Which medications in the drug class Local Anesthetic/NSAID Combination are used in the treatment of Open Inguinal Hernia Repair?

Answer

Local Anesthetic/NSAID Combination

Newer locally active analgesic modalities provide nonopioid options for postoperative pain management. The combination of bupivacaine and meloxicam was approved by the FDA in May 2021. Approval was based on the EPOCH-2 phase 3 trial. Among 418 patients undergoing unilateral open inguinal herniorrhaphy, bupivacaine/meloxicam demonstrated superior, sustained pain reduction through 72 hours, significantly reduced opioid consumption, and resulted in significantly more opioid-free subjects compared with saline placebo and bupivacaine.^[60]

Bupivacaine/meloxicam (Zynrelef)

Indicated as a single dose that provides postsurgical analgesia for up to 72 hours after open inguinal herniorrhaphy. Apply solution without a needle into the surgical site after final irrigation and suctioning and before the suturing of each layer (when multiple tissue layers are involved). The solution is instilled above and below the fascial repair.

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Media Gallery

Anatomy of inguinal canal.
Anatomy of nerves of groin.
Open inguinal hernia repair. Skin incision.
Open inguinal hernia repair. Division of external oblique aponeurosis.
Open inguinal hernia repair. Cord structures and hernia sac encircled by Penrose drain.
Open inguinal hernia repair. Hernia sac separated from cord structures.
Open inguinal hernia repair. Development of preperitoneal space.
Open inguinal hernia repair. Deployment of Prolene Hernia System (PHS).
Open inguinal hernia repair. Final position of Prolene Hernia System (PHS) mesh.
Open inguinal hernia repair. Closure of external oblique aponeurosis.
Open inguinal hernia repair. Skin closure.
Open inguinal hernia repair. Draping and incision.
Open inguinal hernia repair. External oblique aponeurosis with external inguinal ring.
Open inguinal hernia repair. External oblique aponeurosis with external inguinal ring.
Open inguinal hernia repair. Reflected part of inguinal ligament exposed for fixing inferior edge of mesh.
Open inguinal hernia repair. Inferior flap of external oblique aponeurosis developed to expose inguinal ligament from pubic tubercle to midinguinal point.
Open inguinal hernia repair. Superior flap of external oblique aponeurosis is developed as high as possible to provide ample space for mesh placement.
Open inguinal hernia repair. Lifting up cord with hernia sac medial to external inguinal ring.
Open inguinal hernia repair. Avascular plane between posterior inguinal wall and cord structures.
Open inguinal hernia repair. Cord structures and hernia sac looped along with ilioinguinal and genitofemoral nerves.
Open inguinal hernia repair. Cremaster muscle picked up to be incised longitudinally between hemostats.
Open inguinal hernia repair. Indirect hernia sac dissected and being separated from lipoma of cord and cord structures.
Open inguinal hernia repair. Lipoma of cord dissected free and excised.
Open inguinal hernia repair. Indirect hernia sac separated from cord structures in midinguinal region toward neck of sac.
Open inguinal hernia repair. Voluminous indirect hernia sac separated from cord structures in midinguinal region up to neck of sac.
Open inguinal hernia repair. Hernia sac being divided near neck.
Open inguinal hernia repair. Contents of hernia sac reduced and proximal end to be sutured closed.
Open inguinal hernia repair. Anterior wall of distal sac incised to prevent hydrocele formation.
Open inguinal hernia repair. Fixation of lower edge of mesh.
Open inguinal hernia repair. First medialmost stitch in mesh, fixed about 2 cm medial to pubic tubercle, where anterior rectus sheath inserts into pubis.
Open inguinal hernia repair. Same suture is utilized as continuous suture to fix lower edge of mesh to reflected part of inguinal ligament up to internal ring.
Open inguinal hernia repair. Lower edge of mesh sutured to inguinal ligament up to internal inguinal ring. To accommodate cord structures, lateral end of mesh is divided into wider upper (two thirds) tail and narrower lower (one third) tail.
Open inguinal hernia repair. Wider upper tail of mesh is passed underneath cord, and mesh is placed posteriorly in inguinal canal behind spermatic cord.
Open inguinal hernia repair. Fixation of upper edge of mesh.
Open inguinal hernia repair. Slit made in mesh to accommodate iliohypogastric nerve. Two interrupted sutures are taken under vision to fix upper edge of mesh while safeguarding iliohypogastric nerve.
Open inguinal hernia repair. Upper tail is crossed over lower tail around spermatic cord, thus creating internal ring. Lower edges of two tails are tucked together to inguinal ligament just lateral to internal ring.
Open inguinal hernia repair. Tails are then passed underneath external oblique aponeurosis to give overlap of about 5 cm beyond internal ring.
Open inguinal hernia repair. External oblique aponeurosis sutured with 2-0 polypropylene.
Open inguinal hernia repair. Subcutaneous tissue approximated with 3-0 plain catgut.
Open inguinal hernia repair. Skin approximated with 2-0 polypropylene subcuticular suture.
Hesselbach triangle. Image courtesy of Wikimedia Commons.

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Author

Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS Professor of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India

Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS is a member of the following medical societies: Association of Surgeons of India, Indian Association of Surgical Gastroenterology, Indian Society of Gastroenterology, Medical Council of India, National Academy of Medical Sciences (India), Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

Harry L Adler, MD Assistant Clinical Professor of Surgery, Mount Sinai Hospital; Assistant Director and Consulting Physician, Maimonides Medical Center

Harry L Adler, MD is a member of the following medical societies: American College of Physician Executives, American College of Surgeons, and Association for Academic Surgery