Medication Summary
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Local Anesthetics
Class Summary
Local anesthetic agents are used to increase patient comfort during the procedure.
Lidocaine anesthetic (Xylocaine)
Lidocaine is an amide local anesthetic used in a 0.5-1% concentration in combination with bupivacaine (50:50 mixture). This agent inhibits depolarization of type C sensory neurons by blocking sodium channels. Epinephrine prolongs the duration of the anesthetic effects from lidocaine by causing vasoconstriction of the blood vessels surrounding the nerve axons.
Bupivacaine (Marcaine, Sensorcaine)
Bupivacaine 0.25% may be used in combination with lidocaine plus epinephrine (50:50 mixture). It decreases permeability to sodium ions in neuronal membranes. This results in the inhibition of depolarization, blocking the transmission of nerve impulses.
Bupivacaine implant (XaraColl)
Surgically placed local anesthetic implant. It is indicated for management of postsurgical pain after open inguinal hernia surgery.
Local Anesthetic/NSAID Combination
Class Summary
Newer locally active analgesic modalities provide nonopioid options for postoperative pain management. The combination of bupivacaine and meloxicam was approved by the FDA in May 2021. Approval was based on the EPOCH-2 phase 3 trial. Among 418 patients undergoing unilateral open inguinal herniorrhaphy, bupivacaine/meloxicam demonstrated superior, sustained pain reduction through 72 hours, significantly reduced opioid consumption, and resulted in significantly more opioid-free subjects compared with saline placebo and bupivacaine. [60]
Bupivacaine/meloxicam (Zynrelef)
Indicated as a single dose that provides postsurgical analgesia for up to 72 hours after open inguinal herniorrhaphy. Apply solution without a needle into the surgical site after final irrigation and suctioning and before the suturing of each layer (when multiple tissue layers are involved). The solution is instilled above and below the fascial repair.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
Class Summary
These agents have analgesic, anti-inflammatory properties and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase activity (COX) and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Diclofenac (Voltaren-XR, Cataflam, Zipsor, Cambia)
Diclofenac inhibits prostaglandin synthesis by decreasing COX activity, which, in turn, decreases formation of prostaglandin precursors.
Ibuprofen (Advil, Ultraprin, I-Prin, Motrin IB)
Ibuprofen is the drug of choice for patients with mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Sulindac (Clinoril)
Sulindac decreases the activity of COX and, in turn, inhibits prostaglandin synthesis. Its action results in the decreased formation of inflammatory mediators.
Naproxen (Anaprox, Aleve, Naprosyn, Naprelan)
Naproxen is used for the relief of mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing the activity of the enzyme COX, which results in prostaglandin synthesis.
Meloxicam (Mobic)
Meloxicam decreases COX activity, and this, in turn, inhibits prostaglandin synthesis. These effects decrease the formation of inflammatory mediators.
Ketoprofen
Ketoprofen is used for relief of mild to moderate pain and inflammation. Small dosages are indicated initially in small patients, elderly patients, and patients with renal or liver disease. Doses higher than 75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe the patient's response.
Flurbiprofen
Flurbiprofen may inhibit COX, thereby inhibiting prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Analgesics
Class Summary
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who experience moderate to severe pain.
Acetaminophen and codeine (Tylenol #3)
This combination is indicated for the treatment of mild to moderate pain.
Hydrocodone bitartrate and acetaminophen (Vicodin ES, Lortab, Lorcet Plus, Norco, Maxidone)
This agent is indicated for the relief of moderately severe to severe pain.
Tramadol (Ultram, Ryzolt)
Tramadol is an analgesic that probably acts over monoaminergic and opioid mechanisms. Its monoaminergic effect is shared with tricyclic antidepressants. Tolerance and dependence
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Anatomy of inguinal canal.
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Anatomy of nerves of groin.
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Open inguinal hernia repair. Skin incision.
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Open inguinal hernia repair. Division of external oblique aponeurosis.
