Two-Year Clinical Outcomes and Postoperative Pain in an Enhanced Recovery after Surgery Protocol for Open Ventral Hernia Repair

Ventral hernia repair is a common surgical operation, with more than 350,000 procedures performed every year in the United States. The two techniques commonly used to repair ventral hernias are laparoscopic (LVHR) and open (OVHR). These operations have similar outcomes with respect to recurrence rates and postoperative pain; however, LVHR is often associated with fewer postoperative wound infections and a shorter average length of hospital stay (1, 2). Patients may experience variable levels of acute pain after VHR, which typically resolves within four to six weeks following surgery (3). Some patients develop chronic pain lasting more than three months, which can be a clinical challenge and is often associated with a significant and undesirable impact on the patient's quality of life (4). Treatment of postoperative pain is typically multimodal and includes a combination of analgesics, anti-inflammatory medications, steroids, and local nerve blocks (5). Opioids are often prescribed for severe pain. The Minimally Invasive Surgery service at the University of Kentucky developed an ERAS protocol for VHR. A fifteen-element protocol, ERAS aims to measure and improve numerous patient outcomes, including: length of hospital stay, surgical complications, hernia recurrence, and perioperative pain via standardized perioperative care including patient preoperative optimization (6). There is a significant amount of postoperative pain associated with VHR (7). Previous publications have reported no difference in acute postoperative pain scores when comparing LVHR with OVHR (1, 2); however, there are no publications to date that evaluate pain scores in patients managed under an ERAS-type protocol. Our primary study objective is to compare 30-day clinical outcomes and VAS pain scores in patients with standardized care protocol ERAS to pre-ERAS controls following open VHR. We hypothesize that postoperative pain for patients enrolled in an ERAS protocol will be lower than a pre-ERAS control group. In a secondary objective, we aim to determine the effectiveness of multimodal analgesic therapy by examining the effects of epidural, muscle relaxants, and non-opioid analgesics on postoperative pain. We predict that multimodal analgesia effectively reduces postoperative pain. Chronic pain is an epidemic, with recent studies showing that nearly 100 million Americans experience significant chronic or severe pain (8). Though current use in pain management is debated, opioids have traditionally been the gold standard treatment for chronic pain, and prescriptions for opioids have continued to rise in the past twenty years (8, 9). Opioid use remains a common treatment in the surgical setting for postoperative pain. It is well known that opioids cause constipation, nausea, emesis, dizziness, respiratory depression, and slow return to bowel function, all of which may complicate a patient's postoperative recovery (10). Studies have shown that opioid-related side effects may adversely affect surgical outcomes and lower patient satisfaction as well (11-13). A third objective is to assess whether preoperative opioid use adversely affects perioperative pain control. We hypothesize that preoperative opioid users will have greater perioperative pain scores than non-opioid users.