We hypothesized that preoperative (pre-op) ultrasound (US)-guided posterior transversus abdominis plane block (TAP) and US-guided ilioinguinal and iliohypogastric nerve block (ILI+IHG) will produce a comparable analgesia after Lichtenstein patch tension-free method of open inguinal hernia repair in adult men. The genital branch of the genitofemoral nerve will be blocked separately.This is a prospective, randomized, controlled, and observer-blinded clinical study. A total of 166 adult men were randomly assigned to one of three groups: a pre-op TAP group, a pre-op ILI+IHG group, and a control group. An intraoperative block of the genital branch of the genitofemoral nerve was performed in all patients in all three groups, followed by postoperative patient-controlled intravenous analgesia with morphine. The pain intensity and morphine consumption immediately after surgery and during the 24 hours after surgery were compared between the groups.A total of 149 patients completed the study protocol. The intensity of pain immediately after surgery and morphine consumption were similar in the two “block” groups; however, they were significantly decreased compared with the control group. During the 24 hours after surgery, morphine consumption in the ILI+IHG group decreased compared with the TAP group, as well as in each “block” group versus the control group. Twenty-four hours after surgery, all evaluated parameters were similar.Ultrasound-guided ILI+IHG provided better pain control than US-guided posterior TAP following the Lichtenstein patch tension-free method of open inguinal hernia repair in men during 24 hours after surgery.  The Lichtenstein patch tension-free method of open inguinal hernia repair2http://www.postoppain.org/working-group/) published a procedure-specific review and guideline for analgesia following inguinal hernia repair in 2012, in which ILI+IHG were strongly recommended preoperatively (pre-op) and during surgery .4The PROSPECT Working Group (Ultrasound (US)-guided posterior transversus abdominis plane block (TAP) has been described as an appropriate method of post-op analgesia for abdominal wall incisions below the umbilicus. Inguinal hernia repair was also included.Anatomically, sensory innervation of the male inguinal region is from the Th12–L2 nerves, and “the spermatic sympathetic plexus contains the sensory fibers for the testis.”16We suggest that the ilioinguinal and iliohypogastric nerves may be appropriately blocked using both US-guided techniques, TAP and ILI+IHG, since both techniques produce the same block of the ilioinguinal and iliohypogastric nerves; the only difference is that TAP is a compartment block, while ILI+IHG blocks the truncal.In order to compare the effect of TAP and ILI+IHG on post-op pain intensity, pain must be eliminated from the structures innervated by the genital branch of the genitofemoral nerve; an intraoperative block of the genital branch of the genitofemoral nerve should be used in all patients; and the same pharmacological treatment should be offered for post-op pain. Our model includes post-op, patient-controlled analgesia with intravenous morphine (PCA). No previous trials have compared US-guided TAP versus US-guided ILI+IHG in adult men undergoing inguinal hernia repair using the open Lichtenstein patch tension-free method. We tested the hypothesis that both US-guided TAP and US-guided ILI+IHG provide comparable post-op analgesia, together with morphine consumption, following Lichtenstein patch hernioplasty during the first 24 hours post-op.This is a prospective, randomized, controlled, and observer-blinded clinical study; enrollment began after receiving Hillel Yaffe Review Board approval and written informed patient consent. Study eligibility was as follows: male; over the age of 18; physical status of I–III based on the American Society of Anesthesiologists criteria; and scheduled to undergo elective inguinal hernioplasty using the unilateral open Lichtenstein patch tension-free method. The rationale only to include males in the trial was based on the aim to compare data among maximally identical groups. In total, 186 patients were eligible for the study.Exclusion criteria were recurrent hernia, previous episode of incarceration, inguino-scrotal hernia, or sliding inguinal hernia.Patients were instructed regarding the use of a 100 mm visual analogue scale (VAS) graded from 0 (without pain) to 100 (intolerable pain).Based on the exclusion criteria, 20 patients were excluded from the study. The inclusion group  was randomized into three groups: TAP, ILI+IHG, and control . RandomiThe patients and the investigator who collected the data during the post-op period were blinded to the group assignments throughout the trial.Premedication was limited to intravenous (IV) fentanyl (0.5 μg/kg), midazolam (0.03 mg/kg), and local anesthesia via injection of lidocaine . Standard American Society of Anesthesiologists monitoring and supplemental oxygen  were applied throughout the procedure.The same anesthesiologists (A. Stav or L.R.) performed all pre-op US-guided peripheral nerve blocks using an ultrasound system  with a 6–13 MHz linear array transducer (L25x). A 22-gauge 80 mm Pajunk Sono Tap cannula  was used to perform the blocks. All pre-op blocks were performed using aseptic techniques in the “block room.”The local anesthetic injected for the nerve blocks comprised bupivacaine 5 mg/mL with adrenaline 5 μg/mL. The same volume of 20 mL of local anesthetic was injected for TAP and ILI+IHG to ensure similar local anesthetic doses and volumes, and to facilitate appropriate comparison of perioperative pain and morphine consumption between the groups.The TAP and ILI+IHG procedures were conducted using techniques described by Hadzic.16The genital branch of the genitofemoral nerve was blocked intraoperatively in all patients in all three groups by the surgeon during exploration of the spermatic cord under direct vision at the level of the internal inguinal ring. “All the genital branches passed through the ventral aspect of the internal ring, entered the ring and continued within the spermatic cord.”The success of the sensory block was tested by pin-prick in the inguinal crease  30 min after completion of the pre-op procedure (both groups) by an independent investigator who was blinded to the previously performed block. Patients were additionally excluded from the study if a failed block was diagnosed .A standardized general anesthesia protocol was used for all patients. Lornoxicam 8 mg IV was injected 30 min before the end of surgery.All operations were performed by or under the supervision of the same experienced surgeons (A.T. or M.K.). Morphine was initiated via PCA IV in the postanesthesia care unit (PACU) for all patients. The PCA protocol was as follows: a loading bolus of 2 mg IV morphine; 1 mg for the subsequent bolus, followed by a lockout period of 5 min, with a maximal dosage of 50 mg within a 4-hour period. Patient-controlled analgesia continued post-op for 24 hours.2 (m2). Preoperative pain at rest and during motion was measured using a visual analogue scale (VAS).Variables assessed before and during surgery included patient characteristics ). Body mass index (BMI) was calculated using the following formula: BMI = BW (kg)/heightIf moderate, severe, or intolerable pain was experienced by the patient in the PACU immediately post-op, then morphine was initially injected using a titration method until pain relief was achieved,The primary end-point of the study included three parameters: pain intensity immediately post-op, morphine and other analgesic consumption 24 hours post-op, and pain intensity following termination of the effect of the peripheral nerve blocks in the “block” groups, i.e. 24 hours post-op.The parameters for the secondary end-point were: PONV (yes/no), PACU time of stay, and the correlation between block performance time and the patients’ body mass index (BMI).A priori power analysis was performed using “G* Power 3.0.10”© with a fixed effects, omnibus, one-way ANOVA for all groups. A total sample size of 66 was considered adequate to achieve an effect size of 0.5 with an α error probability of 0.05 and a power (1-β error probability) of 0.95. After all exclusions, our study included 149 patients.post-hoc test, if necessary.Statistical analysis was performed using “IBM SPSS Statistics 20”©. Continuous numerical parameters were analyzed according to the Shapiro–Wilk test for distribution normality, followed by the Levene test for homogeneity of the variances . Parameters with a normal distribution and homogeneous variances were compared by one-way ANOVA followed by Tukey’s post-hoc test was used following the Kruskal–Wallis test, if necessary.The Kruskal–Wallis test was used when an abnormal distribution of the continuous variables was detected. The Mann–Whitney The intensity of VAS-measured pain was also analyzed using the Kruskal–Wallis test followed by the Mann–Whitney test, if necessary.P<0.05 was considered statistically significant.Frequency tables and Pearson chi-square tests were used to compare the proportions between the categorical variables among the groups. Pearson correlation was used to assess the correlation between BMI and block performance time in each group. A value of Study data were collected between October, 2011 and September, 2015. The results of our trial are presented according to the standards of reporting Clinical Trials (CONSORT) statement using a CONSORT flow chart . The datPain intensity in the PACU and morphine consumption was not significantly different between the TAP and ILI+IHG groups; however, they were significantly decreased when compared with the control group . This waProphylaxis of PONV with 8 mg ondansetron IV prior to induction of anesthesia was effective. No PONV occurred in the 147 evaluated patients. One patient in the TAP group and one patient in the control group suffered from nausea, but no vomiting occurred during the immediate post-op period or during the 24 hours post-op. This was the secondary end-point of the trial.The duration of PACU stay was similar in all groups.Following PACU discharge, the patients in all groups were treated with PCA.Pain intensity (VAS) at rest and during motion 24 hours post-op was similar in all groups . MorphinAcute pain following open hernia repair is maximal on the day of surgeryIn contrast to Aveline et al.,8Our inclusion and exclusion criteria enabled the selection and comparison of similar groups of patients with regard to the pre-op data, gender , and patients suffering from primary inguinal hernia . Primary open hernioplasty via the Lichtenstein tension-free technique was used in all patients. The same concentration and volume of local anesthetic was used for all patients in the two pre-op block groups. All pre-op blocks were performed by the same experienced anesthesiologists; an intraoperative block of the genital branch of the genitofemoral nerve was performed or controlled by the same experienced surgeons. A very high level of similarity among all three groups is a strong advantage of our trial as compared to other similar studies.25In our prospective randomized controlled and observer-blinded trial, pain intensity and morphine consumption immediately post-op (in the PACU) were significantly less in the TAP and ILI+IHG groups compared with the control group; however, there were no differences between the TAP and ILI+IHG groups themselves. This finding indicates that both methods of US-guided blocks produce significant post-op pain relief immediately after surgery, with no significant difference between the procedures.Twenty-four hours post-op, when the action of bupivacaine has decreased significantly or has ceased, no differences in pain intensity were observed among the all groups. Total morphine and dipyrone consumption in the ILI+IHG group was significantly decreased compared with the TAP and control groups; however, the TAP and control groups were similar. This finding indicates that the ILI+IHG produces superior pain relief compared to TAP during the 24 hours post-op, but not immediately after surgery.Our results may be explained by the hypothesis that the spread of local anesthetic during and after injection differs following TAP and ILI+IHG. Posterior TAP is a compartment block, and the spread of local anesthetic is relatively large, i.e. from Th7 to L1.Our study has several limitations as follows:There were strong inclusion criteria: limited to men, primary inguinal hernia, and hernioplasty using the Lichtenstein tension-free method. Thus, the conclusions of the trial are relevant for a specific pathology, gender, and method of operation.We used two scales for the pain intensity measurement, including the modified NP scaleLornoxicam 8 mg IV was injected 30 min before the hernioplasty ended; dipyrone was used as needed to treat mild pain or discomfort during the post-op period; those agents may have influenced pain intensity and morphine consumption.It is impossible to examine the individual anatomical variations of the ilioinguinal and iliohypogastric nerves pre-op. These potential variations have been examined and described by Klaassen et al.The data from this prospective, randomized, controlled, and observer-blinded clinical study lead to several important conclusions.Both regional anesthesia methodologies (US-guided TAP and US-guided ILI+IHG) may be used as components of multimodal anesthesia following a primary unilateral open Lichtenstein patch tension-free inguinal hernioplasty in adult men.Both blocks provided comparative analgesia, as well as a similar morphine-sparing effect immediately after the surgery, which was performed under general anesthesia.During the 24 hours after surgery, US-guided ILI+IHG  was superior to US-guided TAP (a compartment block) in terms of the morphine-sparing effect, i.e. ILI+IHG provided significantly better analgesia.Prophylaxis of PONV with 8 mg ondansetron IV prior to anesthesia induction was effective.The duration of PACU stay was similar in all three groups.There was no correlation between the time of block performance and BMI.Potential anatomical variations in the ilioinguinal and iliohypogastric nerves, which are impossible to diagnose prior to surgery, could play a role in the intensity of post-op acute pain. This was a significant limitation of the trial.


