title: Laparoscopic total extraperitoneal (TEP) inguinal hernia repair under epidural anesthesia: a detailed evaluation.
abstract: BACKGROUND
  Laparoscopic total extraperitoneal (TEP) inguinal hernia repair is as efficacious as the open Lichtenstein procedure, can be learned with proper training, and causes less postoperative pain, better cosmesis, and earlier return to work. The one major factor preventing the widespread acceptance of TEP is the requirement for general anesthesia (GA). In contrast, open hernia is performed using local or regional anesthesia, thereby having the advantage of quicker recovery, decreased postoperative nausea and vomiting (PONV), fewer hemodyanamic changes, reduced metabolic responses to surgical stress, and better muscle relaxation. This study attempted to evaluate whether laparoscopic TEP can be performed under less invasive anesthesia, such as regional anesthesia, and to determine its feasibility and limitations
  
  
  METHODS
  All total of 22 male patients were studied between January 2002 and March 2003 in a tertiary care referral hospital. Epidural anesthesia with 2% lignocaine with adrenaline (Adr) was given via a lumbar epidural catheter, achieving a sensory level of T6. The standard technique for TEP was followed, using three midline infraumbilical ports.
  
  
  RESULTS
  Twenty-two patients (20 unilateral, 2 bilateral) underwent operation. The mean operating time was 67.8 +/- 18 (range, 40-110) min. All 22 cases were started with epidural anesthesia, 7 of which (31.9%) were converted to GA; the other 15 (68.1%) were completed under epidural anesthesia. All cases were successfully completed laparoscopically, and there were no conversions. There were no intraoperative complications. There was no significant difference between the cases conducted under epidural anesthesia (67.6 +/- 23 min) and those converted to GA (69.3 +/- 7.3 min). There was no statistically significant difference between the conversion rates of smaller versus larger hernias in this study (p value 0.22). A significant association of success of the procedure was seen with a sensory level of T6 and above (2/15 conversions to GA; i.e., 13.3%) and cases with a sensory level below T6 (5/7 converted; i.e., 71.4%) and adequate epidural catheter length (p = 0.015). Prevention and management of pneumoperitoneum and subsequent shoulder-tip pain was the key to preventing conversions (6 of 9 converted to GA; i.e., 67%; p = 0.006). There were no significant postoperative complications, and no recurrences were noted during a mean follow-up period of 29 months (range, 20-36 months).
  
  
  CONCLUSIONS
  From the present study it is clear that TEP is possible under epidural anesthesia provided a minimal sensory level of T6 is achieved. To achieve that level, an appropriate higher site for catheter insertion and/or adequate intraepidural catheter length needs specific attention. Pneumoperitoneum, shoulder-tip pain, intraoperative straining, and inadequate preperitoneal space are factors whose interplay leads to conversion to GA. The size of the hernia is not related to pneumoperitoneum or conversion to GA.
authors.affiliation: Department of Surgery, Maulana Azad Medical College, New Delhi, 110002, Delhi, India. drplal@vsnl.net
authors.forename: Pawanindra
authors.initials: P
authors.lastname: Lal
authors.forename: P
authors.initials: P
authors.lastname: Philips
authors.forename: K N
authors.initials: KN
authors.lastname: Saxena
authors.forename: R K
authors.initials: RK
authors.lastname: Kajla
authors.forename: J
authors.initials: J
authors.lastname: Chander
authors.forename: V K
authors.initials: VK
authors.lastname: Ramteke
mesh_terms: D000328:Adult; D000767:Anesthesia, Epidural / Q000379:methods*; D000768:Anesthesia, General / Q000379:methods; D005500:Follow-Up Studies; D006552:Hernia, Inguinal / Q000175:diagnosis* / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D010147:Pain Measurement; D010149:Postoperative Pain / Q000503:physiopathology*; D010537:Peritoneum / Q000601:surgery; D011028:Pneumoperitoneum, Artificial; D011336:Probability; D011446:Prospective Studies; D018570:Risk Assessment; D055502:Secondary Prevention; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome