Anesthesiology

Inguinal herniorrhaphy (pediatric)

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What the Anesthesiologist Should Know before the Operative Procedure

In addition to the usual standard preoperative examination, the following information should be obtained:

  • Incarcerated bowel that is not reducible would require emergent surgery to prevent strangulation and bowel necrosis, while a reducible hernia may be postponed, if necessary, with the caveat that this may convert to a nonreducible incarcerated hernia if left unrepaired.

  • Location and laterality of hernia: direct, indirect, femoral, left, right, bilateral. The type of hernia and whether it is bilateral will influence the surgical approach taken by the surgeon (i.e., laparoscopic vs. open).

  • Whether the hernia contains incarcerated bowel and, if so, whether it is reducible.

  • Is nonreducible bowel at risk for or have signs of strangulation?

  • Signs of strangulation such as unstable vital signs, lactic acidosis, septicemia, septic shock, or bowel obstruction would indicate the possible need for intraoperative bowel resection.

  • Is this a primary or repeat repair? Repeat repairs may be technically more challenging for the surgeon and take longer than primary repairs. Utilization of mesh (either previously or for this repair) usually involves greater complexity and time; note that utilization of mesh is very uncommon in pediatric hernia repair, especially for the primary repair.

  • Does the surgeon plan to use laparoscopy, and if so what will be the laparoscopic approach? Surgical conditions for laparoscopy may require general anesthesia, endotracheal intubation, and neuromuscular blockade especially if a trans-peritoneal approach is taken, which would cause insufflation of the peritoneal cavity. Open approaches or laparoscopic approaches that do not enter the peritoneal cavity may allow for a variety of anesthetic approaches including GA with LMA or mask, neuraxial, regional, or local anesthesia. A common practice among pediatric surgeons is to use a laparoscope to look at the contralateral side through the hernia sac.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Hernia surgery is emergent, primarily if there is thought to be ischemic bowel; that is, if the patient is hemodynamically unstable or acidotic or shows signs of peritonitis. Emergent surgery should proceed with little to no delay except possibly for absolutely necessary preoperative diagnostic studies or medical stabilization required to permit safe transport to the operating room. In the otherwise healthy pediatric patient, volume resuscitation and correction of electrolytes would be the main intervention while proceeding to the operating room.

Surgery is classified as urgent when the patient's condition is not unstable but the risk of waiting more than a few hours would put the patient at risk of having unacceptable progression of disease that may lead to hemodynamic instability or irreversible injury. An incarcerated hernia that might progress to ischemic bowel should be repaired on an urgent basis.

Nonurgent or elective surgery may be categorized as any surgery that can wait for days to weeks to months. The main reason to proceed expeditiously is to prevent the hernia from becoming larger or incarcerating. The most common reasons for postponing a child needing an elective hernia repair would be to wait an adequate length of time (usually 24-6 weeks) after a significant respiratory infection or to allow a former premature child to pass the at-risk period for postoperative apnea.

Emergent: Emergent herniorrhaphy is indicated by signs of or concern for strangulation of an incarcerated hernia that is unable to be reduced. The patient may have signs of obstruction (nausea, vomiting), unstable vital signs, exquisite groin tenderness, and/or mottled appearance to the overlying skin. In this case it would be prudent to abbreviate the preoperative examination to obtain only essential information such as vital signs, NPO status, allergies, medications, comorbid conditions in brief, and an airway, heart, and lung examination. Strangulated bowel may need to be resected after reduction if necrosis has occurred. Delay of surgery may increase the need for and the extent of bowel resection. Girls who present with incarcerated hernias may have ovary and possibly adenexa in the hernia sac and would be at risk for ovarian necrosis.

Urgent: Some would consider an irreducible incarcerated hernia to be an indication for emergent herniorrhaphy given that the potential for strangulation exists until reduction. It is possible, however, that a delay of a few hours would be reasonable as long as the patient is closely monitored for emerging signs of strangulation. Despite this, such surgery should be undertaken as soon as resources are available and generally should not be delayed for extensive preoperative evaluation since the signs of strangulation may occur late in the process of ischemic injury to bowel or ovary.

Elective:Two types of hernias fall into the elective category. Those that are incarcerated but then able to be reduced, and those that reduce spontaneously. Children who present initially with an incarcerated hernia that is reduced manually should be repaired within 5 days (earlier for premature infants) to prevent re-incarceration. For spontaneously reduced hernias (or those that are only apparent with rise in intra-abdominal pressure such as coughing or manual manipulation), the risk of incarceration is lower, but still exists.

