Inguinal hernia repair

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Inguinal hernia repair
Anesthesia type General
Airway ETT
Lines and access Peripheral IV
Monitors Standard ASA / 5-Lead EKG
Primary anesthetic considerations
Preoperative
Intraoperative RSI if urgent/emergent
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 most 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 laparoscopic hernia repair are usually healthy. 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

  • Standard GETA setup

Patient preparation and premedication

  • Midazolam
  • Tylenol 1g

Intraoperative management

Monitoring and access

  • Standard ASA monitors
  • 5-lead EKG
  • Urinary catheter
  • OG tube depending on surgeon preference
  • 1-2 peripheral IVs

Induction and airway management

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

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 Regional-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
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.