Research
Original Investigation | PACIFIC COAST SURGICAL ASSOCIATION
Periprosthetic Anesthetic for Postoperative Pain
After Laparoscopic Ventral Hernia Repair
A Randomized Clinical Trial
Aimee E. Gough, MD; Steven Chang, MD; Subhash Reddy, MBBS; Lisa Ferrigno, MD; Marc Zerey, MD;
Jonathan Grotts, MA; Samantha Yim, BSN; David S. Thoman, MD
IMPORTANCE Laparoscopic ventral hernia repair (LVHR) using mesh is a well-established
intervention for ventral hernia, but pain control can be challenging.
Supplemental content at
jamasurgery.com
OBJECTIVE To determine whether instillation of a long-acting local anesthetic between the
mesh and the peritoneum after LVHR reduces pain or narcotic requirements.
DESIGN, SETTING, AND PARTICIPANTS A prospective, double-blind, randomized clinical trial
with data collection during a brief hospital stay in a tertiary care, community teaching hospital
over 3 years between December 15, 2011, and March 28, 2014. Of 120 screened patients
undergoing LVHR in this intention-to-treat analysis, 99 eligible patients were randomized.
Forty-two patients received the study drug, and 38 patients received placebo. Patients with a
history of chronic narcotic use were excluded.
INTERVENTION After mesh placement, a long-acting local anesthetic (bupivacaine
hydrochloride, 0.50%) or placebo (0.9% normal saline) was injected between the mesh and
the peritoneum.
MAIN OUTCOMES AND MEASURES Postoperative pain (on a standard scale ranging from 0 to
10), and narcotic medication use (intravenous morphine equivalents). There were no adverse
events.
RESULTS Baseline and operative characteristics were similar except that the treatment group
was older (61.8 vs 52.3 years, P = .001). After surgery, pain scores in the recovery room (3.2 vs
4.7, P = .003), interval total narcotic use (6.7 vs 12.5 mg, P = .003 at <4 hours and 0 vs 2.7 mg,
P = .01 at 8-12 hours), and total intravenous narcotic use (9.2 vs 17.2 mg of morphine sulfate
equivalents, P = .03) were significantly less in the treatment group.
CONCLUSIONS AND RELEVANCE Administration of a long-acting local anesthetic between the
mesh and the peritoneum significantly reduces postoperative pain and narcotic use after
LVHR.
TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01530815
Author Affiliations: Department of
Surgery, Santa Barbara Cottage
Hospital, Santa Barbara, California
(Gough, Chang, Reddy, Ferrigno,
Zerey, Grotts, Yim, Thoman);
Department of Surgery, Community
Hospital of the Monterey Peninsula,
Monterey, California (Chang);
Department of Surgery, Cleveland
Clinic, Cleveland, Ohio (Reddy).
JAMA Surg. doi:10.1001/jamasurg.2015.1530
Published online July 8, 2015.
Corresponding Author: Aimee E.
Gough, MD, Department of Surgery,
Santa Barbara Cottage Hospital, 400
W Pueblo St, Santa Barbara, CA
93105 ([email protected]).
(Reprinted) E1
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Univ Hosp Case Med Ctr User on 07/16/2015
Research Original Investigation
Periprosthetic Anesthetic After Laparoscopic Ventral Hernia Repair
L
aparoscopic ventral hernia repair (LVHR) has become a
well-established intervention for ventral hernias. Advantages of laparoscopic repair include decreased hospital length of stay and fewer wound infections, with similar
low rates of hernia recurrence compared with open repair.1,2
However, postoperative pain may be equivalent to that of the
open approach3 and continues to be a concern and a possible
drawback to LVHR.
Intense pain immediately following LVHR is common and
results in a 2-day hospitalization on average for pain
management.2 This pain has been attributed to the sutures and
tacks used to fix the mesh to the anterior abdominal wall. Methods for controlling the pain, including lidocaine, 5%, patches
applied to the abdomen4 and local anesthetic injected during
surgery to suture sites,5 have been evaluated, with varying success demonstrated. Other studies have evaluated local anesthetic delivered via catheter to the surgical site6 and local anesthetic injected to specific sites of pain after surgery,7 with
mixed results and with concern about increased cost plus risk
of infection at the surgical site.