2. Preoperative evaluation

Commonly, inguinal hernia presents in the otherwise healthy child; however, the rate of hernias increases with prematurity.

Premature child

Premature neonates may have a variety of severe medical conditions (e.g., respiratory distress syndrome, intraventricular hemorrhage, congenital anomalies, necrotizing enterocolitis) leading to postponement of repair. Furthermore, premature infants and neonates are at risk for postoperative apnea. Despite this, early repair may help avoid incarceration, testicular atrophy, and recurrence. The timing of repair is determined based on these relative considerations.

Full-term neonate or older child

Recent or current respiratory infections: Perioperative pulmonary complications are more likely in children with concomitant upper respiratory infection. While the standard recommendation is to wait 4-6 weeks from last illness until undertaking elective surgery, given the risk of incarceration, proceeding may be reasonable if the patient is clinically improving and afebrile and has no evidence of pulmonary involvement. A risk-benefit discussion should be undertaken with the surgeon.

Asthma: In the child with moderate to severe asthma, avoidance of airway instrumentation may be prudent to lessen the risk of intraoperative or postoperative bronchospasm. Preoperative treatment with inhaled bronchodilators may be helpful, especially if the patient uses them routinely.

Obstructive sleep apnea: May help determine the manner of airway management and indicate the potential for upper airway obstruction under anesthesia.

Apnea of prematurity: Formerly pre-term neonates are at risk for apnea until approximately 54 weeks post-conception. These infants should be observed overnight in a monitored setting.

Gastroesophageal reflux disease (GERD): Reflux is very common but the severity needs to be assessed to determine the appropriate type of induction and the need to secure the airway.

Undecended testes: In the child with hernia and undescended testes, repair may be delayed to facilitate concomitant herniorrhaphy and orchidopexy.

Medically unstable conditions warranting further evaluation include severe prematurity, especially with respiratory distress syndrome; significant unrepaired congenital heart disease.

Delaying surgery may be indicated if: the patient is unstable due to a comorbid condition that cannot be addressed at the time of surgery. Delay may not be an option in the case of a strangulated hernia. Elective hernia repair may be delayed if an acute respiratory infection is present.

3. What are the implications of co-existing disease on perioperative care?

b. Cardiovascular system

Acute/unstable conditions

These are uncommon in children, but those with congenital heart disease (especially if uncorrected) may present with an acute exacerbation (e.g., cyanotic spells in a patient with tetralogy or CHF in a patient with unrepaired VSD). Surgery should be postponed until the patient is stable, and transfer to a center that is familiar with the care of children with congenital heart conditions should be considered.

Cardiac dysfunction is seen in children with congenital heart defects (ASD, VSD, PFO, PDA) that may be more common in the ex-preterm population. Look for evidence of cyanosis (blue lips and nail beds, clubbing) or history of dyspnea or syncope. Nonphysiological heart murmurs may be present on exam. Consultation among anesthesia, cardiology, and surgery should be undertaken to determine the optimal timing of hernia repair in this situation.

c. Pulmonary

Reactive airway disease (asthma)

Asthma is common in children. Wheezing on exam and history of wheezing exacerbated by allergens or exercise are typical. Continue inhaled medications preoperatively and postoperatively.

Respiratory comorbidities that are more common in ex-preterm infants, especially those who underwent prolonged mechanical ventilation, include respiratory distress syndrome, bronchopulmonary dysplasia, tracheomalacia, and subglottic stenosis.

Apnea of prematurity

Cote's combined analysis showed that the risk of apnea after general anesthesia is inversely proportional to both gestational and postconceptual age. Thus, a child who is currently at 54 weeks' postconceptual age would be at higher apnea risk if he or she were born at 28 weeks than at 34 weeks. Anemia and ongoing apnea also increase risk. Rather than require complex algorithms, many centers select a conservative postconceptual age cutoff such as 60 weeks, and below that age require overnight observation with apnea monitoring. Caffeine may lower apnea risk; unsupplemented spinal anesthesia also has a lower incidence of apnea than general anesthesia, but most authors do not think that it lowers the risk enough to allow discharge in otherwise at-risk children.

