|Year : 2017 | Volume
| Issue : 1 | Page : 29-34
Ultrasound-guided ilioinguinal, iliohypogastric, and genitofemoral nerve block versus spinal subarachnoid blockade for inguinal hernia repair
Dorreya M Fekry1, Nagwa A Megahed2, Mohammed H EL-Lakany2, Maha Mahmoud Soliman Yakout MSc 2
1 Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Alexandria University, Alexandria, Egypt
2 Department of Anaesthesia, Medical Research Institute, Alexandria University, Alexandria, Egypt
|Date of Submission||11-Apr-2016|
|Date of Acceptance||22-Oct-2016|
|Date of Web Publication||22-Mar-2017|
Maha Mahmoud Soliman Yakout
165 El Horrya Road, El Hadara 21648
Source of Support: None, Conflict of Interest: None
All anesthetic methods have been used for inguinal hernia repair surgeries. The use of local anesthesia (LA) techniques such as the ilioinguinal iliohypogastric nerve block (IHNB) may be the most convenient method for patients who are unfit for general anesthesia or spinal anesthesia (SA). The use of ultrasound (US)-guided techniques increases the success rate of the IHNB. The use of intravenous sedation increases the acceptability of LA techniques.
The aim of this study was to evaluate the effectiveness, safety, and complications of US-guided IHNB and genital branch of genitofemoral nerve (GF) block in comparison with SA for inguinal hernia repair surgeries.
Patients and methods
The current study was carried out on 42 patients of American Stroke Association classes I and II. Patients with recurrent, bilateral, irreducible, or large scrotal hernias were excluded.
The patients were randomly divided into two equal groups using the closed envelope method, groups 1 and 2.
Group 1 included 21 patients who were anesthetized using US-guided IHNB with 25 ml of 0.5% isobaric bupivacaine and genital branch of GF nerve block with 10 ml of 0.5% isobaric bupivacaine.
Group 2 included 21 patients who received SA using 3 ml of 0.5% hyperbaric bupivacaine and 25 μg fentanyl.
All patients received sedation as continuous propofol infusion. The propofol infusion dose was titrated until the sedation score was 4 using Ramsay Sedation Score.
Patients receiving IHNB had better hemodynamic stability when compared with the SA group. The total postoperative analgesia was significantly lower and the first dose of postoperative analgesia was significantly delayed in the IHNB group. Postoperative ambulation was significantly early in the IHNB group.
US-guided IHNB and genital branch of GF nerve block under sedation are good anesthetic techniques for inguinal hernia repair surgeries.
Keywords: genitofemoral nerve block, herniorrhaphy, ilioinguinal iliohypogastric nerve block, propofol sedation
|How to cite this article:|
Fekry DM, Megahed NA, EL-Lakany MH, Yakout MM. Ultrasound-guided ilioinguinal, iliohypogastric, and genitofemoral nerve block versus spinal subarachnoid blockade for inguinal hernia repair. Res Opin Anesth Intensive Care 2017;4:29-34
|How to cite this URL:|
Fekry DM, Megahed NA, EL-Lakany MH, Yakout MM. Ultrasound-guided ilioinguinal, iliohypogastric, and genitofemoral nerve block versus spinal subarachnoid blockade for inguinal hernia repair. Res Opin Anesth Intensive Care [serial online] 2017 [cited 2020 May 31];4:29-34. Available from: http://www.roaic.eg.net/text.asp?2017/4/1/29/202693
| Introduction|| |
All anesthetic methods have been used for inguinal hernia repair surgeries. The choice of the anesthetic technique depends on its acceptability by the patient and surgeon, the feasibility and safety of the procedure, surgical method, medical history, comorbidities, and the cost. Epidemiological data have found that general anesthesia (GA) is used in 60–70% of cases, central neuraxial blockade in 10–20%, and regional anesthesia with sedation in 5–15% of the cases ,.
The use of local anesthesia (LA) techniques may be the most convenient method for patients who are unfit for GA or spinal anesthesia (SA) due to cardiovascular disease, cerebrovascular disease, severe respiratory disease, severe liver impairment, or coagulopathies. Ilioinguinal (II) iliohypogastric nerve block (IHNB) and genital branch of the genitofemoral nerve (GF) blocks may be used for inguinal hernia repair surgeries .
