Inguinal hernioplasty under la Mdm Siti Fareeda General Surgeon HSAJB

LA Techniques Troubleshooting Post op care

Advantages Safe Effective Easy Lower incidence of side effects Rapid mobilization Ambulatory / day care surgery Intraoperatively : 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.

Patient selection Primary/ reducible inguinal hernia BMI less than 30 Emotional stability and fully understand the procedure ?age Precaution – on double antiplt/ anticoagulant Exclusion – size – inguinoscrotal - complicated cases - recurrent - significant uncontrolled comorbids with asymptomatic reducible hernia

Preparation of patient Reassessed and marked preoperatively Written consent - the possibility of conversion to general anesthesia should he or she experience difficulty in tolerating the procedure because of anxiety or discomfort VERY IMPORTANT  MONITORING OF PATIENT Pulse oximetry and 3L/min oxygen therapy Cardiac monitoring NIBP Peripheral venous access

Team player 3 doctors – one operating surgeon - one assistant - one monitor patient 2 staff nurses – one scrub nurse - one circulating nurse PPK

SEDATION Iv midazolam (dormicum) 0.05-0.1mg/kg Iv pethidine 1-2mg/kg Dilute and standby reversals Iv flumazenil 0.5mg Iv naloxone 0.4mg

Positioning Correct surgical side (left or right) should be confirmed Patient - supine position, with the upper extremities comfortably secured For large defects, slight Trendelenburg positioning – reduce visceral contents Prepared and draped in standard surgical fashion  groin site is exposed. The patient’s head is left open to allow conversation with the surgeon. Surgeon stands on the side  hernia Assistant stands on the opposite side

PROPHYLACTIC ANTIBIOTIC IV Augmentin (ampicillin/sulbactam) 1.2g Or IV cephalosporin (1st generation) 30 minutes pre incision

LA Combination short and long acting 0.5% lignocaine – 2-3mg/kg 0.5% marcaine (bupivacaine) – 2mg/kg - to prolong the action (3-6h) Dilution with NS Caution with adrenaline in pt with Hpt, arrhythmia and liver dysfxn

Blocking technique Marking point 10mls 1.5cm medial to ant superior iliac spine 5mls incision 5mls external oblique aponeurosis 5mls cord area 5mls at pubis 5mls deep ring

Principles of repair Direct sac  (pushed back) into the extraperitoneal space, sometimes with plication of the transversalis fascia Indirect sac  dissected and opened, ligation of proximal sac Bilateral hernias  to repair one hernia at a time, 4-6 weeks avoid - bilateral infection and the higher risk of penile and scrotal edema

Mesh Permanent Overlap beyond the defect’s edges (eg, 5 × 10 cm to 7.5 × 15 cm) lighter, more porous  maintain the strength of the repair  less inflammatory response  less discomfort

Surgical steps subcutaneous fat Scarpa fascia down to the external oblique aponeurosis external inguinal ring and the lower border of the inguinal ligament Division of the external oblique aponeurosis from the external ring laterally for up to 5 cm ** ilioinguinal nerve Superior and inferior flaps of the external oblique aponeurosis Mobilization of the spermatic cord structures, along with the cremaster  encircled with a tape isolation of the hernia sac – direct vs indirect lipoma  excised to reduce the bulk of the cord Placement and fixation of mesh In males, gentle pulling of the testes back down to their normal scrotal position Closure in layers

Incision is placed about 2FB above and parallel to the inguinal ligament, beginning from the pubic tubercle and extending 5-6 cm laterally subcutaneous fat is then opened along the length of the incision, Superficial pudendal and superficial epigastric vessels.

external oblique aponeurosis external inguinal ring and the lower border of the inguinal ligament

Division of the external oblique aponeurosis from the external ring laterally for up to 5 cm ** ilioinguinal nerve Superior and inferior flaps of the external oblique aponeurosis

Mobilization of the spermatic cord structures, along with the cremaster  encircled with a tape

isolation of the hernia sac – direct vs indirect lipoma  excised to reduce the bulk of the cord

Medial side  sharp corners of the mesh are trimmed to conform to the patient’s anatomy Compensate for future shrinkage  extend 3-4 cm beyond the boundary of the inguinal triangle Compensate for increased intra- abdominal pressure when the patient stands up  lax in the posterior wall First medial most stitch fixes the mesh 2 cm medial to the pubic tubercle  avoid needle through the periosteum of the bone  chronic postoperative pain.

Complications Sedation Agitation Anxious and not cooperative ~1% LA - Acute toxicity - hypersensitivity reaction Haematoma SSI ~2% Post op urinary retention - rare

Acute toxicity CNS – dizziness, blurred vision and tremors  convulsion  resp arrest CVS – hypotension, bradycardia  cardiac arrest What to do? Call for help Supine and raise the leg ABC Inotropic support Convulsion – diazepam - thiopentone

Hypersensitivity reaction Urticaria Oedema Anaphylactic reaction

Post op care Day care surgery – may discharge with advice and with reliable caretaker Analgesia – paracetamol + Diclofenac sodium Resume daily activity ~1/52 post op

Advice to pt upon discharge Signs of side effects of sedation Haematoma / bruising Seroma Rarely - Ischemic orchitis 0.2-1.1% --> painful testicular swelling and fever POD 2-3

Conclusion Inguinal hernia repair under local anaesthesia is safe and convenient. Reduce the waiting time for GA/ spinal benefits  reduced risk of cardiopulmonary complications, short hospital stay and early return to routine life. Choose your patient Explain well to patient

Let the workshop begin