Jeffrey A. Norton MD
Surgeon
Harry A. Oberhelman MD, FACS
Surgeon
Martin Angst MD
Anesthesiologist
P.626
Exploratory or Staging Laparotomy
Surgical Considerations
Description: Exploratory laparotomy is indicated primarily in patients suffering abdominal trauma or other acute abdominal catastrophes. It is important that a thorough and systematic intraabdominal examination be carried out to prevent missing significant injuries (e.g., ruptured duodenum or transected pancreas). Any active bleeding should be controlled prior to a systematic examination. Other indications for laparotomy include certain patients with fever of undetermined origin or those in whom a specific diagnosis cannot be made, or for staging of selected patients with Hodgkin's disease. A staging laparotomy (Fig. 7.9-1) consists of splenectomy, wedge and needle biopsies of both lobes of the liver, and biopsies of the periaortic, celiac, mesenteric, and portahepatic lymph nodes. In young women, suturing (pexing) the ovaries in the midline protects them from radiation. Indications for staging in Hodgkin's disease and lymphomas vary from institution to institution, but PET /CT scans have limited their use.
Basically, the procedure begins with a midline abdominal incision; then the abdomen is explored, and both needle and wedge biopsies of the liver may be performed. The spleen may be removed by incising the lateral peritoneal attachment and delivering the spleen into the wound. The short gastric vessels are cut and ligated and the splenic vessels exposed. These are cut individually and ligated, and the spleen is removed. Paraaortic nodes are exposed through a left paraaortic incision in the retroperitoneum, and removed for biopsy. Lymph channels are clipped to prevent lymphatic leakage. The nodes dissected extend to the inferior margin of the duodenum. It may be necessary to cross the aorta and biopsy any enlarged nodes on the right side. More recently, laparoscopy is being performed for staging of certain intraabdominal malignancies (e.g., pancreatic cancer); however, its use has decreased with improved multiphasic CT scans.
Usual preop diagnosis: Abdominal trauma; Hodgkin's disease or other lymphomas
|
Figure 7.9-1. Staging laparotomy. (Reproduced with permission from Scott-Conner C.E.H., Dawson DL: Operative Anatomy, 2nd edition. Lippincott Williams & Wilkins, Philadelphia: 2003.) |
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Summary of Procedures
|
|
Staging Laparotomy |
Exploratory Laparotomy |
|
Position |
Supine |
⇐ |
|
Incision |
Midline abdominal |
⇐ or transverse |
|
Special instrumentation |
Abdominal retractor |
⇐ |
|
Unique considerations |
Ovarian pexy |
Careful monitoring of VS in trauma patients |
|
Antibiotics |
Cefoxitin 1 g iv |
Cefazolin iv 1 g; 1–2 g iv in trauma patients |
|
VTE prophylaxis |
Heparin 5000 units sq |
⇐ |
|
Surgical time |
1.5–2 h |
Variable, 1–2 h+ |
|
Closing considerations |
Splenic bed hemostasis |
Hemostasis |
|
EBL |
100–200 mL |
Variable, 200–500 mL |
|
Postop care |
NG decompression; PACU → ward |
ICU for trauma patients |
|
Mortality |
< 1% |
2–5% |
|
Morbidity |
Prolonged ileus: 10–15% |
⇐ |
|
Pain score |
6–8 |
6–8 |
Patient Population Characteristics
|
Age range |
15–60 yr |
15–75 yr |
|
Male:Female |
1:1.5 |
1:1 |
|
Incidence |
Common |
⇐ |
|
Etiology |
Unknown |
Trauma |
|
Associated conditions |
Hodgkin's disease (95%); lymphoma (5%) |
Other visceral or vascular injuries in trauma |
Anesthetic Considerations
(Procedures covered: exploratory/staging laparotomy that is not trauma-related; splenectomy)
Preoperative
Typically, nongynecologic patients presenting for staging laparotomy (which may include splenectomy) have Hodgkin's disease or other lymphomatous disorder. Apart from the primary disease, these patients are typically in reasonably good health and will not have had radiation or chemotherapy before the staging laparotomy. Patients presenting forsplenectomy may be divided into two less healthy groups: (a) trauma patients (whose management is described in Trauma Surgery, p. 737) and (b) a more complex group with myeloproliferative disorders and other
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varieties of hypersplenism. The periop management of these two groups is more complicated. The latter group may have received chemotherapy and/or radiation therapy, which may affect a variety of organ systems. It is incumbent upon the anesthesiologist to be aware of the periop implications of these adjunctive treatments. The actual extent of a staging or exploratory laparotomy can vary substantially. A good understanding of the surgeon's plan and its inherent risks (e.g., removing tumor in close proximity to a major blood vessel) is crucial for providing adequate anesthesia care.
