Local injection for the treatment of suture site pain after laparoscopic ventral hernia repair

Transabdominal sutures (TAS) used for mesh fixation in laparoscopic ventral hernia repair (LVHR) are an occasional source of prolonged postoperative pain. We sought to analyze the incidence of TAS site pain and the efficacy of local treatment methods. A retrospective review of patients who underwent LVHR from January 1999 to August 2002 was performed to identify patients experiencing suture site pain. Patients were considered candidates for injection therapy if their discomfort lasted 10 days postoperatively. Patient demographics, hernia size, mesh size, and subjective pain intensity were recorded. Treatment consisted of injection circumferentially around the suture site with 0.25 per cent bupivacaine with one to 200,000 epinephrine and 1 per cent lidocaine at the level of the abdominal musculature. Statistical (P < 0.05) significance was determined by chi-square, logistic regression, and analysis of variance. One hundred three patients (42 men and 61 women) with a mean age of 53 years (range 26-78) and weight of 99.8 kg (range 61-239) underwent LVHR. Mean hernia size was 192 cm² (range 12-450) and mean size of mesh placed measured 534 cm² (range 100-1200). Twenty-four patients (23%) complained of prolonged discomfort at a transabdominal suture site and were injected postoperatively in the office as described. Of these 58 per cent were female and 42 per cent were male. Logistic regression demonstrated increasing mesh size was the only factor (P < 0.01) that correlated with the need for injection. Twenty-two of 24 patients (92%) undergoing injection therapy had complete relief of their symptoms. Twenty patients required a single injection and two patients required two injections to treat their TAS site pain. After local injection failure two patients were referred to an anesthesia pain service; one underwent intercostal nerve block with complete resolution of pain, while the other is currently in treatment. There were no complications. Suture site pain was present after LVHR in 23 per cent of our patients. Increasing mesh size is associated with a greater chance of suture site pain. It appears to be effectively treated postoperatively with the injection of a local anesthetic at the TAS site. The mechanisms by which short-duration anesthetics relieve chronic pain are not fully understood.