Pain after lap ventral hernia repair with mesh?

[MD Dreams]

What has your experience been with patients pain level after they have had a laparoscopic ventral/incisional hernia repair with mesh (using tacs)? Had a patient like this today who woke up with a great deal of pain and it took large amounts of narcotics + ketorolac + valium to finally control his pain. This seemed odd to me, I didn't think of this procedure as a painful one. Any thoughts/suggestions appreciated.

By the way, I haven't posted in a long time, it's good to be back. I've learned a lot from this board. Hope to be able to contribute now that I am an anesthesiology resident (man, I can't believe how time has flown)!

Does anyone know how we can change our screen name?

Thanks

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[Jeff05]

not sure why you're giving valium, except to put him out of his misery.
if your morphine or fentanyl isn't touching him, go to dilaudid. just dose it appropriately. for opioid naive start with 0.2-0.5mg q10min. it will get better.

or just whip out the U/s and throw in a TAP block. takes 5 min.

 

[MD Dreams]

I thought that a component of his pain might be visceral (from the surgical insuflation) or spasmotic which I've heard valium helps with. We ended up giving him 4 mg Dilaudid (1mg in OR and 3 in PACU). It seems like a lot of opiates for a small surgery. That's why I'm confused.

I'm not sure what a TAP is? He did get local from the surgeons at the trochar insertions.

 

[Jeff05]

http://www.heartweb.com.au/downloads/TAPblock.pdf
TAP

 

[nutmegs]

For our surgeon who does these frequently, we put in epidurals... they do seem to have a lot of pain afterwards even though it's a laproscopic procedure. I was under the impression that TAP blocks aren't as effective when you need to cover both above and below the umbilicus due to being limited by the volume you can infiltrate into 4 different compartments.

 

[Monty Python]

What has your experience been with patients pain level after they have had a laparoscopic ventral/incisional hernia repair with mesh (using tacs)? Had a patient like this today who woke up with a great deal of pain and it took large amounts of narcotics + ketorolac + valium to finally control his pain. This seemed odd to me, I didn't think of this procedure as a painful one. Any thoughts/suggestions appreciated.

By the way, I haven't posted in a long time, it's good to be back. I've learned a lot from this board. Hope to be able to contribute now that I am an anesthesiology resident (man, I can't believe how time has flown)!

Does anyone know how we can change our screen name?

Thanks

Did the surgeon check for scrotal insufflation before you woke up the pt? Our best surgeon checks on any kind of laparoscopic hernia repair and occasionally has to manually decompress an enlarged scrotum, enough to make my eyes water.

 

[periopdoc]

I can't imagine how a large segment of meshed foreign material tacked right up against the peritoneum can be anything except excruciatingly uncomfortable even if it is placed laparoscopically.

In my limited experience these hurt like a b****. Of course that is quite a fair amount of hydromorphone if he is truly opiate naive.

- pod

 

[TrustMe]

Had a consult on chronic pain last month similar to this. Fat lady with several previous attempts by outside surgeons to repair a ventral hernia. Came for lap component separation and hernia repair with mesh. She had been on Percocet at home for several years during all of her previous attempted repairs. She was on PCA at good dose and still not comfortable. I talked to the surgery resident and they said that apparently the lap. component separation for the hernia repair can be quite painful post-op according to the attending. I too was surprised that a laparoscopic procedure was so painful, most others seem to be fairly painless post-op.

 

[NavyFlightDoc]

Having done a surgery internship, I agree with PeriopDoc. How could this possibly be a comfortable procedure postop? The mesh is tacked to the peritoneum in as many places as the surgeon felt necessary. Basically an iatrogenic peritonitis, so it should hurt, ALOT. anyhow, not surprised at significant pain postop, since all the patients that I took care of postop intern-year had mucho pain after this procedure.

doesn't matter if it's open vs laparoscope vs psychically placed, if you put a bunch of staples in your peritoneum, it is going to hurt.

 

[Planktonmd]

These surgeries are very painful and the worst part is that usually surgeons don't tell the patient to expect severe pain post op.
I usually do an intrathecal Fentanyl + Morphine for those with good results (if they are staying in the hospital post op).
If they are being discharged home then You can do Fentanyl only.