The aim of the present study was to compare clinically the incidence of postoperative pain after endodontic treatment using the Reciproc System, taking into account the operator’s experience.P<0.05.One hundred patients scheduled for routine endodontic treatment were enrolled in this study. Endodontic treatment was carried out in a single visit by undergraduate and postgraduate students. The chemomechanical preparation of root canals was performed with Reciproc instruments. Pretreatment and postoperative pain was recorded using a visual analogue scale (VAS). Postoperative pain and the need for analgesic consumption were assessed at 4, 8, 16, 24, 48 and 72 hours post-treatment. The data were analyzed using the Mann–Whitney U and Chi-Square test, and the significance was set at P<0.05).The mean value of pain after root canal treatment was 1.13±1.94 and 1.91±2.07 on a VAS between 0 and 10 in treatments performed by undergraduate and postgraduate students, respectively. There was a significant difference in the incidence of postoperative pain between the two groups (The prevalence of postoperative pain was high in the treatments performed by postgraduate students in comparison with undergraduate students. This suggests that operator experience has an influence on the prevalence of postoperative pain after root canal treatment. Key words:Post-endodontic pain, root canal treatment, reciprocating systems, Expert operators Inexperienced operators. Root canal treatment is a common procedure that aims to preserve the tooth by treating diseases of the dental pulp and periradicular region . TherefoPostoperative pain, described as the perception of any annoyance after root canal treatment, is reported by 25-40% of patients, regardless of their pulp and periradicular status -5. Post-Post-endodontic pain can be caused by several factors . The moset al.  files, the concept of shaping canals with a single-file was introduced in endodontics . Accordiet al. , recipro . The study was reviewed and approved by the Institutional Ethics in Research Committee.-Patient selectionA total of 100 consecutive adults were included in this study. The sample size calculation, based on an error of alpha of 0.05 and a power of 80%, indicated that a sample size of 38 in each group would be required to detect differences. Hence, 50 teeth assigned to each group were considered sufficient to ensure a representative sample.The aims and design of the study were explained to the patients, who gave their oral and written informed consent. Prior to treatment, the medical and dental history of the patients was taken. Gender, age, tooth type and location in the arch, as well as preoperative pain intensity, periapical condition, and pulp diagnosis  were all recorded. The exclusion criteria included: immunosuppressed patients, pregnancy, consumption of any type of medication before treatment, history of intolerance to nonsteroidal anti-inflammatory drugs, patients under 18 years old, patients with pacemakers, root canal retreatment, the presence of internal or external resorption teeth, and open apex.-Treatment ProtocolOf the total sample of 100 patients, 50 were treated by undergraduate students and 50 by students of the endodontic master postgraduate program. The treatment protocol was the same for both groups. After clinical examination, the cold test  was used to determine pulp vitality, which was verified by the presence or absence of bleeding from the root canals during endodontic access preparation. If there was no response after 5 seconds of applying a cotton pellet and non–bleeding, the teeth were classified as necrotic. The treatment was performed on all the patients in a single visit.Anesthesia was performed with local infiltration using 4% articaine with 1:100.000 epinephrine . Rubber dam isolation was placed after access cavity preparation with sterile round diamond burs and Endo-Z burs . Working length (WL) was established with a #10 K-file and an apex locator , and confirmed with a periapical radiograph.Root canal shaping was performed in accordance with the manufacturer’s instructions. For each canal, the Reciproc instrument  selection was as follows: the R25 files (25.08) were used in narrow and curved canals when the #20 K-type file (Dentsply) could not achieve the WL passively. For medium and large canals in which the #20 or #30 K-type files were placed passively up to the working length, the R40 (40.06) or R50 (50.05) files were used, respectively. Then, 1 mL of 4.2% sodium hypochlorite (NaOCl) was placed in the access cavity before introducing the Reciproc instrument into the canals, in a slow in-and-out pecking motion, without completely removing the file from the root canal, and the range of motion did not exceed 3-4 mm. Debris on the instrument was removed using alcohol-soaked gauze, after every 3 in-and-out (pecking) motions. During instrumentation, the canals were irrigated with 4.2% NaOCl solution with a plastic syringe and a closed-end needle . Apical patency was maintained throughout the shaping procedure by using a #10 K type file between each in-and-out pecking motion. The instruments were driven in a torque control endodontic motor  in Reciproc All Mode. Each tooth was shaped with a single-use file, after which the files were discarded.Upon completion the instrumentation procedure, 1ml 10% citric acid was used to remove smear layer. A final flush with 4.2% NaOCl was performed, and the canals were dried with paper points. The canals in both groups were filled with a warm gutta-percha obturation technique. AH-Plus cement  was used as the root canal sea-ler. Each canal access was sealed with a flowable composite  and the access opening was temporarily filled with a Cavit restoration .-Assessment of Postoperative Pain and Statistical AnalysisPre- and postoperative pain was assessed using the Huskinsson  visual aP < .05.According to our previous study , postopeP > .05).P > .05).The mean age of the patients in the undergraduate group was 45.3 years, and in the postgraduate group was 46.1 years. The Mann–Whitney test showed no significant difference in age distribution between the two groups .The mean baseline pretreatment pain in the undergraduate student group and the Endodontic Postgraduate student group was 1.99±3.20 and 2.35±2.75, respectively, with no significant differences (P< .05).Overall, the mean value of pain after root canal treatment performed by undergraduate students was 1.13±1.94 on a VAS scale between 0 and 10, while in treatments performed by postgraduate students, the mean value of postoperative pain experienced by patients was 1.91±2.07. There was a significant difference in the incidence of postoperative pain between the two groups (P < .05).The mean incidence of postoperative pain was 41% (41/100). Slight, moderate, and severe pain was experienced by 21%, 15% and 5% of the patients, respectively. In the undergraduate group 18%, 12%, and 4%, of patients experienced slight, moderate, and severe pain, respectively, whereas in the postgraduate group, 26 patients (52%) reported no pain, 12 (24%) slight pain, 9 (18%) moderate pain, and only 3 (6%) reported severe pain . The consumption of analgesics in both groups was significantly higher in patients who experienced more pain (P < .001).Of the 100 patients, only 30 (30%) reported having taken analgesics. In the undergraduate group, 28% of patients (14/50) reported having taken analgesics, a value similar to that obtained in the postgraduate group , showing no significant difference . These results are in accordance with Walton et al. . We found no differences in sex, tooth type, pulpal and periapical status, position of the tooth in the arch, and presence or absence of symptoms before treatment between the two groups. Another possible explanation may be that, in the present study, the undergraduate students took considerably longer to perform root canal procedures. This could result in a longer exposure of tissues to irrigant solutions, which could drastically reduce bacteria , the mean pain in both groups was less than 2. According to several authors  movements, the Reciproc instrument was cleaned and the debris removed from the instrument until WL was achieved. The WL was determined with an EAL and confirmed radiographically.We did not consider the apical diameter as a variable to evaluate postoperative pain. The Reciproc file was chosen based on the manufacturer’s recommendations. It can be argued that apical enlargement may have an impact on postoperative pain; nevertheless, a recent study on postoperative pain after apical enlargement demonstrated that patients with and without apical enlargement experienced the same level of postoperative pain and the same need for analgesic intake .et al. (Postendodontic pain is highly subjective and is influenced by several factors . Pain maet al.  in theiret al. ,27,38.We used a Reciproc system, which offers easier root canal preparations and requires a simpler learning curve . This coet al. (One of the main concerns in pain research is the subjective evaluation of pain. Thus, any decision to take analgesics will depend on this subjectivity . In our et al. , who repWithin the limitations of this study, we conclude that operator experience has an influence on the prevalence of postoperative pain after root canal treatment. Our findings showed that the Reciproc System is a good option for operators without experience in endodontics.