Direct sonographic visualization of the IHNB improves the quality of the block, increases success rate to 95%, and reduces the risk for complications, whereas the conventional technique of IHNB is associated with a failure rate of 40%. The postoperative requirements for additional analgesics are significantly lower in the ultrasound (US)-guided nerve block method compared with the conventional ‘blind’ fascia click method ,.
The genital branch of the GF nerve is blocked during inguinal herniorraphy to decrease the pain induced by traction of the hernia sac and to improve the quality of analgesia for surgery in the inguinal region ,.
The use of intravenous sedation increases the acceptability of LA techniques. Moreover, it improves the success rate of the repair. Propofol sedation provides rapid recovery due to rapid distribution and short elimination half-life. The brief duration of action ensures prompt responsiveness to changes in its infusion rate and could easily be maintained at the desired level of sedation by varying the infusion rate. The use of propofol decreases the level of postoperative sedation, drowsiness, and confusion ,.
| Aim|| |
The aim of this study was to evaluate the effectiveness, safety, and complications of US-guided IHNB and genital branch of GF block in comparison with SA for inguinal hernia repair surgeries.
| Patients and methods|| |
The current study was carried out on 42 patients of American Stroke Association classes I and II. Patients with recurrent, bilateral, irreducible, or large scrotal hernias were excluded. The patients were randomly divided into two equal groups using the closed envelope method.
All patients were evaluated the day before surgery. All patients were informed on whether they will be undergoing US-guided IHNB and genital branch of GF nerve block or SA and how the procedure will be performed in either technique. All patients were trained to use visual analogue scale (VAS) to express their pain. All patients received a sedating dose of midazolam (2–3 mg) before the procedure.
Group 1: IHNB
A linear probe with 10 Hz frequency with a depth of 3 cm was placed at the anterior superior iliac spine in an oblique manner at the line joining the umbilicus and the anterior superior iliac spine. The nerves lie in the fascial split between the internal oblique and the transversus abdominis. After negative aspiration, 25 ml of 0.5% isobaric bupivacaine was deposited between the transversus abdominis and the internal oblique. After LA injection, the split widens because of spread of the drug.
The genital branch of the GF
The US probe was placed parallel and 1.25 cm above the inguinal ligament scanning over the external iliac artery and vein. At this location, the probe was tilted slightly cephalad to visualize the inferior epigastric artery that is emerging medially from the external iliac artery. The needle was introduced in-plane from the lateral end of the probe until the needle tip was at the lateral vicinity of the inferior epigastric artery, and then 10 ml of 0.5% isobaric bupivacaine was deposited after negative aspiration.
An incremental dose of 25 μg fentanyl was scheduled intraoperatively for patients who may experience pain. The total amount of fentanyl used was measured at the end of operation.
Group 2: SA
The patients received SA. 0.5% hyperbaric bupivacaine, and 25 μg fentanyl was injected in the subarachnoid space between the L2 and the L3.
- Patient refusal.
- Allergy to LA or any included medications.
- Recurrent, bilateral, irreducible, incarcerated, or large scrotal hernias.
- Severe liver, renal, or cardiovascular diseases.
- Infection at the site of injection.
- Psychiatric disorder.
- Obesity (BMI >35).
- Lengthy operation duration of more than 120 min.
- Neurological disease.
- Severe deformities of the spinal column, such as severe kyphoscoliosis, arthritis, and pervious lumbar fusion surgeries.
Data were fed to the computer and analyzed using IBM SPSS software package, version 20.0 (IBM SPSS statistics for windows, version 20.0 Armonk, NY: IBM Corp.). Student’s t-test was used for normally distributed quantitative variables such as demographic data, surgery duration, duration and onset of the block, and total propofol consumption. Analysis of variance with repeated measures was used for normally distributed quantitative variables, to compare two periods such as heart rate and blood pressure. The Mann–Whitney test was used for abnormally distributed quantitative variables such as motor power, ambulation time, VAS, sedation score, and patients and surgeons’ satisfaction.
