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 most 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>  
'''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 laparoscopic hernia repair are usually healthy. However, this surgery can be emergent in cases of hernia incarceration or strangulation, usually requiring an open procedure.
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.
 
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=== Operating room setup ===
=== Operating room setup ===


* Standard GETA 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 depending on surgeon preference
* Consider:
* 1-2 peripheral IVs
** 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 and intubation
* 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 19:44, 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
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]

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

  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.