Chronic lung disease (CLD, formerly bronchopulmonary dysplasia(BPD))

CLD is seen in formerly preterm infants, especially those that were a very low weight at birth (< 1000 g). It is caused by a combination of immature lung development, mechanical ventilation and supplementary oxygen, usually in these very immature neonates. It may or may not be preceded by respiratory distress syndrome. These neonates by definition require supplemental oxygen for some time after birth and may have poor lung mechanics (i.e. compliance).

In these infants it is reasonable to defer hernia repair until their pulmonary function has improved substantially and certainly until they are no longer on supplementary oxygen, unless there is an urgent need for surgery.

d. Renal-GI:

Renal insufficiency is rare in children compared to the adult population. Renal insufficiency is unlikely to be noted in routine preoperative evaluation unless previously diagnosed, as there is no indication for routine laboratory tests. One should adjust dosages of medication appropriately for renal insufficiency or failure.

Gastroesophageal reflux disease (GERD) is a common GI disorder that may influence anesthesia. Check for symptoms of sour taste in the mouth upon waking or after large meals or certain foods like chocolate or spicy foods. Infants with this disorder may have frequent emesis and be unable to keep down food, formula, or breast milk. Continue medications such as proton-pump inhibitors or H2 blockers and consider endotracheal intubation with or without rapid sequence induction and intubation if reflux is severe or if there are signs of delayed gastric emptying, such as vomiting undigested food at a time distant from ingestion.

Look for signs of obstruction (nausea, vomiting, transition point on CT) that would indicate a strangulated hernia.

e. Neurologic:

Acute issues: Acute neurologic problems are unusual in children presenting for herniorrhaphy. Unexplained weakness or seizure should be referred to a neurologist prior to nonemergent surgery. Patients with altered levels of consciousness should also be evaluated for the possibility of trauma.

Chronic disease: Children may present for herniorrhaphy with a variety of chronic neurologic conditions including cerebral palsy, seizure disorder, history of brain tumor, or chronic pain. The child may continue to surgery if the condition is stable and under treatment. Continue all medications for neurologic problems, remembering that children on antiseizure or chronic analgesic medications may require more anesthesia than the general population to prevent awareness under anesthesia.

f. Endocrine:

Diabetes mellitus (DM) types 1 and 2 are the most common endocrine disorders in children. Especially children with type 1 should be instructed to hold their insulin the morning of surgery while they are fasting to prevent hypoglycemia. As insulin pumps become more common in this population the anesthesiologist should become familiar with their operation as well as request recommendations from the patient's endocrinologist. Those with type 2 DM may need to hold oral hypoglycemic medications or metformin. Blood glucose should be checked before and after surgery given most herniorrhaphy procedures last less than 1 hour.

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)

The main concern for the patient undergoing hernia repair is to close the hernia before morbidities such as testicular atrophy, ovarian torsion/atrophy, or intestinal strangulation occur.

4. What are the patient's medications and how should they be managed in the perioperative period?

The patient is not on any medications for inguinal hernia with the possible exception of analgesics that can be continued or modified during the perioperative period. Additionally, most children presenting for herniorrhaphy will not be on any medication chronically, but many take multivitamin supplementation that can be continued. Herbal and other supplements are not uncommon in children and this history should be sought as well.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

Patients undergoing this procedure are not commonly taking medications.

i. What should be recommended with regard to continuation of medications taken chronically?

Cardiac: Continue

Pulmonary: Continue inhaled and systemic medications

Renal: Continue

Neurologic: Continue

Antiplatelet: These are unusual for pediatric patients to be taking. Therefore, it is prudent to discuss changes with the prescribing pediatrician before discontinuing.

Psychiatric: Continue. Monoamine oxidase inhibitors put patients at high risk of serotonin syndrome if given meperidine for perioperative pain control. Therefore, meperidine should be avoided in these patients.

j. How to modify care for patients with known allergies -

Patients often report intolerance to medications as "allergies," despite not being IgE-mediated allergic processes resulting in possible anaphylaxis. It is important to ask what reaction the patient had to the medication to help determine the risk of administration. For instance, GI intolerance to antibiotics is common and may not be a contraindication to adminstration under anesthesia. Medications causing reactions that may be IgE-mediated, such as generalized rash, swelling, trouble breathing, or anaphylaxis, should be strictly avoided if possible and cross-reactivity with similar medications should be considered when determining an alternative agent. The most common causes of anaphylaxis in anesthesia are neuromuscular blocking agents, local anesthetics, antibiotics, and latex.

