1. Inguinal hernioplasty under la
Mdm Siti Fareeda
General Surgeon
HSAJB

2. LA
Techniques
Troubleshooting
Post op care

3. 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.

4. 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

5. 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

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

7. 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

8. 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

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

10. 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

11. 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

12. 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

13. 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

15. 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

16. 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.

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

18. 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

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

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

21. 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.

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

23. 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

24. Hypersensitivity reaction
Urticaria
Oedema
Anaphylactic reaction

25. 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

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

27. 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

28. Let the workshop begin