Efficacy of Crural Block in Improving Pain Following Laparoscopic Hiatus Hernia Repair: A Cohort Comparison Study

Abstract

Hiatus hernia repair is a common gastrointestinal surgery performed worldwide for the treatment of gastro-oesophageal reflux. In the last two decades, there has been a widespread shift from open to laparoscopic repair and this has been proven to significantly reduce postoperative pain, an earlier discharge and a faster return to work. Importantly, there is an obvious gap in the literature regarding postoperative pain experiences and whether any analgesia adjuncts are utilised and to what effect they have on reducing pain and reducing the need for traditional analgesia such as opioids. One novel adjunct uncommonly utilised clinically but not thus far researched is diaphragmatic crural regional infiltration with long-acting local anaesthesia, aiming to dampen pain signals generated from the abdominal and thoracic dissection performed during hiatus hernia repair. This is a low risk, low effort technique performed intraoperatively by the surgeon under direct vision at the end of surgery targeting the vagal afferent nociceptive nerve fibres found in the crural fibres, a viable target for blockade by local anaesthesia. A cohort comparison study was performed at a single centre assessing the effects of crural infiltration with long-acting local anaesthesia performed routinely by one higher volume upper gastrointestinal surgeon, whose cohort is the intervention group. The primary end points assessed were postoperative pain outcomes and opioid requirements and the intervention cohort’s results were compared against that of another high volume upper gastrointestinal surgeon at the same hospital who does not perform crural infiltration. Consecutive cases were analysed from 2019-2021, comparing the two cohort groups’ primary endpoints. Crural infiltration was found to be opioid-sparing, with patients requiring 2mg less morphine each day compared to the non-interventional group. In addition, the interventional cohort experienced reduced peak pain scores compared to the non-interventional group. Increasing age was protective against postoperative pain whilst patients who had purely para-oesophageal hernias experienced more pain than other hernia types. There  appear to be potential positive effects of crural anaesthesia infiltration following hiatus hernia repair, though not statistically significant in this study. As such more research into its effects as  it can be an important adjunct in reducing postoperative pain.