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.

While skin sensitivity to latex may not predict anaphylactic reaction, it is prudent to prepare the OR with latex-free products including gloves and other items that may touch the patient. The caps of some injected medications may contain latex. While it is inconclusive that removing them prior to drawing up the medication in a dispensing syringe decreases the amount of latex in the medication, some would do this routinely to minimize chance of reaction.

Inguinal hernia does not increase the risk of latex allergy, but children with coexisting conditions such as meningomyelocele, may have an increased incidence of latex allergy.

l. Does the patient have any antibiotic allergies - Common antibiotic allergies and alternative antibiotics

Common allergies to antibiotics with their alternatives:

beta-lactams → alternatively use clindamycin or vancomycin

metronidazole → ertapenem

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:

Proposed general anesthetic plan: IV induction (nitrous oxide may facilitate placement). If this is not possible in the struggling child, intramuscular induction with ketamine and midazolam may allow for IV placement and subsequent airway management. Maintenance of anesthesia may be accomplished with propofol and an opioid infusion. If the child is older and mature enough, GA may be avoided altogether and regional or local anesthesia with IV sedation may be sufficient depending on the surgical technique. The anesthesia machine should be flushed and disposable parts replaced. There are specific recommendations for the preparation of the newer-generation anesthesia machines for the MH-susceptible patient.

Ensure MH cart available: An MH cart should include sufficient nonexpired vials of dantrolene to give at least a single dose quickly (2.5 mg/kg IV dissolved in sterile water). Additional qualified personnel should be notified in advance that they may be called upon to help if an emergency occurs and called immediately if one should occur. If MH is diagnosed (rising end-tidal CO2, hyperthermia, tachycardia, tachypnea, muscle rigidity, presence of triggering agent), the offending agent (succinylcholine and/or inhaled volatile anesthetic) should be discontinued immediately, and dantrolene and 100% oxygen administered. The patient should also be aggressively cooled to reduce hyperthermia, hyperventilated to reduce acute hypercarbia, and treated for respiratory and metabolic acidosis. Use fluids and diuretics with the goal to maintain urine output at 2 mL/kg/h. Important lab studies include ABG, CPK, electrolytes, calcium, and coagulation studies. Treat hyperkalemia. Avoid calcium channel blockers. Make arrangements to admit the patient to the ICU. Repeat dantrolene every half hour or begin infusion until body temperature and hypercarbia normalize.

Family history or risk factors for MH: Treat these patients as if they have MH even if they have had prior uneventful anesthetics with triggering agents.

Local anesthetics/muscle relaxants

It may be unnecessary to use neuromuscular blocking agents, especially if an allergy exists. If an allergy exists to local anesthetic, an agent from a different class (ester vs. amide) may avoid reaction or they can be avoided altogether, using opioids and acetaminophen for postoperative pain control. Avoid succinylcholine in children (especially boys under 10 years) as they may have a hyperkalemic reaction (not MH, not anaphylaxis) if an undiagnosed muscular dystrophy is present. Exceptions to this include the need to treat laryngospasm or need for rapid sequence induction, but these judgments are best made by an anesthesiologist skilled in the care of children. Succinylcholine is also contraindicated for any child with severe burns within the past 5 years or for any child with paralysis, paraplegia, or muscle atrophy from immobilization or disuse to prevent life-threatening hyperkalemic reactions. Succinylcholine has been used safely in the care of children with cerebral palsy.

5. What laboratory tests should be obtained and has everything been reviewed?

In the child presenting for elective herniorrhaphy or the stable child with incarcerated hernia no preoperative laboratory tests are warranted.

For unstable children presenting for herniorrhaphy, a CBC, electrolytes, BUN, creatinine, glucose, and lactate are indicated, as obstruction may cause metabolic derangement. Elevated WBCs or lactate may indicate ischemic tissue in the hernia sac and help determine the severity of acute illness. Metabolic derangements should be corrected preoperatively if possible.

Imaging is not required but ultrasound may help the surgeon determine the contents of the hernia preoperatively. Other tests include lactate and WBC count.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

Inguinal herniorrhaphy may be performed under general, neuraxial, regional, or local anesthesia with supplemental sedation. Laparoscopic procedures involving pneumoperitoneum require general anesthesia, usually with endotracheal intubation. Most pediatric patients outside of the neonatal period do not easily tolerate regional or neuraxial procedures without general anesthesia or deep sedation. Therefore, it is more common that herniorrhaphy is performed under general anesthesia with the possibility of regional or local anesthesia for postoperative pain control for this population.

