Open Inguinal Hernia Repair Periprocedural Care

Updated: Aug 09, 2016
  • Author: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS; Chief Editor: Kurt E Roberts, MD  more...
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Periprocedural Care

Preprocedural Planning

For better hemostasis, sharp dissection is preferred to blunt dissection. This is one operation in which, as the saying goes, every red blood cell must be caught.

If a lipoma is present in the spermatic cord, as is often the case, it should be excised to reduce the bulk of the cord; cord structures, however, must be protected. Some surgeons excise the cremaster muscle fibers in the cord; others prefer not to.

With a direct hernia, the sac is not dissected and opened, as is done with an indirect inguinal hernia. Rather, it is inverted (pushed back) into the extraperitoneal space, sometimes with plication of the transversalis fascia.

Bilateral hernias can be repaired in a single procedure, especially with a Lichtenstein tension-free mesh hernioplasty. Some surgeons, however, prefer to repair only one hernia at a time, deferring repair of the other for about 4-6 weeks; this avoids the risk of bilateral infection and the higher risk of penile and scrotal edema after bilateral inguinal hernia repair.

If the hernia is irreducible or obstructed, the sac should be opened first at its fundus, before it is dissected up to its neck, to allow evacuation of toxic fluid and inspection of the bowel for ischemia. If the conventional technique, in which the sac is first completely dissected up to its neck, is followed, the ischemic bowel may slip back into the peritoneal cavity before the sac is opened at its fundus and may then be difficult to retrieve for inspection.

Ischemic bowel is blue-black and thick-walled, lacks luster, feels firm to the touch, and has no peristalsis. The bowel must be wrapped in moist warm packs, and 100% oxygen should be delivered for a few minutes. The bowel is then reassessed for viability. Any nonviable bowel will have to be resected.

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Equipment

No special equipment is required for inguinal hernia repair. Standard operating room anesthesia equipment, outfitted for possible conversion to general anesthesia and endotracheal intubation, is required. For high-risk patients with comorbid conditions, a cardiac monitor and a pulse oximeter should be available.

A standard open surgical tray should be available. Instruments and materials on hand may include the following:

  • Syringe
  • 25-Gauge needle
  • Surgical knife with blade
  • Mosquito forceps
  • Dissecting scissors
  • Polypropylene (Prolene) or polyester mesh
  • Langenbeck retractors
  • Adson thumb forceps
  • Needle holder
  • Sutures (absorbable or nonabsorbable)
  • Penrose drain or umbilical tape
  • Noncrushing intestinal clamps (in case bowel resection is required, in a strangulated hernia)

A self-retaining (eg, Adson) retractor, though not essential, may eliminate the need for an assistant. The umbilical tape or Penrose drain may be used to retract the mobilized spermatic cord, but a hernia ring forceps can also be used. If the neck of the hernia sac is particularly tight, the use of a grooved probe or dissector may help minimize injury to the contents.

The mesh must be a permanent material large enough to produce a wide overlap beyond the defect’s edges (eg, 5 × 10 cm to 7.5 × 15 cm). Many manufacturers have now shifted toward lighter, more porous constructions that maintain the strength of the repair but putatively reduce the inflammatory response. [11, 42, 43, 44, 45] These meshes may decrease long-term discomfort, but possibly at the cost of increased recurrence rates (eg, from inadequate fixation or overlap). [5]

The question of absorbable versus permanent sutures to secure the mesh is based on surgeon preference; to date, there has been no evidence conclusively favoring one type over the other. Sutures made of polyglactin or polypropylene are commonly used, with undyed polyglactin often preferred for subcutaneous tissue. A theoretical advantage of absorbable suture is that if nerve impingement is inadvertently caused, the suture material disappears with time. The authors prefer to use absorbable (2-0 polyglactin) sutures for mesh fixation.

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Patient Preparation

Anesthesia

Inguinal hernia repair can be performed with the following types of anesthesia:

  • General
  • Regional (spinal epidural)
  • Local (infiltration field block)

The choice of anesthesia technique may be influenced by patient preferences and the medical history. The current trend toward increasing utilization of ambulatory surgery tends to favor local anesthesia, which allows quick recovery time and thus is safe for early discharge. For older patients or those with high American Society of Anesthesiologists (ASA) scores (indicating underlying cardiovascular or pulmonary disease), local anesthesia causes much less hemodynamic compromise and is far better tolerated than general anesthesia.

