Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

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B.J. Dunkin
Possible Preoperative Strategies in Select Patients
• Gaba agonists. Patients with a history of tolerance to opioids
may be considered for the preoperative use of gabapentin or
pregabalin.
– Gabapentin 600–900 mg the night before surgery, followed
by 600–900 mg TID for up to 72 h.
– Pregabalin 75–150 mg the night before surgery, followed
by 75–150 mg BID for up to 72 h.
Nonrecommended Preoperative Strategies
• NSAIDs with significant COX-1 inhibition. Ketorolac is an
extreme outlier in its inhibitory effect on COX-1 relative to
COX-2. As a result, the FDA warns against its use as a prophylactic
analgesic prior to any major surgery. Because pre- and/or
intraoperative infiltration of local anesthetics provides good
analgesia in the immediate postoperative period, ketorolac
should be administered immediately at the end of the procedure
when the risk of postoperative bleeding can be more accurately
assessed by the surgeon.
• Local anesthetic plus epinephrine . Adding epinephrine to the
local anesthetic does not significantly decrease the risk of toxicity
in the dosages associated with inguinal hernia repair and
does not improve its analgesic effect. It may, however, result in
undesirable cardiovascular side effects.
Intraoperative Pain Management
Recommended Intraoperative Strategies
• Anesthetic technique
– Local anesthesia (inguinal nerve block or TAP block/field
block/infiltration techniques), with or without intravenous
sedation, is recommended because it is associated with less
postoperative pain and provides additional recovery benefits
(earlier ambulation, less urinary retention) compared
with spinal, epidural, or general anesthesia. Intraoperative
use of local anesthetic injection techniques post-incision is
as effective as preoperative administration.