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
Postoperative Pain Management
Recommended Postoperative Strategies
• NSAIDS . Conventional or COX-2-selective NSAIDs should be
used in the postoperative setting. If they have not been administered
pre- or intraoperatively, then they should be started as
early in the postoperative period as possible. Because of the
associated risks of bleeding and gastroduodenal ulcer with conventional
NSAIDs, many surgeons prefer using a COX-2-
selective formulation. NSAIDS are best taken on a scheduled
basis, not as needed, and may be continued for 1–2 weeks
postoperatively.
• Acetaminophen (APAP) . APAP is recommended for routine pain
therapy in combination with conventional NSAIDs/COX-2-
selective inhibitors or weak opioids. It may be taken on a scheduled
basis if the patient is not taking any other APAP formulation,
or as needed if included in another formulation such as a weak
opioid (e.g., hydrocodone plus APAP).
• Weak opioids . Weak opioids are recommended when conventional
NSAIDs or COX-2-selective inhibitors plus APAP are not
sufficient or contraindicated. The most commonly prescribed
weak opioid in the USA is hydrocodone, where it is only available
in formulations that combine it with APAP. This must be
taken into consideration when using this weak opioid in combination
with IV or oral APAP.
• Strong opioids . Strong opioids are recommended as rescue analgesia
for severe pain in addition to the use of nonopioid agents.
They are not recommended for first-line analgesia because of
side effects that may delay early ambulation.
Nonrecommended Postoperative Strategies
• Continuous wound infusion with local anesthetic . Continuous
infusion of an intermediate-acting local anesthetic using either
an elastomeric or electric pump has shown longer duration of
postoperative analgesia compared to infiltration alone. However,
in hernia surgery, it is unclear as to whether the infusion should
be in the subcutaneous or subfascial space and whether use of
this system is superior to TAP block or nerve/field block using