The aim of this study was to determine the risk factors of neuropathic pain (NP) in the patient with carpal tunnel syndrome (CTS) before and after the carpal tunnel release. One hundred and two CTS patients were enrolled in the study. The pain score was measured by the visual analogue score. NP was determined by the painDETECT (PD) questionnaire. All subjects were divided into 3 groups at 12 weeks after surgery: an Improved, Unchanged, and Worsened group. The risk factors of worsening NP after surgery were evaluated. Conclusions. The surgery was very effective on NP of CTS; however, the PD in 7% of hands worsened after surgery. Risk factors before surgery that predicted worse NP after surgery were found to be a younger age, weaker pain, and the absence of night pain. We found that 36% and 18% of patients with CTS had neuropathic pain before and 12 weeks after surgery, respectively, and pain was significantly stronger than in those without NP. The PD score of eight hands worsened after surgery. In the “Improved group,” the average age at the surgery was younger and the pain score was lower than in the “Unchanged group.” Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy of the median nerve at the wrist . In the Pain is classified into nociceptive pain and neuropathic pain (NP). Damage or dysfunction of the central or peripheral nervous system induces the development of NP , 8. SeveHowever, only a few papers have described changes in NP before and after treatment for several diseases. In patients with shoulder impingement syndrome, those with high preoperative levels of central sensitization, often induced by NP, had a poor outcome after surgery . HoweverThe aim of this study was to evaluate NP in patients with CTS and the change in NP after surgery and to identify risk factors for persistent NP after surgery through an observational consecutive clinical study.This study was approved by the Institutional Review Board (IRB) of Tsuruta Orthopaedic Clinic. Informed consent was obtained from each patient.The subjects of this study consisted of consecutive patients that were newly diagnosed with idiopathic CTS in December 2011 and December 2014 at a single center .CTS was diagnosed based on the clinical and electrophysiological findings, and 425 hands were nominated as having CTS. The exclusive criteria for distinguishing idiopathic from secondary carpal tunnel disease include the presence of trauma or rheumatoid arthritis, being in the perinatal period, and being on hemodialysis. One hundred and nine hands in 102 patients who completely answered the questionnaire with over 12 weeks of follow-up were incorporated into the current study .The distal latency of the median nerve in electrophysiological study was measured using the Neuropack U device . For the electrophysiological measurement, the distal latency of the median nerve was induced at the abductor pollicis brevis 7 cm distal from the stimulated point by stimulating the median nerve halfway between the palmaris longus and flexor carpi radialis. A pinch gauge  was used to measure the power of the tip pinch between the thumb, index finger, and little finger. A Manual Muscle Testing (MMT) system was used to measure the muscle power of the abductor pollicis brevis . The MMTAll patients completed the Visual Analogue Scale (VAS) examination and painDETECT (PD)  screeninThe patients were also asked to fill out the Japanese Society for Surgery of the Hand version of the Disability of Arm, Shoulder, and Hand questionnaire (DASH-JSSH)  in orderThe subjects were divided into 3 groups at 12 weeks after surgery: an Improved, Unchanged, and Worsened group. The “Improved group” included any hands going from likely to possible or unlikely, or from possible to unlikely. The “Worsened group” included any hands going from unlikely to likely or possible, or from possible to likely.The rest of the patients were designated as the “Unchanged group.” t-test. The male-to-female ratio and the existence-to-nonexistence of night pain ratio were compared using the χ2 test. The proportions of Unlikely NP versus Possible or Likely NP before and after surgery were compared using the McNemar test. Statistical significance was set at p < 0.05. Several factors were compared between the Improved, Unchanged, and Worsened groups at 12 weeks after surgery using an analysis of variance (ANOVA) followed by Scheffe's test.All statistical analyses were performed using the SPSS software program for Windows . The mean age, disease duration, distal latency, S-W test, MMT of APB, tip pinch, grip power, pain score (VAS), and DASH score between two groups were compared using Student'sThe characteristics of the patients are shown in p < 0.01), before versus 8 weeks after operation (p < 0.01), before versus 12 weeks after operation (p < 0.01), 4 versus 8 weeks after operation (p = 0.063), 4 versus 12 weeks after operation (p < 0.01), and 8 versus 12 weeks after operation (p = 0.256). Therefore, there were significantly fewer patients with NP at 4, 8, and 12 weeks after surgery than with NP before surgery. Furthermore, a significant reduction in the number of patients with NP after surgery occurred at 8 weeks after surgery.p < 0.05). Before surgery, all pain scores except for night pain in the “Improved group” were higher than those in the “Unchanged group” . However, there was a significant difference in the rate of existence of night pain between these two groups. At 12 weeks after surgery, night pain in the “Worsened group” was significantly stronger than in the “Improved group” or “Unchanged group.”No significant differences were noted in the DASH score before or at 12 weeks after surgery in any groups.Carpal tunnel release is the most common surgical treatment for CTS, and many symptoms of CTS are improved after surgery; however, surgery fails to completely resolve symptoms in some patients . The risCTS is one of the most common causes of NP because it is the major entrapment neuropathy . HoweverSecond, the PD might have issues concerning the indication, as it was initially developed to assess back pain . The appGenerally, the pain level of NP is larger than the pain level of nociceptive pain and may cause chronic pain . We noteThe proportion of CTS patients with night pain is significantly higher in those with NP than in those without NP before surgery . HoweverCarpal tunnel release always affects the symptom of CTS. However, 8 hands (7%) were classified into the “Worsened group.” The values in the “Improved group” were higher than those in the “Unchanged group” for all pain scores except night pain before surgery. In addition, the hands in the “Improved group” had night pain at a higher rate than those in the other groups . This reIn the present study, younger patients with CTS did not necessarily experience an improvement in their symptoms after carpal tunnel release. One of the reasons for this may be because the threshold of pain in older patients might have been higher than in young patients . This suThere are some guidelines concerning the pharmacological management of NP –29. In tSeveral limitations associated with the present study warrant mention. First, the study group was relatively small. In particular, the 8 hands in the “Worsened group” may be too small sample size to demonstrate statistical significance. However, the current study is the first report to investigate the efficacy of carpal tunnel release on NP in patients with CTS. These findings should be investigated further in future preliminary studies. Second, we did not examine the relationship between NP and the patients' quality of life. However, the current study included the DASH score to assess the activity of daily life, and this score can be used in place of a quality of life assessment.n = 20) had NP. No relationship between the DASH scores and NP was detected. Strong pain was found to be significantly associated with NP both before and after surgery. Risk factors before surgery predicting worse NP after surgery were younger age, weaker pain, and the absence of night pain. The absence of night pain and weak pain before surgery did not guarantee good postoperative results. Unfortunately, the current study could not clarify the mechanism underlying the relationship between various pains before surgery and the clinical results after surgery. In clinical settings, it is necessary to conduct intervention, including administering medication, according to the symptoms of each case.In conclusion, 36% of patients with CTS had NP, and their muscle strength was significantly weaker and their pain significantly stronger than in those without NP before surgery. At 12 weeks after open carpal tunnel release, 18% of patients (


The aim of this study is to detect the possible reasons of abdominal pain in the patients aged 65 and older admitted to emergency department (ED) with complaint of abdominal pain which is not related to trauma, to determine the length of hospitalization of old (65–75 age) and elderly (aged 75 and older) patients, and to define the hospitalization and mortality rates. In the study, 336 patients were included. Groups were compared in respect to gender, internal or surgical prediagnoses, complaints accompanying abdominal pain, vital findings, comorbidities, requested consultations, hospitalizing service, waiting time in the ED and in the hospital, and treatment methods. Of the patients, 48.2% were male, and 51.8% were female. While 52.4% of the patients were in 65–74 age group, 47.6% of them were aged 75 years and above. An internal disease was detected in 76.8% of the patients as an origin of abdominal pain. Most common prediagnoses were biliary diseases and diseases related to biliary tract followed by nonspecific abdominal pain, abdominal pain secondary to malignity, ileus, and acute gastroenteritis, respectively. The most frequent finding accompanying abdominal pain was vomiting. The most frequent chronic disease accompanying abdominal pain was hypertension in both age groups. We observed that 75.9% of the patients required consultation. We detected that 48.8% of the patients with abdominal pain were hospitalized and they were hospitalized mostly by gastroenterology ward (24.8%). Surgical treatments were applied to the 17.6% of the patients with abdominal pain. Clinical findings become indistinct by age, and differential diagnosis of abdominal pain gets more difficult in geriatric patients. Therefore, physicians should consider age related physiological changes in order to distinguish geriatric patients admitted to emergency service with abdominal pain from pathological cases requiring immediate surgical operation. The number of elderly people (≥65 years old) is increasing both in Turkey and internationally due to improved living conditions and decreased mortality rates. Knowing the characteristics of elderly patients admitted to emergency departments can provide guidance for diagnosis and treatment approaches . As the After ethical approval, medical records of patients older than 65 years admitted to our ED with abdominal pain in the last year were investigated retrospectively. Inclusion criteria were patients with abdominal pain older than 65 years. Medical records of the patients were detected for age, gender, vital signs, complaints accompanying abdominal pain , comorbidities, duration of abdominal pain, length of ED stay , prediagnosis in the ED, consultations required , wards that the patients were admitted to , length of stay (LOS) of the patients in the hospital , choice of treatment , and outcomes . The patients were divided into subgroups according to age (65–74 years and above 75 years) and diagnoses . Patients under 65 years and with traumatic abdominal pain were excluded from the study.n) and percentage (%) were given for categorical variables. Median, minimum, and maximum values were given for continuous variables. In comparison