Age and weight of the patients and the surgery duration were measured. Sensory block onset and duration were recorded. The total amount of intraoperative fentanyl consumed in group 1 was measured. Motor power assessment was carried out 5 min after the block and immediately postoperatively using the modified Bromage Scale ([Table 1]). Ambulation time was documented.
Heart rate and mean arterial blood pressure (MABP) were recorded before induction of anesthesia, after induction, 5 min and then every 15 min intraoperatively, and 30 min, 1 h, and every 4 h for the first 24 h postoperatively.
Postoperative pain was assessed at 30 min, 1 h, and every 4 h postoperatively for 24 h using the VAS (0–10), in which 0=no pain and 10=severe pain. The time to first need for rescue analgesia and the total rescue analgesia doses were recorded.
Total propofol used intraoperatively was recorded. Postoperative sedation was recorded using Ramsay Sedation Score ([Table 2]) immediately upon arrival into the postanesthesia care unit and after 30 min. Patients’ and surgeon’s satisfaction was assessed.
| Results|| |
No significance was recorded as regards the demographic data and surgery duration ([Table 3]).
As regards the vital signs, on comparing the two groups, the heart rate changes showed no significance ([Figure 1]), whereas the MABP changes between the two studied groups revealed that the MABP was significantly lower at 5, 15, 30, and 45 min after induction in group 2 (SA) ([Figure 2]).
|Figure 1 Comparison between the two studied groups according to heart rate (bpm). IHNB, ilioinguinal iliohypogastric nerve block; SA, spinal anesthesia.|
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|Figure 2 Comparison between the two studied groups according to mean arterial blood pressure (mmHg). IHNB, ilioinguinal iliohypogastric nerve block; SA, spinal anesthesia.|
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The onset of sensory block was significantly earlier in group 2 (SA). The duration of sensory block was significantly longer in group 2 (IHNB). The total amount of fentanyl given to the patients in group 1 (IHNB) was measured and ranged from 25 to 75 μg, with a mean of 42.65±17.15 μg. The motor power assessment using the modified Bromage Scale was significantly different 5 min after the block and immediately postoperatively. The ambulation time was significantly shorter in group 1 (IHNB) ([Table 4]).
|Table 4 Comparing sensory block onset and duration, motor block and ambulation time|
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The VAS when compared between two groups revealed that significantly higher readings were found at the fourth and 16th hour measurements in group 2 (SA). The time to first need for rescue analgesia was significantly shorter in group 1 (IHNB) and the total analgesia requirements were lesser ([Table 5]).
The total dose of propofol used intraoperatively was significantly higher in group 1 (IHNB) and the sedation score showed no significance between the two groups in all measurements. The patient satisfaction showed no significant difference between the two groups. Surgeon satisfaction was significantly higher in group 2 (SA) ([Table 6]).
| Discussion|| |
The significant difference in the intraoperative MABP between the two studied groups may be due to the hypotensive effect of SA. SA causes blockade of preganglionic sympathetic fibers, thus decreasing the systemic vascular resistance causing peripheral pooling of blood, which reduces the venous return and preload .
Although the onset of the sensory block is slower in group 1 (IHNB), the use of the US guidance was proved to shorten the onset time of the sensory block. Koscielniak-Nielsen , who reviewed the benefits of the US-guided blocks, reported that the block onset was reduced in all US-guided blocks while comparing US-guided method in six different peripheral nerve blocks with the nerve stimulator and the landmark-based methods.
The motor power was assessed using the modified bromage scale 5 min after the block and immediately postoperatively. The difference in motor power was significant between the two groups. The IHNB does not affect the motor power, whereas the SA produces intense sensory motor blockade and sympathetic blockade.
Ghani et al.  showed that the IHNB does not affect the motor power except if femoral nerve palsy accidently occurs, especially with blind infiltration. Transient femoral nerve palsy is a recognized complication after II and iliohypogastric nerve block. It causes knee weakness. The reported time of onset of transient femoral nerve palsy following surgery varies from 2–6 h. It usually resolves within 24–36 h.
In the current study, the VAS in group 2 (SA) was significantly higher at the fourth hour (P=0.002) and the 16th hour (P=0.002) postoperatively when compared with VAS in group 1 (IHNB).