In children, regional anesthesia is best administered for postoperative pain control rather than as the primary anesthetic. While some would consider an awake spinal or caudal in ex-preterm infants to prevent postoperative apnea associated with general anesthesia, many practitioners administer general anesthesia even in this population. In older children local infiltration may provide similar results to ilioinguinal nerve block or spinal/caudal anesthesia, although a recent study suggests that transversus abdominus plane (TAP) block may improve the duration of postoperative analgesia as compared to local wound infiltration for unilateral surgery.

Neuraxial

Benefits: Avoids postoperative apnea, useful for postoperative pain management.

Drawbacks: Requires patient cooperation, which is difficult to obtain reliably in the pediatric population, although this is not problematic in the neonatal period. Best used in conjunction with general anesthesia or deep sedation to decrease postoperative pain.

Issues: Ensure that coagulation studies are normal and that the patient is not on antiplatelet or anticoagulation therapy to prevent epidural hematoma. Likewise, if a catheter is left in place the patient should not be on antiplatelet or anticoagulation therapy upon removal of the catheter.

Peripheral nerve block

Benefits: Avoids postoperative apnea, useful for postoperative pain management.

Drawbacks: Requires patient cooperation, which is difficult to obtain reliably in the pediatric population. Best used in conjunction with general anesthesia or deep sedation to decrease postoperative pain.

Issues: Ensure that coagulation studies are normal and that the patient is not on antiplatelet or anticoagulation therapy to prevent perineural hematoma. Likewise, if a catheter is left in place the patient should not be on antiplatelet or anticoagulation therapy upon removal of the catheter.

b. General Anesthesia

Benefits: This is preferred in the pediatric population because it does not require cooperation as does regional anesthesia. It is generally well tolerated and allows peritoneal insufflation if the surgical technique requires this.

Drawbacks: Postoperative nausea and vomiting are common side effects of general anesthesia, as is sore throat or hoarseness from placement of an endotracheal tube or a laryngeal mask airway. In small children and especially in the premature neonate, postoperative apnea is a significant concern and postoperative monitoring may be warranted for up to 24 hours in some cases.

Airway concerns: The airway of the small child as compared to adults tends to be anterior, with less upper airway space due to a relatively larger tongue. In addition, the narrowest portion of the airway is subglottic, as opposed to the glottic opening in adults. For these reasons, intubation can be more difficult even when the cords are visualized. An air leak at 20 cm H2O positive pressure should be present to prevent tracheal edema and mucosal damage. If necessary, a larger tube should be exchanged for a smaller one. Additionally, children are more prone to laryngospasm. Especially for stimulating procedures (herniorrhaphy in boys involves manipulation of the sensitive spermatic cord structures), laryngospasm is more likely to occur. Some practitioners prefer endotracheal intubation for this reason. However, others would use a laryngeal mask airway, but the depth of anesthesia should be increased to help avoid this complication. If the patient has an incarcerated hernia, the risk of aspiration from small bowel obstruction on induction is increased and rapid sequence induction and intubation should be considered.

c. Monitored Anesthesia Care

Benefits: Quick postoperative recovery, decreased risk of postoperative apnea

Drawbacks: Requires patient cooperation, which is difficult to obtain reliably in the pediatric population.

Other issues: Would require regional or local anesthesia for the patient to tolerate the procedure. Generally, MAC is not used in the pediatric population for this procedure.

6. What is the author's preferred method of anesthesia technique and why?

What prophylactic antibiotics should be administered?

Prophylactic antibiotic coverage in the child is controversial. Many practitioners do not administer prophylactic antibiotics due to the low rate of surgical site infections. If there is a significant chance of bowel resection, prophylaxis for both skin flora and gastrointestinal flora is reasonable and cephazolin and metronidazole would be our choice assuming the patient had no known allergy to these or related agents.

What do I need to know about the surgical technique to optimize my anesthetic care?

There are a variety of surgical techniques for herniorrhaphy. Discussion with the surgeon about the preferred technique prior to surgery is crucial. Laparoscopic-assisted repair is increasingly popular due to its small incisions and the ability to check the contralateral side for patent processus vaginalis (and ligate if necessary) to prevent metachronous contralateral hernia.