of categorical variables, Pearson's chi-square test and Student T-test were used. For comparison of body temperature between patient groups, Mann–Whitney U test was used. p < 0.05 was considered as statistically significant.Data were analyzed using Statistical Package for Social Sciences (SPSS) for Windows® 21.0 programme. Frequency  and 174 were female (51.8%). While 176 patients were involved in 65–74 years group (52.4%), 160 were involved in 75 years and above group (47.6%).p > 0.05). Comparison of patient characteristics according to age groups is summarized in Mean age of the patients was 74.8 ± 6.5 years . While mean age of female patients was 75.3 ± 6.0, mean age of male patients was 74.2 ± 6.0. Mean age of the patients according to gender was not statistically significant (p > 0.05). When complaints accompanying abdominal pain were compared between age groups, no statistical significance could be determined.When source of abdominal pain was investigated, 258 patients had a medical source (76.8%) and 78 had a surgical source (23.2%). Of the patients with medical diagnoses, 53.5% were in 65–74 years group and 46.5% were in 75 years and above group. Of the patients with surgical diagnoses, 48.7% were in 65–74 years group and 51.3% were in 75 years and above group. No statistical significance could be determined when patients were investigated according to age, gender, and source of abdominal pain (p < 0.05).When complaints accompanying abdominal pain were compared, nausea/vomiting and gas extraction inability were found to be statistically significant in males (p > 0.05). Additionally, when complaints were compared as medical and surgical sources, diarrhea, jaundice in medical sources, and gas extraction inability in surgical sources were found significantly higher (p = 0.027).In 77.4% of the patients, a chronic illness was determined. Cerebrovascular diseases (CVD) were statistically significant in patient group above 75 years (p < 0.05).When chronic diseases were compared according to gender, hypertension (HT) in males and Diabetes Mellitus (DM) and congestive heart failure (CHF) in females were found to be statistically significant (p < 0.05).When accompanying diseases were compared between medical and surgical sources of abdominal pain, HT and liver cirrhosis were significant in medical sources (p = 0.008).Mean values of vital signs of the patients on admission to ED were as follows: systolic blood pressure: 120.0 ± 20.4 mmHg, heart beat: 84.0 ± 13.4 beats/minute, and temperature: 36.6 ± 0.6°C. Blood pressure was found to be significantly higher in females than males , followed by cholecystectomy (7.1%) and appendectomy (2.9%).When patients were classified according to duration of abdominal pain , no statistical significance could be determined between gender, age, and prediagnoses.For 265 patients (75.9%), a consultation was required. Of the patients admitted, 133 (50.2%) were in 65–74 age group and 132 (49.8%) were in 75 age and above group. When consultations were investigated, 118 (44.5%) patients consulted with internal medicine specialists, 72 (27.2%) with general surgery specialists, 50 (18.9%) with both internal medicine and general surgery specialists, and 25 (9.4%) with other specialists.The most common diagnosis was biliary and biliary tract diseases (19.6%) followed by nonspecific abdominal pain (11.9%) and abdominal pain related to malignity (9.8%). Subgroups of biliary and biliary tract diseases were choledocholithiasis (11.3%), cholangitis (5.1%), cholecystitis (2.1%), and cholelithiasis (1.2%).Of the patients, 164 (48.8%) were hospitalized, 131 (39.0%) were discharged from ED, and 41 (12.2%) have died. Of those who were discharged, 107 (81.7%) were discharged with full recovery and 24 (18.3%) rejected treatment and left the ED with written consent.While majority of the geriatric patients (41.8%) were followed in the observation room of the ED, 24.7% were followed in gastroenterology and 17.6% were followed in general surgery wards.p < 0.05).When LOS of patients were investigated, majority of the patients were determined to stay 0–6 hours. Patients with abdominal pain of medical source had significantly longer LOS  rupture . BengtssIt is fact that threshold for consultation in geriatric patients is recommended to be low . Mert etNonspecific abdominal pain—abdominal pain without a specific origin—is common among young patients. Bavunoğlu et al. reported that nonspecific abdominal pain is seen in less than 15% of geriatric patients . Gün et As age advances, infectious diseases are seen more frequently in elderly patients due to immune system weakening . Our stuIt is well-known that acute appendicitis is more common in young patients when compared to geriatric patients. Numerous studies revealed that the frequency of acute appendicitis in geriatric patients is 5–10% , 43. DurIn a study, Türker et al. reported that 33% of the patients with abdominal pain have been discharged with full recovery following medical treatment. Of these patients, 18.4% were discharged for outpatient follow-up, 18.7% were hospitalized in general surgery ward, 9.4% were hospitalized in internal medicine ward, 4.5% were discharged following ED observation, 1.9% left the ED voluntarily, and 0.4% have died . In anotIn the literature, it is reported that mortality rates in geriatric patients related to emergency surgery vary between 11% and 37% –47. In oIn our study, the most common ward where the patients were hospitalized was found to be internal medicine, particularly gastroenterology ward. It was previously reported that hospitalization rates of patients with abdominal pain vary between 18.9% and 63.2% , 5, 43. In a report by Chan et al., it was stated that 1.4–2.9% of the patients admitted to EDs leave the ED without being seen by a physician due to prolonged LOS in the ED . This raIn the literature, medical treatment is the most common treatment method in geriatric patients with abdominal pain , 52, 53.Results of our study revealed that the most common cause for abdominal pain in geriatric patients is biliary tract disorders. We also determined that majority of the patients with abdominal pain have a concomitant chronical illness. The most common complaints accompanying abdominal pain are nausea/vomiting and gas extraction inability. Mortality rate in geriatric patients with abdominal pain is 12.2% and higher in males. As the age advances, both rates of surgical procedures and mortality rate increase.


Patients experience pain and discomfort during active orthodontic treatment with fixed appliances. Pain is considered a subjective response to noxious stimuli. It can vary from person to person and is influenced by certain factors such as age, gender, previous pain experiences, stress or anxiety, and type of appliance.The objective of this literature review was to discuss conventional versus recently introduced treatment modalities used in pain management for orthodontic patients.According to the reviewed articles, both pharmacological and non-pharmacological methods were introduced in orthodontic pain management. However, orthodontists must use their best professional judgment to assess each case individually and select an appropriate treatment modality based on pain threshold level of an individual.Nevertheless, further investigations are required in this field. Pain relatively starts within four hours, increases over the next 24 hours, and decreases within seven days after initial bonding and placement of separators. The main cause of pain and discomfort in orthodontic treatment is due to multiple factors such as pressure, ischemia, inflammation, and edema related to tooth movement. The most common method of measuring pain intensity is the numerical rating scale (NRS) and visual analogue scale (VAS). Pharmacological and non-pharmacological methods can be relatively used in orthodontic pain management . MoreovePain intensity can also be affected by the type of appliance. Patients with fixed appliances report significantly greater pain intensity than those with removable ones . InvisalA simple and non-invasive preoperative sensory technique of using a cold pressor test aids in predicting the risk of developing pain in patients undergoing orthodontic treatment. Self-reported pain was reduced after archwire placements as the individual's pain tolerance increased. This experiment might help highlight an individual’s variations and preferred method of pain management .Nevertheless, some patients might suffer from underlying orofacial pain conditions. A multidisciplinary approach is required in the management of orofacial pain disorders . TherefoThe objective of this review was to discuss conventional versus recently introduced treatment modalities used in pain management for orthodontic patients.22.1et al. conducted a meta-analysis to evaluate the effect of non-steroidal anti-inflammatory drugs (NSAIDs) in managing pain. Of the 1,127 studies, seven were included. No statistically significant difference was found between ibuprofen and paracetamol (acetaminophen) administration in relieving pain. It was evident from the literature that ibuprofen lowered pain at two hours and six hours after intervention but not at 24 hours when pain peaks. To some extent, ibuprofen relieves pain in the initial stage of treatment [Several studies discussed the importance of pharmacological management of pain during orthodontic treatment. Angelopoulou reatment .A report based on a literature review states that NSAIDs impede tooth movement and also increase the risk of root resorption. Therefore, paracetamol (acetaminophen) was considered the safest NSAID that had no influence on the range of tooth movements as well as root resorption and other adverse effects that might occur within the oral cavity . HoweverOn the other hand, preoperative analgesics were found to be effective in reducing pain and discomfort after intervention in patients with dental anxiety and fear . AnotherA study compared the preoperative administration of conventional NSAIDs (ibuprofen and acetaminophen) to meloxicam. Meloxicam administered at a dose of 7.5 mg was as effective as acetaminophen 650 mg and ibuprofen 400 mg in controlling orthodontic pain. Acetaminophen was declared the treatment of choice, as the drug had no gastrointestinal tract (GIT) toxicity and did not impede tooth movements. Nevertheless, meloxicam, which has the least GIT toxicity, can be an alternative option for patients in whom NSAIDs are contraindicated .p<0.001) with the topical anesthetic as compared to the placebo group. Therefore, this methodology might be beneficial for patients with a low pain threshold as it could potentially relieve pain and discomfort after the placement of orthodontic elastomeric separators.In a recent study by M. Abu Al-Melh and Andersson , the eff2.2p=0.031), and the median VAS between the two groups was 25 mm at 24 hours (p=0.038). Hence, the authors concluded that chewing gum significantly decreased both the impact and pain from fixed orthodontic appliances. There was no evidence that chewing gum increased the incidence of appliance breakages [p>0.39). Therefore, BW (bite wafers) were also considered as effective as OTC analgesics for pain control in adolescents [Other treatment modalities in orthodontic treatment include chewing gum and biting on wafers. A study was conducted on 57 orthodontic patients to determine whether the use of chewing gum reduced the impact and pain caused by fixed orthodontic appliances. The difference between the median total impact score at 24 hours was 16  and an experimental group . In conclusion, sugar-free chewing gum may reduce the level of ibuprofen use in the experimental group. However, it has no clinical/statistical significant effect on bond failures .A research demonstrated that the use of systemic acupuncture preoperatively by qualified professionals