What the Anesthesiologist Should Know before the Operative Procedure

Repair of inguinal hernia is one of the most common surgeries performed in the United States, but anatomical, surgical, anesthetic, and medical considerations can vary greatly, especially in regard to patient age. In male infants and children, inguinal hernias arise from patency of the peritoneal tract formed by the testes migratory from abdomen to scrotum. Asymptomatic contralateral tract patency has been reported to occur in 40%-60% of infants. In healthy infants and children, elective inguinal herniorrhaphy is typically an ambulatory procedure.

The premature infant is at increased risk for inguinal hernias and bilateral presentation. The lower the patient’s gestational age at birth, the higher the incidence. Prematurity is also associated with an increased risk of comorbidities and anesthetic complications, the most serious being postoperative apnea. Premature infants at increased risk may require 23-hour monitored observation after the procedure.

In adults, inguinal hernias can be congenital or secondary to weakening of abdominal musculature. Repairs can be more extensive, including revisions of unsuccessful repairs and the insertion of synthetic materials. Laparoscopic or laparoscopic-assisted approaches are common for all age groups.

1. What is the urgency of the surgery?

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

Hernias, by definition, are the protrusion of organ(s) or tissue through a deficit in a boundary that normally contains it. When organs such as intestine, liver, spleen, or gonad are placed at risk by this displacement, urgent or emergency treatment may be necessary.

Emergency: Strangulation, blood flow compromise, of an intra-abdominal organ requires an immediate surgical response. Rapid sequence precautions and technique may be indicated, especially in infants and children who will not cooperate with a regional or filed block.

Urgent: Repeat episodes of herniation and/or difficulty in reducing the hernia are indication to repair the deficit sooner than later. Time should be allowed for adequate NPO status and optimization of comorbid disease.

Elective: The vast majority of hernias repairs are performed electively allowing for preoperative evaluation and postoperative planning.

2. Preoperative evaluation

The vast majority of infants and children coming for repair of inguinal hernias are otherwise healthy. Premature infants may have underlying cardiovascular, pulmonary, and hematological conditions.

Medically unstable conditions warranting further evaluation include bronchopulmonary dysplasia, reactive airway disease, and anemia in premature infants.

Delaying surgery may be indicated if there is concurrent upper respiratory infections, worsening respiratory exam, and hemoglobin that is less than 10 g/dL

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

Perioperative evaluation

Premature infants should be evaluated for the continued need for supplemental oxygen, apnea and bradycardia monitoring, bronchodilators, diuretics, and iron supplementation. Full-term infants less than 6 months of age should have their preoperative hemoglobin measured. Adults should have standard ASA preoperative testing according to their age and medical condition.

b. Cardiovascular system

N/A

c. Pulmonary

BPD/reactive airway disease

Premature infants showing signs of respiratory distress and increased work of breathing such as retractions, tachypnea, wheezing, and desaturation may require optimization of their medical therapy. If symptoms are acute, postponement of surgery may be necessary.

d. Renal-GI:

Gastroesophageal reflux disease: Treatment for this disorder is common in premature infants.

e. Neurologic:

N/A

f. Endocrine:

N/A

g. Additional systems/conditions

N/A

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

N/A

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?

N/A

j. How To modify care for patients with known allergies –

N/A

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.

N/A

l. Does the patient have any antibiotic allergies- [Tier 2- Common antibiotic allergies and alternative antibiotics]

N/A

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: A total intravenous anesthetic (TIVA) using propofol or dexmedetomine, opioids and/or benzodiazepines in combination with a regional block are acceptable technique
Ensure MH cart available: [MH protocol]
Family history or risk factors for MH: Patient’s with an immediate family member with a positive MH history should not be exposed to triggering agents.

Local anesthetics/ muscle relaxants: Patients with known allergies to local anesthetics should not receive regional or field blocks. Multiple analgesics are available to prevent/treat pain.