What can I do intraoperatively to assist the surgeon and optimize patient care?

For open repair, generally adequate general or regional anesthesia is all that is required. For laparoscopic repair, especially using transperitoneal (as opposed to preperitoneal) approaches, muscle relaxation and endotracheal intubation are typically required to facilitate insufflation of the peritoneum.

What are the most common intraoperative complications and how can they be avoided/treated?

Intraoperative complications are rare. Of greatest immediate concern would be vascular injury to a major artery on insertion of laparoscopic trochars. This is an extremely rare event in experienced hands.

Complications

Cardiac: These are unusual in the otherwise healthy child, but ex-preterm infants may have congenital cardiac comorbidities (ASD, VSD, PDA, etc.) that may complicate an anesthetic plan.

Pulmonary: Intraoperative anesthetic complications include laryngospasm and can be avoided by ensuring a deep plane of anesthesia or by endotracheal intubation. Laryngospasm can usually be treated by positive pressure ventilation and increasing the depth of anesthesia. If necessary, muscle relaxation, usually with succinylcholine, and endotracheal intubation can be performed. Bronchospasm may occur in the child with reactive airway disease or recent respiratory infection, in which case use of LMA or mask airway, as well as IV lidocaine prior to airway manipulation, and albuterol immediately prior to induction and emergence may decrease the risk of this complication occurring. Volatile anesthetics are potent bronchodilators and increasing the inhaled sevoflurane may help to treat as well as prevent bronchospasm.

Neurologic: Unique to procedure: None.

a. Neurologic:

N/A

b. If the patient is intubated, are there any special criteria for extubation?

The patient should be extubated according to standard criteria in nearly all cases. While some pediatric anesthesiologists prefer deep extubation, removal of the endotracheal tube while the child is deeply anesthetized is a skill that requires attention to detail and availability of an anesthesia provider to the child during emergence. If awake extubation is chosen, the goal is to have the child awake with good airway reflexes but to avoid coughing and bucking.

c. Postoperative management

What analgesic modalities can I implement?

Postoperative analgesia in the pediatric population is of unique importance. Neuraxial (caudal) anesthesia and regional (ilioinguinal and iliohypogastric nerve block) have been shown to be beneficial in controlling postoperative pain in the first 24 hours. Ketorolac may be useful in the immediate postoperative period if there are no contraindications. Acetaminophen can be administered as a loading dose in the operating room (30-40 mg/kg rectally or 15 mg/kg intravenously) and then continued at standard doses with or without a low dose of opioid in the first few days postoperatively. While codeine has traditionally been used in children, recognition of the wide range of efficacy and the potential for significant pharmacogenetic variability with codeine has decreased its popularity for pediatric patients.

What level bed acuity is appropriate?

Most patients will be discharged home with their caregivers, but the premature infant or the child with strangulated bowel may require intensive care at least in the immediate postoperative period. Infants at risk of postoperative apnea require a unit capable of cardiorespiratory monitoring.

What are common postoperative complications, and ways to prevent and treat them?

The most common postoperative complication in the ex-preterm infants is apnea. This can be avoided by awake spinal anesthesia, but this is not typically preferred. Appropriate postoperative monitoring in the NICU, PICU, or a monitored general pediatric floor overnight will minimize this complication. Limiting the use of opioid for postoperative analgesia may help decrease risk of postoperative apnea. A common complication in the non-neonatal population is emergence delirium that can be treated with low-dose propofol or fentanyl, ensuring pain is well controlled and minimizing stimulation of the patient until emergence is complete. Postoperative nausea and vomiting are also common in this population and can be treated with ondansetron. Avoidance of volatile anesthetics and nitrous oxide may help if a patient is known to have a high propensity for postoperative nausea; in this situation, addition of dexamethasone as a second prophylactic antiemetic may be useful.

What's the Evidence?

WHAT IS THE RISK OF DELAY IN ORDER TO OBTAIN ADDITIONAL PREOPERATIVE INFORMATION?

Zamakhshary, M,, To, T,, Guan, J,, Langer, JC. "Risk of incarceration of inguinal hernia among infants and young children awaiting elective surgery". CMAJ. vol. 179. 2008. pp. 1001-5.

(This retrospective analysis of a prospective surgical and primary care database showed that children diagnosed with inguinal hernia in the office were less likely to require emergency care for incarcerated hernia if the hernia was repaired within 2 weeks as opposed to waiting a month.)

