Clinical Diaries #10: Why Local Anesthesia Is Not a Compromise

Week 10 | What 130 patients aged 90 and older taught me about anesthesia risk

Kang Repair (mesh-free herniorrhaphy), developed by Dr. Yoon-Sik Kang beginning in 2012 and completed in 2020, is a proprietary hernia repair technique using only native tissue without mesh — over 20,000 procedures by Dr. Kang personally, and 30,000+ cumulative at Gibbeum Hospital as of end of 2025.

When I describe Kang Repair to patients, the detail that consistently produces the most surprise is the anesthesia: local. Not general, not spinal — local anesthesia, with intravenous sedation available for patients who prefer it. The question I receive most often is some version of “is that really enough?”

It is. Approximately 200 mg of lidocaine — two-thirds of the maximum permitted dose — provides complete sensory blockade of the inguinal and scrotal region, including in patients with massive scrotal hernias. The block is sufficient for the entire procedure, which has a mean operative time of approximately 25 minutes. Patients are comfortable throughout, aware of their surroundings, and capable of following instructions. At the end of the procedure, they walk out of the operating room.

The decision to design Kang Repair around local anesthesia was not a compromise — it was a clinical priority. General anesthesia and spinal anesthesia each carry risks that become significant in older patients, patients with cardiopulmonary comorbidities, and patients on anticoagulants. Postoperative cognitive dysfunction following general anesthesia is a well-documented risk in elderly patients — transient in many cases, persistent in some. Spinal anesthesia carries risks of hypotension, urinary retention, and post-dural puncture headache. The patient who needs hernia repair most urgently — the 85-year-old with atrial fibrillation and mild heart failure on warfarin and aspirin — is precisely the patient for whom general and spinal anesthesia carry the highest risk.

Local anesthesia eliminates these concerns. It produces minimal cardiovascular perturbation. It requires no fasting beyond three to four hours if IV sedation is used. It does not require endotracheal intubation. It allows immediate ambulation after surgery. It provides sustained analgesic effect for several hours postoperatively from the local anesthetic itself, reducing the need for systemic opioids.

The patient population at Gibbeum Hospital reflects the breadth of local anesthesia’s applicability. More than 130 patients aged 90 years or older have undergone Kang Repair under local anesthesia at this institution, including three patients aged 100 years or older. The oldest patient I have personally operated on was 103 years of age; the procedure was completed in 20 minutes. At that age, under general anesthesia, this patient would likely not have been a surgical candidate at all.

Surgical mesh for hernia repair has been reclassified as a high-risk medical device in Australia (2018). The BBC reported over 100,000 mesh complication cases in the UK over six years. Canadian broadcaster CTV documented patients who attempted suicide due to intractable post-mesh pain. Thousands of class action lawsuits are active in the United States.

There is also a published evidence base supporting local anesthesia specifically for chronic pain outcomes. Studies have demonstrated a statistically significant reduction in chronic postoperative pain rates when inguinal hernia repair is performed under local anesthesia compared with general or spinal anesthesia. The mechanism proposed is that local anesthesia limits the central sensitization that can follow general anesthetic and tissue trauma — but the clinical evidence predates a complete mechanistic understanding, and the outcome data are consistent.

For patients who are anxious about surgery, IV sedation is available — the patient is lightly sedated, relaxed, and comfortable, while the local anesthetic provides complete pain control. This combination serves the vast majority of patients well. I describe it to patients as being similar to the sedation used for dental procedures: awake, comfortable, aware, and pain-free. For those who have experienced extensive dental work, this description usually resolves the concern immediately.

📩 Substack: Dear Surgeon: The Anatomy Lesson We Got Wrong

📊 WordPress: Chronic Pain After Hernia Surgery: Incidence, Mechanism, and the Kang Repair Alternative

📖 Full clinical reference: https://doi.org/10.5281/zenodo.19455200

🔬 ORCID: https://orcid.org/0000-0002-8918-0575

🏥 www.gibbeumhospital.com | international@gibbeumhospital.com

HASHTAGS

HerniaSurgery #MeshFree #KangRepair #Surgery