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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 15  |  Issue : 1  |  Page : 40-44

Comparison of spinal and segmental epidural anesthesia in patients undergoing inguinal hernia repair


Department of Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi(M), Wardha, Maharashtra, India

Date of Submission29-Nov-2019
Date of Decision10-Dec-2019
Date of Acceptance20-Dec-2019
Date of Web Publication13-Oct-2020

Correspondence Address:
Dr. Saibaba Thammishetty
Department of Anaesthesiology, JNMC, Sawangi, Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_194_19

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  Abstract 


Aim: The aim of the study was to evaluate whether epidural analgesia is more advantageous over spinal anesthesia. Material and Methods: Patients who are undergoing elective inguinal hernia repair of aged between 18 and 80 years of either sex, belonging to the American Society of Anesthesiologists Class I and II were randomly distributed and given spinal and epidural anesthesia. Results: Segmental epidural anesthesia was given with 0.5% 6 ml at L1–L2 intervertebral space to compare mainly hemodynamic parameters.

Keywords: Bupivacaine, epidural anesthesia, inguinal hernia repair, segmental epidural block


How to cite this article:
Thammishetty S, Chandak A V. Comparison of spinal and segmental epidural anesthesia in patients undergoing inguinal hernia repair. J Datta Meghe Inst Med Sci Univ 2020;15:40-4

How to cite this URL:
Thammishetty S, Chandak A V. Comparison of spinal and segmental epidural anesthesia in patients undergoing inguinal hernia repair. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2020 Oct 28];15:40-4. Available from: http://www.journaldmims.com/text.asp?2020/15/1/40/297975




  Introduction Top


Pain is the most common symptom of all the symptoms that one can get, for which a patient seeks medical advice and whatever may be the basic cause they demand a relief.

From ancient times, medical profession has attempted various methods of pain relief. The introduction and development of epidural analgesia and anesthesia played a significant role in achievement over pain, which is one of the most interesting chapters in the field of medicine.

Anesthesia technique for inguinal herniorrhaphy should be cost effective with respect to speed of recovery, patient comfort, and associated incremental costs.[1]

Inguinal hernia repair can be performed under spinal, epidural, general, and inguinal field block. Epidural anesthesia is suitable for lower abdominal surgery and on lower limbs. It has some specific advantages over spinal anesthesia such as avoidance of postspinal headache, less chances of meningitis, and minimal chances of nausea and vomiting in intraoperative and postoperative period.[2] Inguinal hernia is most commonly seen in elderly age group and the above stated complications will be more severe. In the case of simple inguinal hernia repair, which is confined between the level of the 12th thoracic and 1st lumbar dermatomes, an upper analgesic level of the 8th to the 10th thoracic dermatomes is satisfactory.[3]


  Patients and Methods Top


The present study had been carried out after approval of the Ethics and Screening Committee of Jawaharlal Nehru Medical College (JNMC), Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha.

Written and informed consent was obtained from all the patients prior to procedure.

Study design

  1. Study period: 1 year from October 2018 to September 2019
  2. Study area: Department of Anaesthesiology Acharya Vinoba Bhave Rural Hospital affiliated to JNMC
  3. Research design: Comparative randomized study
  4. Study population: Adult patients, 18–80 years of age.


Inclusion criteria

  1. Patients undergoing elective inguinal hernia repair
  2. Patients aged between 18 and 80 years of either sex
  3. Patients belonging to American Society of Anesthesiologists (ASA) Class I and II
  4. Mallampati Grade I and II.


Exclusion criteria

  1. Patients not willing to participate
  2. Deranged coagulation profile
  3. Peripheral neuropathy
  4. Emergency obstructed hernia
  5. Patients <18 years and >80 years
  6. Patients with ASA Class III and IV
  7. Mallampati Grade III and IV
  8. Patients with ischemic heart diseases
  9. Morbid obese patients
  10. Pregnant patients
  11. Patients with difficult venous access and veins
  12. Patients with history of allergic response to bupivacaine.


Sixty patients fulfilling all the inclusion and exclusion criteria and posted for elective hernioplasty surgery were equally and randomly allocated in two groups (i.e. 30 in each groups). Randomization was done using computer-generated random number table and allocation of same in sealed envelope technique.

