Enhanced Recovery Pathway After Laparoscopic Hernioplasty in Patients With Ventral Hernias: Is It Necessary to Apply?

Abstract

The aim: To study the effectiveness of the enhanced recovery after surgery (ERAS) protocol for laparoscopic hernioplasty (LH) in patients with ventral hernias (VH).
 Materials and methods: 190 patients with VH after laparoscopic prosthetic hernioplasty with intraperitoneal mesh placement (IPOM) were included in the study and divided into two groups. The study group (ERAS group) included 92 (48.4%) patients to whom the ERAS protocol was applied, the control group (preERAS group) – 98 (51.6%) patients. The width of the hernia was more than 10 cm in 25 (13.2%) patients of the ERAS group. For them botulinum toxin type A (BTA) was injected into the muscles of the anterior abdominal wall 4 weeks before the operation. In the postoperative period, the duration of the operation, hospital length of stay, the intensity of the pain syndrome and well-being, the level of C-reactive protein (CRP) and interleukin-6 (IL-6) on the first postoperative day were evaluated.
 Results: After the introduction of BTA in 25 patients of ERAS group, the hernial defect decreased by an average of 4.6±0.62 mm and in all cases became less than 10 cm (р<0.001). The average duration of LH in the study and control groups did not differ statistically (ERAS; 91.2±37.41 min vs preERAS 88.9±30.05 min, p=0.76). In 2 hours after the operation, it was possible to activate all patients of the study group and 78 (79.6%) of the control group, within 4-6 hours – the other 20 (20.4%) patients of the control group. Using the ERAS protocol demonstrated significantly less intensity of pain syndrome according to visual analogue scale (VAS), complaints of nausea (р<0.001), bloating (р=0.017), feelings of hunger, thirst and general weakness (р<0.001). At the same time, there was no statistically significant difference in the presence of defecation (р=0.31). The average level of CRP after surgery was significantly higher in the control group compared to the study group (preERAS; 43.63 ± 13.90 vs ERAS; 16.55 ± 9.97, p<0.001). The level of IL-6 similarly increased more significantly in the control group (pre ERAS; 34.03 ± 18.18 vs ERAS; 11.44 ± 5.30, p<0.001). The length of hospital stay after surgery did not differ statistically between the groups (р=0.21).
 Conclusions: The use of the ERAS protocol during laparoscopic hernioplasty IРOM for patients with VH can reduce the intensity of the pain syndrome in the postoperative period and increase the patient's subjective assessment of their condition. The use of BTA in the preoperative period allows the implementation of the ERAS protocol even when used with large ventral hernias.