Difference between revisions of "Inguinal hernia repair"
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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.<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> | ||
== | 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>. | ||
=== Patient evaluation === | ==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. | 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. | ||
| Line 24: | Line 26: | ||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
| | | If strangulated, hypotension and tachycardia possible | ||
|- | |- | ||
|Respiratory | | Respiratory | ||
| | | | ||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal | ||
| | |If strangulated, dehydration from fever and emesis possible | ||
|- | |- | ||
|Hematologic | |Hematologic | ||
| | |If strangulated, leukocytosis/leukopenia possible | ||
|- | |- | ||
|Renal | |Renal | ||
| Line 45: | Line 47: | ||
|} | |} | ||
=== Operating room setup === | ===Operating room setup=== | ||
=== Patient preparation and premedication === | ===Patient preparation and premedication=== | ||
* Midazolam | *Midazolam | ||
* Tylenol 1g | *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. -->=== | ||
* Standard ASA monitors | *Standard ASA monitors | ||
* 5-lead EKG | *5-lead EKG | ||
* 1 peripheral IV | *1 peripheral IV | ||
* Consider: | *Consider: | ||
** Urinary catheter | **Urinary catheter | ||
** OG tube | **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. -->=== | ||
* If general, ETT vs. LMA | *If general, ETT vs. LMA | ||
** ETT with RSI if urgency does not allow appropriate NPO | **ETT with RSI if urgency does not allow appropriate NPO | ||
=== 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. -->=== | ||
* Supine, arms tucked | *Supine, arms tucked | ||
=== 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. --> === | ===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. -->=== | ||
* | *If laparoscopic, place OG/NG before surgical incision to decompress the stomach if indicated | ||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->=== | ||
* Avoid nitrous until after abdomen is de-insufflated | *Avoid nitrous until after abdomen is de-insufflated | ||
* PONV prophylaxis | *PONV prophylaxis | ||
== Postoperative management == | ==Postoperative management== | ||
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ||
* PACU/holding area for 1-2h followed by discharge home | *PACU/holding area for 1-2h followed by discharge home | ||
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->=== | ||
* Oral analgesics | *Oral analgesics | ||
* Non-opioid 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) | ||
* | * 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" | ||
|+ | |+ | ||
! | ! | ||
| Line 119: | Line 116: | ||
| | | | ||
|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 | |Supine, arms out | ||
|- | |- | ||
| Line 149: | Line 145: | ||
|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:Surgical procedures]] | ||
[[Category:General surgery]] | [[Category:General surgery]] | ||
[[Category:Intestinal surgery]] | [[Category:Intestinal surgery]] | ||
<references /> | |||
Revision as of 00:01, 30 June 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]
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 |
|
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.