To address the need for improved pain control after LVHR,
we proposed that intraoperative delivery of a long-acting local analgesic, bupivacaine hydrochloride, 0.50%, to the operative site under direct visualization would improve postoperative pain control. Therefore, narcotic requirements would
be reduced, without the safety concerns or cost associated with
more invasive delivery methods of pain medication.
Methods
After Cottage Health System Institutional Review Board approval, all patients undergoing LVHR at Santa Barbara Cottage Hospital between December 15, 2011, and March 28, 2014,
were screened for trial eligibility. Individuals were eligible if
they were 18 years or older, undergoing LVHR with no other
planned procedure, and agreeable to completing a postoperative pain journal. Patients were excluded from the trial if they
had an allergy or sensitivity to bupivacaine, had a history of
chronic pain requiring daily opiates, were cognitively unable
to complete the postoperative pain journal, or underwent an
additional unplanned procedure.
After written informed consent was obtained, patients’
medical records were reviewed for their medical and surgical
history. Patients were prospectively randomized via a generated randomization sheet8 in a double-blind fashion to receive the study drug (bupivacaine hydrochloride, 0.50%, in the
treatment group) or placebo (0.9% normal saline in the control group). Participants, surgeons (M.Z. and D.S.T.), and caregivers assessing outcomes were all blinded to the intervention. Laparoscopic ventral hernia repair was performed by a
standardized approach,9 including the use of preoperative antibiotics, reduction of hernia sac contents, and complete adhesiolysis. All port sites were infiltrated with 4 mL of 0.50%
bupivacaine before their placement. A permanent mesh treated
to decrease visceral adhesions was chosen to allow for at least
a 4-cm overlap of mesh and fascia circumferentially. In most
cases, the fascial defect was closed with permanent suture beE2
fore mesh placement. Mesh fixation was achieved by a combination of tacks and transfascial sutures as determined by surgeon preference. On conclusion of the operation and before
desufflation, the study drug (bupivacaine or placebo) was instilled under direct visualization into the space between the
mesh and the parietal peritoneum to coat the fixation points
and layer the study drug on top of the mesh. A proportional
dose of study drug was determined by the size of the mesh:
each patient received 1 mL of study drug per centimeter of mesh
in its greatest dimension. If patients had multiple hernia defects, the total hernia size was calculated as the sum of the area
of both hernias.
In the postanesthesia care unit (PACU), pain was assessed and recorded by nursing staff using a 7-point or 10point visual analog scale. The PACU pain score was calculated as the mean of all pain scores obtained in the PACU. When
participants were transferred to the ward, they self-reported
pain using a standard 10-point numerical rating scale every 30
minutes for the first 90 minutes, every hour for the next 24
hours, and then every 4 hours until discharge. At each of the
intervals, study participants rated their pain, recorded the
value, and noted if they were resting, sitting, walking, or coughing. Ward pain scores were calculated as the mean of pain scores
obtained during the first 90 minutes after leaving the PACU and
then over each subsequent 3-hour interval.
In the PACU, patients received intravenous (IV) narcotic
medication, limited to combinations of fentanyl citrate, morphine sulfate, and hydromorphone hydrochloride. If meperidine hydrochloride was administered for shivering, its narcotic dose was also included. When patients tolerated oral
intake, they were transitioned to oral analgesia in the form of
hydrocodone bitartrate–acetaminophen. While surgical patients often also receive and benefit from nonsteroidal antiinflammatory drugs, their administration in this study was prohibited to avoid confounding variables. Doses of IV and oral
narcotics were converted using a validated conversion equation to IV morphine equivalents (IVMEs).10 The mean pain
medication requirements were determined from the total of
IVMEs used over 4-hour intervals.
Sample size estimation showed that 40 patients were
needed in each group to detect a difference of 20% in pain
medication use in the first 4 hours after surgery between the
treatment and control groups, with a power of .95 and a level
of significance of .05. Continuous data were summarized as
the mean (SD) or the median (interquartile range). Discrete data
were summarized using the number in the group (percentage
of the group). Two-sided unpaired t test, Mann-Whitney test,
or χ2 test was used where appropriate. Statistical significance
was set at P < .05. Analysis was performed in a statistical computing environment (R; The R Foundation). The study protocol can be found in the trial protocol in the Supplement.
