Mr James Kirkby-Bott
Surgery

Hernia repair surgery: local vs. general anaesthetic

Written by: Mr James Kirkby-Bott

Published: 19/11/2019

Edited by: Laura Burgess

There are three different types of anaesthesia that may be used in cases of surgery; general, epidural or local anaesthesia. Often, a procedure such as open hernia repair is performed under local anaesthetic as it is the most effective and comfortable choice for this type of technique.

One of our top surgeons Mr James Kirkby-Bott explains the main differences between local and general anaesthetic and what happens during surgery under both types of pain medicine.

Surgeon

Can local anaesthetic be used for both keyhole and open hernia repair?

No. You can only use local anaesthetic to perform an open repair. It is not possible to do a keyhole repair under local anaesthetic.

Who has had open inguinal hernia repair with local anaesthesia?

Local anaesthetic open hernia repair is a very popular technique with patients that have undergone this procedure and surgeons that have the experience to perform it well. There is good evidence from a series of thousands of patients that local anaesthetic repair is comfortable, safe and effective.

The British Hernia Society recommends it and many hernia clinics all over the UK recommend this technique as having equivalent or better outcomes compared to keyhole (laparoscopic) surgery or open repairs performed under general anaesthetic. It is suitable for anyone; I have even performed this successfully in those with serious mental illness and anxiety issues.

It is considered to be the safest technique with the quickest recovery in those usually felt to be too old or frail for a repair under general anaesthetic. In frail patients or those with a lot of other health problems that can affect recovery from general anaesthetic, having local anaesthetic repair can make surgery both feasible and day-case care also possible where otherwise a longer inpatient stay might have been required.

However, it is a good choice of technique for anyone having groin hernia surgery. The limitation to local anaesthetic repair is the size of the defect and the body habitus of the patient. Large hernias can be repaired successfully and comfortably in slim patients while in patients who are overweight very large hernias are more difficult in obese patients any local anaesthetic repair is difficult or impossible to do comfortably.

How do I know if local anaesthesia is best for me? (instead of regional or general)

There are pros and cons to every technique. Each have their advocates and some techniques do suit some more than others. The following will hopefully explain the pros and cons of the techniques available. Consider the choice as being between an open or keyhole technique and then between a local and general anaesthetic approach.

To understand the difference, it is helpful to think of the risks of each. One aspect of local anaesthetic I like is that the patient can cough when asked during the procedure. This helps demonstrate that the hernia has been fully and completely repaired. It is not possible to check the quality of the repair in a patient that is asleep.

Question	Open repair	Keyhole (laparoscopic) repair
What is the risk of the hernia recurring?	Up to 5% in a lifetime.	Up to 5% in a lifetime.
What is the chance of altered skin sensation?	Moderate risk, though most are temporary.	Low risk of happening.
What is the chance of bowel or bladder injury and the consequence?	No or very little chance.	The chance is real but the risk is low. If it happens it is important to notice it at the time of surgery. If not, the consequence is severe, if not fatal.
Is there a risk of chronic pain?	Approximately 0.5% can experience longstanding discomfort.	Less chance than with an open repair but still happens.
What is the recovery time?	For a one-sided (unilateral) hernia repair there is no proven difference in recovery time for keyhole over open repair.	For either technique, the recovery time is around 10 days to return to normal daily activity. Certain sports and occupations, however, might take longer (4-6 weeks) to get back to.

Question	Local anaesthetic	General anaesthetic
Will I be awake?	Yes, unless some light sedation is used, but that is not suitable for everyone.	No, you will be fully unconscious and paralysed if having keyhole surgery.
Will I feel any pain?	A local anaesthetic is injected and like going to the dentist, this can sting for 15-20 seconds. Then the area becomes numb. You will be ‘aware’ that we are doing something, but not feel pain.	No pain but you will have the discomfort of the first needles and anaesthetic agent that can last 15-20 seconds.
How long does the effect of the anaesthetic last?	About 6 hours initially but the total pain felt post-surgery seems to be less with a return to comfortable activity. You will still need some pain relief in the days that follow. No nausea or the ‘hangover’ effect of a general anaesthetic.	It takes about 30 minutes to 2 hours to recover and wake up. You will then feel discomfort, nausea and have a ‘hangover’ effect. This can last a couple of days.

Can hernia repair cause problems with passing urine?

There is less chance of not being able to pass urine with a local anaesthetic. Even in older and frailer patients with pre-existing prostate enlargement and altered urine flow, not being able to pass urine is rare. I have seen it once in 200 cases. The reason is with local anaesthetic no opiate painkillers are needed and the inflammatory effect of surgery is reduced.

Moderate to high risk depending upon any pre-existing prostate problems. A combination of opiate painkillers, pre-existing poor urine flow and the inflammatory effect of surgery can make passing urine impossible at least for a couple of days. Usually, a catheter is required in this group for 48 hours.

How long will my hospital stay be after my hernia repair surgery?

Daycare is the aim of all patients so that they go home on the same day. An overnight stay is recommended for those with no one at home especially if a general anaesthetic has been given.

Do not hesitate to book an appointment with Mr Kirkby-Bott if you would like to discuss your surgery options.

By Mr James Kirkby-Bott

Surgery in Southampton

Mr James Kirkby-Bott is a consultant general surgeon based in Southampton. He specialises in endocrine surgery and is an expert in the management of endocrine diseases, hernias and gallbladder problems. He also set up one of the UK's leading acute surgery and trauma units in Southampton. Mr James Kirkby-Bott can be seen privately at Nuffield Wessex Hospital and Spire Southampton University Hospital on various days. Mr Kirkby-Bott qualified at St George's Medical School and went on ...

By Mr James Kirkby-Bott
Surgery

Mr James Kirkby-Bott is a consultant general surgeon based in Southampton. He specialises in endocrine surgery and is an expert in the management of endocrine diseases, hernias and gallbladder problems. He also set up one of the UK's leading acute surgery and trauma units in Southampton.

Mr James Kirkby-Bott can be seen privately at Nuffield Wessex Hospital and Spire Southampton University Hospital on various days.

Mr Kirkby-Bott qualified at St George's Medical School and went on to train as an endocrine surgeon at the Hammersmith Hospital in London and was the International Endocrine Fellow in Lille, France where he spent 12 months carrying out research and operating alongside leading specialists. When awarded his Fellowship of the European Board of Surgery in Endocrine surgery he was one of just four surgeons in the UK to be awarded this. Mr Kirkby-Bott founded the Wessex Endocrine Society, a charity providing patient centred training and education in surgical endocrinology across Wessex.

Mr Kirkby-Bott is a Q member and specialist in Quality Improvement (QI) having been involved in numerous QI projects and regional lead for the Emergency Laparotomy Collaborative (2015-2017) and The Wessex Emergency Surgery Network (2017-present). He is currently Consulting for the Academic Health Science Networks emergency laparotomy project. In 2018 he was appointed to a senior role in University Hospital Southampton as co-director for clinical outcomes.

Other awards to his name include the Norman Tanner Prize medal, given by the Royal Society of Medicine in 2008 and Braun Aesclepius prize in endocrine surgery awarded in 2011. Mr Kirkby-Bott is equally committed to his research and has several scientific papers on the role of vitamin D in parathyroid surgery, as well as several book chapters and the first textbook dedicated to Parathyroid disease, to his name.