27 G Quinckeneedle) with hyperbaric bupivacaine 0.5% (1.8–2.4 mlaccording to the patient’s height and weight) in the L2–3 intervertebral space. During spinal injection, thepatients lay in the lateral horizontal position, with theoperative side down. No supplementary opioids weregiven during the operation. The patients were ran-domised into one of two groups when the anaestheticlevel was at least Th 10, as assessed with an ice cubeon the skin. The ilioinguinal-iliohypogastric nerveblock (IINB) was performed by the surgeon as rec-ommended by von Bahr (11) and implemented by Bu-gedo et al. (6). From a point 3 cm medial to the an-terior superior iliac spine, a needle was introducedthrough the abdominal skin, until the needle piercedthe aponeurosis of the external oblique muscle. Be-neath this, either 10 ml 0.5% plain bupivacaine (B-IINB group) or 10 ml of saline (S-IINB group) wasinjected in a fanlike manner after careful aspiration ina double-blind fashion. All personnel involved in thepatients’ treatment were blinded. Surgery was startednot earlier than 5 min after the injection.

Monitoring included ECG, noninvasive arterialblood pressure and pulse oximetry. Ketoprofen 100mg i.v. infusion was administered 10 min before theend of surgery during 20 min and after this an ad-ditional dose of 100 mg i.v. during 2–3 h. Aftersurgery, the patients stayed first in the post anaes-thesia care unit (PACU) and were then transferred tothe DSU for complete recovery before being dis-charged home. The patients evaluated the intensity oftheir pain on a linear analogue pain scale (VAS) rang-ing from 0 (no pain) to 10 cm (intolerable pain) 2, 3and 4 h after the end of surgery. VAS was also regis-tered when the patient requested analgesic in the

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PACU and the DSU before discharge, and daily, in themorning, and when additional analgesic was neededduring seven days at home.

In the PACU, the first additional analgesic was 0.05mg fentanyl i.v. (if VAS score Ø5) or 30 mg ketorolaci.v. (VAS∞5). The second analgesic, if needed, was ke-torolac after fentanyl or fentanyl after ketorolac. Afterthis the additional analgesic was fentanyl, if necess-ary. At home, the patients took 100 mg ketoprofenorally (maximally 300 mg/d), if needed.

Discharge criteria included complete motor recov-ery, ability to void, absence of nausea, bleeding andexcessive pain.

Statistical analysis was performed using the two-tailed unpaired t-test, Mann-Whitney U-test and chi-square test. The repeated measurements were ana-lysed using two-tailed analysis of variance for re-peated measurements. Statistical significance wasconsidered at P,0.05. Results are given as mean∫SD,unless otherwise indicated.

Results

Patient characteristics and surgery time were compar-able between the groups (Table 1). The cephaled ex-tension of sensory analgesia (‘‘cold’’ test) was aboveTh 10 and none of the patients needed any analgesicsduring surgery.

The number of patients who needed supplementaryanalgesics after surgery, before the discharge, wassmaller in the B-IINB group (P,0.01) (Table 2), andalso the mean number of doses of supplementary an-algesics was smaller (P,0.05) in the B-IINB groupthan in the S-IINB group (Table 3). Mean VAS scoreswere 1.1∫1.3, 1.5∫1.5 and 1.7∫1.4 at 2, 3 and 4 h aftersurgery in the B-IINB group and 1.6∫1.5, 2.4∫1.7 and2.6∫1.7, respectively, in the S-IINB group (P,0.01).Mean VAS scores were 3.3∫0.9 if the patient needed

Table 1

Patient characteristics and surgery time.

B-IINB group S-IINB group(nΩ50) (nΩ50)

Age (yr) 56 (24–83) 56 (29–79)Weight (kg) 77∫9 75∫9Height (cm) 176∫7 176∫7Sex (M/F) 47/3 46/4ASA (I/II) 23/27 28/22Surgery time (min) 32∫11 32∫11Time from end of surgery 345∫63 359∫70

to discharge (min)*

Values are mean∫SD, (range) or number.*The ‘‘discharge criteria’’ were reached earlier.

Nerve blocks and analgesia after herniorrhaphy

Table 2

Number of patients (%) who needed postoperative analgesics beforedischarge (for about 6 h) or after discharge (for seven days).

B-IINB group S-IINB group(nΩ50) (nΩ50) P

Before discharge 26 (52) 39 (78) ,0.01After discharge 48 (96) 45 (90) nsPostoperative analgesics 48 (96) 46 (92) ns

Table 3

Mean supplementary analgesic requirements before discharge.

B-IINB group S-IINB group P

Ketorolac (mg) 16∫15 23∫13 ,0.05Fentanyl (mg) 15∫29 50∫59 ,0.01

Values are mean∫SD.

ketorolac, 4.2∫1.4 if he needed fentanyl and 1.7∫1.5at discharge in the B-IINB group, and 3.4∫1.3, 4.9∫1.4and 2.2∫1.5, respectively, in the S-IINB group, with-out significant differences between the groups.

In those patients who required postoperative anal-gesics, 48 in the B-IINB group and 46 in the S-IINBgroup, the average time latency was 8.1 (0.9–54.7) hand 4.3 (0.4–20.6) h, respectively (P,0.01).

After the discharge, during seven days, there wasno significant difference between the groups in thenumber of patients who needed ketoprofen (Table 2)and in the mean doses of ketoprofen per patient658∫373 mg in the B-IINB group and 806∫534 mg inthe S-IINB group. If the patient needed ketoprofen,mean VAS scores were 3.0∫1.4 in the B-IINB groupand 3.0∫1.3 in the S-IINB group without significantdifference. There was no significant difference in thedaily VAS scores between the groups during the homefollow-up (mean B-IINB 1.2∫0.8 vs S-IINB 1.4∫1.1).Five patients in the B-IINB group and ten patients inthe S-IINB group needed ketoprofen still on the sev-enth postoperative day. There were no significant dif-ferences in adverse events between the B-IINB and S-IINB groups regarding postoperative nausea (2 vs 4patients respectively) and urinary retention (2 vs 3).No postdural puncture headache, transient neurologicsymptoms or any other complications occurred in thestudy patients.