Results
During the study period, 120 patients were assessed for study
eligibility (Figure). Of those assessed for the trial, 99 patients
were eligible, provided informed consent for the study, and
JAMA Surgery Published online July 8, 2015 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Univ Hosp Case Med Ctr User on 07/16/2015
jamasurgery.com
Original Investigation Research
Periprosthetic Anesthetic After Laparoscopic Ventral Hernia Repair
Figure. Consolidated Standards of Reporting Trials Diagram
120 Assessed for eligibility
21 Excluded
11 Patient declined participation
2 ≥2 Procedures done
2 Chronic narcotic use before surgery
2 Surgery cancelled
1 Mentally incapacitated
1 Open procedure
1 French was primary language
1 Physician determined patient was not
good candidate because of prior
surgery in region
99 Randomized
46 Normal saline
38 Received allocated intervention
8 Did not receive allocated intervention
2 Two separate pieces of mesh used
1 Taking pain medication before surgery
2 Did not receive study drug
1 Previous mesh and complicated
hernia repair
1 No mesh used for repair
1 ≥2 Procedures done
53 Bupivacaine hydrochloride
42 Received allocated intervention
11 Did not receive allocated intervention
4 ≥2 Procedures done
3 Did not receive study drug
1 Chronic narcotic use before surgery
1 Surgery canceled
2 Unknown
38 Analyzed
42 Analyzed
were prospectively randomized. During the course of the study,
19 patients were excluded from the final analysis, most frequently because they did not receive the study drug (n = 5) or
because more than 1 procedure was performed (n = 5). In total,
80 patients with incisional, umbilical, and epigastric hernias
completed the study and were included in the final analysis
as the control group (38 receiving 9% normal saline) and the
treatment group (42 receiving bupivacaine, 0.50%). Although 5 surgeons participated in the study, 74% (59 of 80) of
the patients were operated on by 2 of us. Each surgeon had
cases distributed evenly between the treatment and control
groups. The trial ended when the predetermined enrollment
goal was reached.
Patient and Surgical Characteristics
The patients in the control group were significantly younger
(52.3 vs 61.8 years, P = .001), but they otherwise had characteristics similar to those of the treatment group, including sex
and type of hernia repaired (Table 1). Most hernias were reported as incisional type (n = 39), with fewer being umbilical
(n = 33) or epigastric (n = 19). The median operative details for
the control vs treatment groups were also similar, including
surgery length (58.5 vs 58.0 minutes, P = .64), PACU length of
stay (117 vs 113 minutes, P = .91), number of tacks used (30.7
vs 32.5, P = .52), hernia size (4.0 vs 4.2 cm2, P = .65), mesh size
(176.7 vs 150.0 cm2, P = .60), and volume of study drug (15 vs
15 mL, P = .97). There were no significant differences among
the 5 surgeons’ patients regarding hernia size or mesh size.
There was a significant difference in the number of tacks used
by the different surgeons, ranging from 19.6 to 33.9 (P = .02).
jamasurgery.com
Shown are patient enrollment,
randomization, and analysis.
Study Outcomes
The study outcomes were postoperative pain and narcotic
medication use. These results are summarized in Table 2.
Postoperative Pain Assessment
The 7-point and 10-point visual analog scales used in the PACU
were normalized to a 10-point scale to allow for overall comparison of the PACU and ward pain scores. Patients who received the study drug had significantly lower mean pain scores
during their PACU stay (3.2 vs 4.7, P = .003); pain scores at later
intervals were not significantly different. Although the patients in the wards noted their level of activity during pain
assessment (resting, sitting, walking, or coughing), there
were insufficient data to evaluate pain during activity separately. Given that the treatment group was older than the
control group, the relationship between age and postoperative pain was evaluated, and there was no correlation found
between age and pain in the treatment group or the control
group. Although the surgeons used significantly different
numbers of tacks, an evaluation of PACU pain scores stratified by individual surgeon showed no significant difference
across the 5 groups.
Narcotic Medication Use Assessment
Patients in the treatment group required significantly less IV
narcotic medication than patients in the control group at less
than 4 hours after surgery (6.7 vs 11.6 mg of IVMEs, P = .004).