In disagreement with the present study, Bang et al.  reported that the VAS of patients receiving IHNB with monitored anesthesia care measured right after surgery was significantly higher than that of patients receiving SA. However, clinically, the situation did not demand analgesics even though the difference was statistically significant. It also showed that the difference in VAS on postoperative day one was not significant between the two studied groups.
A study conducted by Song et al.  comparing GA, SA, and IHNB with monitored anesthesia care showed that the VAS in the recovery room 30 min postoperatively was lower in the IHNB group. Using the 100 mmVAS, the score was 15±14 mm in the IHNB group and 34±32 mm in the SA group.
In agreement with the present study, Dongare and Dongare  showed that the time when the patient demanded first rescue analgesic postoperatively was significantly earlier in the SA group compared with the IHNB group. They observed that the mean analgesia duration was 188.5±24.6 min in the SA group and 361.5±74.4 min in the IHNB group.
In disagreement with the present study, Yilmazlar et al.  conducted a study to compare SA with IHNB and it showed that the time to first dose of rescue analgesia postoperatively was 3.30±0.2 h in the SA group and 2.7±0.13 h in the IHNB group. The difference in the result may be attributed to the use of US guidance in the present study and the addition of the genital branch of GF block.
Hu et al.  conducted a pilot study to evaluate US-guided IHNB. The study showed that all patients had successful blocks, without complications. The mean opioid consumption was 10 mg of intramuscular morphine during the first 24 h.
In the present study, total amount of propofol used intraoperatively in group 2 (SA) was significantly lesser than that in group 1 (IHNB). The intravenous sedation may be required as LA blocks pain sensation, but pressure sensation and traction on deeper tissues are not eliminated. The anesthesiologist must adjust the level of the sedation that makes the patient and the surgeon comfortable until the end of the procedure .
In agreement with the present study, a study conducted by Song et al.  showed that the total dosage of propofol used during surgery was higher in the IHNB block group with monitored anesthesia care and significantly different from the spinal and general groups.
Propofol has rapid redistribution and short elimination half-life that result in a rapid recovery from the effects of a single bolus dose, as well as following a continuous infusion. Propofol has rapid onset and short duration of action ensures prompt responsiveness to changes in its infusion rate, which can be achieved using a variable rate infusion. Propofol is the nearest to an ideal agent for sedation during regional anesthesia .
A study conducted by Dongare and Dongare  to compare IHNB versus SA for hernia repair as a day-case surgery showed that, during the hernia sac handling, LA infiltration, supplemental sedation, or analgesia may be required. For any discomfort during surgery, supplementation was given with bolus propofol up to1 mg/kg. It also showed that GF block improves intraoperative analgesia.
In the present study, the ambulation time in IHNB was significantly earlier than that in the SA group.
Song et al.  showed that the time to home readiness was significantly earlier in patients receiving IHNB+MAC (133±68 min) than in patients receiving SA (280±80 min).
In the study conducted by Dongare and Dongare , there was a significant difference in time to postoperative ambulation between the two groups. The mean duration of postoperative ambulation was 298.6±27.9 min in group 1 (SA) and 120.1±15.8 min in group 2 (IHNB).
Comparison between the two studied groups according to the patient satisfaction was nonsignificant.
In agreement with the present study, Bang et al. , who conducted a study to compare SA with IHNB under monitored anesthesia care, showed that patients’ satisfaction in the recovery room was nonsignificant between the two groups.
On comparing surgeon satisfaction, in group 2 (SA), surgeons were significantly more satisfied. The reasons for this limited use could be the surgeon’s desire for a relaxed operating area or the reputation of LA because of a previous nonoptimal technique with unacceptable intraoperative pain as a consequence. Another drawback is the surgeon’s lack of familiarity with the technique .
In contrast to the present study, Bang et al. , who conducted a study that compared SA with IHNB under monitored anesthesia care, showed that surgeon satisfaction was significantly higher in the IHNB group.
| Conclusion|| |
US-guided IHNB provides good anesthetic technique for inguinal hernia repair surgeries. Addition of the genital branch of the GF enhances the intraoperative analgesia. Sedation enhances patient and surgeon acceptability to LA techniques.