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Open inguinal hernia repair. Cord structures and hernia sac encircled by Penrose drain.
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Open inguinal hernia repair. Hernia sac separated from cord structures.
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Open inguinal hernia repair. Development of preperitoneal space.
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Open inguinal hernia repair. Deployment of Prolene Hernia System (PHS).
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Open inguinal hernia repair. Final position of Prolene Hernia System (PHS) mesh.
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Open inguinal hernia repair. Closure of external oblique aponeurosis.
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Open inguinal hernia repair. Skin closure.
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Open inguinal hernia repair. Draping and incision.
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Open inguinal hernia repair. External oblique aponeurosis with external inguinal ring.
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Open inguinal hernia repair. External oblique aponeurosis with external inguinal ring.
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Open inguinal hernia repair. Reflected part of inguinal ligament exposed for fixing inferior edge of mesh.
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Open inguinal hernia repair. Inferior flap of external oblique aponeurosis developed to expose inguinal ligament from pubic tubercle to midinguinal point.
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Open inguinal hernia repair. Superior flap of external oblique aponeurosis is developed as high as possible to provide ample space for mesh placement.
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Open inguinal hernia repair. Lifting up cord with hernia sac medial to external inguinal ring.
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Open inguinal hernia repair. Avascular plane between posterior inguinal wall and cord structures.
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Open inguinal hernia repair. Cord structures and hernia sac looped along with ilioinguinal and genitofemoral nerves.
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Open inguinal hernia repair. Cremaster muscle picked up to be incised longitudinally between hemostats.
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Open inguinal hernia repair. Indirect hernia sac dissected and being separated from lipoma of cord and cord structures.
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Open inguinal hernia repair. Lipoma of cord dissected free and excised.
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Open inguinal hernia repair. Indirect hernia sac separated from cord structures in midinguinal region toward neck of sac.
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Open inguinal hernia repair. Voluminous indirect hernia sac separated from cord structures in midinguinal region up to neck of sac.
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Open inguinal hernia repair. Hernia sac being divided near neck.
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Open inguinal hernia repair. Contents of hernia sac reduced and proximal end to be sutured closed.
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Open inguinal hernia repair. Anterior wall of distal sac incised to prevent hydrocele formation.
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Open inguinal hernia repair. Fixation of lower edge of mesh.
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Open inguinal hernia repair. First medialmost stitch in mesh, fixed about 2 cm medial to pubic tubercle, where anterior rectus sheath inserts into pubis.
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Open inguinal hernia repair. Same suture is utilized as continuous suture to fix lower edge of mesh to reflected part of inguinal ligament up to internal ring.
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Open inguinal hernia repair. Lower edge of mesh sutured to inguinal ligament up to internal inguinal ring. To accommodate cord structures, lateral end of mesh is divided into wider upper (two thirds) tail and narrower lower (one third) tail.
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Open inguinal hernia repair. Wider upper tail of mesh is passed underneath cord, and mesh is placed posteriorly in inguinal canal behind spermatic cord.
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Open inguinal hernia repair. Fixation of upper edge of mesh.
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Open inguinal hernia repair. Slit made in mesh to accommodate iliohypogastric nerve. Two interrupted sutures are taken under vision to fix upper edge of mesh while safeguarding iliohypogastric nerve.
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Open inguinal hernia repair. Upper tail is crossed over lower tail around spermatic cord, thus creating internal ring. Lower edges of two tails are tucked together to inguinal ligament just lateral to internal ring.
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Open inguinal hernia repair. Tails are then passed underneath external oblique aponeurosis to give overlap of about 5 cm beyond internal ring.
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Open inguinal hernia repair. External oblique aponeurosis sutured with 2-0 polypropylene.
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Open inguinal hernia repair. Subcutaneous tissue approximated with 3-0 plain catgut.
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Open inguinal hernia repair. Skin approximated with 2-0 polypropylene subcuticular suture.
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Hesselbach triangle. Image courtesy of Wikimedia Commons.