  • Group “S” (n = 30) – Receiving spinal anesthesia (intrathecal 0.5% bupivacaine “H” 2.5 ml)
  • Group “E” (n = 30) – Receiving epidural anesthesia (0.5% bupivacaine 6 ml).


Study procedure

  • After preanesthetic checkup following investigations will be done as routine – Hemoglobin, complete blood count, liver function test, kidney function test, serum electrolytes, electrocardiography (ECG), and chest X-ray
  • Procedure was explained to the patients and written informed and valid consent was obtained from each patient
  • Patients were shifted to preoperative room, intravenous access obtained in forearm with 18G cannula and lactated Ringer's solution or normal saline 500 ml was infused intravenously before the procedure.


Standard anesthesia monitoring were used, including

  • Noninvasive arterial blood pressure (NIBP)
  • ECG and
  • Oxygen saturation with pulse oximetry
  • Pulse rate
  • Respiratory rate.


Subarachnoid block

Under all aseptic precautions, patients back was painted, prepared, and draped. Subarachnoid block was instituted in sitting or lateral position by midline approach by using disposable Quincke spinal needle (25G) at L3–L4 intervertebral space. Patients were monitored continuously, using NIBP, pulse oximeter, and electrocardiogram. After, subarachnoid block, fluid therapy was maintained with lactated ringers solution (2 ml/kg/h) or normal saline (2 ml/kg/h).

Segmental epidural block

With patient in sitting position, back was cleaned, painted, and draped, to achieve and maintain asepsis. A 2 ml lignocaine 2% of solution was injected locally in L1–L2 space into the skin and subcutaneous tissue. An 18G epidural needle was advanced up to interspinous ligament. A 10 cc loss of resistance syringe with 2 ml of air in it was attached at the hub of the needle after removing the stylet. The needle was then advanced slowly until loss of resistance felt. Epidural space was confirmed with hanging drop technique. Six milliliter of single shot 0.5% bupivacaine given. An 18G epidural catheter was threaded through the needle and secured in the epidural space with 5 cm of length into the epidural space. Following this, needle was removed and catheter strapped firmly to the back of the patient with an adhesive tape. Distal end of the catheter was covered with a sterile gauge piece and a cover. During this whole procedure, care was taken not to advance either the needle or the catheter as chance of piercing the dura or a blood vessel is there.

Statistical methods

  • The two groups were compared using Student's t-test, represented as mean ± standard deviation (continuous data) and Chi-square for categorical data
  • The null hypothesis was rejected at P < 0.05
  • Data collected was analyzed with Statistical Package for Social Sciences version 16 and rational deductions derived.



  Results Top


  1. In this study, there was no statistical significance in mean age, height, and weight of patients in both groups. In our study, [Table 1] shows that while using the minimal quantity of local anesthetic drug of 6 ml, the extent of spread of analgesia was tested 5–10 min after the block was given and at the end of surgery. The extent of analgesia was elicited with the help of pin prick. In this study, all the patients who received 6 ml the analgesic effect was found to be satisfactory
  2. As shown in [Table 2], we can say that the highest sensory level between the two groups was compared. In Group S, three subjects (10.0%) reached T6 level and 27 (90.0%) reached T8 level while all the subjects in Group E reached T10 level. Hence, in this study, we achieved a level up to T10 adequately with 6 ml of 0.5% bupivacaine
  3. In this study, [Table 2] shows that almost all the patients were comfortable, analgesia, and surgical relaxation was adequate no supplementation is required during surgery
  4. Onset and duration of analgesia: Many studies did not mention about the duration of analgesia
  5. Table 1: Details of age (year), weight (kg), and height (cm) of the study population

    Click here to view
    Table 2: Comparison of highest sensory level between the two groups