|
Respiratory |
Patients who have splenomegaly may have a degree of left lower lobe atelectasis and compromised ventilation 2° intraabdominal pathology: ↓ FRC →↑ A-a gradient + ↓ PaO2. This should be evaluated by physical exam. Some may have been treated with chemotherapeutic agents (e.g., bleomycin at a total dose > 200 mg/m2) that cause pulmonary pathology including fibrosis. Toxic drug effects are potentiated by smoking, XRT, and high FiO2. |
|
Cardiovascular |
Patients with systemic disease requiring splenectomy may be chronically ill and have ↓ cardiovascular reserve. Patients who have received certain chemotherapeutic agents (e.g., doxorubicin at a dose > 550 mg/m2) may suffer from cardiotoxic side effects that can be worsened by XRT. Manifestations include CHF and dysrhythmias. |
|
Neurological |
Patients may have neurological deficits from receiving certain chemotherapeutic agents (e.g., peripheral neuropathies caused by vinblastine and cisplatin or CNS pathology caused by 5-fluorouracil and mithramycin). Evidence of neurologic dysfunction should be documented in the preop evaluation. |
|
Hematologic |
Patients are likely to present with splenomegaly 2° hematologic disease (e.g., Hodgkin's disease, non-Hodgkin's lymphoma, chronic leukemia, myeloid metaplasia, thrombotic thrombocytopenic purpura, idiopathic autoimmune hemolytic anemia, and sickle cell disease). Cytopenia is very common. Myelosuppression should be anticipated in all patients receiving active chemotherapy. |
|
Hepatic |
Some chemotherapeutic agents (e.g., methotrexate and mithramycin) may be hepatotoxic. Evaluation of LFTs should be considered in patients at risk. |
|
Renal |
Some chemotherapeutic drugs (e.g., methotrexate and cisplatin) are nephrotoxic and patients may present with impaired renal function. |
|
Laboratory |
Other tests as indicated from H&P |
|
Premedication |
Consider midazolam 1–2 mg iv. In patients with suspected gastrointestinal stasis the use of a H2-antagonists (e.g., ranitidine 50 mg iv) and metoclopramide (10 mg iv) 1 h preop, and Na citrate (30 mL po) 10 min preop may be used to minimize the risk of pulmonary aspiration. Metoclopramide is contraindicated in patients with bowel obstruction or perforation. A supplemental intravenous steroid dose (e.g., 25–100 mg hydrocortisone) may be required in patients receiving preop steroids as part of their chemotherapeutic regimen. |
Intraoperative
Anesthetic technique: GETA ± epidural for postop analgesia. If postop epidural analgesia is planned, placement of catheter prior to anesthetic induction is helpful to establish correct placement in the epidural space (accomplished by injecting 1–2% lidocaine (50–100 mg) via the epidural catheter to elicit a segmental block). The use of epidural anesthetic techniques for postoperative pain control in patients undergoing major, nonvascular abdominal surgery has been shown to provide superior pain control compared with IV-PCA. However, adequate pain control can be achieved with the use of IV-PCA.
