INTRAPERITONEAL INFILTRATION OF EXPAREL REDUCES POSTOPERATIVE PAIN AND THE NEED FOR OPIOIDS FOLLOWING LAPAROSCOPIC HIATA HERNIA REPAIR WITH FUNDOPEXY

Introduction: Fundopexy can result in postoperative pain. We aimed to assess the role of preemptive intraperitoneal infiltration of Exparel (Bupivacaine) at the site of planned fundopexy to reduce postoperative pain. Methods: Patients with fundopexy were included. Ten ml of Exparel was infiltrated locally into the port sites before skin incision and closure. Starting on 11/10/2022, 20 ml of Exparel was infiltrated laparoscopically into the peritoneum at the level of the lower lateral left hemidiaphragm and extended to the left upper and lateral abdominal wall at the site of planned fundopexy. Shoulder massages with Voltaren (diclofenac) were applied to decrease shoulder pain if needed. The variables compared between the No-Exparel vs. Exparel group in the Post-Anesthesia Care Unit (PACU) included the number of patients with pain score of zero on arrival, pain scores on arrival, patients with pain scores of zero throughout the stay in PACU, patients who required opioids and Morphine Milligram Equivalent (MME), patients with pain scores of zero prior to discharge, pain scores prior to discharge and the need for Voltaren massages. The number of same-day surgeries, ER visits, and readmissions were compared. Values are median (IQR). Results: From 06/03/2022 to 11/21/2023, there were 191 hiatal hernia repairs, 41/191 (21.5%) Toupet fundoplications were excluded and 150/191 (78.5%) fundopexies were included in the study; 118/150 (78.7%) were primary and 32/150 (21.3%) were reoperative; 73/150 (48.7%) did not receive Exparel, and 77/150 (51.3%) received Exparel. Comparing No-Exparel vs. Exparel group, there was no difference in age/sex/BMI/hiatal hernia type and size. The operative time was 106 min (84-132) vs. 116 (97-149), p=0.020. The number of patients with a pain score of zero on arrival to PACU was 12/73 (16.4%) vs. 32/77 (41.6%), p=0.001, the median pain score on arrival to PACU was 5.9 (3.8-7.3) vs. 3 (0-5), p<0.001; 30/150 (20.0%) had pain scores of zero throughout the stay in PACU: 8/73 (11.0%) vs. 22/77 (28.6%), p=0.007. Patients who required opioids in PACU were 30/73 (41.1%) vs. 18/77 (23.4%), p=0.023 with MME of 4 (3.3-10.7) vs. 4 (3.3-10.7), p=0.813. The number of patients with a pain score of zero prior to discharge from PACU was 13/73 (17.8%) vs. 30/77 (39.0%), p=0.006. The median pain score prior to discharge was 5 (3-6) vs. 2 (0-4), p<0.001. Shoulder massages with Voltaren were required in 66/73 (90.4%) vs. 48/77 (62.3%), p<0.001. There was no difference in the number of same-day surgeries, ER visits, and readmissions between No-Exparel vs. Exparel. Conclusion: Intraperitoneal infiltration of Exparel reduces the postoperative pain, increases the number of patients with zero pain in PACU, and decreases the number of patients requiring opioids and Voltaren massage to shoulders following laparoscopic hiatal hernia repair with fundopexy.