    Click here to view


    In our study, [Table 3] shows that in the present study the onset of anesthesia was significantly lower for Group S (5.60 ± 0.59) compared to Group E (12.06 ± 0.90). The duration of anesthesia was significantly lower for Group S (150.66 ± 23.62) compared to Group E (125.16 ± 23.79). With these findings we can say that onset of analgesia was relatively late and duration of analgesia was less as compared to Group S but the total duration was adequate enough in the study group In our study, the mean heart rate between the two groups at various time intervals was compared. The results did not show any statistically significant difference (P > 0.05) for mean heart rate at various time intervals except at 5 min. At 5 min, the mean heart rate for Group S was higher than Group E In our study, [Table 4] shows that the mean systolic blood pressure between the two groups at various time intervals was compared. The results showed statistically significant difference for mean systolic blood pressure at 5 min (P < 0.001), 10 min (P < 0.001), 15 min (P < 0.001), 20 min (P < 0.001), 25 min (P < 0.001), and 30 min (P < 0.001) between the two groups
    Table 3: Comparison of duration of surgery, onset of anesthesia, time taken to reach highest level of anesthesia and duration of anesthesia (min)

    Click here to view
    Table 4: Comparison of mean systolic blood pressure between the two groups at various time intervals

    Click here to view


  6. [Table 5] shows that the mean diastolic blood pressure between the two groups at various time intervals was compared. The results showed statistically significant difference for mean diastolic blood pressure at 10 min (P < 0.001), 15 min (P < 0.001), 20 min (P < 0.001), 25 min (P < 0.001), 30 min (P < 0.001), 40 min (P < 0.001), and 50 min (P = 0.004) between the two groups.
Table 5: Comparison of mean diastolic blood pressure between the two groups at various time intervals

Click here to view


[Table 6] shows that the mean arterial pressure between the two groups at various time intervals was compared. The results showed statistically significant difference for mean arterial pressure at 5 min (P = 0.029), 10 min (P < 0.001), 15 min (P < 0.001), 20 min (P < 0.001), 25 min (P < 0.001), 30 min (P < 0.001), 40 min (P = 0.001), and 50 min (P = 0.034) between the two groups. With these observations we can say that there were no significant hemodynamic changes in Group E as compared to Group S.

In this present study, there were no cases of dural puncture. [Table 7] shows that the adverse effects between the two groups was compared. In Group S, there were two cases of shivering and nausea each and one case of vomiting. In Group E, only one case experienced nausea. There was NO statistically significant difference in adverse effects between the two groups (P = 0.308) respiratory depression, retention of urine, and any neurological complications were not encountered in the present study.
Table 6: Comparison of mean arterial pressure between the two groups at various time intervals

Click here to view
Table 7: Comparison of adverse effects between the two groups

Click here to view



  Discussion Top


  1. In this study, we got excellent quality of analgesia with 6 ml 0.5% bupivacaine in segmental epidural block. Patients were comfortable and surgical relaxation was also achieved


  2. Cedric Prys-Roberts and Andrew M. S. Black stated that segmental epidural block with local anesthetic is far more satisfactory when placed at correct vertebral level and in more than 90% of patients undergoing lower abdominal surgeries where block required is between T10 and L2 the volume of local anesthetic required is 5 ml[4]

    Sachidanand et al.[5] studied 53 patients as excellent analgesia and relaxation, i.e. patient comfortable, analgesia, and surgical relaxation adequate no supplementation is required during surgery. Forty-seven patients had good analgesia and mild discomfort during surgical procedure, which required Additional top-ups of local anesthetic at an incremental dose of 1 ml

  3. The highest sensory level between the two groups were compared. In Group S, 3 subjects (10.0%) reached T6 level and 27 (90.0%) reached T8 level while all the subjects in Group E reached T10 level. Hence, in this study, we achieved a level up to T10 adequately with 6 ml of 0.5% bupivacaine
  4. In the present study, the onset of anesthesia was significantly lower for Group S (5.60 ± 0.59) compared to Group E (12.06 ± 0.90). The duration of anesthesia was significantly lower for Group S (150.66 ± 23.62) compared to Group E (125.16 ± 23.79). With these findings, we can say that the onset of analgesia was relatively late and duration of analgesia was less as compared to Group S but the total duration was adequate enough in the study group


  5. In a study by Prys Roberts and Andrew Black, stated that in 90% of the patients undergoing lower abdominal surgeries where block required is between T10 and L2 the volume of local anesthetic required is 5 ml and the duration of block with Bupivacaine 0.5% is limited to 3–4 h[4]