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|
Induction |
Standard induction (see p. B-2) except in patients at risk for pulmonary aspiration, who require a rapid-sequence induction (see p. B-4). |
|
|
Maintenance |
Standard maintenance (see p. B-2). High inspired O2 concentrations (>30%) may aggravate chemotherapy-induced (e.g., bleomycin) lung injuries. Combined epidural/GA: the epidural catheter ideally is placed at a level corresponding to the surgical site (generally, low thoracic). This allows the use of both lipophilic and hydrophilic drugs at the lowest possible dose, adds flexibility to the anesthesiologist's choice of agents, and minimizes the likelihood of side effects. A continuous infusion (after an initial bolus dose) is the preferred mode of administering epidural local anesthetics because satisfactory analgesia can be achieved without major fluctuations in BP. Lower concentrations of bupivacaine (0.125–0.25%) can be infused to provide supplemental analgesia, whereas higher concentrations (0.5%) may improve surgical conditions (complete motor block). The infusion rate is contingent on the desired segmental spread, but often ranges between 4–8 mL/h. Longer-acting hydrophilic opioids (e.g., hydromorphone 0.4–0.6 mg or morphine 2–3 mg for an epidural placement at the lower thoracic spine) can be injected as a bolus along with the initial bolus dose of a local anesthetic. However, hydrophilic opioids tend to spread rostrally within the intrathecal space and may cause sedation and respiratory depression if dosed too aggressively. Vulnerable patients include the elderly, patients with obstructive airway disease and patients suffering from obesity. The use of epidural local anesthetics is associated with sympatholysis and ↓ BP has to be anticipated. Critical ↓ BP is treated with fluids iv and/or vasopressors (e.g., ephedrine 5–10 mg iv). In patients undergoing a surgical procedure with a significant risk for major bleeding, it is prudent to delay administration of epidural local anesthetics until the critical part of surgery has been completed. Systemic sedatives (e.g., opiates and benzodiazepines) should be minimized as they increase the likelihood of postop respiratory depression. |
|
|
Emergence |
Most patients can be extubated at the end of surgery. Patients undergoing extensive surgery with major fluid shifts may require prolonged intubation until cardiovascular stability and sufficient reduction of soft-tissue edema (compromised airway) is achieved. |
|
|
Blood and fluid requirements |
IV: 14–16 ga × 1–2 |
Potential for major blood loss. In patients with difficult iv access, postinduction placement of additional access is prudent. In splenectomy patients, Plt transfusions should be given after ligation of splenic vessels (↓ sequestration). |
|
NS/LR @ 6–10 mL/kg/h |
Intraoperative fluid therapy should be titrated to a patient's particular needs (adequate peripheral perfusion, urine output > 0.5mL/kg/h, no base deficit). Overly generous intraoperative fluid administration may be associated with postoperative morbidity (e.g., delayed recovery of bowl function) and extended hospital stay. |
|
|
Monitoring |
Standard monitors (seep. B-1). |
Others as indicated by patient's status. To prevent hypothermia during long operations, use warming blanket(s), consider heated humidifier and warming room temperature. Place an arterial line in patients with hemodynamic instability or those at risk for significant intraop bleeding. Consider CVP for guiding fluid management, particularly in patients with concomitant cardiovascular disease. Monitoring UO is mandatory. |
|
Positioning |
[check mark] and pad pressure points |
|
|
Complications |
Unexpected bleeding |
Plt transfusion may be necessary. |
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Postoperative
|
Complications |
Bleeding |
Patient should be recovered in ICU or hospital ward that is accustomed to treating side effects of epidural local anesthetics and opiates (e.g., arterial hypotension, respiratory depression, breakthrough pain, nausea, pruritus). |
|
Pain management |
Epidural analgesia |
Epidural analgesia provides superior postop pain control, compared to other analgesic modalities. In high-risk patients, epidural analgesia may ↓ incidence of respiratory complications, but beneficial effects on other systems have not yet been demonstrated in patients undergoing nonvascular abdominal surgery. |
|
Tests |
CXR, if CVP placed perioperatively |
Suggested Readings
P.631
Splenectomy
Surgical Considerations
Description: Through a midline abdominal or left subcostal incision, the spleen is mobilized by dividing the lateral peritoneal attachments while the spleen is retracted medially. (Relevant anatomy is shown in Fig. 7.9-2.) Once the spleen is delivered into the operative wound, the short gastric vessels are clamped, cut, and ligated. The splenic artery and vein are then exposed with care being taken not to injure the tail of the pancreas. By keeping the splenic hilum between the operator's fingers and thumb, inadvertent bleeding can he controlled easily. Accessory spleens (incidence, 15–30%) also should be looked for if the splenectomy is being done for a hematologic disorder. They are found along the cephalad and caudad edges of the pancreas behind the stomach and in the area of the gastrohepatic ligament, greater omentum, and the splenic hilum. All patients undergoing splenectomy should receive polyvalent pneumococcal and H-influenza vaccines. Children may also require vaccination against meningococcus.
Variant procedure or approaches: Following trauma, efforts at splenic salvage (splenorrhaphy) may be made, if possible, to preserve all or part of the spleen. This may be accomplished by the use of local hemostatic techniques (electrocoagulation, argon beam coagulator, Surgicel or Gelfoam soaked in thrombin, microfibrillar collagen, and the use of fine sutures or mattress sutures with Teflon felt pledgets). Recently, splenectomy has been performed laparoscopically if the spleen is near normal size (see Laparoscopic Splenectomy, p. 581).
