Patients More Likely to Skip Opioids After Robotic Hernia Repair

Originally published by our sister publication General Surgery News

CHARLOTTE, N.C.—Patients who undergo laparoscopic or robotic inguinal hernia repair require fewer opioids to manage their postoperative pain compared with open surgery, with a trend toward no opioid consumption after robotic repair and with increasing age, according to the results of a new study.

“A lot of initial research that compared open and minimally invasive surgery found less pain and less opioid use with the minimally invasive procedures; however, since the advent of robotic surgery, no one had really looked at whether robotic surgery results in even less pain and less opioid use than laparoscopic surgery,” said Thomas W. Clements, MD, a surgical fellow at The University of Texas Health Science Center at Houston.

“We wanted to compare the three approaches in regards to pain and opioid use.”

The study prospectively enrolled patients from Northwestern Medicine system hospitals. They collected patients’ self-reported data via automated text messages and smartphone surveys after open, laparoscopic and robotic inguinal hernia repairs. They used data from the electronic health record for patient characteristics, surgical procedures, and the providers’ prescribing habits and other characteristics.

Ultimately, 224 patients participated. A substantial minority, 85 patients (38%), reported taking no opioids; patients who underwent robotic surgery were twice as likely to forgo opioids compared with those who had laparoscopic or open procedures, and the likelihood of patients reporting no opioid use increased significantly with age.

Of the 139 patients who reported opioid use, the median number of pills taken was five across all three approaches. The number of pills taken greater than zero was not related to surgical approach; rather, it was associated with low-volume providers, prior opioid use and obesity.

“The finding that fewer opioids were needed with minimally invasive procedures was not shocking, but there were other interesting findings. People who underwent robotic surgery were more likely to use no opioids at all compared with laparoscopic or open surgery,” Dr. Clements said.

He observed that in inguinal hernia repair, the idea that a minimally invasive repair will necessarily result in less pain than an open repair is not universally accepted. “Some surgeons argue that they make such small incisions that their open inguinal hernias are equivalent to minimally invasive repairs in terms of postoperative pain. But in this study, we see more patients in the robotic group avoided opioids altogether.”

Dr. Clements and his colleagues speculate that this may have to do with the amount of torque placed on ports, or with the ability to do a more careful hemostatic dissection in a robotic procedure. “We don’t have any way to prove cause through this study, but those are a couple of the hypotheses we generated based on the results of this paper.”

Another important feature of the study is that it focused on patient-reported consumption, not opioid prescriptions. “What we’re reporting here is actual patient use—they told us each day whether they used a pill or didn’t, and how many pills they used. We were capturing their opioid use in real time,” said Jonah J. Stulberg, MD, PhD, MPH, an associate professor at The University of Texas McGovern Medical School, in Houston.

“So much of the literature out there will confuse prescription data with opioid use data. It’s really important that we get more high-level data about what patients are actually taking and who’s taking it. We consistently see a proportion of patients who will use whatever you prescribe them; that’s why there’s this push not to prescribe any,” he said.

Dr. Stulberg added that the question researched in this study—whether opioid use varied by surgical approach—was relevant, “but also that it being a relatively low-pain, outpatient surgery, can we predict or shoot toward not prescribing opioids at all for a large portion of our patients?”

Dr. Clements presented the study at the 2022 annual meeting of the American Hernia Society.

Robert J. Fitzgibbons, MD, the Harry E. Stuckenhoff Professor and chairman of the Department of Surgery at Creighton University School of Medicine, in Omaha, Neb., said the study addresses what has been a hotly debated topic in inguinal hernia surgery: whether there is any pain advantage associated with laparoscopic or robotic surgery.

“This appears to show evidence that there is less opioid consumption with robotic inguinal repair, especially in patients who were elderly. But I’m not sure this study will change practice much because there is so much subjectivity to narcotic use, such as whether patients used narcotics before and their pain tolerance. Measuring opioid consumption doesn’t always tell you the whole story about pain management.

“I think this study is interesting, but it will need to be confirmed in future studies.”