For Lichtenstein hernioplasty, local anesthesia is safe and generally preferable. By permitting immediate postoperative mobilization and discharge of the patient on a day-care basis, it helps minimize the length of the hospital stay, the incidence of complications, and the cost of treatment. In addition, a patient under local anesthesia can be asked to cough during the procedure to help the surgeon identify any additional hernias that may be present and to confirm the adequacy of the prosthetic repair.

Large randomized control trials have found overall anesthesia time, urinary retention, and postoperative pain to be less after local anesthesia than after regional or general anesthesia. [46, 47] Although a follow-up study of recurrence by Nordin et al reported an increase in reoperation for recurrence in the local anesthesia group, the investigators suggested that this increase may be negated with increasing use of the Lichtenstein mesh technique and concluded that further follow-up is warranted. [48]

When hernia repair is performed under local anesthesia, patients still feel the discomforts of pressure and traction; such discomforts can be minimized by administering anxiolytic agents. Additionally, the patient must always give consent for the possibility of conversion to general anesthesia should he or she experience difficulty in tolerating the procedure because of anxiety or discomfort.

Commonly used local anesthetics include the following [49] :

  • 0.5-1% lidocaine with epinephrine
  • 0.25% bupivacaine
  • A combination of these two agents in a 50:50 mixture

A field block is applied by injecting along the site of incision, from superficial to deep, and lateral to the pubic tubercle, to provide anesthesia to the deeper structures. (See Local Anesthetic Agents, Infiltrative Administration.) To block the ilioinguinal nerve, an injection is placed just medial to the anterior superior iliac spine. [50]

Additional amounts of the local agent may be injected throughout the procedure. For example, administration of the agent below the fibers of the external oblique aponeurosis, as described by Lichtenstein’s group, anesthetized the three major nerves by flooding the enclosed inguinal canal and served to hydrodissect the underlying ilioinguinal nerve (thus making it less prone to injury when the aponeurosis was incised). [51]

Other techniques, such as epidural anesthesia, have been widely reported, but results depend largely on local expertise.

Elective inguinal hernia repair is considered a clean procedure and, as such, should carry a surgical site infection rate of less than 2%. The data remain controversial, but one meta-analysis supported the use of antibiotic prophylaxis in the performance of a mesh-based repair. [51] Cephalosporins (eg, cefazolin) are commonly administered by the anesthesiologist in a single dose before the skin incision. [52] A properly powered, prospectively randomized study is needed to determine whether such prophylaxis is necessary.

Positioning

The correct surgical side (left or right) should be confirmed and marked preoperatively in the holding area.

The patient should be placed in the supine position, with the upper extremities comfortably secured. He or she should be at ease, and the position should be comfortable for the surgical team. For large defects, slight Trendelenburg positioning may facilitate exposure by reducing the visceral contents into the abdomen.

The surgical site is prepared and draped in standard surgical fashion, so that the patient’s upper abdomen and lower limbs are covered and only the intended operative groin site is exposed. The patient’s head is left open to allow conversation with the surgeon. The surgeon stands on the side of the patient where the hernia is located, and the assistant stands on the opposite side.

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Monitoring and Follow-up

With the routine use of mesh for hernia surgery, the recurrence rate has fallen to less than 1%. Although some recurrences occur early, cases may be reported many years later. A thorough clinical evaluation, a high degree of suspicion, and appropriate follow-up are advised for keeping track of recurrences. A follow-up visit is routinely scheduled for 1 week after the procedure. Thereafter, follow-up is scheduled on an as-needed basis.

Although the postoperative course is generally uncomplicated, patients must be routinely instructed to recognize certain signs and symptoms that can alert them to potential complications. [1, 40]

Patients with chronic groin pain, postoperative neuralgia, paresthesias, neurapraxia, or hypoesthesia for more than 6 months after surgery should be referred for further evaluation, surgical exploration, and, if required, excision of the involved nerve. A multidisciplinary approach at a pain clinic is an option for the treatment of chronic postherniorrhaphy pain. Surgical means of treating specific causes of such pain include the following:

  • Resection of entrapped nerves
  • Mesh removal (in mesh-related pain)
  • Removal of fixating sutures
  • Burying the nerve endings in the internal oblique muscle

Large-scale studies examining the convalescence period after elective inguinal hernia repair convincingly demonstrated that the median length of absence from work was 7 days when patients were advised by their surgeons to limit the recuperation period and to resume normal activities within 1 day after the procedure. [1, 53] Moreover, these studies confirmed that the risk of recurrence was not increased by early resumption of activities. Thus, with adequate analgesia, patients can safely return to their daily duties.

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