What the Anesthesiologist Should Know before the Operative Procedure
Inguinal hernia repairs are one of the most commonly performed surgeries in the world. Most inguinal hernia repairs are performed electively as outpatient procedures. However, in the case of an incarcerated hernia, emergency surgery is performed to reduce the risk of bowel strangulation. Elective cases can either be performed laparoscopically or open, but even surgeons who usually use endoscopic approaches use an open approach in incarcerated or strangulated hernias. In general, inguinal hernia repairs may utilize general, regional, or even local anesthesia.
1. What is the urgency of the surgery?
What is the risk of delay in order to obtain additional preoperative information?
Emergent: If the hernia is incarcerated, surgery should be performed immediately within 6-12 hours of presentation to reduce the incidence of bowel necrosis and the need for bowel resection.
Urgent: Symptomatic hernias that are reducible can undergo elective surgery with vigilance.
Elective: In the case of an elective inguinal hernia repair, the lifetime risk of incarceration is presumed to be 4%-6%. Therefore, delay in performing the surgery in order to obtain additional preoperative information is generally acceptable.
2. Preoperative evaluation
The patient population for inguinal hernia repairs range from premature infants to the elderly. Typically, those who present for elective hernia repair are generally healthy. Routine medical optimization should be sought for those undergoing elective herniorrhaphy.
Medically unstable conditions warranting further evaluation include recent myocardial infarction, unstable angina, unstable arrhythmias, cerebrovascular accidents, and uncontrolled chronic obstructive pulmonary disease.
Delaying surgery may be indicated if: preoperative evaluation for elective procedures reveals medical conditions that may impact morbidity and mortality during surgery, such as cardiac or pulmonary disease. Delaying surgery for emergent cases would not be warranted, as the risks of bowel strangulation and necrosis outweigh the potential benefits of further preoperative testing.
3. What are the implications of co-existing disease on perioperative care?
b. Cardiovascular system
Acute/unstable conditions: Recent MI, stable/unstable angina, or arrhythmias. Routine evaluation should be sought, including baseline EKG and chest xray. If patients present with symptoms concerning for cardiac disease including both stable and unstable angina, cardiac clearance should be obtained, which may include a cardiology consult, cardiac stress test, echocardiogram, or even a cardiac catheterization.
Baseline coronary artery disease or cardiac dysfunction – Goals of management: A complete history and physical should be performed to assess for potentially
worrisome signs and symptoms such as decreased exercise tolerance, increased angina symptoms, etc. Preoperative testing should be undertaken where appropriate.
g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
4. What are the patient's medications and how should they be managed in the perioperative period?
h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
i. What should be recommended with regard to continuation of medications taken chronically?
j. How To modify care for patients with known allergies –
k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
l. Does the patient have any antibiotic allergies- – Common antibiotic allergies and alternative antibiotics]
m. Does the patient have a history of allergy to anesthesia?
Malignant hyperthermia (MH)
Documented: Avoid all trigger agents such as succinylcholine and inhalational agents. Follow a proposed general anesthetic plan: total intravenous anesthesia with propofol ± opioid infusion ± nitrous oxide. Ensure an MH cart is available [MH protocol].
Family history or risk factors for MH
Local anesthetics/muscle relaxants: Recall that local anesthetics belong to two chemical classes (amides and esters). If a true allergy is present, it is most likely due to an ester class local anesthetic. Indeed, even in this rare situation the allergy may be from a local anesthetic metabolite such as para-amino-benzoic acid (PABA) or a preservative. If a true allergy is suspected, either a local anesthetic from another chemical class should be used or local anesthetic use should be withheld.
5. What laboratory tests should be obtained and has everything been reviewed?
Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
Inguinal hernia repairs can be performed with regional anesthesia, general anesthesia, or local anesthesia, depending on the preference and comfort level of each anesthesia provider and surgeon.
a. Regional anesthesia
Benefits: Regional anesthesia results in decreased postoperative analgesic requirements and incidence of postoperative nausea and vomiting compared to general anesthesia. Additionally, some surgeons employ an intraoperative patient-initiated Valsalva maneuver to test the repair, which is only possible under regional anesthesia.
Drawbacks: Neuraxial blocks require additional time to perform the block and have the possibility of (1) total block failure and (2) inadequate pain control.
Anticoagulation: There is an increased risk of spinal hematoma formation with patients who are receiving anticoagulation perioperatively. Several guidelines exist from the American Society of Regional Anesthesia and Pain Medicine regarding needle placement in the setting of anticoagulation:
Low-molecular-weight heparin: Needle placement should be postponed at least 10-12 hours after the last dose.
Warfarin: Anticoagulation therapy with oral warfarin should be ideally stopped 4-5 days prior to needle placement. The INR should be checked and the procedure may be initiated after confirmation of a normal INR.
NSAIDs: No specific concerns regarding concomitant use of NSAIDs and neuroaxial blockade.
Ticlopidine and clopidogrel: Ticlopidine should be discontinued for 14 days prior to procedure, and clopidogrel should be discontinued for 7 days prior to procedure
GP IIb/IIIa inhibitors: Discontinue 8-48 hours prior to needle placement.
b. General Anesthesia
Benefits: The use of general anesthesia allows for neuromuscular blockade and thus complete muscle relaxation, which may be beneficial based on the operating surgeon’s preferences. Laparoscopic procedures that require insufflation of the peritoneum must use general anesthesia.
