Most patients who undergo the fast recovery open preperitoneal hernia repair do NOT require general anesthesia for hernia surgery. Most patients can have this surgery under intravenous (IV) sedation and injected local anesthetic in the area. This allows most patients to wake up relatively quickly after surgery, and therefore spend less time in the hospital and more time at home recovering. By avoiding general anesthesia, patients have a decreased risk of postoperative nausea, vomiting, and urinary retention. Recent international guidelines suggest that local anesthesia with IV sedation for inguinal hernia repair leads to the best outcomes in patients. For the Shouldice, non-mesh, inguinal hernia repair we almost exclusively perform the repair under local anesthesia with minimal IV sedation.
Most of our patients are able to avoid general anesthesia for inguinal hernia repair.There are exceptions, of course, and the following people often require general anesthesia: Patients who are overweight and have a Body Mass Index (BMI) greater than 28, patients who have had their prostate removed, and patients with recurrent hernias will often require general anesthesia. 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.
All of our patients get a combination of short acting and long acting anesthetics (numbing medications) injected into the skin and as a nerve block. The main benefit here is that these injections take place prior to cutting tissue, therefore blocking the pain sensation of the trauma caused to the tissues during surgery. This is similar to a dental procedure where the pain response is blocked for hours after the surgery allowing for less pain after surgery. The main side effect with this type of anesthesia is that a small percentage of patients will have temporary weakness in their leg after surgery. This is caused by the anesthetic injected in the surgical site reaching the femoral nerve that controls the leg.. This always wears off 6-18 hours. In rare cases, there is enough weakness in the leg that a protective foam knee brace is provided to patients for the evening after surgery.
IV sedation anesthesia for hernia surgery
Intravenous sedation is the most common type of anesthesia used in outpatient hernia surgery. A combination of a few different IV medications is given to patients, starting before and continuing to the end of surgery. An anesthetist or anesthesiologist is present from beginning to end of this type of anesthesia to ensure safety. Patients’ heart rate, blood pressure, and breathing is monitored the entire time. To ensure safety, supplemental oxygen is provided, and patients breathe on their own during the whole procedure.
General anesthesia for hernia surgery
For patients with a BMI over 28 or a more complicated hernia, general anesthesia is often required for hernia repair. In our practice, less than 10% of patients require general anesthesia. In general anesthesia, inhalation agents are used for sedation. These inhalation agents are sometimes combined with chemical muscle relaxation for paralysis and mechanical ventilation via intubation. In this level of anesthesia, patients are not breathing on their own. This type of anesthesia is required for all laparoscopic and robotic procedures. This is the type of anesthesia that is usually given for most general surgery procedures, including gallbladder surgery and colon surgery. In our practice we utilize this type of anesthesia only in situations where patients’ safety is enhanced by this form of anesthesia.
Since the evidence shows that local anesthesia with IV sedation is superior to general anesthesia for inguinal hernia repair, we prefer to use local with sedation in patients where this is an appropriate option. It is important for patients to understand the differences between anesthesia when choosing one repair type over another.
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.