can reduce pain in both male and female patients. Hence, it was considered a safe method of pain control .Moreover, studies have emphasized that psychological perspective and behavioral management might help in preventing pain in orthodontic patients. Studies focused on the idea of establishing good orthodontist-patient communication. Pain can be prevented if orthodontists explain and guide their patients about expected pain during treatment , 20. In However, a recent database search revealed that the quality of evidence for non-pharmacological interventions to manage orthodontic pain was very low. Further prospective research with long follow-up is required .p = 0.02) [Low-level laser therapy (LLLT) had been introduced earlier as another treatment modality for orthodontic pain control. Besides its analgesic effect, LLLT enhances tissue recovery and accelerates tooth movement. Several studies have discussed the proposed benefits of this treatment modality. A meta-analysis was conducted, and out of 186 results, only 14 randomized clinical trials (RCTs) with a total of 659 participants met the inclusion criteria. The results showed that diode LLLT significantly reduced pain by 39% compared to the placebo groups ( = 0.02) . However = 0.02) , 27.Single-dose, helium-neon laser therapy was found to be effective in reducing orthodontic pain in patients with maxillary canine retractions. The therapy contributed to a 12.1% pain reduction compared to the placebo group. But the study had its own limitations, and no previous studies had investigated the effectiveness of helium-neon laser therapy versus other laser types .A recent systematic review demonstrated that LLLT might improve orthodontic treatment by accelerating tooth movements and modulating acute pain, as well as preventing relapse. The quality of scientific evidence that supported LLLT use in modulating acute pain was low. Further research with robust study designs and conformity of laser methods will be required to reveal the worth of LLLTs in modern times as a routine method of orthodontic pain control . Bayani Analgesics and laser irradiation remained effective in the management of orthodontic pain at its peak intensity among all used interventions. However, further research is required to improve the quality of evidence .p>0.05) and significantly lower fiber, chromium, and beta-carotene (p<0.05) compared with the control group [Above all, dietary modifications are necessary during orthodontic treatment. Patients must be motivated towards healthier eating habits. A study was designed with 180 patients to compare dietary intake between orthodontic patients and control subjects. The authors concluded that orthodontic patients consumed higher total calories, proteins, and carbohydrates (ol group . Riordanol group . A qualiol group . Howeverol group . Moreoveet al. [A recent study conducted by Cozzani et al. , shows tOrthodontists must use their best professional judgment to assess the pain threshold level of each patient individually. Effective orthodontist-patient communication and targeted nutritional guidance may help in preventing pain and discomfort experienced by the patients to some extent. However, based on the available literature, analgesics remained the effective and routine methodology of pain management. Moreover, while prescribing analgesics, orthodontists must be aware of the pharmacological action as well as the pros and cons related to each drug. A maximum recommended dose should be taken into consideration for each patient. Patients with special conditions such as psychological pain or trigeminal neuralgia often require collaboration with their specialists and advanced care management. Nevertheless, pain management is a complex phenomenon. Therefore, further investigations combining different methods of orthodontic pain control with appropriate study designs and large sample sizes are required.


In this study, we present results after laparoscopic duodenojejunostomy for five patients with protracted superior mesenteric artery syndrome. The procedure can be performed with minimal perioperative risk and very short postoperative stay. It provides significant postoperative symptom relief for many patients with typical presentation of the syndrome. Superior mesenteric artery syndrome (SMAS) is a rare but complicated medical problem. SMAS, also known as Cast syndrome, chronic duodenal ileus, or Wilkie's syndrome Upper gastrointestinal contrast series shows dilatation of the stomach and proximal duodenum, delayed gastric emptying of 4–6 h, and obstruction of the horizontal part of duodenum The disease has typically a chronic intermittent character and mainly affects young women between 10 and 30 years of age The SMAS may be seen in association with psychological symptoms. While psychological problems itself can cause pain after food intake, vomiting, appetite loss, and anorexia, the SMAS can also lead to psychological and social problems including depression and anorexia due to the severity of the disease.Treatment begins with conservative management including nasogastric decompression, correction of electrolyte imbalance, and nutritional optimization. The main goal of conservative treatment was body mass restoration and recovery of water and electrolyte balance.Duodenojejunostomy for patients with chronic duodenal ileus was first suggested by Bloodgood Other surgical techniques include gastrojejunostomy and lysis of Treitz ligament, both of which have been shown to be inferior to duodenojejunostomy In this report, we describe a consecutive series of five patients with SMAS who underwent laparoscopic treatment at Oslo University Hospital from January 2007 to June 2013. Patients were referred to the center from local hospitals after ineffective conservative nutritional as well as medical treatment.The aim of the study was to analyze postoperative outcomes and changes in quality of life after laparoscopic duodenojejunostomy for SMAS.This case series is based on patients that fulfilled the criteria for SMAS and were operated with duodenojejunostomy at Oslo University Hospital between April 2009 and March 2013.The study includes five female patients with median age of 19 (range 14–33) years. The diagnosis was confirmed with CT angiography for three patients, triplex ultrasound for one patient, and triplex ultrasound combined with CT angiography for the remaining one. The imaging diagnostic shows a narrow aortomesenteric angle (between 10 and 20°).A 12‐mm trocar was placed via umbilicus using open‐entry technique. After establishing of pneumoperitoneum, two additional 5‐mm trocars were placed lateral to the rectus abdominis muscle at the right and left side, and 12‐mm trocar below in the right flank  Fig. . The resIntra‐ and postoperative parameters were registered retrospectively from Electronic Health Records retrieved from referring hospitals and from Oslo University Hospital.To grade intraoperative unfavorable incidents and postoperative complications, the Oslo revision of the Satava approach for surgical error evaluation and the modified Accordion classification were applied, respectively The patients were asked to retrospectively assess their preoperative life quality by use of quality of life questionnaires and McGill pain index. The patients performed this during a time period of 6 months to 3 years postoperatively. The same pain index and questionnaires were used to determine their postoperative quality of life during the follow‐up period. The follow‐up period lasted between 1 and 5 years after surgical treatment.Quality of life assessment was based on the Norwegian version of EORTC QLQ‐C30 version 3.0 and supplemented by EORTC QLQ‐CR29 As the abdominal pain was determined as the most disabling symptom, the Norwegian short version of McGill pain index (NSF‐MPQ) t‐test with an alpha level of 0.05. Statistical analysis was performed using the statistical package IBM SPSS version 22.0 .Post‐ and preoperative scores were tested for normality using the Shapiro–Wilk test, and differences were then compared using pair‐sampled The study was approved by the Regional Committee for Medical Research Ethics. All patients received written information on the purpose and the design of the study and gave their expressed written consent.All patients underwent laparoscopic duodenojejunostomy without conversion to open or hand‐assisted procedure. No intraoperative unfavorable incidents were reported. Median operative time was 95 (range 91–110) min. No measurable bleeding beyond the suction tube (considered to contain <50 mL) was detected.The postoperative course for every patient was uneventful, and the patients started to drink and eat during the day of the surgery. The median postoperative hospital stay was 1 (range 1–2) day.Patients were observed during a follow‐up period of 1–5 years.Postoperative median restoration of the weight was 5 (range 0–8) kg, and the corresponding median improvement of BMI index was 1.8 (range 0–2.8).After surgery, patients 1, 2, 3, and 4 presented significant improvement of McGill pain index, visual analogue scale of pain, and PPI score compared to baseline. Patient 5 did not show any improvement  and 5 (0 points). Scale “Weight” was improved for all five patients from mean level 33.3–80.0. “Sexual interest” score was assessed for patients 2, 3, and 5 (patient 1 and 4 were virgins at a baseline time). No difference comparing to baseline was found (100 points for patient 3 and 0 points for patient 2 and 5)  and were excluded from further analysis. The scale “Dyspareunia” was not applicable.P‐value 0.022).Scales “Abdominal pain” and “Bloating” improved for patients 1, 2, 3, and 4 and stayed at the same level for patient 5. A significant difference was found in mean values for the scale “Abdominal pain”  With laparoscopic duodenojejunostomy, the SMAS can be managed with minimal trauma, short hospital and convalescent period, together with good intra‐ and postoperative results. This might question whether laparoscopic treatment might be a viable substitution to the prolonged nasointestinal nutrition for the patients with severe symptoms affecting daily activity and with clean radiological criteria. However, to answer this question, a comparison of two treatment options with large sample size and evaluation of complications is necessary.To our knowledge, this is the first study to address quality of life in patients treated by laparoscopic duodenojejunostomy for SMAS. Because SMAS is a rare gastrointestinal syndrome, it is difficult to assess a large cohort of patients. However, even for a case series of five patients, a significant overall improvement of health status, physical activity, emotional, and social status, as well as relief of the most bothering and severe symptoms was achieved.During the individual analysis of each patient, four of five patients reported complete relief of the symptoms after operation and prolonged follow‐up. The last patient was suffering from chronic pain after previous esophageal surgery, and full pain relief could probably not be expected.In addition to symptom relief and a great improvement in quality of life, this series demonstrates the benefits of minimally invasive surgery, including minimal pain, short hospital stay, early convalescence and return to work, and good cosmetic outcomes.LB: participated in study's design, carried out data acquisition, performed the statistical analysis, and drafted the manuscript. NT: helped to draft the manuscript, participated in study's design, and interpreted the data. ÅAF, BIR, AMK, and RR: critically revised the manuscript and implemented important changes in the context. BE: conceived of the study, helped to draft the manuscript, and participated in its design and coordination. All authors read and approved the final manuscript.The authors declare that they have no competing interests.