The authors thanks to Dr. Ayman Farouk Aly for his great support and work regarding the surgical aspect of the study that helped to achieve the goal of the research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kulacoglu H. Current options in inguinal hernia repair in adult patients. Hippokratia 2011; 15:223–231.
Kehlet H, White PF. Optimizing anaesthesia for inguinal herniorrhaphy: general, rogional, or local anaesthesia? Anesth Analg 2001; 93:1367–1369.
Simons M, Aufenacker T, Bay-Nielsen M, Bouillot J, Campanelli G, Conze J et al.
European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2009; 13:343–403.
Eichenberger U, Greher M, Kirchmair L, Curatolo M, Moriggl B. Ultrasound-guided blocks of the ilioinguinal and iliohypogastric nerve: accuracy of a selective new technique confirmed by anatomical dissection. Br J Anaesth 2006; 97:238–243.
Weintraud M, Lundblad M, Kettner SC, Willschke H, Kapral S, Lönnqvist PA et al.
Ultrasound versus landmark-based technique for ilioinguinal-iliohypogastric nerve blockade in children: the implications on plasma levels of ropivacaine. Anesth Analg 2009; 108:1488–1492.
Al-Alami AA, Alameddine MS, Orompurath MJ. New approach of ultrasound-guided genitofemoral nerve block in addition to ilioinguinal/iliohypogastric nerve block for surgical anaesthesia in two high risk patients: case report. Open J Anes 2013; 3:298–300.
Sasaoka N, Kawaguchi M, Yoshitani K, Kato H, Suzuki A, Furuya H. Evaluation of genitofemoral nerve block, in addition to ilioinguinal and iliohypogastric nerve block, during inguinal hernia repair in children. Br J Anaesth 2005; 94:243–246.
Poli M, Biscione R, Bacchilega I, Saravo L, Trombetti P, Amelio G et al.
Subarachnoid anaesthesia vs monitored anaesthesia care for outpatient unilateral inguinal herniorrhaphy. Minerva Anestesiol 2008; 75:435–442.
White PF, Smith I. Use of sedation techniques during local and regional anaesthesia. Canad J Anaesth 1995; 42:38–54.
Rooke GA, Peter RF, Arnold FJ. Hemodynamic response and change in organ volume during spinal anaesthesia in elderly men with cardiac disease. Anesth Analg 1997; 85:99–105.
Koscielniak-Nielsen ZJ. Ultrasound‐guided peripheral nerve blocks: What are the benefits? Acta Anaesthesiol Scand 2008; 52:727–737.
Ghani KR, McMillan R, Paterson-Brown S. Transient femoral nerve palsy following ilio-inguinal nerve blockade for day case inguinal hernia repair. J R Coll Surg Edinb 2002; 47:626–629.
Bang YS, Park C, Lee SY, Kim M, Lee J, Lee T. Comparison between monitored anaesthesia care with remifentanil under ilioinguinal hypogastric nerve block and spinal anaesthesia for herniorrhaphy. Korean J Anaesthesiol 2013; 64:414–419.
Song D, Greilich NB, White PF, Watcha MF, Tongier WK. Recovery profiles and costs of anaesthesia for outpatient unilateral inguinal herniorrhaphy. Anesth Analg 2000; 91:876–881.
Dongare DH, Dongare HC. Comparison of ilio-inguinal ilio-hypogastric nerve block versus spinal anaesthesia for hernia repair as day care surgery. Perspect Med Res 2014; 2:7–12.
Yilmazlar A, Bilgel H, Donmez C, Guney A, Yilmazlar T, Tokat O. Comparison of ilioinguinal-iliohypogastric nerve block versus spinal anaesthesia for inguinal herniorrhaphy. Southern Med J 2006; 99:48–52.
Hu P, Harmon D, Frizelle H. Ultrasound guidance for ilioinguinal/iliohypogastric nerve block: a pilot study. Ir J Med Sci 2007; 176:111–115.
Höhener D, Blumenthal S, Borgeat A. Sedation and regional anaesthesia in the adult patient. Br J Anaesth 2008; 100:8–16.
Nordin P, Hernell H, Unosson M, Gunnarsson U, Nilsson E. Type of anaesthesia and patient acceptance in groin hernia repair: a multicentre randomised trial. Hernia 2004; 8:220–225.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]