Drawbacks: There is an increased incidence of nausea and vomiting compared to regional and local anesthesia. Also, patients who are at high risk for perioperative complications (i.e., cardiac disease, etc.) may tolerate the procedure better under with other forms of intraoperative management such as local or regional anesthesia.
Airway concerns: Patients are generally intubated to allow the use of muscle relaxants.
c. Local Anesthesia
Benefits: A retrospective review of adult inguinal hernia repairs performed by Sanjay and Woodward in the UK found that local anesthesia compared to general anesthesia resulted in higher “day-case rates” (outpatient procedure rates), 82.6% vs. 45.6%, respectively. Patients who had local anesthesia had lower postoperative analgesic requirements, a lower incidence of urinary retention, decreased time to first meal after surgery, and higher satisfaction rates compared to those who received general anesthesia. Local anesthesia is also beneficial for those patients with multiple comorbidities that would make them high risk for perioperative complications under general anesthesia.
Drawbacks: As with any local anesthetic procedure, inadequate pain control can be a problem, leading to possible conversion to general anesthesia. Also, laparoscopic inguinal hernia repairs that require insufflation of the peritoneum cannot be performed with local anesthetic alone. Poor diffusion of local anesthetic into scar tissue makes this technique less successful in cases of reoperation.
Other issues: Local anesthesia requires careful patient selection. The patients must be informed of the possible discomfort they may feel during the procedure. Sedation may be utilized; however, local anesthesia may not be suitable for those patients who may be overly anxious.
6. What is the author's preferred method of anesthesia technique and why?
Our preferred method of anesthesia is local anesthesia with moderate sedation. This decreases the need for inpatient admission, and leads to higher patient satisfaction rates.
Preoperative antibiotic prophylaxis is a controversial issue with inguinal hernia repairs. A recent systemic review published in 2007 does not recommend for or against the use of intravenous prophylactic antibiotics. Thus, either 1 gram of cefazolin or no antibiotics may be administered preoperatively depending on the local practice.
What do I need to know about the surgical technique to optimize my anesthetic care?
Types of surgical procedures: Randomized controlled trials do not demonstrate differences in recurrence rates or overall complications between open and laparoscopic hernia repairs. Success of either approach is mainly dependent upon the skill of the surgeon.
Laparoscopic hernia repair: This approach results in less postoperative pain and quicker return to normal daily activities of life.
a. Neurologic: *** Type Here.
b. If the patient is intubated, are there any special criteria for extubation?
c. Postoperative management
Multimodal analgesic for postoperative pain control is typically adequate and may entail administration of long-acting local anesthesia (by surgeon), ketorolac, acetaminophen, and opioids. A small minority of patients require overnight admission, and most undergo this procedure as an outpatient.
What's the Evidence?
Morales-Conde, S, Socas, M, Fingerhut, A. Surg Endosc. (Supports statement regarding surgical techniques in what the anesthesiologist should know about the procedure.)
Deveney, KE, Doherty, GM. “Hernias and other lesions of the abdominal wall”. Current diagnosis and treatment: surgery. (Supports statement regarding surgical techniques in what the anesthesiologist should know about the procedure.)
Javid, PJ, Brooks, DC, Zinner, MJ, Ashley, SW. “Hernias”. Maingot’s abdominal operations. (Supports statement regarding surgical techniques in what the anesthesiologist should know about the procedure.)
Ohana, G, Manevwitch, I, Weil, R, Melki, Y, Seror, D, Powsner, E, Dreznik, Z. “Inguinal hernia: challenging the traditional indication for surgery in asymptomatic patients”. Hernia. vol. 8. 2004. pp. 117-20. (Supports statement regarding surgical techniques in what the anesthesiologist should know about the procedure.)
Sanchez-Manuel, FJ, Lozano-García, J, Seco-Gil, JL. “Antibiotic prophylaxis for hernia repair”. Cochrane Database Syst Rev. 2007. pp. CD003769(Supports perioperative antibiotic choice.)
Sanjay, P, Woodward, A. “Inguinal hernia repair: local or general anesthesia”. Ann R Coll Surg Engl. vol. 89. 2007. pp. 497-503. (Supports author's choice of anesthetic.)
Horlocker, TT. “Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy”. Reg Anesth Pain Med. vol. 35. 2010. pp. 64-101. (Supports recommendations regarding regional anesthesia.)
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- What the Anesthesiologist Should Know before the Operative Procedure
- 1. What is the urgency of the surgery?
- What is the risk of delay in order to obtain additional preoperative information?
- 2. Preoperative evaluation
- 3. What are the implications of co-existing disease on perioperative care?
- b. Cardiovascular system
- c. Pulmonary
- d. Renal-GI:
- e. Neurologic:
- f. Endocrine:
- g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
- 4. What are the patient's medications and how should they be managed in the perioperative period?
- h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
- i. What should be recommended with regard to continuation of medications taken chronically?
- j. How To modify care for patients with known allergies -
- k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
- l. Does the patient have any antibiotic allergies- - Common antibiotic allergies and alternative antibiotics]
- m. Does the patient have a history of allergy to anesthesia?
- 5. What laboratory tests should be obtained and has everything been reviewed?
- 6. What is the author's preferred method of anesthesia technique and why?
- a. Neurologic: *** Type Here.
- b. If the patient is intubated, are there any special criteria for extubation?
- c. Postoperative management