Perioperative management - Lichtenstein Repair of Inguinal Hernia - general and visceral surgery

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  • Indications

    Elective:

    • Primary inguinal hernia in patients > 30 years, except for small lateral hernias
    • Recurrent inguinal hernia

    Emergency surgery:

    • Incarcerated inguinal hernia
  • Contraindications

    • Patients who are absolutely inoperable
    • No other contraindications since the procedure can be performed under local anesthetics
  • Preoperative diagnostic work-up

    • Manual examination with patient standing
    • Digital rectal examination in men > 50 years 
  • Special preparation

    • Marking the side of the hernia examined with the patient standing
    • 1/2 hour before skin incision a single-shot antibiotic regimen is recommended, e.g., with 2nd generation cephalosporin
  • Informed consent

    • Recurrence
    • Seroma
    • Hematoma
    • Secondary healing
    • Infection
    • Mesh infection
    • Vascular and nerve injury
    • (Secondary) bleeding
    • Chronic groin pain such as ilioinguinal syndrome
    • Injury to the spermatic duct
    • Testicular atrophy
    • Redo procedure
    • Bowel resection
    • Death
  • Anesthesia

  • Positioning

    • 27-3
    • Supine
    • Both arms abducted
  • Operating room setup

    • 27-4
    • Surgeon stands on side of hernia
    • 1st assistant and scrub nurse together on opposite side; instrument table on the side of the surgeon over feet of patient.
  • Special instruments and fixation systems

    • Basic instrument tray
    • Lichtenstein mesh
  • Postoperative Management

    Postoperative analgesia:

    Nonsteroidal anti-inflammatory drugs usually suffice; if necessary, they can be enhanced by opioid analgesics.

    Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management).

    This link will take you to the International Guideline Library.

    Postoperative care:

    After the operation a sand bag may be placed on the wound for a few hours; remove any Redon drain on postoperative day 1 or 2

    Deep venous thrombosis prophylaxis:

    Unless contraindicated, the moderate risk of thromboembolism (surgical operating time > 30 min) calls for prophylactic physical measures and low-molecular-weight heparin, possibly adapted to weight or dispositional risk, until full ambulation is reached.

    Note: Renal function, HIT II (history, platelet check)

    This link will take you to the International Guideline Library.

    Ambulation:

    Unrestricted; gradual return to physical activity; full physical activity, as tolerated, after one week; all activities permitted after four weeks the latest.

    Physical therapy:

    Respiratory therapy for prevention of pneumonia only in bedridden patients.

    Diet:

    Unrestricted

    Bowel movement:

    Laxatives may have to be started on postoperative day 2

    Work disability:

    1-2 weeks