Patient requirement for adequate post-operative analgesia is difficult to predict and thus our American colleagues at the Abdominal Core Health Quality Collaborative (ACHQC) are to be congratulated on their 'forensic' report with regard to use of opioid analgesia following inguinal hernia repair in approximately 2000 patients [1]. As in many series, a repair under local anaesthesia is the strongest predictor (P < 0.001) of not requiring the use of opioids, closely followed by cases where local anaesthesia (LA) was added to a general anaesthetic (GA) (P = 0.022). The next question is how should this be administered? Traditionally, aliquots of the preferred solution are arbitrarily injected into the depths of the incision on wound closure. Whilst not scientific in its approach, this additional analgesia is better than none.Whilst we often offer LA repair, many patients wish a GA and thus resident/trainee exposure to this valuable approach can be limited. Indeed when carrying out a GA repair, we always administer 20 ml of an equal mixture of 0.5% Bupivacaine and 1% Lignocaine with 1:200,000 adrenaline on opening the canal as if the operation was being performed wholly under LA. This is in essence a form of pre-emptive analgesia and proved to be very useful as in our recent observational cohort study [2]. This approach led to lower requirements of post-operative opioid analgesia and anti-emetics. Not only were patients less likely to fail day case discharge criteria, but trainees also gain experience in peri-incisional LA infiltration. We recommend this simple step for all patients undergoing a repair under a GA and encourage surgeons who may be uneasy with regards to pure LA repairs to judge its benefits.
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