  6. The mean heart rate between the two groups at various time intervals was compared. The results did not show any statistically significant difference (P > 0.05) for mean heart rate at various time intervals except at 5 min. At 5 min, the mean heart rate for Group S was higher than Group E. the mean systolic blood pressure between the two groups at various time intervals was compared. The results showed statistically significant difference for mean systolic blood pressure at 5 min (P < 0.001), 10 min (P < 0.001), 15 min (P < 0.001), 20 min (P < 0.001), 25 min (P < 0.001) and 30 min (P < 0.001) between the two groups. The mean diastolic blood pressure between the two groups at various time intervals was compared. The results showed statistically significant difference for mean diastolic blood pressure at 10 min (P < 0.001), 15 min (P < 0.001), 20 min (P < 0.001), 25 min (P < 0.001), 30 min (P < 0.001), 40 min (P < 0.001), and 50 min (P = 0.004) between the two groups. That the mean arterial pressure between the two groups at various time intervals was compared. The results showed statistically significant difference for mean arterial pressure at 5 min (P = 0.029), 10 min (P < 0.001), 15 min (P < 0.001), 20 min (P < 0.001), 25 min (P < 0.001), 30 min (P < 0.001), 40 min (P = 0.001), and 50 min (P = 0.034) between the two groups. With these observations we can say that there were no significant hemodynamic changes in Group E as compared to Group S Odom (1936), Guiterrez (1939), Doglitotti (1939), and Dawkins (1954) claimed that the hypotension in epidural block is less than that from spinal analgesia


  7. The adverse effects between the two groups were compared. In Group S, there were two cases of shivering and nausea each and one case of vomiting. In Group E only one case experienced nausea. There was NO statistically significant difference in adverse effects between the two groups (P = 0.308) respiratory depression, retention of urine and any neurological complications were not encountered in the present study.


Dawkins and Steel (1971) claimed to be as 1.6% in 282 cases of thoracic epidurals as against 2.6% in 397 cases of lumbar epidurals. This is because of the obliquity of the anatomy of the spinous processes.[6],[7]


  Conclusion Top


Based on the present clinical comparative study, we can conclude that segmental epidural block with 6 ml of 0.5% bupivacaine is found to be safe and fulfill the surgical requirement. Because of limited spread of analgesia involving only few segments, i.e. T12–L2, it can be successfully employed. Very minimal hemodynamic changes were recorded. This technique can be safely used in elderly patients. 0.5% bupivacaine 6 ml is effective for segmental epidural block for inguinal hernia repair.

Thus, this study concludes that “segmental epidural anesthesia is advantageous over spinal anesthesia.”

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Song D, Greilich NB, White PF, Watcha MF, Tongier WK. Recovery profiles and costs of anesthesia for outpatient unilateral inguinal herniorrhaphy. Anesth Analg 2000;91:876-81.  Back to cited text no. 1
    
2.
Cheng PA. The anatomical and clinical aspects of epidural analgesia, Part I and II. Anesth Analg 1963;42:398-407.  Back to cited text no. 2
    
3.
Prithviraj P. Textbook of Regional Anaesthesia. Vol. 1. Elsevier (USA): Churchill Livingstone; 2003. p. 568.  Back to cited text no. 3
    
4.
Blomberg R. The dorsomedian connective tissue band in the lumbar epidural space of humans: An anatomical study using epiduroscopy in autopsy cases. Anesth Analg 1986;65:747-52.  Back to cited text no. 4
    
5.
Sachidanand RS, Devulapalli PK, Rao BS, Chandrashekhar B, Srinath M. Segmental epidural anaesthesia for inguinal hernia repair. J Evid Based Med Healthcare 2015;2:6244-57.  Back to cited text no. 5
    
6.
Cousins MJ, Bridenbaugh PO. Spinal neural blockade in neural blockade. In: Clinical Anaesthesia and Management of Pain. 3rd ed. Philadelphia: Lippincott – Raven; 1998. p. 675.  Back to cited text no. 6
    
7.
Swarnkar M, Jindal R. Obstructed Obturator Hernia: A Diagnostic Dilemma. J Krishna Inst Med Sci Univ 2019;8:115-7.  Back to cited text no. 7
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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