The treatment group also required significantly less of all narcotics during the 8 to 12 hours after surgery (0 vs 2.7 mg of
IVMEs, P = .01). With oral medication included in the analy(Reprinted) JAMA Surgery Published online July 8, 2015
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Univ Hosp Case Med Ctr User on 07/16/2015
E3
Research Original Investigation
Periprosthetic Anesthetic After Laparoscopic Ventral Hernia Repair
Table 1. Baseline Characteristics
Normal Saline
(n = 38)
Characteristic
Bupivacaine Hydrochloride
(n = 42)
P Value
Age, mean (SD), y
52.3 (12.0)
61.8 (13.9)
.001
Male sex, No. (%)
21 (55.3)
23 (54.8)
.96
Type of hernia repaired, No. (%)
Incisional
20 (52.6)
19 (45.2)
.51
Incarcerated
10 (26.3)
12 (28.6)
.82
Umbilical
15 (39.5)
18 (42.9)
.76
Epigastric
8 (21.1)
11 (26.2)
.59
58.0 (20.2)
.64
Surgery length, median (IQR), min
58.5 (31.5)
PACU LOS, median (IQR), min
117 (55)
113 (76)
.91
15 (3)
15 (4)
.97
Volume of study drug used, median (IQR), mL
No. of tacks used, median (IQR)
30.7 (9.9)
32.5 (14.3)
.52
Absorbable tacks used, No./total No. (%)a
20/37 (54.1)
18/41 (43.9)
.37
Mesh
176.7 (111.9)
150.0 (186.9)
.60
Hernia
4.0 (13.5)
4.2 (20.5)
.65
Size, median (IQR), cm2
Pain before surgery on VAS of 1 to 10, median (IQR)
Transfascial sutures used, No./total No. (%)a
0 (1)
17/37 (45.9)
Hospital LOS, median (IQR), d
0 (3)
16/41 (39.0)
1 (0)
.33
.54
1 (0)
.77
Abbreviations: IQR, interquartile
range; LOS, length of stay;
PACU, postanesthesia care unit;
VAS, visual analog scale.
a
The total numbers of patients vary
because of missing data.
Table 2. Study Outcome Measures
Outcome Measure
Normal Saline
(n = 38)
Bupivacaine Hydrochloride
(n = 42)
P Value
Time to regular diet intake, median (IQR), min
1084 (952)
543 (821)
.41
376 (304)
302 (244)
Time to ambulation, median (IQR), min
Pain in PACU on VAS of 1 to 10, mean (SD)
.70
4.7 (1.8)
3.2 (2.6)
.003
At <1.5 h
4.8 (2.2)
4.4 (2.4)
.43
At 2.5 to 5.5 h
4.6 (2.3)
4.2 (2.2)
.43
At 6.5 to 9.5 h
4.3 (2.6)
4.2 (2.3)
.85
At 10.5 to 13.5 h
3.8 (2.7)
3.7 (2.1)
.94
At 14.5 to 17.5 h
4.2 (2.8)
3.6 (2.6)
.49
At 18.5 to 21.5 h
4.1 (1.8)
3 (2.5)
.24
At 22.5 to 24.5 h
2.7 (1.4)
3.6 (2.5)
.42
Resting pain in ward on VAS of 1 to 10, mean (SD)
All narcotics used after surgery, median (IQR), mg of IVMEs
At <4 h
12.5 (9.8)
6.7 (11.2)
.003
At 4 to <8 h
2.0 (5.0)
3.3 (5.3)
.93
At 8 to 12 h
2.7 (6.3)
0 (3.3)
.01
At >12 h
6.7 (15.4)
4.8 (17.3)
.51
Narcotics used, median (IQR), mg of IVMEs
IV at <4 h after surgery
11.6 (9.8)
6.7 (11.1)
.004
Total IV
17.2 (21.7)
9.2 (18.6)
.03
6.7 (13.3)
6.7 (15.0)
.34
25.2 (38.7)
19.5 (29.1)
.15
Total oral
IV plus oral
sis of the first 4 hours, the total narcotic medication requirement (IV plus oral) remained significantly less in the treatment group (6.7 vs 12.5 mg of IVMEs, P = .003). Beyond the
initial 4 hours after surgery, narcotic use was similar between
the 2 groups. The total volume of IV narcotics used during the
hospital stay was significantly less in the treatment group (9.2
vs 17.2 mg of IVMEs, P = .03). There was no difference in the
total narcotic use (IV plus oral) during the hospital stay (19.5
E4
Abbreviations: IQR, interquartile
range; IV, intravenous;
IVMEs, IV morphine equivalents;
PACU, postanesthesia care unit;
VAS, visual analog scale.
vs 25.2 mg of IVMEs, P = .15). In the control group, pain medication used in the first 4 hours represented half of all the total
narcotics used (12.5 of 25.5 mg of IVMEs). Again, because individual surgeons used different numbers of tacks, the amount
of pain medications used per each of the surgeon’s patients was
examined, and no significant difference was found between
the treatment and control groups. There were no adverse events
or unintended effects.
