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Local Anesthesia for Inguinal Hernia Repair

(Originally posted 22 September 1997 on About Anesthesiology)

INTRODUCTION
Many practitioners and institutions routinely and successfully employ local anesthesia for inguinal hernia repairs. Although there are certainly other options (including general anesthesia and regionl anesthesia such as spinal or epidural), local offers some unique advantages to the patient. As such, here is a short summary about the use of local for these operations including a discusssion of advantages and disadvantages.

Obviously, the choice of anesthesia will be influenced by patient preferences and needs. In addition, to complete any operation successfully under local anesthesia requires a surgeon who is comfortable with the technique and willing to stop surgery and place additional local anesthesia should this become necessary. Interestingly with inguinal hernia repair it is rarely, if ever, necessary to supplement with additional injections once the initial infiltration is complete. Reported experiences with it have been uniformly positive.

Advantages of Local Anesthesia
Minimal physiological disturbance which may be an advantage in the patient in whom you wish to avoid a general anesthetic and in whom a regional technique may be contraindicated. This could include patient's with serious cardiac or respiratory diseases which could tolerate other types of anesthesia but would be at reduced risk if given only local anesthesia.

Postoperative pain relief is another benefit. At out institution we inject with a mixture of lidocaine and bupivicaine which gives quick anesthesia but long-lasting pain relief following the operation.

The primary advantage, and the reason that we utilize this technique for almost all of our patients, is quick recovery and ambulation allowing a quick discharge of ambulatory surgery patients to home.

Disadvantages of Local Anesthesia
Surgery on the awake patient must be carried out gently and the surgeon must be willing to adapt both technique and pace to the needs of the patient. Incisional pain is usually blocked. However, some pressure sensation and traction on tissues, particularly the peritoneum, can be uncomfortable for the patient. The patient should be warned about these possibilities and be told that the operation may be slightly uncomfortable at times but should not be painful. Obviously careful patient selection, proper informed consent, and preoperative patient education are very important.

Some sedation during the operation may be required for anxious patients which loses some of the benefits of avoiding other anesthetic techniques in higher risk patients. Again, we usually utilize this technique on relatively healthy, ambulatory patients.In this population, the addition of small amounts of sedation, especially with the shorter acting agents available today, does not delay discahrge. Patients who are excessively nervous may not be suitable for surgery with this technique. Almost always, these patients can be identified during pre-operative interview, but we always consent our patients for regional and general techniques as backup anesthetic methods just in case.

Placement of Local Anesthesia
It should go without saying that attention should be given to the maximal allowable dosages of local anesthetic for your patient's weight. Also, even with a straight local technique, equipment for full resuscitation and for other methods of anesthesia should be available, checked and ready to go.

Constant communication should be kept with the patient during injection because (a)the patient will experience what is being done and (b)the level of consciousness of the patient is a good monitor for accidental intravascular or intraneural injection. Standard anesthetic monitoring of vital signs should be performed during the placement of local anesthesia dna throughout the operation.

The nerve supply of the area comes from the anterior branches of the six lower intercostal nerves which continue forward onto the abdominal wall with the last thoracic nerve. The iliohypogastric and ilioinguinal nerves (T12 and L1) supply the sensory distribution of the lower abdomen.

The genitofemoral nerve (L1 and L2) supplies the structures that make up the inguinal cord as well as the anterior scrotum by means of the genital branch. It also supplies the skin and subcutaneous tissues of the femoral triangle via the femoral branch.

These nerves are easily blocked by an injection of local anesthetic just medial to the anterior superior iliac spine and lateral to the pubic tubercle. This will provide anesthesia to the depper structures that will be dissected and manipulated. It should also give some anesthesia to the parietal peritoneum of the hernia (the sac). In addition, local anesthesia should be injected subcutaneously along the inguinal line (along the intended line of incision) to provide anesthesia at that location.

SpecificsThe anterior superior iliac spine should be identified. From a point approximately teo centimeters medial to this, 5-10cc of local anesthesia should be given under the external oblique in a fanwise fashion.

Identify the pubic tubercle. Inject just laterally to this landmark toward the umbilicus and also more laterally. 5cc of local injected in each direction is usually suifficient.

Complete the block by injecting along the line of intended incision. Keep some local anesthetic ready to supplement as necessary (most commonly utilized for the sac once it is exposed). Sometimes, traction on the hernia sac with inadequate anesthesia can cause bradycardia and a feeling of "light-headedness" in the patient. This is best treated by stopping the surgery, treating with atropine if necessary, and administering additional local anesthetic prior to proceeding.

Complications usually result from intravenous injection of a large amount of local anesthetic. This can be avoided by aspiration prior to injection and by keeping the needle moving while injecting the volumes of local anesthetic mentioned.

 

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