This prospective and observational study was conducted on 131 patients of the American Society of Anesthesiologist (ASA) I-III aged 18-75 years who undergoing unilateral or bilateral inguinal hernia repair after obtaining the ethical committee approval and written informed consent from the patients at Diyarbakır Gazi Yaşargil Training and Research Hospital. The study was conducted in accordance with the Helsinki II declaration.
Patients under 18 and over 75 years of age, ASA IV, a history of allergy to agents, analgesic drug use in the last 48 hours, morbid obese (BMI> 35), confusion, coagulopathy, local infection at the injection site were excluded from the study. In addition, patients with heart, lung, hematologic, metabolic and endocrine problems were also excluded. Furthermore, patients who did not want to be included in the study, who refused the spinal anesthesia procedure and who failed the spinal anesthesia procedure were excluded. The patients were informed about the procedure and Visual Analogue Scale (VAS, 0 = no pain, 10 = severe pain) at the preoperative visit. Postoperative nausea-vomiting (PONV) was evaluated with a 3-point system (0: no nausea and vomiting, 1: nausea, but no vomiting, 2: nausea with or without nausea).
Demographic data such as age, gender, height, weight, duration of surgery, postoperative discharge time and postoperative analgesia method were recorded. Patients were allocated into three groups: USG-guided TAP block (Group 1), USG-guided LAI (Group 2) and IVD (Group 3).
Standard anesthesia regime was received to all patients. After a preoperative 6-8 hour fasting period, patients were presented to the operation room. Heart rate (HR), non-invasive arterial pressure (NIBP), electrocardiogram (ECG) and peripheral oxygen saturation (SpO2) monitoring were performed as standard. 0.02 mg / kg midazolam(Zolamide 5mg / 5ml amp, Vem, Turkey) was administered for premedication to peripheral vascular access. IV saline was initiated at 10-15 ml / kg and the patient was placed in a sitting position. After sterilization, an experienced anesthesiologist performed a subarachnoid puncture through the L3-4 or L4-5 intervertebral space with a 26 G quincke needle (Egemen, Izmir, Turkey). After cerebrospinal fluid flow was seen, spinal anesthesia was performed with 12-15 mg heavy bupivacaine (Bupivon, Spinal heavy 0.5%, Onfarma, Turkey). The patients were then placed in the supine position. Before surgery, USG-guided TAP block was performed preemptively to Group 1 patients, USG-guided LAI to the surgical incision line, and 50 mg IVD was administered to Group 3 patients. When the motor block reached 3 on the Bromage Scale (0: no paralysis, the patient can fully flex the foot and knee; 1: can only move the knee and feet, cannot lift the leg straight, hip flexion is present; 2: no knee flexion; 3: complete motor block), and sensorial block reached the level of thoracic 6-8, surgical procedure was allowed. In case of failed spinal anesthesia, general anesthesia was performed and these patients were excluded from the study. Heart rate and NIBP values were recorded every 5 minutes during the operation. Patients with bradycardia and / or hypotension were treated with atropine and / or ephedrine. The study was completed with 120 patients who had failed spinal anesthesia and those who were discharged early from the hospital voluntarily (Figure 1).
TAP block was performed under USG guidance (Esaote, MyLab Six, Netherlands) before the surgery. After sterilization, the linear USG probe (5-10 MHz) was transversely placed on the mid-axillary line between the iliac crest and costal margine (Figure 2). USG visualised skin-subcutaneous tissue, external oblique, internal oblique and transversus abdominis muscles and peritoneal cavity (Figure 3). A 20 G nerve block needle (Stimuplex Ultra 360, B.Braun, Melsungen, Germany) was imaged with in-plane technique to advance the facial plane between the internal oblique and transverse abdominis muscles. The injection point was confirmed by hypoechoic image with 0.2 to 0.4 mL of normal saline. Then, 20 mL 0.25% bupivacaine (Buvasin 0.5%, Istanbul, Turkey) was injected to the facial plane by intermittent following negative aspiration by hydrodissection technique (Figure 4). In bilateral cases, the procedure was performed to both sides in the same way. All blocks were performed by a single experienced anesthesiologist.
Local Anesthetic Infiltration
LAI was performed under USG guidance before the surgical procedure. 20 mL 0.25% bupivacaine was injected after the following negative aspiration with a 20 G nerve block needle into and around the incision line to be pre-marked by the surgeon, and between the incision line and under the aponeurosis external oblique (Figure 5). All LAI were performed by a single experienced anesthesiologist.
Intravenous Dexketoprofen Application
50 mg dexketoprofen trometamol (Metadem, 5mg / 2ml amp, Vem, Turkey) was administered to the IVD group before surgery. Patients were given intravenous doses of 50 mg dexketopropophen in repeated doses in the postoperative period every 8 hours until discharge.
The patients were taken to the postanesthetic care unit after the operation. All patients received 10 mg / kg paracetamol iv infusion every 6 hours postoperatively. Postoperative pain severity was evaluated by VAS score. VAS score and nausea and vomiting scores were recorded at 30. min, 1, 2, 4, 8, 12, 16 and 24 hours postoperatively. Those with a VAS score of 0 had no pain (excellent analgesia) and those with ≤3 were considered mild pain without rescue analgesics. Patients with a VAS score of 4-6 were considered as moderate pain and patients with 7-10 were considered as severe pain. According to the VAS score, iv tramadol was given 400mg / day maximum every 8 hours if necessary. 24-hour mean VAS scores were calculated.
Number of patients who required rescue analgesic, time of first analgesic requirement, duration of analgesia, mean tramadol consumption, side effects and complications were recorded during the first 24 post-operative hours. Patients with nausea and vomiting were given intravenous 4 mg ondansetron (Kemoset, 8mg / 4ml, Deva, Turkey). After the postoperative follow-up, patients without any problems were discharged.
G-Power version 126.96.36.199 (Universität Kiel, Germany) was used to calculate the sample size. An alpha error of 0.05, Power (1-β err probe) 0.95, Numerator df 3, Number of groups 3 and effect size 0.4 were considered and the minimum number of patients included in the study was calculated as 112.
SPSS 16.0 for Windows (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. Statistically numerical data mean and standard deviation; categorical data were expressed as frequency and percentage. The comparison of categorical data in the groups was analysed with chi-square test and the results were given as n%. The Kolmogorov-Smirnov test was used to determine whether the numerical data matched the normality distribution. One-way ANOVA test was used to compare the normality distribution and Kruskal-Wallis test was used to compare the non-normality distribution. Post Hoc analysis was used to determine the difference between the groups after sig nificant values. In all comparisons, p <0.05 was considered statistically significant.