Zh.O. Ushnevych Regional anaesthesia in surgery of anterior abdominal wall hernia within enhanced recovery programme. – Qualification scientific work in the form of a manuscript.
Dissertation for the degree of Doctor of Philosophy in the speciality 222 — “Medicine” (22 — Health Care) — the Danylo Halytsky Lviv National Medical University, the Ministry of Health of Ukraine, Lviv, 2025.
The study was aimed at improving the quality of the perioperative management of patients who undergo surgeries for anterior abdominal wall herniae, under the regional analgesia within the enhanced recovery programme based on the examination of stress markers, heart rate variability, postoperative recovery rate, and pain management efficacy.
In 2022–2025, 91 in-patients of the Surgery Department No. 3 of the “Lviv Regional Clinical Hospital”, a municipal non-profit enterprise, were examined and analysed.
The study involved 91 patients, aged 18–80, who underwent surgical treatment for anterior abdominal wall herniae. The patients were divided into three groups depending on the anaesthesia method. Group 1 (n = 31) — patients undergoing surgery under general multicomponent intravenous anaesthesia with muscle relaxation and assisted ventilation. The average age of the patients was 58.5 ± 13.1 years, 74.2 % were men and 25.8 % were women. Group 2 (n = 30) — patients who had neuroaxial (epidural) anaesthesia for the surgical treatment of their anterior abdominal wall hernia. The average age of patients was 61.7 ± 2.8 years, 83.3 % were men and 16.7 % were women. Group 3 (n = 30) — patients, who underwent surgeries for anterior abdominal wall herniae under regional blockade — rectus sheath (RS) block and transabdominal plane (TAP) block. The average age of patients was 67.4 ± 2.6 years, 73.3 % were men and 26.7 % were women.
In terms of localization, inguinal herniae prevailed, accounting for 67.7 %, 90.0 %, and 80.0 % in patients of Groups 1, 2, and 3, respectively. The TAPP (trans abdominal preperitoneum) laparoscopic surgery was usually performed in patients from Group 1 (41.9 %). Patients of the Groups 2 and 3 had inguinal hernia repair using the Lichtenstein technique (90.0 % and 76.7 %, respectively).
The patients with anterior abdominal wall hernias were examined according to the recommendations of the European Hernia Society, the ERAS association, and the local protocol of the Lviv Regional Clinical Hospital, approved for the patients’ care pathway “Anterior abdominal wall hernia” on May 27, 2020.
The most common comorbidity among the investigated patients of Groups 1, 2, and 3 was hypertension (HT), registered in 77.4 %, 66.7 %, and 73.3 %, respectively. The number of patients in Group 3 who had a history of coronary artery disease (CAD) and/or acute coronary syndrome (ACS) (63.3 % and 43.3 %, respectively) was the highest as compared to patients in Group 1 (48.4 % and 12.9 %) and Group 2 (26.7 % and 10.0 %, respectively). The ejection fraction (EF) of Group 3 patients was below the norm (55–70 % for adults) and reliably 8.4 % lower as compared to Groups 1 and 2 under investigation (p < 0.05). The score “3” was registered in patients of Groups 1, 2, and 3 under investigation, which amounted to 19.4 %, 44.0 %, and 70.0 %, respectively. Thus, patients with a high risk of developing intraoperative cardiovascular complications prevailed in Groups 2 and 3.
The risk rate of developing postoperative thromboembolism was assessed using the Caprini score. High risk (≥5 points) prevailed in all the investigated groups, amounting to 51.7 % in Group 1, 60.7 % in Group 2, and 69.0 % in Group 3. The measures of preventing the postoperative complications of thromboembolism were taken regarding 87.1 % of patients in Group 1, 86.7 % in Group 2, and 96.7 % in Group 3, which had no reliable differences among groups.
A higher number of patients with the anaesthetic risk, according to ASA III, was present in Group 3 which was 1.5 and 1.9 times higher as compared to Groups 1 and 2, respectively. Thus the patients with moderate and high risks of developing intraoperative complications prevailed in all groups. Therefore, the substantiation of implementing the ERAS strategy while performing surgical interventions for patients who undergo surgeries for anterior abdominal wall herniae with comorbidity is an urgent task.
Therefore, regional (fascial) blocks ensured adequate, prolonged, and uniform analgesia during the first postoperative day compared to the neuroaxial blockade, which provided analgesia up to four hours after the surgery.