Discussion

We have shown that preincisional IINB with 0.5%bupivacaine reduced analgesic requirements in the

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early postoperative period in patients undergoingopen inguinal hernia repair. A prolonged time to thefirst analgesic requirement, extending clearly beyondthe expected duration of the nerve block with bupiva-caine, was evident in most patients. However, becausethe pain intensity and the need for analgesics afterdischarge at home were quite low, also in the S-IINBgroup, a small improvement in these parameters maynot be revealed even in a study comprising 100 pa-tients (12). The fact that postoperative pain was rela-tively well controlled also in those patients who didnot receive bupivacaine for the IINB may be, in part,due to the choice of bupivacaine spinal anaesthesiafor surgery and administering a large dose of NSAIDbefore the block wore off.

In an earlier study (13), there was no significant dif-ference in total morphine requirements for the first 24h between patients who received an inguinal fieldblock with lignocaine either before or after surgery,which was performed under general anaesthesia. In acomparable setting, Ejlersen et al. (3), however,showed that preincisional lignocaine infiltration ascompared to postincisional infiltration, decreased theneed for supplementary analgesic doses for the first 6h after surgery, i.e. for the duration of the studyperiod. In fact, a similar beneficial immediate effect ofthe local anaesthetic infiltration has been observed byNehra et al. (14) and was observed now by us, too. Inthe study by Ejlersen et al. (3), the exact duration ofthe analgesia induced by the infiltration block beyondthe time of discharge remains open, but it seems tohave exceeded the duration of the lignocaine infil-tration block. The similarity of their and our results isstriking also because the proportion of painfree (i.e.,not needing analgesic) patients (42%) at 6 h post-operatively was the same as that at discharge of thepatients in our study (48%).

Local anaesthetics are popular in day-surgery units,and their efficacy in reducing postoperative pain afteringuinal herniorrhaphy has been investigated usingdifferent application modes, e.g., IINB (5, 6, 15), ingui-nal field block (13), wound infiltration techniques (16)and wound instillation of local anaesthetic (17, 18).It has been shown that IINB with 0.25% bupivacaineprovided some postoperative pain relief in adults andpaediatric patients undergoing inguinal her-niorrhaphy (5, 15). However, the effect of local anaes-thetic infiltration block on pain after inguinal her-niorrhaphy appears to be controversial, depending onsurgical and anaesthetic techniques (7, 8). Tverskoy etal. (7), for instance, have shown that spinal anaes-thesia without additional nerve blocks decreasedpostoperative pain significantly after inguinal her-

J. Toivonen et al.

niorrhaphy compared with general anaesthesia at 24h and at 48 h, but not any further on the tenth dayafter surgery. Interestingly, by adding preincisionallignocaine infiltration in another general anaesthesiagroup, pain relief at 24 h was even better than that inthe spinal anaesthesia group (7).

Harrison et al. (4), who provided general anaes-thesia for surgery, showed that preincisional IINB andwound infiltration with 0.5% bupivacaine failed toproduce an analgesic effect beyond the first 6 h afterelective hernia repair. Ding and White (5) failed toshow that preincisional IINB with 0.25% bupivacainecombined with an infiltration of the incisional sitewith 1% lignocaine, as well as with propofol sedationwould have decreased the requirement for postopera-tive opioid medication in the PACU, though the VASscore at 30 min after entering the PACU was lower inthe bupivacaine-treated patients compared with thesaline-treated patients. On the other hand, they wereable to demonstrate a prolonged benefit of adding theIINB to the treatment, as the need for oral analgesicmedication was reduced for the first 24 h (total studyperiod). Bugedo et al. (6) found that preincisionalIINB with 0.5% bupivacaine under spinal anaesthesiareduced postoperative pain and requirement of anal-gesics for 48 h after herniorrhaphy compared with pa-tients operated under spinal anaesthesia alone. How-ever, in their study nerve block with bupivacaine re-duced requirements for analgesic medication chieflyin the first 9 h after surgery, but no further from 24 hto 48 h after surgery, so that their result in require-ment of analgesics after surgery can be regarded assimilar to our result. Although simple to apply,wound instillation or spray with local anaesthetic pro-vides only moderate pain relief (17) and has not beenfound better than local anaesthetic infiltration (18).

The variable extent of analgesia reported after IINBfor the control of postherniorrhaphy pain is confusing(8) and more studies are needed. Due to the surgicaltrauma, nociceptive impulses start to enter the centralnervous system as soon as the block wears off and,therefore, at least in theory, central sensitisation can-not be prevented (19). Not only the duration of theimpulse-blocking analgesic action but also the type ofsurgery (trauma) may play a role in the appearanceof clinical analgesia (20).

In summary, we have shown that in adult out-patients undergoing open repair of inguinal herniaunder spinal anaesthesia, the use of an IINB with 0.5%bupivacaine reduced postoperative pain and the re-quirement of analgesic medication before discharge,i.e., for approximately 6 h. We failed to show anylonger lasting analgesic benefit of the IINB after her-

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niorrhaphy, possibly due to a low frequency and in-tensity of pain in the patients’ home environment.

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Address:Juhani ToivonenDepartment of AnaesthesiaSouth Carelian Central HospitalValto Käkelänkatu 1FIN-53130 LappeenrantaFinlande-mail: juhani.toivonen/ekshp.fi