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 or spinal or local
| airway = ETT
| airway = ETT/LMA if GA
| lines_access = Peripheral IV
| lines_access = Peripheral IV
| monitors = Standard ASA / 5-Lead EKG
| monitors = Standard
5-Lead ECG
| considerations_preoperative =  
| considerations_preoperative =  
| considerations_intraoperative =  
| considerations_intraoperative = RSI if nonelective
| considerations_postoperative = PONV, urinary retention
| considerations_postoperative = PONV
Urinary retention
}}
}}
'''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> 


Surgical repair of inguinal hernias 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 most 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. 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>.


== Preoperative management ==
==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.


=== Patient evaluation ===
Adult patients presenting for laparoscopic hernia repair are usually healthy. However, this surgery can be emergent in cases of hernia incarceration or strangulation, usually requiring an open procedure.
{| class="wikitable"
{| class="wikitable"
|+
|+
Line 24: Line 28:
|-
|-
|Cardiovascular
|Cardiovascular
|
| If strangulated, hypotension and tachycardia possible
|-
|-
|Respiratory
| Respiratory
|
|
|-
|-
|Gastrointestinal
|Gastrointestinal
|
|If strangulated, dehydration from fever and emesis possible
* In cases of strangulation, patients may be dehydrated from fever and emesis
|-
|-
|Hematologic
|Hematologic
|
|If strangulated, leukocytosis/leukopenia possible
|-
|-
|Renal
|Renal
Line 43: Line 46:
|-
|-
|Labs
|Labs
|
|Hb/Hct for healthy patients, otherwise as indicated from H&P
* Hb/Hct for healthy patients, otherwise as indicated from H&P
|}
|}


=== Operating room setup ===
===Operating room setup===


=== Patient preparation and premedication ===
===Patient preparation and premedication===


=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
*Midazolam
*Tylenol 1g


== Intraoperative management ==
==Intraoperative management==


=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
===Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->===


=== 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. --> ===
*Standard ASA monitors
*5-lead EKG
*1 peripheral IV
*Consider:
**Urinary catheter
**OG tube


* Pre-oxygenate with 100% FiO2
===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. -->===
* Standard induction and intubation
** Consider RSI in emergent cases in which patient has not been appropriately NPO


=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
*If general, ETT vs. LMA
**ETT with RSI if urgency does not allow appropriate NPO


* Supine, arms tucked
===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->===


=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
*Supine, arms tucked


* Standard maintenance
===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->===
** 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<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
*If laparoscopic, place OG/NG before surgical incision to decompress the stomach if indicated


== Postoperative management ==
===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===


=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
*Avoid nitrous until after abdomen is de-insufflated
*PONV prophylaxis


* PACU/holding area for 1-2h followed by discharge home
==Postoperative management==


=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===


* Oral analgesics
*PACU/holding area for 1-2h followed by discharge home
* Non-opioid analgesics
 
===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->===
 
*Oral analgesics
*Non-opioid analgesics
** Ketoralac (Toradol)
** Ketoralac (Toradol)
** Acetaminophen (Tylenol)
**Acetaminophen (Tylenol)
* IV narcotics for breakthrough pain
*IV narcotics for breakthrough pain


=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===


* PONV
*PONV
* Urinary retention (consider straight catheterization of bladder prior to emergence)
* Urinary retention (consider straight catheterization of bladder prior to emergence)
* Hemorrhage from trocar insertion
* If laparoscopic, hemorrhage or organ damage from trocar insertion
* Subcutaneous emphysema from pneumoperitoneum
*Subcutaneous emphysema from pneumoperitoneum


== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==


{| class="wikitable"
{| class="wikitable wikitable-horizontal-scroll"
|+
|+
!
!
!Open
!Open
!Laparoscopic
!Laparoscopic
!Local/MAC
|-
|-
|Unique considerations
|Unique considerations
|
|
|Preferred for recurrent or bilateral hernias
|Preferred for recurrent or bilateral hernias
|Appropriate in some elective cases, surgeon-dependent
|-
|-
|Position
|Position
|Supine
|Supine
|Supine, arms tucked
| Supine, arms tucked
|Supine, arms out
|-
|-
|Surgical time
|Surgical time
|
|
|1-2h
|1-2h
|1-2h
|-
|-
|EBL
|EBL
|
|
|<50mL
|<50mL
|<50mL
|-
|-
|Postoperative disposition
|Postoperative disposition
|
|PACU
|1-2h in PACU > home
|1-2h in PACU > home
|PACU
|-
|-
|Pain score
|Pain score
|
|
|3-4
|3-4
|
|-
|-
|Potential complications
|Potential complications
|
|
|Recurrence of hernia
|
Orchalgia, neuralgia
*Recurrence of hernia
 
*Orchalgia, neuralgia
Bowel obstruction
* Bowel obstruction
 
*Bladder injury (rare)
Bladder injury (rare)
|
|}
|}


== References ==
==References==
[[Category:Surgical procedures]]
[[Category:General surgery]]
[[Category:Intestinal surgery]]


[[Category:Surgical procedures]]
<references />

Latest revision as of 23:05, 4 April 2022

Inguinal hernia repair
Anesthesia type

General or spinal or local

Airway

ETT/LMA if GA

Lines and access

Peripheral IV

Monitors

Standard 5-Lead ECG

Primary anesthetic considerations
Preoperative
Intraoperative

RSI if nonelective

Postoperative

PONV Urinary retention

Article quality
Editor rating
In development
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]

The anesthetic technique ranges from local to spinal to general anesthesia. 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].

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 If strangulated, hypotension and tachycardia possible
Respiratory
Gastrointestinal If strangulated, dehydration from fever and emesis possible
Hematologic If strangulated, leukocytosis/leukopenia possible
Renal
Endocrine
Labs Hb/Hct for healthy patients, otherwise as indicated from H&P

Operating room setup

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

  • If general, ETT vs. LMA
    • ETT with RSI if urgency does not allow appropriate NPO

Positioning

  • Supine, arms tucked

Maintenance and surgical considerations

  • If laparoscopic, place OG/NG before surgical incision to decompress the stomach if indicated

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)
  • If laparoscopic, hemorrhage or organ damage from trocar insertion
  • Subcutaneous emphysema from pneumoperitoneum

Procedure variants

Open Laparoscopic Local/MAC
Unique considerations Preferred for recurrent or bilateral hernias Appropriate in some elective cases, surgeon-dependent
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

  1. ↑ Jaffe, Richard A; Schmiesing, Clifford A; Golianu, Brenda (2014). Anesthesiologist's manual of surgical procedures. ISBN 978-1-4963-0594-7. OCLC 888551588.
  2. ↑ 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.

Top contributors: Olivia Sutton, Barrett Larson, Chetra Yean and Chris Rishel

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