Percutaneous needle liver biopsy (PLB) is frequently associated with pain and anxiety. This may discourage the patients for biopsy, and rebiopsies, if needed. We planned a study to investigate the efficacy of additional analgesia or sedation for PLB.The study has been designed as a single-center, prospective study. The PLB was planned for 18- to 65-year-old consecutive patients who were included in the study. The patients were divided into three premedication groups as control, Meperidine, and Midazolam. Hospital Anxiety and Depression Scale (HADS) was used to measure each subject’s anxiety level. Fifteen minutes before the biopsy, 1 mL 0.9% NaCl subcutaneously (sc), 1 mg/kg (max 100 mg) Meperidine sc, or 0.1 mg/kg (max 5 mg) Midazolam intravenously was administered to patients respectively. Then PLB was done with 16 G Menghini needle. The day after, the patients were asked about feelings regarding biopsy.Groups were similar by gender and age. The HADS scores prior to PLB and on visual analog scale  score during PLB were similar. In the three groups, 7, 12, and 7 patients, respectively, experienced no pain. Other patients explained pain as mild or moderate or severe. The number of patients who agreed for possible rebiopsy was higher in Meperidine and Midazolam groups than in the control group.Premedication with Meperidine or Midazolam in PLB would improve patients’ tolerance, comfort, and attitude against a possible repeat PLB.How to cite this article: Sezgin O, Yaras S, Ates F, Altintas E, Saritas B. Effectiveness of Sedoanalgesia in Percutaneous Liver Biopsy Premedication. Euroasian J Hepato-Gastroenterol 2017;7(2):146-149. Although noninvasive alternatives such as transient elas-tography and the fibro test have partly been superseded, PLB is still a gold standard method for the diagnosis of liver disease and the response to treatment. There is no consensus on analgesic and/or sedative premedication for PLB, in terms of the agents to be used and cost-effectiveness. In our daily practice, we use either local anesthesia alone or Meperidine and Midazolam additionally, for PLB premedication. The biopsy procedure is often frightening and uncomfortable for the patient. Such experiences can discourage patients for the follow-up biopsies in the future. It sounds logical that if the biopsy procedure is comfortable, the biopsy and repeat biopsy if needed would be more acceptable by the patients. We designed a study to evaluate the effectiveness of analgesia and sedation in addition to local anesthesia.1 A detailed explanation on how to use the 10-cm blank VAS was given to all subjects by one investigator (SY). Premedication was applied in a double-dummy pattern, resembling each other in all groups. The study was approved by the Mersin University Pharmaceutical Research Commission, decree B.30.2.MEU.0.20.05.04./70, dated Mar 16, 2011. Liver biopsy procedures were managed by the same practitioner, experienced for PLB (SY), during the study period. Written informed consent was obtained from patients. Standard percutaneous liver biopsy is performed on patients fasted overnight, in the same position: Lying on the back, right arm under the head, and then by transabdominal ultrasonography, the most appropriate entry location is detected in the skin and marked.2 The biopsy site was located with bedside ultrasonography usually in the seventh or eighth intercostal space in the midaxillary line. Before the procedure, pretreatment agents were given according to the patient group, without the knowledge of the practitioner. Then place of biopsy was cleaned with povidone-iodine followed by skin and sc anesthesia with 10 mL prilocaine HCl . Then, PLB was performed with the standard 16 gauge disposable Menghini needle aspiration. After the biopsy procedure, the patient then was made to lie on his/her right side for 1 hour and then supine for 4 hours and pulse and blood pressure were monitored regularly in order to detect complications early. Then, patients without any problem were discharged. The next day the patients came to the clinic, and were evaluated with ultrasound for any subcapsular, intrahepatic, or peritoneal bleeding. All patients were questioned with a questionnaire if there was a state of anxiety prior, during, and after the procedure and thoughts about their pain and the biopsy procedure. A 10-cm blank VAS was used to grade the intensity of the subjects’ pain. Subjects were asked to mark their pain intensity on this scale, with 0 indicating no pain and 10 indicating the worst imaginable pain. Spielberger Anxiety Questionnaire was used to measure each subject’s anxiety level before the biopsy. Participants were requested to complete the HADS3 to state the level of anxiety before biopsy. The results obtained were used for statistical analysis. In addition, patients were asked whether they remembered the PLB process, to evaluate retrograde amnesia related to Midazolam.The study was designed as a single-center study. Neither practitioner nor the patient who underwent the procedure knew the premedication. In our gastroenterology clinic, all patients who accepted and met the inclusion and criteria were consecutively invited and included in the study. All patients were informed about the need for PLB, the technical process, and possible complications. The patients were consecutively divided into three groups: Control , Meperidine, and Mid-azolam, without knowledge of biopsy practitioner and the patients. Participants were requested to complete a demographic and general health questionnaire, as well as the Spielberger Anxiety Questionnaire, which was used to measure each subject’s state anxiety level approximately 2 hours before the biopsy.The data from Meperidine, Midazolam, and the control groups were analyzed with Shapiro-Wilk test to check whether they were in normal distribution. For parameters with normal distribution, descriptive statistics were given such as mean and standard deviation. For parameters which were inconsistent with normal distribution, median and percentile values were given. Number and percentage values were given as descriptive statistics for categorical parameters. Mann-Whitney U test was used to compare all three groups, about mean values of pain which the patient perceived during the biopsy and the day after. Kruskal-Wallis test was used to compare the groups with the mean values of pain the patient perceived during the biopsy and the day after. Student’s t-test was used to compare the average length of biopsy material between the patients. The average age differences between groups were analyzed with variance analysis. The proportional differences between the two groups, if any, were analyzed with the Z test. Chi-square analysis was used for determining the relationship between categorical variables.A total of 90 patients were enrolled in the study, with 30 patients in each group. There were 62 males, 28 females with mean age of 41.63 years. The average age, sex distribution, education, and PLB indications were not different between the groups. There was no difference between the groups on anxiety level (HADS score) before the PLB. Totally 11/90 patients (12.2%) were very anxious and even thought of giving up the process a few times. Remaining 28/90 patients (31.1 %) were anxious and 51/90 patients (56.7%) did not feel worried. Three groups were similar in answer to the question: "How did you feel during the PLB?" Most of the patients were observed to be relaxed during the process. There were no differences between the three groups on the pain (VAS score) during the PLB. In our study, there were pain due to biopsy in 71.1% of patients . The pain was located on the abdomen  or radiating to the right shoulder . No patient stated severe pain. There was no pain requiring hospitalization. The average length of tissues achieved during PLB was 23 ± 9 mm and the length of the liver tissue was not associated with pain level. The conceptions of patients about the process, after the process, patients stating the process difficult accounted for 20% of the control group, 6.7% of the Meperidine group and 6.6% of Midazolam group respectively. Although more patients in the control group had stated the process as difficult than the patients in the other groups, there was no statistical difference between the groups. There were differences between the control group and both the Meperidine and Midazolam groups on the answer to the question for their attitude about the repeat biopsy. The rates of the patients who said he/she would accept the repeat biopsy without thinking were 33% in control group, 53% in Meperidine group, and 50% in Midazolam group. The difference was statistically significant (p < 0.035). The rates of those a bit worried about the process were 50, 30, and 33%, respectively (p < 0.035). The rates of the patients who said he/ she would reject the rebiopsy were 13.3% in control group, 6.7% in Meperidine group, and none in the Midazolam group. There were no major complications or side effects observed during PLB procedures.3 Liver biopsy is frequently associated with pain and anxiety. Moderate to severe pain, often requiring hospitalization, is seen in 1 to 5% of patients in the past series.45 Despite its prevalence and intensity, little has been done to evaluate the pain associated with liver biopsy or its treatment, so far. The procedure is usually performed under local anesthesia only. Mild anxiolytic treatment plus local anesthetic infiltration seem to produce insufficient analgesia, thus indicating that a more profound analgesic treatment is required for better control of this pain.6Percutaneous needle liver biopsy is a fundamentally important procedure in the evaluation of chronic and acute liver diseases.7Meperidine is a phenylpiperidine derivative opiate analgesic with its analgesic effects found by chance in 1939. Meperidine 75 to 100 mg given sc causes analgesia equal with 10 mg morphine given in the same way. There is also a sedating effect. Duration of action is shorter than that of morphine; elimination half-life is 3 to 4 hours. It is widely used in particular in musculoskeletal pain, for headache relief, cancer pain, lumbar disc herniations, all kinds of postoperative pain, applications of sedation, and analgesia.8 It has anxiolytic, sedative, hypnotic, anticonvulsant, muscle-relaxant, and anterograde amnesic effects. Its chemical structure is different from classic benzodiazepines such as diazepam, and this is responsible for its unique characteristics of rapid absorption and rapid metabolism.9Midozolam is a short-acting, water-soluble benzodi-azepine drug that acts similarly to diazepam on y-amino butyric acid-associated benzodiazepine receptors.10Efficacy and safety of diazepam and Meperidine combination were investigated in pediatric patients for gastrointestinal procedures such as colonoscopy, endos-copy, and liver biopsy and concluded that it is an effective and reliable method in patients older than 6 months.11 in 41 patients totally . They concluded that Midazolam administration before and after biopsy procedure reduces the discomfort of the patients during the biopsy procedure and improves compliance of the patients in the necessity of repeat biopsy. Our study reveals this conclusion. The rates of the patients who said they would reject the rebiopsy were 13.3% in control group, 6.7% in Meperidine group, and none in the Midazolam group. Midazolam could be more convenient than Meperidine because of its anterograde amnestic effect. Interestingly, our patients mostly remembered the process, even in the Midazolam group.In the literature, very few studies were aimed at the prevention of pain and anxiety due to liver biopsy. In those studies, the goals and results were different. The use of Midazolam in PLB was studied by Brouillette et al12 We hypothesized which drug (Midazolam or Meperidine) is more effective for premedication. In this context, there were no differences between both the drug groups about