Hernia Repair - Laparoscopic

Pediatric

Inguinal hernia repair (herniorrhaphy) and hydrocele repair are most common. It is caused when the processus vaginalis (small pouch of peritoneum) fails to obliterate

Hydroceles are identical to hernias but have smaller necks and only intraperitoneal fluid - not bowel - can pass through them. Tends to close at age 2; if not, then repaired

Umbilical hernias tend to close over the first 5 years, and they are repaired when large >2 cm or persistent

Complications

Damage to vas deferens or testicular vessels, low incidence of infertility with bilateral repairs

Minor bleeding and reoccurrence are uncommon, and bowel resection is rarely necessary

Anesthesia complications

Laryngospasm, bronchospasm, local anesthetic toxicity, hypothermia, hypoglycemia

Overnight observation for premature children <48-60 weeks for apnea

Preoperative Considerations

Position

Supine

Pain Score

3-5

Mortality

<1%

Adult

Increased abdominal pressure secondary to chronic cough, bladder outlet obstruction, constipation, pregnancy, vomiting, and obesity. These factors should be managed preop to prevent reoccurrence

Hernias may become incarcerated, obstructed, or strangulated, requiring emergency surgery

Fluid and electrolyte imbalance is likely

Complications

Post-dural punctual headache/urine retention with regional anesthesia

Wound dehiscence with coughing/straining

Prevalence of hernias: Premature to adolescent, male to female 5:1 in ages <2 years

Position: Supine, arms tucked or to side < 90 degrees. Pressure points padded. Eyes taped after induction

Anesthetic considerations

Spinal T4-T6, 0.75% Bupivacaine in 8.25% dextrose - 10-15mg/ 0.5% Tetracaine in 5% dextrose- 12-16mg

Consider adding Fentanyl 10-20mcg. (note coagulation tests)

Local by the surgeon with sedation

GA due to pneumoperitoneum, possible need for muscle relaxation, and management of patient discomfort - often shoulder and chest discomfort with pneumoperitoneum

ETT to prevent any aspiration and possible OGT

Monitors: Pulse ox, ECG, NIBP, Temp, Bair hugger. PNS if using muscle relaxants

Antibiotics per surgeon: possible cefazolin

Incision

Inguinal hernia and hydrocele via lower-lateral abdominal skin crease incision or laparoscopically with insertion of trocars

Umbilical hernia through a transverse incision in the infraumbilical skin fold or insertion of trocars

Surgical time: 40 min - 1 hr

Preop area: Verify NPO, consent signed, questions answered, then Versed 2 mg IV as needed

Induction

Preoxygenation

Lidocaine 1 mg/kg/IV

Propofol 1-2 mg/kg/IV

Fentanyl 1-3 mcg/kg/IV

Succinylcholine 0.5-1.5 mg/kg/IV

ETT

Maintenance

Isoflurane

Fentanyl

Emergence

Zofran IV, avoid coughing on extubation, use lidocaine IV and via ETT.

Consider deep extubation (spontaneous ventilation, suctioned, emerge on the mask)

Pneumoperitoneum          

• Provides a view of the surgical area, room for instruments to move
• There is a high risk for complications as the inferior vena cava, aorta, iliac arteries, and veins, as well as bladder, bowel, and uterus are close to the infraumbilical site
• Gas embolism symptoms: hypotension, dysrhythmias, cyanosis, pulmonary edema, Millwheel murmur
  • Release Pneumoperitoneum, place on the left side and aspirate air if possible
• Risk of pneumothorax due to barotrauma (increased PIP due to decreased pulmonary compliance)
• Left shoulder pain (CO₂)
  • Alleviate with three big breaths after CO₂ is released before the closure of the abdominal wall

Advantages: Decreased post-op pain, less post-op pulmonary impairment, reduction in post-op ileus, shorter hospital stay, earlier ambulation, and smaller incision

Anesthetic considerations

• Increased intraabdominal pressure, which predisposes to passive gastric regurgitation, possible NG to decompress and minimize the risk of aspiration
• Increased intraabdominal pressure also appears to decrease splanchnic perfusion and hepatic blood flow significantly
• High risk of PONV - Zantac, Reglan, Alka-Seltzer Gold, Zofran, and Decadron
• Try to keep intra-abdominal pressure <15 mmHg
• Increased risk of atelectasis, decreased FRC, increased PIP
• Risk of hypercarbia from absorbed CO₂, monitor ETCO2 and decreased PaO₂
• Avoid Nitrous oxide as it can diffuse into CO₂-containing intraabdominal space and increase distention
• Decreased venous return, decreased CO, and increased SVR
• Increased MAP, increased HR (baroreceptor response)
• Bradycardia due to distention of Vagus nerve/vagal reflex evoked by bowel traction
• Trendelenburg position increases intrathoracic pressures (cephalad displacement of abdominal contents), which activates baroreceptor reflex through CNIX in the carotid and CN X in the aortic arch, leading to increased PNS and decreased SNS activity
• Trendelenburg with increased risk of R main stem intubation
• Reverse Trendelenburg with increased FRC and decreased work of breathing
• Neuromuscular blockade
  • Lower insufflation pressures, better visualization, prevent movement
• Celiac reflex can be initiated indirectly as a result of pneumoperitoneum
  • The symptoms are bradycardia, apnea, and hypotension