|
Figure 7.9-2. Anatomic relation of the spleen to the liver, diaphragm, pancreas, colon, and kidney. The stomach is sectioned to illustrate the anatomic relations in situ. (Reproduced with permission from Greenfield LJ, Mulholland MW, Oldham KT, et al., eds: Surgery: Scientific Principles and Practice, 3rd edition. Lippincott Williams & Wilkins, Philadelphia: 2001.) |
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Usual preop diagnosis: Staging laparotomy results; trauma; immune thrombocytopenic purpura; hereditary spherocytosis; other hereditary hemolytic anemia types; or a variety of myeloproliferative disorders
Summary of Procedures
|
|
Splenectomy |
Splenorrhaphy |
|
Position |
Supine |
⇐ |
|
Incision |
Midline or left subcostal |
⇐ |
|
Special instrumentation |
Suitable abdominal retractors |
⇐ |
|
Unique considerations |
Potential for major blood loss during procedure; avoid splenic laceration and damage to tail of pancreas. |
⇐ |
|
Antibiotics |
Cefoxitin 1 g iv |
⇐ |
|
VTE prophylaxis |
Heparin 5000 units sq |
⇐ |
|
Surgical time |
1–2 h |
1–2 h |
|
Closing considerations |
Adequate hemostasis |
⇐ |
|
EBL |
50–100 mL |
200–500 mL |
|
Postop care |
NG decompression; PACU (nontrauma) |
⇐ |
|
Mortality |
0–3% |
⇐ |
|
Morbidity |
Thrombocytosis: > 1,000,000 → VTE |
⇐ |
|
Pain score |
5–7 |
5–7 |
Patient Population Characteristics
|
Age range |
Any age |
|
Male:Female |
1:1 |
|
Incidence |
Common |
|
Etiology |
See Usual preop diagnosis, above. |
|
Associated conditions |
Blood dyscrasia (30–50%); abdominal or thoracic trauma (25%); Hodgkin's disease (5–10%); tumors (5%) |
Anesthetic Considerations
See Anesthetic Considerations following Exploratory or Staging Laparotomy, p. 527.
Suggested Readings
P.633
Excision of Intraabdominal, Retroperitoneal Tumors
Surgical Considerations
Description: Intraabdominal and retroperitoneal tumors, other than those of visceral origin, consist primarily of sarcomas (liposarcoma, fibrous histiocytomas, mesenteric fibromas, and gastrointestinal stromal tumors). They are usually approached through a long midline incision for adequate exposure and to assess their resectability. Resection of such lesions may require excision of adjacent or involved small bowel or large intestine or other involved abdominal viscera. Care must be taken not to injure the ureters or major vessels, particularly at the root of the mesentery to the small bowel. It may be prudent to have ureteral stents placed to avoid injury to the ureters. If residual microscopic tumor remains, IORT may be indicated. In certain tumors, the patient may still benefit from “tumor debulking” (removing as much tumor as possible and treating the remaining tumor with radiation and/or chemotherapy). Operative approaches are dictated by location of tumor. Although most operative approaches are transabdominal, some retroperitoneal tumors may be approached retroperitoneally via oblique incision on either side of the abdomen. Some require thoracoabdominal incisions.
Usual preop diagnosis: Intraabdominal or peritoneal tumor
Summary of Procedures
|
Position |
Supine |
|
Incision |
Midline abdominal or transverse |
|
Unique considerations |
Availability of blood |
|
Antibiotics |
Cefoxitin 1–2 g iv preop |
|
VTE prophylaxis |
Heparin 5000 units sq |
|
Surgical time |
3–4 h |
|
Closing considerations |
Hemostasis |
|
EBL |
300–1000 mL |
|
Mortality |
1–3% |
|
Morbidity |
Respiratory problems: 5–10% |
|
Pain score |
8–10 |
Patient Population Characteristics
|
Age range |
Variable, 20–75 yr |
|
Male:Female |
1:1 |
|
Incidence |
Common |
|
Etiology |
Unknown |
|
Associated conditions |
Partial bowel obstruction (10–15%); hydronephrosis (10–15%) |
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Anesthetic Considerations
See Anesthetic Considerations for Intestinal and Peritoneal Procedures, p. 522, and for Exploratory or Staging Laparotomy, p. 627.
Suggested Readings
Drainage of Subphrenic Abscess
Surgical Considerations
Description: Abscesses may occur in subphrenic spaces, including the right subphrenic, right subhepatic, left subphrenic, lesser sac, or bare area of the liver (Fig. 7.9-3), following peritonitis, abdominal surgery or trauma. It is
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important to know the anatomy of these spaces for making a correct diagnosis and for treatment. Most commonly abscesses are drained by interventional radiology (85%), but some may require an open surgical approach.
|
Figure 7.9-3. Anatomy of subphrenic abscess. (Reproduced with permission from Baker RJ, Fischer JE: Mastery of Surgery, Vol. I. Lippincott Williams & Wilkins, Philadelphia: 2001.) |
Drainage is accomplished by a posterior or anterior extraperitoneal approach or by a transpleural approach, depending on location of the abscess. Lesser sac abscesses are best approached by an anterior transperitoneal route. Abscesses in the bare area of the liver are drained posteriorly. After the abscess is localized, the cavity is entered by finger dissection and drained. Loculations are broken up and the cavity thoroughly irrigated with NS or a suitable antibiotic solution. Appropriate drains are placed and the wound is closed in a conventional manner. Cultures are routinely obtained.
