Inguinal Hernia Repair (open or lap)
Patient phenotype
Adult male predominantly (10:1), elderly more incarceration risk. Outpatient surgery typical. May be elective (reducible) or emergent (incarcerated/strangulated).
Procedure
Open: 5-7 cm groin incision, identify cord/round ligament, reduce hernia, mesh repair. Laparoscopic: TAPP or TEP approach with 3 ports. ~45-90 min.
Anesthetic plan
Open: spinal OR GA OR ilioinguinal/iliohypogastric block + MAC. Laparoscopic: GA only (insufflation). Multimodal opioid-sparing.
Setup
- ·Standard ASA monitors
- ·PIV
- ·Spinal kit if neuraxial chosen
- ·TAP/ilioinguinal block kit with US
- ·Multimodal: APAP, NSAID, local infiltration
Biggest concerns by phase
Surgical approach drives anesthesia choice
Open with mesh: spinal preferred in elderly, regional block + sedation for healthier. Laparoscopic: GA mandatory (insufflation, head-down). TEP can sometimes be done under spinal but exceptional.
Strangulated hernia — full stomach + sepsis
If bowel strangulated (>24h symptoms, peritonitis): treat as emergency RSI, may need bowel resection, possibly septic. Different beast from elective.
Lap pneumoperitoneum effects
Standard pneumoperitoneum concerns — hypercarbia, hemodynamic, position. Reverse Trendelenburg for inguinal.
Cord/ilioinguinal nerve identification
Surgeon may request avoid neuromuscular blockade for nerve identification (open approach). Confirm before deep paralysis.
PONV moderate risk + multimodal pain
Apfel ~2 typical. Dex + ondansetron prophylaxis. Pain: TAP block or ilioinguinal block at end + local infiltration + NSAID + APAP. Minimal opioid for outpatient discharge.
Outpatient discharge criteria
Most discharge home within 2-4 hours. Watch: spinal recovery + voiding (urinary retention with neuraxial), pain control, PONV, surgical site bleeding. Driver required.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
Healthy 55-year-old male for outpatient open inguinal hernia. Surgeon prefers spinal. Patient is on aspirin 81 mg + clopidogrel (stent 6 months ago). What do you do?
What an examiner probes for
- ▹ASA continue (cardiac protective)
- ▹Clopidogrel: ASRA = hold 5-7 days for neuraxial — usually NOT held for stent within 1 yr
- ▹Discuss with cardiology: stent timing risk vs. spinal benefit
- ▹Alternative: GA + TAP block / ilioinguinal block
- ▹Document risk-benefit conversation with patient
Sources
- Miller's Ch 71
- ASRA Anticoagulation Guidelines
Anatomy reference
Sourced reference images. 4 matches for "abdominal wall pelvic".
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