Inguinal hernia repair

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
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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 commonly performed laparoscopically, especially in patients with recurrent or bilateral hernias, but can be performed open as well. The anesthetic technique ranges from local to spinal to general anesthesia.

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.

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)