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

Hemoglobin levels: Premature infants and infants less than 6 months of age

Electrolytes:Premature infants on diuretics

Coagulation panel: None

Imaging: None

Other tests: Premature infants: Pulse oximetry values for baseline oxygen saturation

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

Anesthesia for inguinal herniorrhaphy can be achieved with nerve blocks, neuraxial blocks, general anesthesia, or a combination of these techniques.

a. Regional anesthesia: Subarachnoid, epidural, caudal, ilioinguinal, iliohypogastric, transverse abdominal plane (TAP) blocks

Neuraxial

Benefit: Neuraxial blocks offer the advantage of bilateral anesthesia and postoperative analgesia for patients undergoing bilateral repairs. In premature infants, anesthesia solely with subarachnoid blocks and no sedation may decrease the risk of postanesthesia apnea.
Drawbacks: Older infants and children will require general anesthesia or sedation to cooperate with block placement.
Issues: GA combined with a caudal block using local anesthetics of intermediate duration alone or in combination with preservative-free analgesics or adjuncts is a popular approach.

Peripheral nerve block

Benefit: Peripheral blocks offer the advantage of unilateral anesthesia and postoperative analgesia for patients undergoing unilateral repairs while avoiding the delivery of unneeded anesthesia/analgesia to the contralateral side or lower extremities. In premature infants anesthesia solely with subarachnoid blocks and no sedation may decrease the risk of postanesthesia apnea.
Drawbacks: Older infants and children will require general anesthesia or sedation to cooperate with block placement. Peripheral nerve blocks may be inadequate for complex repairs and laparoscopic approaches.
Issues: Ultrasound-guided placement of these blocks has increased their use and safety.

b. General anesthesia

Benefits: General anesthesia insures cooperativity for block placement, if used, and surgery. GA may be necessary for complex repairs and techniques using laparoscopy.

Drawbacks: Complications and side effects associated with general anesthesia can be observed in these patients including laryngospasm, sore throat, and postoperative nausea and vomiting.

Other issues: In premature infants, exposure to general anesthesia and sedatives can alter respiratory drive resulting in periodic breathing patterns, episodes of desaturation, bradycardia, and apnea.

Airway concerns: Although laparoscopy is frequently used in children to examine the contralateral inguinal canal during herniorrhaphy, laryngeal mask airways are frequently used in patients older than 6-12 months of age. For younger children or those undergoing longer explorations, endotracheal intubation is common.

c. Monitored anesthesia care (MAC)

Benefits: In older, cooperative patients, MAC can reduce the risks and side effects of general anesthesia.

Drawbacks: MAC will not be sufficient for repairs that include a laparoscopic approach. In addition, it requires cooperation and maturity not typically found in young children.

Other Issues: A field block can be used for anesthesia for this surgery but is optimal for simple and unilateral repairs.

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

For otherwise healthy children undergoing inguinal hernia repair, an inhalation induction with sevoflurane, insertion of a laryngeal mask airway (LMA), and placement of a caudal block with ropivacaine is a our preferred technique. With an LMA in place, sevoflurane is the maintenance agent of choice. A one-time dose of rectal acetaminophen 30-40 mg/kg may be given to supplement the postoperative analgesia supplied by the caudal block. The addition of opioids, ketamine, and clonidine has been shown to prolong and intensify the block but is also associated with increased postoperative sedation. Because patients undergoing herniorrhaphy are at moderate risk for postoperative nausea and vomiting, ondansetron is given intravenously at the completion of surgery.

For premature infants and infants less than 6-12 months of age, endotracheal intubation is chosen over LMA. Some practitioners advocate subarachnoid blocks for premature infants to avoid the complications of general anesthesia. This technique requires cooperative surgeons and the avoidance of sedatives and is not uniformly supported by the literature.

What prophylactic antibiotics should be administered?

None are indicated.

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

Laparoscopic examination of the contralateral side occurs after repair of the hernia but before closure. The surgeon, using the surgical incision, will insufflate the abdomen and perform the laparoscopy. With the minimal insufflation and brief examines, patients typically tolerate the procedure with no problems. When the repair is obtained solely with laparoscopy,endotracheal intubation may be needed depending on surgical technique.

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

Deepening the anesthetic and assisting ventilation may be needed during manipulation of the spermatic cord and laparoscopic examination.

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

Even with GA and a working caudal block, laryngospasm can occur during spermatic cord manipulation. The level of general anesthesia should be deepened during this step of the procedure.

a. Neurologic: *** Type Here.

