A surgeon should be able to offer the best combination of surgery and anesthesia. This is particularly so in the common problem of a symptomatic groin herniation in older adults who often harbor multiple co-morbidities and are taking various medications. Whilst we offer a local anesthetic (LA) repair many patients wish a general anesthetic (GA) and it is clearly our duty, all things considered, to offer the best individual approach. Unfortunately, in interviews conducted with 40 veterans from three sites, Mai et al. found that shared decision making was not consistently employed 1. Indeed it would be useful if such structured interviews were more common. On recollection my original feeling was one of surprise when a repair under local was suggested! I had a left hernia repair some years ago under GA and no mention had been made of repair under local. But things have moved on. So would I recommend hernia repair under local to others? Absolutely—with perhaps the usual provisos. Obesity will obviously increase the technical problems of a repair. Those of a nervous disposition would find the whole experience difficult, but suitable sedation would no doubt help! In my case having an anesthetist present was very helpful—not so much for relief of anxiety or pain—but as a pleasant distraction from the surgery. We enjoyed a wide ranging conversation during the procedure- probably an annoyance to the surgeon but helpful to me. There is no doubt a downside to general anaesthesia in the elderly—those vulnerable grey cells again! Also the complications associated with spinal and regional analgesia—all things we discussed during the operation! So would I go through the experience again?—absolutely—if I had to! I tell everybody I didn't feel a thing—obviously a very skilful surgeon! The “entrenched” attitude to minimally invasive surgery (MIS) among the clinicians interviewed is most unfortunate but understandable in the US Healthcare system 1. However can you really improve on a LA “subcutaneous MIS” repair in older adult patients? Finally, LA groin hernia repairs have been around a long time and are well tried and tested. Indeed with regards to the use (or over use) of post-operative opioid analgesia a LA repair is the strongest predictor (p < 0.001) of not requiring the use of opioids 2. This also improves cognitive and functional recovery in older adults. Both authors have read and contributed to the writing of this letter. The authors have nothing to report. The authors declare no conflicts of interest. This publication is linked to a related article by Mai et al. To view this article, visit https://doi.org/10.1111/jgs.70402.
Hamlyn et al. (Wed,) studied this question.