Prosthetic repair of umbilical hernias in adults with local anesthesia in a day-case setting: a comprehensive report from a specialized hernia center

Abstract

Umbilical hernia is a common surgical problem. However, there seems to be a certain discrepancy between its importance and the attention it has received in the literature to date. This prospective study aimed to report a detailed analysis of prosthetic umbilical hernia repairs with local anesthesia in a day-case setting. It was planned to enroll 100 consecutive patients who underwent an elective umbilical hernia repair with local anesthesia. Patients who required general anesthesia and simultaneous hernia repairs were excluded. The procedure including local anesthesia and intravenous sedation was explained to the patients in detail by the operating surgeons and the anesthesiologist. The following parameters were strictly recorded: gender, age, body mass index (BMI), concomitant diseases, history of hernia (primary/recurrent), size of fascial defect, duration of operation, level of intravenous sedation (light/moderate), discharge time, and complications. There were 54 male and 46 female patients. The mean age was 48.6 years (24-78 years). Four patients were older than 70 years of age. Forty-one patients had 84 concomitant diseases. Eleven patients had a recurrent hernia. Female patients more frequently presented with a recurrent hernia than male patients (19.6 vs. 3.7%, P = 0.009). A standard polypropylene mesh was used in the onlay position in 91 cases. In nine cases, a light mesh was placed in the preperitoneal space. A closed vacuum drain was left in situ in 37 cases. Light sedation was set in 86 cases, whereas 12 patients received a moderate sedation. Monitored anesthesia care was used in two cases. When moderate sedation was needed, a concurrent increase in lidocaine dose and total volume was recorded. There was a positive correlation between increased lidocaine use and high midazolam dose and additional propofol requirement. The mean total local anesthetic volume was 33 ml (10-63 ml). Lidocaine doses displayed a large range between the cases (70-600 mg). The mean lidocaine dose was 263.3 mg (standard deviation [SD]: 103.4). No bupivacaine was given in 19 cases, whereas the mean bupivacaine dose was 35.1 mg (0-100 mg) in 81 cases. The mean duration in the operation room was 69 min (25-150 min). It was significantly longer for recurrent hernias than primary ones (95 vs. 65 min; P = 0.0001). Higher total volume and higher lidocaine doses were required for the repair of recurrent hernias. In addition, it was observed that the longer the operation time, then the longer the lidocaine dose and the higher the total volume of local anesthetic agents. The patient satisfaction rate was 97%. The mean discharge time was 122 ± 58 min (45-420 min). Sixty-seven patients were sent home within 2 h. Early wound problems were observed in 11 patients. Small seromas and hematomas developed in six cases, and dissolved without drainage. Three superficial surgical site infections diagnosed by erythema and enduration were recorded without obvious suppuration. No recurrence was recorded after a mean follow-up of 17 months (5-41 months). One patient complained of pain at the lower edge of a standard polypropylene mesh at the third postoperative month. The repair of umbilical hernias with local anesthesia in a day-case setting is a good option, with low infection and recurrence rates. Most patients can be discharged early as planned. Separate doses and total volume of local anesthetic agents needed for umbilical hernia repair are clearly higher than those used in inguinal hernia repair. Patients with higher BMI, recurrent hernia, and defects larger than 3 cm may require higher local analgesic doses. The patient satisfaction is very good when the patients are provided with detailed information about day-surgery and local anesthesia.