Difference between revisions of "Inguinal hernia repair"
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{{Infobox surgical case reference | {{Infobox surgical case reference | ||
| anesthesia_type = General | | anesthesia_type = General vs. Spinal vs. Local | ||
| airway = ETT | | airway = ETT vs. LMA for GA | ||
| lines_access = Peripheral IV | | lines_access = Peripheral IV | ||
| monitors = Standard ASA / 5-Lead EKG | | monitors = Standard ASA / 5-Lead EKG | ||
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}} | }} | ||
'''Inguinal hernia repair''' is performed to fix a defect in the abdominal wall that allows abdominal contents to protrude into the inguinal canal, and it is one of the most commonly performed surgeries worldwide. This procedure is | '''Inguinal hernia repair''' is performed to fix a defect in the abdominal wall that allows abdominal contents to protrude into the inguinal canal, and it is one of the most commonly performed surgeries worldwide. This procedure is commonly performed laparoscopically, especially in patients with recurrent or bilateral hernias, but can be performed open as well.<ref>{{Cite book|last=Jaffe|first=Richard A|url=http://public.ebookcentral.proquest.com/choice/publicfullrecord.aspx?p=3418805|title=Anesthesiologist's manual of surgical procedures|last2=Schmiesing|first2=Clifford A|last3=Golianu|first3=Brenda|date=2014|isbn=978-1-4963-0594-7|language=English|oclc=888551588}}</ref> | ||
== Preoperative management == | == Preoperative management == | ||
=== Patient evaluation === | === Patient evaluation === | ||
Adult patients presenting for | Adult patients presenting for inguinal hernia repair are usually healthy and this procedure is typically performed in the outpatient setting. However, this surgery can be emergent in cases of hernia incarceration or strangulation, usually requiring an open procedure. | ||
{| class="wikitable" | {| class="wikitable" | ||
|+ | |+ | ||
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=== Operating room setup === | === Operating room setup === | ||
* | * The choice of anesthetic technique ranges from local infiltration to spinal to general. For a patient with no existing comorbidities, the decision can be based on the complexity of the anatomy, expected duration, surgeon preference, and/or patient preference. Studies have found no difference between spinal vs GA (with LMA) in early or late outcomes<ref>{{Cite journal|last=Burney|first=Richard E.|date=2004-02-01|title=Comparison of Spinal vs General Anesthesia via Laryngeal Mask Airway in Inguinal Hernia Repair|url=https://jamanetwork.com/journals/jamasurgery/fullarticle/396375|journal=Archives of Surgery|language=en|volume=139|issue=2|pages=183|doi=10.1001/archsurg.139.2.183|issn=0004-0010}}</ref>. | ||
=== Patient preparation and premedication === | === Patient preparation and premedication === | ||
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* Standard ASA monitors | * Standard ASA monitors | ||
* 5-lead EKG | * 5-lead EKG | ||
* Urinary catheter | * 1 peripheral IV | ||
* OG tube | * Consider: | ||
** Urinary catheter | |||
** OG tube | |||
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | === Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | ||
<u>For General Anesthesia</u> | |||
* Pre-oxygenate with 100% FiO2 | * Pre-oxygenate with 100% FiO2 | ||
* Standard induction | * Standard induction | ||
** Consider RSI in emergent cases in which patient has not been appropriately NPO | ** Consider RSI in emergent cases in which patient has not been appropriately NPO | ||
* ETT vs. LMA | |||
** | |||
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | === Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | ||
Revision as of 18:44, 6 May 2021
Inguinal hernia repair
| Anesthesia type |
General vs. Spinal vs. Local |
|---|---|
| Airway |
ETT vs. LMA for GA |
| Lines and access |
Peripheral IV |
| Monitors |
Standard ASA / 5-Lead EKG |
| Primary anesthetic considerations | |
| Preoperative | |
| Intraoperative |
RSI if urgent/emergent |
| Postoperative |
PONV, urinary retention |
| Article quality | |
| Editor rating | |
| User likes | 0 |
Inguinal hernia repair is performed to fix a defect in the abdominal wall that allows abdominal contents to protrude into the inguinal canal, and it is one of the most commonly performed surgeries worldwide. This procedure is commonly performed laparoscopically, especially in patients with recurrent or bilateral hernias, but can be performed open as well.[1]
Preoperative management
Patient evaluation
Adult patients presenting for inguinal hernia repair are usually healthy and this procedure is typically performed in the outpatient setting. However, this surgery can be emergent in cases of hernia incarceration or strangulation, usually requiring an open procedure.