JAMA Surgery Published online July 8, 2015 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Univ Hosp Case Med Ctr User on 07/16/2015
jamasurgery.com
Original Investigation Research
Periprosthetic Anesthetic After Laparoscopic Ventral Hernia Repair
Discussion
This study demonstrated that a simple perioperative injection of bupivacaine between the mesh and the parietal peritoneum in LVHR significantly decreases early postoperative
pain and total (IV plus oral) narcotic medications during the
first 4 hours after surgery. This is consistent with the immediate but transient effect of bupivacaine, with known peak levels by 30 to 45 minutes and a half-life of 2.7 hours.11
Because IV pain medications are used before the tolerance of oral intake and narcotic pills, the finding that the treatment group required less IV narcotics during the hospital stay
supports the conclusion that the intervention’s greatest value
is in the early postoperative period. Almost half of the control
group’s total number of narcotics were administered in the first
4 hours after surgery. Because the distribution of narcotic medication requirements is skewed toward the immediate postoperative period, this interval likely offers the greatest opportunity for an intervention.
Rather than addressing palliation, many earlier studies
sought to identify the etiology of pain after LVHR by evaluating methods of mesh fixation as a source of significant postoperative pain. Helical tack placement may cause irritation of
muscle and peritoneum, and transfascial sutures may lead to
tissue pressure and trauma.5 Variations in these mesh fixation methods have been widely evaluated, demonstrating increased pain with helical tacks12 and with transfascial sutures13
and no differences in outcome measures between the 2
systems.14,15 Similarly, the number of tacks used in mesh fixation has not consistently correlated with the magnitude of postoperative pain.16 A recent meta-analysis confirmed that no fixation method is clearly superior to another. 17 Given that
variability in mesh fixation techniques is unlikely to yield clinically significant results, we chose to focus on a potentially
palliative intervention.
The most common treatment for perioperative pain is opiate analgesics. However, their well-documented adverse effects include respiratory depression, nausea, pruritus, constipation, and delayed return of bowel function. While it would
be difficult to eliminate postoperative narcotic use entirely, a
nonnarcotic adjunct that decreases pain and minimizes opiate requirements is worthy of study.
Previous methods of delivering a long-acting local anesthetic in LVHR have led to promising results, but an ideal system remains to be determined. A randomized but nonblinded trial of lidocaine patches in LVHR demonstrated
postoperative pain reduction.4 Decreased pain was also noted
after perioperative local anesthetic injections through the abdominal wall down to the peritoneum at the site of transfascial sutures.5 However, helical tacking sites were not addressed, and narcotic requirements were not assessed.
Local anesthetic catheter-directed infusion has successfully reduced pain after other procedures, including inguinal
hernia repair, 1 8 open colorec tal procedures, 1 9 and
nephrectomies,20 compared with standard narcotic strategies. However, an elastomeric pain pump device delivering local anesthetic between the mesh and the peritoneum after
jamasurgery.com
LVHR similar to the system used herein was not found to decrease postoperative pain scores or narcotic requirements.6
That pain pump device allows for directed delivery of narcotics over time but also may introduce infection to a surgical site
containing mesh, with additional concerns regarding cost, difficulties of wound care, need for equipment, leakage of medication, and consistency of delivery.5,6 We chose to avoid these
potential drawbacks by using a single dose of bupivacaine delivered throughout the entire area of mesh and to all sites of
abdominal wall fixation.
Laparoscopic ventral hernia repair has become an accepted if not standard approach for the repair of a variety of
ventral hernias, with low reported rates of complications and
recurrences,21 which are comparable if not decreased compared with the traditional open surgery.1,22 Although LVHR is
safe and effective, many patients report considerable pain in
the hospital and after surgery for up to 3 months, which can
substantially affect recovery and quality of life.7,16,23 Aggressive pain control must be addressed as an essential component of a successful LVHR, but much of the previous literature on postoperative pain control is focused on open surgery.