N/A

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

If possible, extubation should be timed to minimize the amount and degree of “bucking”, so as not to compromise the surgical repair.

c. Postoperative management

What analgesic modalities can I implement?

If intraoperative blocks appear to be insufficient, use of intravenous ketorolac can be effective with minimal side effects. Opioids such as morphine and fentanyl can also be used.

What level bed acuity is appropriate?

In premature infants, telemetry with cardiopulmonary monitoring is indicated.

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

Common postoperative complications include (1) emergence delirium, which can be treated with propofol, fentanyl, midazolam, and/or dexmedetomine, and (2) postoperative nausea and vomiting, which can be treated with ondansetron (if not already given intraoperatively), dexamethasone, and/or promethazine. In premature infants, caffeine can be given to prevent or treat periodic breathing patterns.

What's the Evidence?

Ansermino, M, Basu, R, Vandebeek, C, Montgomery, C. “Nonopioid additives to local anaesthetics for caudal blockade in children: a systematic review”. Paediatr Anaesth. vol. 13. 2003. pp. 561-73. (A systematic review comparing local anesthetic with and without nonopioid additives.)

Breschan, C, Jost, R, Krumpholz, R, Schaumberger, F, Stettner, H, Marhofer, P, Likar, R. “A prospective study comparing the analgesic efficacy of levobupivacaine, ropivacaine and bupivacaine in pediatric patients undergoing caudal blockade”. Paediatr Anaesth. vol. 15. 2005. pp. 301-6. (Comparative study of the three local anesthetics with regard to efficacy and duration of motor block following caudal administration.)

Craven, PD, Badawi, N, Henderson-Smart, DJ, O’Brien, M. “Regional (spinal, epidural, caudal) versus general anaesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy”. Cochrane Database Syst Rev. vol. 3. 2003. (Cochrane Database Review comparing the effect of general anesthesia and spinal anesthesia on the incidence of postoperative apnea.)

Klin, B, Efrati, Y, Abu-Kishk, I, Stolero, S, Lotan, G. “The contribution of intraoperative transinguinal laparoscopic examination of the contralateral side to the repair of inguinal hernias in children”. World J Pediatr. vol. 6. 2010. pp. 119-24. (Transinguinal laparoscopic evaluation of the contralateral side during inguinal hernia repair can decrease the incidence of negative explorations.)

Lee, SL, Gleason, JM, Sydorak, RM. “A critical review of premature infants with inguinal hernias: optimal timing of repair, incarceration risk, and postoperative apnea”. J Pediatr Surg. vol. 46. 2011. pp. 217-20. (This paper evaluates the optimal timing for repair, incarceration risk and incidence of postoperative apnea in premature infants with hernias.)

Ozdamar, D, Güvenç, BH, Toker, K, Solak, M, Ekingen, G. “Comparison of the effect of LMA and ETT on ventilation and intragastric pressure in pediatric laparoscopic procedures”. Minerva Anestesiol. vol. 76. 2010. pp. 592-9. (This study suggests the use of the classic LMA for laparoscopic surgery.)

Parelkar, SV, Oak, S, Gupta, R, Sanghvi, B, Shimoga, PH, Kaltari, D, Prakash, A, Shekhar, R, Gupta, A, Bachani, M. “Laparoscopic inguinal hernia repair in the pediatric age group: experience with 437 children”. J Pediatr Surg. vol. 45. 2010. pp. 789(This is a retrospective report of 437 children undergoing laparoscopic inguinal hernia repair.)

Weintraud, M, Lundblad, M, Kettner, SC, Willschke, H, Kapral, S, Lönnqvist, PA, Koppatz, K, Turnheim, K, Bsenberg, A, Marhofer, P. “Ultrasound versus landmark-based technique for ilioinguinal-iliohypogastric nerve blockade in children: the implications on plasma levels of ropivacaine”. Anesth Analg. vol. 108. 2009. pp. 1488-92. (Study showing when using ultrasound techniques for ilioinguinal-iliohypogastric nerve blocks higher maximal concentrations and faster absorption times occur compared to using a landmark based technique.)

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