| System | Considerations |
|---|---|
| Neurologic | |
| Cardiovascular | Strangulation of hernia may result in hypotension, tachycardia |
| Respiratory | |
| Gastrointestinal | In cases of strangulation, patients may be dehydrated from fever and emesis |
| Hematologic | In cases of strangulation, patient may have leukocytosis/leukopenia |
| Renal | |
| Endocrine | |
| Labs | Hb/Hct for healthy patients, otherwise as indicated from H&P |
Operating room setup
- The choice of anesthetic technique ranges from local infiltration to spinal to general. For a patient with no existing comorbidities, the decision can be based on the complexity of the anatomy, expected duration, surgeon preference, and/or patient preference. Studies have found no difference between spinal vs GA (with LMA) in early or late outcomes[2].
Patient preparation and premedication
- Midazolam
- Tylenol 1g
Intraoperative management
Monitoring and access
- Standard ASA monitors
- 5-lead EKG
- 1 peripheral IV
- Consider:
- Urinary catheter
- OG tube
Induction and airway management
For General Anesthesia
- Pre-oxygenate with 100% FiO2
- Standard induction
- Consider RSI in emergent cases in which patient has not been appropriately NPO
- ETT vs. LMA
Positioning
- Supine, arms tucked
Maintenance and surgical considerations
- Standard maintenance
- Consider avoiding nitrous oxide given potential for bowel dissension and increased risk of PONV
- Place OG/NG before surgical incision to decompress the stomach
- Maintain normovolemia and normothermia
Emergence
- Avoid nitrous until after abdomen is de-insufflated
- PONV prophylaxis
Postoperative management
Disposition
- PACU/holding area for 1-2h followed by discharge home
Pain management
- Oral analgesics
- Non-opioid analgesics
- Ketoralac (Toradol)
- Acetaminophen (Tylenol)
- IV narcotics for breakthrough pain
Potential complications
- PONV
- Urinary retention (consider straight catheterization of bladder prior to emergence)
- Hemorrhage from trocar insertion
- Subcutaneous emphysema from pneumoperitoneum
Procedure variants
| Open | Laparoscopic | Local/MAC | |
|---|---|---|---|
| Unique considerations | Preferred for recurrent or bilateral hernias | Surgeon performed blocks/local infiltration
Generally surgeon-specific and elective cases with appropriate patients. | |
| Position | Supine | Supine, arms tucked | Supine, arms out |
| Surgical time | 1-2h | 1-2h | |
| EBL | <50mL | <50mL | |
| Postoperative disposition | PACU | 1-2h in PACU > home | PACU |
| Pain score | 3-4 | ||
| Potential complications | Recurrence of hernia
Orchalgia, neuralgia Bowel obstruction Bladder injury (rare) |
References
- ↑ Jaffe, Richard A; Schmiesing, Clifford A; Golianu, Brenda (2014). Anesthesiologist's manual of surgical procedures. ISBN 978-1-4963-0594-7. OCLC 888551588.
- ↑ Burney, Richard E. (2004-02-01). "Comparison of Spinal vs General Anesthesia via Laryngeal Mask Airway in Inguinal Hernia Repair". Archives of Surgery. 139 (2): 183. doi:10.1001/archsurg.139.2.183. ISSN 0004-0010.