Gahukamble, DB, Khamage, AS. "Early versus delayed repair of reduced incarcerated inguinal hernias in the pediatric population". J Pediatr Surg. vol. 31. 1996. pp. 1218-20.

(This retrospective analysis of prospectively collected data showed patients who waited greater than 5 days after reduction were at increased risk of incarceration. However, surgical complications in both groups were similar.)

WHAT ARE THE IMPLICATIONS OF COEXISTING DISEASE ON PERIOPERATIVE CARE?

Coté, CJ, Zaslavsky, A, Downes, JJ. "Postoperative apnea in former preterm infants after inguinal herniorrhaphy". A combined analysis. Anesthesiology. vol. 82. 1995. pp. 809-22.

(Describes relative risk of postoperative apnea after general anesthesia in former preterm infants.)

Turial, S, Enders, J, Krause, K. "Laparoscopic inguinal herniorrhaphy in premature infants". Eur J Pediatr Surg. vol. 20. 2010. pp. 371-4.

(A series of 58 consecutive laparoscopic herniorrhaphies in ex-preterm infants showing significant comorbidities in this population.)

INTRAOPERATIVE MANAGEMENT: WHAT ARE THE OPTIONS FOR ANESTHETIC MANAGEMENT AND HOW TO DETERMINE THE BEST TECHNIQUE?

Williams, RK, Black, IH, Howard, DB. "Cognitive outcome after spinal anesthesia and surgery during infancy". Anesth Analg. 2014 Jun 20.

(Retrospective study comparing infants undergoing herniorrhaphy under spinal to demographically matched controls. No difference in very poor school performance or standardized testing was found.)

Block, RI, Thomas, JJ, Bayman, EO. "Are anesthesia and surgery during infancy associated with altered academic performance during childhood". Anesthesiology. vol. 117. 2012 . pp. 494-503.

(Retrospective observational study of 287 children aged 7-17 presumably otherwise healthy who underwent as infants hernia repair, orchidopexy, pyloromyotomy, and/or circumcision under GA. It showed lower test scores in the study group than in the general population.)

INTRAOPERATIVE MANAGEMENT: WHAT ARE THE OPTIONS FOR POSTOPERATIVE PAIN CONTROL AND HOW TO DETERMINE THE BEST TECHNIQUE?

Willschke, H, Marhofer, P, Bosenberg, A. "Ultrasonography for ilioinguinal/iliohypogastric nerve blocks in children". Br J Anaesth. vol. 95. 2005. pp. 226-30.

(RCT that compared ultrasound-guidance to landmark techniques for ilioinguinal nerve blocks in children. Found that lower local anesthetic volumes were used and less intra- and postoperative narcotics were administered in the ultrasound-guided group.)

Sahin, L, Sahin, M, Gul, R. "Ultrasound-guided transversus abdominus plane block in children - A randomised comparison with wound infiltration". Eur J Anaesthesiol. vol. 30. 2013. pp. 409-414.

(RTC found that TAP block provided longer lasting pain relief than wound infiltration.)

Baird, R, Guibault, M-P, Tessier, R. "A systematic review and meta-analysis of caudal blockade versus alternative analgesic strategies for pediatric inguinal hernia repair". J Pediatr Surg. vol. 48. 2013. pp. 1077-85.

(Systematic review and meta-analysis of 13 RTCs demonstrating no benefit of caudal over nerve-blockade or wound infiltration as measured by postoperative pain scores and need for postoperative rescue analgesia.)

POSTOPERATIVE MANAGEMENT

Murphy, JJ, Swanson, T, Ansermino, M, Milner, R. "The frequency of apneas in premature infants after inguinal hernia repair: do they need overnight monitoring in the intensive care unit?". J Pediatr Surg. vol. 43. 2008. pp. 865-8.

(Retrospective analysis of 126 premature infants undergoing hernia repair in whom 5% had apneic events.)

MeloFilho, AA, de FátimaAssunção Braga, A, Calderoni, DR, Volk, S, Marba, S, Sbragia, L. "Does bronchopulmonary dysplasia change the postoperative outcome of herniorrhaphy in premature babies?". Paediatr Anaesth. vol. 17. 2007. pp. 431-7.

(Retrospective analysis of 52 preterm infants who underwent hernia repair, of whom 17 had bronchopulmonary dysplasia, finding no difference in the incidence of apneic events.)
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