Medication Summary
For strangulated hernias, broad-spectrum antibiotic therapy should be initiated. Antibiotics are administered routinely if bowel ischemia is suspected.
Antibiotics
Class Summary
Antibiotics are to be used if the patient has a strangulated hernia. Broad-spectrum antibiotics, most commonly ampicillin and gentamicin, should be given in cases of gastroschisis and patients with large omphalocele.
Cefoxitin (Mefoxin)
Multiple regimens that address bowel perforation or ischemic bowel can be used. Cefoxitin provides coverage for both aerobic and anaerobic gram-negative bacteria.
Gentamicin
Gentamicin is an aminoglycoside antibiotic used for gram-negative bacterial coverage. It is commonly used in combination with an agent against gram-positive organisms and one that covers anaerobes. The drug is used in conjunction with ampicillin for prophylaxis in patients with open surgeries.
Dosing regimens are numerous and are adjusted based on creatinine clearance (CrCl) and changes in volume of distribution. Gentamicin may be given intravenously or intramuscularly.
Ampicillin
Ampicillin is used along with gentamicin for prophylaxis in patients with open surgeries. It interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.
Local Anesthetics
Class Summary
Local anesthetic agents are used to increase patient comfort during the procedure.
Lidocaine and epinephrine (Lignospan Forte, Xylocaine with Epinephrine)
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.
General Anesthetics
Class Summary
After standard monitoring equipment is attached and peripheral venous access achieved but before the arterial line is inserted, the midazolam or lorazepam dose is administered.
Propofol (Diprivan, Fresenius Propoven)
Propofol is a phenolic compound unrelated to other types of anticonvulsants. It has general anesthetic properties when administered intravenously. Propofol IV produces rapid hypnosis, usually within 40 seconds. The effects are reversed within 30 minutes following the discontinuation of infusion. Propofol has also been shown to have anticonvulsant properties.
Thiopental
Thiopental is a short-acting barbiturate sedative-hypnotic with rapid onset and a duration of action of 5-20 minutes. Like methohexital, it is most commonly used as an induction agent for intubation. To use thiopental as a sedative, titrate in dosage increments of 25 mg (adjust to lower dose in children).
Antianxiety Agents
Class Summary
These agents are indicated for patients who may experience significant anxiety before a surgery.
Lorazepam (Ativan)
Lorazepam is a sedative-hypnotic of the benzodiazepine class that has a rapid onset of effect and a relatively long half-life. By increasing the action of gamma-aminobutyric acid (GABA), a major inhibitory neurotransmitter, it may depress all levels of the central nervous system (CNS), including the limbic system and reticular formations. Lorazepam is excellent for patients who need to be sedated for longer than 24 hours.
Midazolam
Midazolam is a sedative-hypnotic of the benzodiazepine class that provides initial sedation as well as amnesia.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
Class Summary
These agents have analgesic, anti-inflammatory, and antipyretic properties. Their mechanism of action is not known but may inhibit cyclo-oxygenase (COX) activity 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 the 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 mild to moderate pain.
Acetaminophen (Tylenol, Aspirin-Free Anacin, Cetafen, Mapap Extra Strength)
Acetaminophen is the drug of choice for the treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, as well as in those with upper GI disease or who are taking oral anticoagulants.
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 appear to be uncommon.
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Large right inguinal hernia in 3-month-old girl.
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In this baby with gastroschisis, bowel is uncovered and presents to right inferior aspect of cord.
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Hernia of umbilical cord.
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Note translucent sac in baby with large omphalocele. Umbilical vessels attach to sac.
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Hernia content balloons over external ring when reduction is attempted.
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Hernia can be reduced by medial pressure applied first.
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Infant with Silon chimney placed in treatment of gastroschisis.
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Atrophy of right testis after hernia repair. Note adult-type incision.
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Iatrogenic cryptorchid testis in child. Taking care to position testis in scrotum is integral part of completion of hernia repair in boys.
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Erythematous edematous left scrotum in 2-month-old boy with history of irritability and vomiting for 36 hours. Local signs of this magnitude preclude reduction attempts.
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Testis at operation in 2-month-old boy with history of irritability and vomiting for 36 hours. Capsulotomy was performed, but atrophy occurred. Patient also required bowel resection.
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Ventriculoperitoneal shunt, decreased activity, and acute scrotal swelling in 6-month-old boy.
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Ventriculoperitoneal shunt, decreased activity, and acute scrotal swelling in 6-month-old boy. Abdominal radiograph shows incarcerated shunt within communicating hydrocele. Repair of hydrocele relieved increased intracranial pressure.
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Bassini-type repair approximating transversus abdominis aponeurosis and transversalis fascia to iliopubic tract and inguinal ligament.
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Anatomic locations for various hernias.
