89.02 Can Local Anesthetics Decrease the Use of Postoperative Narcotics in Outpatient Hernioplasty?

Posted on January 26, 2017

T. DiNitto1, D. Hill1, K. Khariton1, M. Castellano1  1Staten Island University Hospital,Northwell Health,Staten Island, NY, USA

Introduction:

Prescription narcotic misuse is an epidemic in the United States. This study set out to examine whether liposomal bupivacaine (Exparel), 0.25% bupivacaine (Marcaine), or 1% lidocaine with epinephrine mixed with 0.25% bupivacaine would decrease the postoperative use of narcotics in ambulatory hernioplasty.

Methods:

A single surgeon performed 427 consecutive tension-free plug and patch mesh hernia repairs under local anesthesia with IV sedation from April 1, 2015 to December 31, 2015. Hernia repairs included inguinal, ventral, incisional, and umbilical. In 9.3% of cases two hernias were repaired during the same procedure. Every patient was seen between six and eleven days post hernioplasty and a standardized pain questionnaire was completed regarding subjective pain, prescription “painkiller”, and over the counter pain medication use in both quantity and duration. The primary endpoint was percentage of patients not requiring narcotics for pain control.

Results:

The Exparel group (147) and the Marcaine group (144) had similar results at 59% and 55% of patients who were able to avoid postoperative narcotics completely. The commonly used lidocaine with epinephrine/Marcaine mixture had only 39% success rate, significantly lower than the other groups.  Included in the study were patients that had two simultaneous hernia repairs where the exparel group only had 5.4% with 14% in the Marcaine.

Conclusion:

Our study demonstrates Exparel and Marcaine performed similarly reducing the need of postoperative narcotic use in outpatient hernia surgery by over 50%.  Both were a considerably better option than the Lidocaine/Marcaine mixture. The average cost difference between Exparel and Marcaine is exponential, with a difference of over 200 dollars per patient. Marcaine provides a significant cost benefit while achieving similar if not better postoperative pain relief and reduces postoperative narcotic use. Because of the similar outcome in pain control as well as the cost benefit, Marcaine has become the standard of care in our hernia center.  

53.19 Wound Dehiscence after Laparotomy: Who Needs Retention Sutures?

Posted on January 26, 2017

A. Pal1, E. Mahmood3, J. Nicastro2, M. Sfakianos2, T. Dinitto1, S. M. Cohn1  2North Shore University And Long Island Jewish Medical Center,Department Of Surgery,Manhasset, NY, USA 3Northwestern University,Feinberg School Of Medicine,Chicago, IL, USA 1Staten Island University Hospital, Northwell Health,Surgery,Staten Island, NY, USA

Introduction: There is a need for predictive models that can help surgeons identify patients at greatest risk for wound dehiscence in order to guide their management to avoid evisceration. We sought to use a large database in order to examine risk factors for developing this complication after midline laparotomy.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a prospectively collected surgical outcomes database compiled by manual chart abstraction. Exploratory laparotomy cases were queried using the primary CPT code from 2005-2013. The independent factors associated with wound dehiscence were examined by multivariate analysis using SAS JMP Pro 11 (Cary, NC, US). The cohort was split into a training dataset of patients from 2005-2009 and a prospective validation dataset from 2010-2013. A backwards logistic regression analysis was performed to identify predictors of wound dehiscence in the training set. The model was then tested in the validation set to estimate the receiver operating curves (ROC) and goodness of fit.

Results: A total of 16,793 patients were included in our analysis. 248 (1.47%) of these patients had a wound dehiscence. Significant predictors of wound dehiscence: deep wound infection (AOR=5.98, 95% CI 3.06 to 10.9, P<0.0001), postoperative pneumonia (AOR=3.25, 95% CI 1.99 to 5.11, P<0.0001), preoperative weight loss (AOR=3.11, 95% CI 1.29 to 10.2, P<0.0083), preoperative sepsis (AOR=3.03, 95% CI 1.91 to 4.70, P<0.0001), superficial wound infection (AOR=2.97, 95% CI 1.63 to 5.05, P<0.0007), and previous operation in the last 30 days (AOR=1.82, 95% CI 1.19 to 2.73, P<0.0061), smoking (AOR=1.49, 95% CI 1.01 to 2.18, P<0.044). The c-statistic for our model was reasonable: 0.73 in the training set and 0.70 in the validation set. The Hosmer-Lemenshow goodness-of-fit statistic was 0.89.

Conclusion: We identified a number of independent risk factors for the development of wound dehiscence which may inform the clinician and lead to improved selection of patients for measures which could reduce the likelihood of evisceration (retention sutures) after laparotomy.