While some strategies from the large body of literature addressing pain control after laparotomy (eg, continuous wound
infusion19) may have a role in laparoscopic surgery, tailoring
the measure of pain control after minimally invasive procedures seems appropriate. To contribute to that effort, this trial
studied immediate postoperative pain, and our results confirm that a simple perioperative intervention can decrease pain
and narcotic requirements. During the course of this study, the
US Food and Drug Administration approved liposomal bupivacaine, a slow-release formulation providing analgesia for up
to 72 hours.24 This may present an even better option although it is now very expensive.
There are limitations and caveats to our findings. One particularly worrisome aspect of pain after LVHR is that it can persist past the acute perioperative period for up to several
months.25 The present study evaluated pain only until the time
of discharge, which was uniformly brief, so we were unable to
address whether early, effective pain control affected subsequent pain after discharge. Patients were aware that their pain
was being observed, so a Hawthorne effect must be considered. However, because patients and all caregivers were blinded
to their group status, any potential influence would be the same
in both groups and would not have contributed to the differences observed. Finally, while our treatment group was significantly older than our control group, statistical analysis failed
to show a correlation between age and pain or narcotic use in
this study.
Conclusions
Laparoscopic ventral hernia repair using mesh is a wellestablished intervention, but postoperative pain remains a challenge. After mesh placement, a long-acting local anesthetic (bupivacaine) injected between the mesh and the peritoneum
significantly reduces early postoperative pain and narcotic use
after LVHR.
(Reprinted) JAMA Surgery Published online July 8, 2015
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Univ Hosp Case Med Ctr User on 07/16/2015
E5
Research Original Investigation
Periprosthetic Anesthetic After Laparoscopic Ventral Hernia Repair
ARTICLE INFORMATION
Accepted for Publication: March 25, 2015.
Published Online: July 8, 2015.
doi:10.1001/jamasurg.2015.1530.
Author Contributions: Dr Thoman had full access
to all the data in the study and takes responsibility
for the integrity of the data and the accuracy of the
data analysis.
Study concept and design: Chang, Thoman.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Gough, Ferrigno,
Thoman.
Critical revision of the manuscript for important
intellectual content: Thoman.
Statistical analysis: Grotts.
Obtained funding: Chang, Thoman.
Administrative, technical, or material support: All
authors.
Study supervision: Thoman.
Conflict of Interest Disclosures: Dr Thoman
reported being a paid consultant to Covidien. No
other disclosures were reported.
Funding/Support: This research project was
supported by a grant from Santa Barbara Cottage
Hospital.
Role of the Funder/Sponsor: The funder had no
role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
Previous Presentation: This study was presented
at the 86th Annual Meeting of the Pacific Coast
Surgical Association; February 20, 2015; Monterey,
California.
Additional Contributions: Santa Barbara Cottage
Hospital physicians Farida Bounoua, MD, Jeffrey
Gauvin, MD, and Stephen Kaminski, MD, provided
access to their surgical patients. No financial
compensation was provided.
REFERENCES
1. Forbes SS, Eskicioglu C, McLeod RS, Okrainec A.
Meta-analysis of randomized controlled trials
comparing open and laparoscopic ventral and
incisional hernia repair with mesh. Br J Surg. 2009;
96(8):851-858.
2. Goodney PP, Birkmeyer CM, Birkmeyer JD.
Short-term outcomes of laparoscopic and open
ventral hernia repair: a meta-analysis. Arch Surg.
2002;137(10):1161-1165.
E6
3. Colavita PD, Tsirline VB, Belyansky I, et al.
Prospective, long-term comparison of quality of life
in laparoscopic versus open ventral hernia repair.
Ann Surg. 2012;256(5):714-722.
4. Saber AA, Elgamal MH, Rao AJ, Itawi EA,
Martinez RL. Early experience with lidocaine patch
for postoperative pain control after laparoscopic
ventral hernia repair. Int J Surg. 2009;7(1):36-38.
5. Bellows CF, Berger DH. Infiltration of suture sites
with local anesthesia for management of pain
following laparoscopic ventral hernia repairs:
a prospective randomized trial. JSLS. 2006;10(3):
345-350.
6. Rosen MJ, Duperier T, Marks J, 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):2637-2643.
7. Carbonell AM, Harold KL, Mahmutovic AJ, et al.
Local injection for the treatment of suture site pain
after laparoscopic ventral hernia repair. Am Surg.
