Recent international guidelines suggest that local anesthesia with IV sedation for inguinal hernia repair leads to the best outcomes after surgery [1,2]. Most patients who undergo the fast recovery open preperitoneal hernia repair or the no-mesh Shouldice repair do NOT require general anesthesia for hernia surgery as these approaches are even less invasive than laparoscopic or robotic surgery. Most patients can have this surgery under intravenous (IV) sedation and injected local anesthetic (bupivicane/lidocaine) in the area. This allows most patients to wake up relatively quickly after surgery, and therefore spend less time in the hospital and recovering at home. By avoiding general anesthesia, patients have less postoperative nausea, vomiting, and urinary problems after surgery.
While most of our patients are able to avoid general anesthesia, the most common exceptions include patients who are overweight and have a Body Mass Index (BMI) greater than 28 patients who have had their prostate removed, and patients with complex recurrent hernias. We have also found that patients with a large abdomen, despite having a normal BMI, sometimes require general anesthesia.
There are several levels of anesthesia that are used in our practice. We work closely with anesthesiologists and nurse anesthetists to give patients the least amount of medications necessary to reduce pain while keeping patients comfortable during and after surgery.
Local anesthetics
All of our patients get a combination of short acting and long acting local anesthetics (numbing medications) injected into the skin and as a nerve block. Similar to a dental procedure, we time these injections at the start of the surgery to block any pain from occurring during the surgery. These medications remain effective for hours after the surgery allowing for less pain in recovery.
IV sedation anesthesia for hernia surgery
Intravenous sedation is the most common type of anesthesia used in outpatient hernia surgery. An anesthesiologist begins delivering a combination of medications through the patient’s IV just before surgery starts. This continues up until the end of surgery. During surgery, patients’ heart rate, blood pressure, and breathing is monitored the entire time by an anesthesia provider. To ensure safety, supplemental oxygen is provided, and patients breathe on their own during the whole procedure.
General anesthesia for hernia surgery
In our practice, less than 10% of patients require full general anesthesia. When we do utilize this form of anesthesia, it is out of necessity because the patient’s safety is enhanced by it. It is required for all laparoscopic and robotic procedures.
In general anesthesia, inhalation agents (gases) are used for sedation. These inhalation agents are sometimes combined with chemical muscle relaxants and mechanical ventilation via a breathing tube. In this level of anesthesia, patients are not breathing on their own. Again, this type of anesthesia is always required for all laparoscopic and robotic procedures. We always aim to provide the highest level of care while keeping patients safe and comfortable during surgery. Surgical approach and anesthesia type are important considerations in preparing for surgery. When possible, we use IV sedation medications and local anesthesia and avoid heavier forms of general anesthesia. Evidence shows that this allows a quicker recovery, less pain, and lower risk of complications like urinary retention in the recovery process. In some cases, general anesthesia is required for safety and we make every effort to keep the recovery process as smooth and comfortable for our patients when this is required.
Watch Dr. Fullington explain the indications for different types of anesthesia during hernia surgery:
About Dr. Reinhorn & Dr. Fullington
Dr. Michael Reinhorn is a specialist in inguinal hernia and umbilical hernia. Dr. Reinhorn started his practice as a full service general surgeon in 2001. In 2012 Dr. Reinhorn started to focus on the care of hernia and pilonidal patients. In 2020, Dr. Nora Fullington was recruited from her work as a general surgeon performing hundreds of laparoscopic hernia repairs to Boston Hernia. Together with their physician assistant team, they provide a focused practice designed to provide a superior clinical experience. The team performs approximately 700 hernia surgeries every year and offers a tailored approach for each patient from anesthesia type to consideration of mesh and no mesh repairs, laparoscopic and open surgery. We have published outcomes and continue to participate in hernia and surgery societies. Our research led to a reduction in opioid prescribing after hernia surgery. Currently, Dr. Reinhorn serves as the chair of the Opioid Reduction Task Force of the Americas Hernia Society Quality Collaborative.
References
1)Balentine CJ, Meier J, Berger M, et al. Using local rather than general anesthesia for inguinal hernia repair is associated with shorter operative time and enhanced postoperative recovery. Am J Surg. 2021;221:902–907. doi: 10.1016/j.amjsurg.2020.08.024. – DOI – PMC – PubMed
2)Prakash D, Heskin L, Doherty S, Galvin R. Local anaesthesia versus spinal anaesthesia in inguinal hernia repair: a systematic review and meta-analysis. The Surgeon. 2017;15:47–57. doi: 10.1016/j.surge.2016.01.001. – DOI – PubMed