the pain level, and the attitude for rebiopsy. There was no patient who regretted rebiopsy in the Midazolam group. This result may be in favor of premedication with Midazolam.In another study, efficacy and safety of the premedication for liver biopsy were investigated in patients with the lysosomal storage disease under 16 years old. A total of 30 patients were included in the study and oral chlorpromazine, Meperidine, and pentobarbital premedication were administered to the patients. Authors concluded that liver biopsy can be performed safely with appropriate patient selection and adequate sedation.13 and Sherlock and Dooley,14 "sedation is not given routinely before biopsy as it may interfere with the patient’s cooperation." Schiff and Schiff15 stated that "it is not necessary to premedicate the patient before the biopsy." Thus, not unexpectedly, a nationwide survey in France showed that sedation or premedication was given in only 46% of 2,084 biopsies.16Furthermore, according to Eisenberg17 Midazolam sedation for the biopsy procedure should be given to anxious patients in accordance with the British Society of Gas-troenterology guidelines, if there is no contraindication. Midazolam should be given with caution in the context of liver disease.18 There is no comment about premedication in Canadian guidelines.Moreover, there are no precise guidelines from international liver societies and the recommendations are different. By American Association for the Study of Liver Diseases guidelines, use of oral or intravenous anxiolytic therapy or conscious sedation is variable; available data indicate that it is safe when used.19In our clinic, percutaneous liver biopsy frequently was applied for patients with viral hepatitis. In an earlier study, we had evaluated retrospectively the ultrasound-assisted liver biopsy procedures of 784 patients in our clinic. In that study, we had found that totally 21.8% of patients stated pain during the process.Accordingly, we estimated that it was interesting to perform a trial comparing the action of Meperidine, Midazolam, and placebo on anxiety, pain, and acceptability of percutaneous liver biopsy. Based on the earlier studies and our own experience, this study was designed to investigate the effects of premedication with Meperi-dine or Midazolam on the pain and anxiety level of the patients who underwent biopsy and the overall acceptability of biopsy by them. In our study, there were pain due to biopsy in 71.1% of patients . The pain was located on the puncture site, and abdomen, or radiated to the right shoulder. No patient stated severe pain. There was no pain requiring hospitalization. There was anxiety in 73.3% of patients before the biopsy process, in our study. Anxiety can interfere with patient compliance, hence the success of process.20 We realized no major difficulty about patients’ understanding of the test during the study.In this study, we used HADS scores of patients for anxiety assessment. The HADS score system was originally written in English language, and has not been validated in Turkish language so far. There are many studies comparing the HADS score system in other languages apart from English, which concluded some difficulties.Our observations during PLB procedures showed that patients’ moods during the biopsy may be quite variable. Some patients can easily tolerate the biopsy procedure only with local anesthesia, some can experience the procedure very irritated and painfully. Though these findings existed at the time, we realized that attitudes may change over time and the patient could change their behavior. Therefore, it sounds like, more the patient comfort, more courageous he/she will be in the next biopsy. Here an important restrictive point may be the addictive properties of both drugs.Another interesting finding of our study was that, although there was no difference about the level of the pain in three groups, the attitude for possible rebiopsy was different in groups favoring the use of premedication.


There is scarce knowledge of physical function and pain due to multiple rib fractures following trauma. The purpose of this follow-up was to assess respiratory and physical function, pain, range of movement and kinesiophobia in patients with multiple rib fractures who had undergone stabilizing surgery and compare with conservatively managed patients.A consecutive series of 31 patients with multiple rib fractures who had undergone stabilizing surgery were assessed >1 year after the trauma concerning respiratory and physical function, pain, range of movement in the shoulders and thorax, shoulder function and kinesiophobia. For comparison, 30 patients who were treated conservatively were evaluated with the same outcome measures.p < 0.01) and less deterioration in two items in Disability Rating Index (sitting and standing bent over a sink) (p < 0.05).The results concerning pain, lung function, shoulder function and level of physical activity were similar in the two groups. The patients who had undergone surgery had a significantly larger range of motion in the thorax , No  Multiple rib fractures are a common and painful condition . GreaterA number of new osteosynthetic implants specifically designed for stabilizing fractured ribs have been developed in recent years , 6. PrevHowever, there is a lack of prospective studies with a long-term follow-up concerning physical function, lung function, mobility and pain. We found in a previous study  that, ofThere is a need for more trials with conservatively managed controls to further examine the effect of stabilizing surgery for rib fractures on long-term pain, physical function and lung function.The aim of this follow-up was therefore to assess respiratory and physical function, pain, range of movement and kinesiophobia in patients with multiple rib fractures who had undergone stabilizing surgery and compare to conservatively managed patients.A consecutive series of 58 patients undergoing surgery at Sahlgrenska University Hospital due to multiple rib fractures during the period September 2010 to March 2012 were considered to participate in the follow up. The criteria for surgery were: (i) Flail chest defined as three or more adjacent ribs each fractured in more than one location, with respiratory insufficiency (ii) Multiple rib fractures (>4) with respiratory insufficiency and also in need of a thoracotomy due to bleeding or air leakage. Respiratory insufficiency was defined as failing arterial oxygenation despite oxygen administration. Patients with previous disease or trauma affecting lung function or range of motion in the rib cage , living too far from the hospital, <18 years or not Swedish speaking were excluded from the list. Of the remaining 41 patients, 4 were deceased, 6 declined so 31 were evaluated  in order to stabilize the fractures. This system applies the concept of angular locked plates and intramedullary nailing and has been tested previously , 15. A tThe patients who were treated conservatively were either admitted to the trauma ward or to the intensive care unit. In most cases, the indication for intensive care was the need for assisted ventilation in flail chest or concurrent injuries requiring support of vital functions. The majority of the patients received, according to routine, intravenous and oral morphine and paracetamol as analgesia. Six of the 30 patients received an addition of epidural anaesthesia with Bupivacain. A pain score <4 was aimed for when giving anaesthesia. Intravenous broad-spectrum antibiotic therapy was given if the patients had chest tubes and low-molecular weight heparin was given subcutaneously for a minimum of one week to prevent thrombosis. The patients received breathing exercises when indicated, based on low saturation or hyper secretion in the lungs. No other information or physical therapy treatment was given at the hospital or at discharge.The following tests/assessments were undertaken at the follow-up:Intermittent or continuous persistent pain and pain during sleep and deep breathing was registered (Yes/No) and use of pain medication. The patients also had the possibility to note what aggravated the pain and what eased it (except pain medication).Forced Vital Capacity (FVC) and Peak Expiratory Flow (PEF) were tested in the sitting position in a standardized manner  accordinBreathing movements were tested by a Respiratory Movement Measuring Instrument, RMMI . The measuring device consists of six laser distance sensors with an accuracy of 0.0003 mm and a measuring frequency of 21Hz, an analogue to digital converter and a computer program for a PC computer. The equipment measures changes in distances between the diodes and the surface. In the tests, the diodes were placed bilaterally, at the level of costae 3, lower part of the thorax (xiphoid process) and abdominally  with a distance of approximately 1/3 of the clavicle on each side of the thorax with the patient in the supine position . Breathith costae and lower thoracic excursion at the level of the xiphoid process [Thorax excursion was assessed using a tape measure (marked in mm) around the circumference at two levels. Upper thoracic excursion was measured at the level of the 4 process , 20. The process . In orde process .th cervical spinal process and 30 cm below when the subject was standing erect and after maximal forward bending of the back and the neck [Thoracic flexion was assessed by measuring the distance between skin marks at the 7the neck .Lateral flexion was measured at the level of the tip of the index finger on the thigh when standing erect and then in a maximal lateral bending position .Active flexion and abduction in the shoulders were measured in the sitting position by a goniometer . The BosPhysical function was estimated using the Disability Rating Index (DRI) that includes 12 items covering activities from dressing and going for walks to lifting heavy objects and exercising. The item responses were rated on visual analogue scales . High vaPhysical level was estimated using a 6-graded scale , where lThe Tampa score was used to evaluate fear of movement and a level > 37 was defined as having kinesiophobia , 28.No power analysis was performed as previous studies are missing. The sizes of the groups are therefore based on results from a consecutive series of patients who had undergone surgery and historical controls, see Fig. U test, Chi 2 test and Fisher’s exact test. Differences in demographic data as age, height and weight, and breathing movements, spirometry and range of motion were analysed with the t-test. Statistically significant differences were set at a p value <0.05.SPSS version 15.0 was used for the statistical analyses. Differences in gender, lung disease, smoking history, pain estimation, physical function, activity level and fear of movement between the two groups were analysed with the Mann–Whitney Results on frequency and persisting/intermittent pain, use of pain medication and pain during maximal breathing are presented in Table FVC was in mean 103 % of the predicted value (SD 20 %) in the group of patients who had undergone stabilizing surgery and 111 % (29 %) in the group who were treated conservatively. Corresponding figures regarding PEF were 107 % (29 %) vs. 104 % (30 %). Four patients who had undergone surgery and two patients treated conservatively had an FVC <85 % of the predicted value. There were no significant differences between the two groups.p = 0.002), but the other positions did not differ significantly.Results of measurements of breathing movement of the injured and the non-injured sides are presented in Table p < 0.05).Range of motion in the thorax is presented in Table p = 0.171 and 0.062).Range of motion in the shoulders is presented in Table p < 0.05). The patients in both groups scored their physical activity to median 4 (range 1–6) i.e. “moderate exercise 1–2 h a week, e.g. jogging or swimming or light physical activities more than 4 h per week”.Results in DRI are presented in