Three-step tumescent local anesthesia technique for inguinal hernia repair

The optimal method of anesthesia for inguinal hernia repair is still controversial. We have developed "three-step tumescent local anesthesia (TLA) technique" for inguinal hernia repair, and recently showed that this technique is acceptable in view of short- and long-term clinical outcomes. Our study included 273 consecutive cases (290 sides) of elective inguinal hernia repair performed under the newly developed technique between September 2003 and May 2019, and overall clinical outcomes were considered to be safe and feasible. Herein, we report the surgical procedure of "three-step TLA technique." Briefly, we rapidly inject the diluted solution of local anesthetic and epinephrine step-by-step into the three following closed tissue space. Initially, 80 mL injection into the subcutaneous tissue before skin incision (Step 1). After the external oblique fascia is exposed, injection of 20 mL into the inguinal canal before the external oblique fascia is incised and opened (Step 2). The hernia sac and spermatic cord are then dissected, and the blunt dissection of the preperitoneal space is made by injecting 20 mL under the internal inguinal ring (Step 3), followed by placing a gauze into the preperitoneal space, creating the space for mesh placement. We consider that the most important point of this technique is achieved through the rapid injection of TLA solution into each closed tissue space, which makes for easier dissection, hemostasis, and good pain control.