2003;69(8):688-691.
8. Dallal GE. Randomization.com. Last modified
March 29, 2013. http://www.randomization.com/.
Accessed December 2011.
9. Heniford BT, Park A, Ramshaw BJ, Voeller G.
Laparoscopic repair of ventral hernias: nine years’
experience with 850 consecutive hernias. Ann Surg.
2003;238(3):391-399.
10. Gammaitoni AR, Fine P, Alvarez N, McPherson
ML, Bergmark S. Clinical application of opioid
equianalgesic data. Clin J Pain. 2003;19(5):286-297.
11. RxList Inc. Sensorcaine: clinical pharmacology.
Last reviewed on RxList May 19, 2009. http://www
.rxlist.com/sensorcaine-drug/clinicalpharmacology.htm. Accessed January 15, 2015.
12. Bansal VK, Misra MC, Babu D, et al. Comparison
of long-term outcome and quality of life after
laparoscopic repair of incisional and ventral hernias
with suture fixation with and without tacks:
a prospective, randomized, controlled study. Surg
Endosc. 2012;26(12):3476-3485.
13. Muysoms F, Vander Mijnsbrugge G, Pletinckx P,
et al. Randomized clinical trial of mesh fixation with
“double crown” versus “sutures and tackers” in
laparoscopic ventral hernia repair. Hernia. 2013;17
(5):603-612.
14. Nguyen SQ, Divino CM, Buch KE, et al.
Postoperative pain after laparoscopic ventral hernia
repair: a prospective comparison of sutures versus
tacks. JSLS. 2008;12(2):113-116.
15. Wassenaar E, Schoenmaeckers E, Raymakers J,
van der Palen J, Rakic S. Mesh-fixation method and
pain and quality of life after laparoscopic ventral or
incisional hernia repair: a randomized trial of three
fixation techniques. Surg Endosc. 2010;24(6):12961302.
16. Eriksen JR, Poornoroozy P, Jørgensen LN,
Jacobsen B, Friis-Andersen HU, Rosenberg J. Pain,
quality of life and recovery after laparoscopic
ventral hernia repair. Hernia. 2009;13(1):13-21.
17. Reynvoet E, Deschepper E, Rogiers X, Troisi R,
Berrevoet F. Laparoscopic ventral hernia repair: is
there an optimal mesh fixation technique? a
systematic review. Langenbecks Arch Surg. 2014;
399(1):55-63.
18. Sanchez B, Waxman K, Tatevossian R,
Gamberdella M, Read B. Local anesthetic infusion
pumps improve postoperative pain after inguinal
hernia repair: a randomized trial. Am Surg. 2004;70
(11):1002-1006.
19. Bertoglio S, Fabiani F, Negri PD, et al. The
postoperative analgesic efficacy of preperitoneal
continuous wound infusion compared to epidural
continuous infusion with local anesthetics after
colorectal cancer surgery: a randomized controlled
multicenter study. Anesth Analg. 2012;115(6):
1442-1450.
20. Forastiere E, Sofra M, Giannarelli D, Fabrizi L,
Simone G. Effectiveness of continuous wound
infusion of 0.5% ropivacaine by On-Q pain relief
system for postoperative pain management after
open nephrectomy. Br J Anaesth. 2008;101(6):841847.
21. Bedi AP, Bhatti T, Amin A, Zuberi J.
Laparoscopic incisional and ventral hernia repair.
J Minim Access Surg. 2007;3(3):83-90.
22. Gonzalez R, Mason E, Duncan T, Wilson R,
Ramshaw BJ. Laparoscopic versus open umbilical
hernia repair. JSLS. 2003;7(4):323-328.
23. Reynvoet E, Berrevoet F. Pros and cons of
tacking in laparoscopic hernia repair. Surg Technol Int.
2014;25:136-140.
24. Candiotti K. Liposomal bupivacaine: an
innovative nonopioid local analgesic for the
management of postsurgical pain. Pharmacotherapy.
2012;32(9)(suppl):19S-26S.
25. Eriksen JR. Pain and convalescence following
laparoscopic ventral hernia repair. Dan Med Bull.
2011;58(12):B4369.
JAMA Surgery Published online July 8, 2015 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Univ Hosp Case Med Ctr User on 07/16/2015
jamasurgery.com