Fig. The proportion of kinesiophobia (Tampa score >37) was 32 % in the group that had undergone stabilizing surgery and 37 % in the group treated conservatively (N.S.)The results of this study imply that patients who had undergone stabilizing surgery due to multiple rib fractures have less deterioration in their range of motion in the thorax and the thoracic spine than patients treated conservatively. In addition, patients who had undergone stabilizing surgery experienced significantly less limitation concerning sitting and standing bent over a sink. However, we were not able to detect any significant differences concerning pain, lung function, shoulder movement and physical function.In this follow-up, 32 % of the patients who had undergone surgery and 50 % of those treated conservatively still had pain in the rib cage at the one-year follow-up. In our previous study of patients who had undergone stabilizing surgery due to multiple rib-fractures,  52 % hadConcerning VC and PEF, there were no significant differences between the groups and the proportion of patients within normal values was high even though nine of the patients undergoing stabilizing surgery had an additional resection of a lobe or segment. Due to the nature of the trauma, we have no lung function results from the patients before the surgery, but all values given are percent predicted . In our In the current study, the patients underwent registration of breathing movements with reliable and sensitive equipment , 29. TheClinically we have noticed that some patients have a satisfactory range of motion but a decreased function in the shoulder after the operation, and we thus added such measurements to this protocol. However, we found no significant differences between the shoulders on the injured or non-injured side in either surgically or conservatively managed patients. The proportion of patients with a restricted range of motion in shoulder abduction after stabilizing surgery are in line with figures by Lardonois et al. . A reasoThe patients in both groups are physically active to the same extent, but most of them less active than they desired. The question is whether the low activity level reflects a reduction after the trauma or whether the participants have a lower activity level in general. Patients in both groups had limitations in their physical function interpreted as a mild to moderate disability. It is always a challenge to evaluate patients after trauma as concurrent injuries may have an impact on activity and results concerning physical function. Collecting more information concerning activity and function previous to the trauma is thus of value for future trials.In this survey we also included the Tampa score to be able to detect whether the patients experienced kinesophobia . After tThe study has several limitations. To compare two series of patients, one of which consists of historical controls is always a weakness. The time from trauma to follow-up differs between our two groups. The patients who were treated conservatively had been injured 2,5–6 years earlier compared to those who had undergone surgery 1–2.5 years earlier. The time-gap may have influenced the results as there have been staff changes and improvements in pain medication, and care during the period. Another difficulty of using historical controls is that the medical records are seldom complete. In our study we were not able to verify the number of patients with flail chest or with lung injury among the patients in the control group because of missing information and less detailed scans which is a limitation.The two groups of patients in our follow up also received different regimens for analgesics. This may have had an impact of remaining pain, however, it is still unclear if pain is an indication to surgery in patients with multiple rib fractures but without flail chest. This follow up was further performed more than a year after surgery and the impact may be of minor importance. A limitation was also that the patients were only asked to assess level of remaining pain after the trauma and not the kind of pain to be able to understand the origin of it. As no radiography was performed at follow-up in order to diagnose non-union fractures it is difficult to distinguish between post-thoracotomy or post-trauma pain in the operated group. However, as there is a high incidence of pain in the conservatively managed group we interpret that the major part of this pain is due to the trauma.It is questionable whether the control group is representative since the majority of patients were invited but refused to participate in the follow-up. On the other hand, the groups evaluated were equal in size and there were no major differences between the groups concerning demographic data and Injury Severity Score (ISS). Another limitation is that the group sizes were rather small to be able to detect significant differences in all the variables used in the study. The results therefore have to be interpreted with caution. The low number of patients also limited the possibility of further statistical analysis as multivariate analysis. In future studies, results from more than one centre may be necessary to be able to reach sufficient power to detect clinically important differences.At the moment, most studies concerning surgery have focused on flail chest and respiratory insufficiency. Surgery seems to be beneficial for some patients, the question remains for which patients. Patients who are difficult to wean off a ventilator because of pain, those with lung injury and deformities of several ribs may be a specific group who may benefit from surgery. At our center, flail chest is an indication for surgery, however, it is still unclear if pain as an indication, with multiple rib fractures but without flail chest, should be operated. This study is too small to make a definitive conclusion if surgery is better than conservative treatment. But we see some indications, such as a tendency for decreased pain, better thoracic range of motion and physical function which would indicate that surgery is preferable. If operation technique could improve in the future with a less invasive approach, it would presumably decrease post-operative pain and the benefit of surgery would be greater than the morbidity of surgery.Patients undergoing surgery have a similar long-term recovery to those who are treated conservatively except for a better range of motion in the thorax and fewer limitations in physical function. Surgery seems to be beneficial for some patients, the question remains which patients benefit.


We report a prospective study of repairs using the Rives technique of the more difficult primary inguinal hernias, focusing on the immediate post-operative period, clinical recurrence, testicular atrophy, and chronic pain. A mesh placed in the preperitoneal space can reduce recurrences and chronic pain.For the larger primary inguinal hernias , we favour preperitoneal placement of a mesh, covering the myopectineal orifice by means of a transinguinal (Rives technique) approach. The Rives technique was performed on 943 patients (1000 repairs), preferably under local anaesthesia plus sedation in ambulatory surgery.The mean operative time was 31.8 min. Pain assessment after 24 h with an Andersen scale and a categorical scale gave two patients with intense pain on the Andersen scale, and four patients who thought their state was bad. Surgical wound complications were below 1%, and urinary retention was 1.2% mostly associated with spinal anaesthesia and, in one case, bladder perforation. There was spermatic cord and testicular oedema with some degree of orchitis in 17 patients. The clinical follow-up of 849 repairs (86.4%), mean (range) 30.0 (12–192) months, gave five recurrences (0.6%), three cases (0.4%) of testicular atrophy, and 37 (4.3%) of post-operative chronic pain .The Rives technique requires a sound knowledge of inguinal preperitoneal space anatomy, but it is an excellent technique for the larger and difficult primary inguinal hernias, giving a low rate of recurrences and chronic pain. The value of a surgical intervention lies in the short and long term results  provided at a reasonable cost . The priThe aim of our work is the prospective study of the Rives technique for repair of the larger primary inguinal hernias , focusing on the immediate post-operative period, clinical recurrence, and chronic pain. The mesh placed in the preperitoneal space, covering the myopectineal orifice of Fruchaud and separated from the neurological plane, is the ideal location hydrostatically and anatomically to prevent the recurrence of the three potential hernia orifices and chronic pain.From January 1992 to April 2014, we performed 1000 primary inguinal hernia repairs in 943 patients using the Rives technique: 198 patients at the Verge del Toro Hospital, Mahon, Menorca , Spain (1992–2001); and 745 patients from October 2007 until April 2014 in ambulatory/short-stay surgery at the Siberia-Serena Hospital, Talarrubias (Badajoz), Spain. In 1994, all the data of the operated patients, which had been collected in paper form, were input into an Access-form database. All data collected thereafter were input into the said database on a daily basis and analysed with Excel.Between 2001 and 2006, the first author did not perform abdominal wall surgery because he was assigned to the coloproctology section of the Infanta Cristina University Hospital, Badajoz, Spain.We use Gilbert’s classification with additions by Rutkow and Robbins . The RivIn ambulatory surgery, all patients are contacted via telephone within 24 h of surgery and pain is evaluated at rest and mobilization using the Andersen scale .Surgical wound complications Table  were belOf the 1000 repairs, 16 patients died in the first year, so that 984 repairs were called for clinical review, and 849 repairs (86.4%) were actually clinically reviewed. The overall results of the follow-up are given in Table The chronic pain measurements registered after 1 year are presented in Table All surgeons who operate inguinal hernias must have deep knowledge of the inguinal region’s anatomy, and this is especially true for the Rives repair technique –17.The preperitoneal space is the most suitable site for the insertion of a mesh  because The internal spermatic fascia is a continuation of the fascia transversalis , and in The inferior epigastric vein and artery are spared. In a few cases of difficult hernias in elderly patients, they were ligated to improve repair. The presence of communicating arteries, aberrant or accessory obturator, which may be as frequent as 30–69% , must beThe lymphoadipose tissue can simulate the presence of a hernial sac in the femoral canal, and when in doubt we explore the subinguinal region to rule out the presence of a sac in the oval fossa.Independently of the existence of a clear femoral hernia, the presence of a wide femoral ring arouses suspicions of a future femoral hernia . NeverthIn Lichtenstein’s technique, the femoral ring is strengthened when judged large, while in the Rives technique this is done systematically. Between 7.9 and 40% –23 of thPost-operative chronic pain is defined by the International Guidelines as a pain that was absent prior to the intervention or is different from that prior to the intervention, and lasts for more than 3 months . FrannebThe incidence of chronic pain of any kind in our patients after 1 year was 4.3% and moderate/severe pain 1.0%. With these results, we can conclude that the polypropylene mesh in preperitoneal position and preservation of the three nerves gives a low chronic post-operative pain rate. However, we needed two neurectomies and four infiltrations for there to be no patient with any pain greater than some mild discomfort.There are simpler options for inguinal hernia repair than the Rives technique. However, our patients presented hernias through large orifices, with weak walls, and frequently with associated co-morbidity.