Variant procedure or approaches: Percutaneous approaches have become more popular as experience is gained by interventional radiologists. This technique should be reserved for unilocular collections, where sterile cavities are not penetrated and a safe route is available.
Usual preop diagnosis: Subphrenic abscess
Summary of Procedures
|
|
Subphrenic Abscess Drainage |
Percutaneous Approach |
|
Position |
Supine or lateral decubitus, right or left |
⇐ |
|
Incision |
Subcostal or oblique abdominal |
None |
|
Special instrumentation |
Drainage tubes |
Special catheters; CT guidance |
|
Antibiotics |
Zosyn (Piperacillin & Tazobactam) 3.375 g q6h |
⇐ |
|
VTE prophylaxis |
Heparin 5000 units sq |
⇐ |
|
Surgical time |
1–1 h |
⇐ |
|
EBL |
50–100 mL |
10–25 mL |
|
Postop care |
Maintain patency of the drainage tubes |
⇐ |
|
Mortality |
< 5% |
⇐ |
|
Morbidity |
Inadequate drainage: 5–10% |
⇐ |
|
Pain score |
7–9 |
4–5 |
Patient Population Characteristics
|
Age range |
Variable, 15–80 yr |
|
Male:Female |
1:1 |
|
Incidence |
Common |
|
Etiology |
Postop (70–80%); peritonitis (25–30%); trauma (5–10%) |
|
Associated conditions |
See Etiology, above. |
Anesthetic Considerations
See Anesthetic Considerations for Intestinal and Peritoneal Procedures, p. 522.
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Suggested Readings
Inguinal Herniorrhaphy
Surgical Considerations
Description: Groin hernias are defects in the transverse abdominis layer, where a direct hernia comes through the posterior wall of the inguinal canal and an indirect hernia comes through the internal inguinal ring (Fig. 7.9-4). Direct hernias are medial to the inferior epigastric artery and vein, whereas indirect hernias are lateral to these vessels. Surgical approach can be either anterior or posterior. In general, an anterior approach (Bassini, McVay's, Shouldice, or mesh repair) is used for primary repair of an indirect or direct inguinal hernia. The Bassini repair consists of ligation of the hernia sac and suturing the conjoint tendon to the shelving edge of Poupart's ligament. McVay's repair sutures the conjoint tendon to Cooper's ligament and usually is reserved for femoral inguinal hernias. Shouldice emphasizes the closing of the transverse fascia and transversus abdominal muscle layers. Currently, the interposing of Marlex mesh or insertion of a Marlex plug between the conjoint tendon, the internal oblique muscle, and the inguinal ligament is commonly used. Other modifications are indicated in special situations.
A posterior approach is used by some surgeons for the repair of femoral hernias and recurrent inguinal hernias and for treating incarcerated and strangulated hernias. The posterior preperitoneal approach is normally performed by suturing the transversus abdominis arch on the superior aspect of the hernia defect to Cooper's ligament and the iliopubic tract on the inferior aspect of the defect.
The laparoscopic approach is indicated for the repair of recurrent or bilateral inguinal hernias and utilizes a preperitoneal patch repair and results in less postop pain and an earlier return to normal physical activity (see Laparoscopic Inguinal Hernia Repair, p. 595).
Usual preop diagnosis: Groin pain or lump
Summary of Procedures
|
Position |
Supine |
|
Incision |
Oblique or transverse |
|
Unique considerations |
Avoid damage to nerve structure and spermatic cord. Avoid interfering with blood supply to testes. |
|
Antibiotics |
Cefazolin 1 gm iv preop |
|
Surgical time |
1–1.5 h |
|
Postop care |
PACU → room |
|
EBL |
25–50 mL |
|
Mortality |
3/100,000 |
|
Morbidity |
Wound abscess: < 3% |
|
Pain score |
4–5 |
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|
Figure 7.9-4. Inguinal anatomy. (Reproduced with permission from Scott-Conner CEH, Dawson DL: Operative Anatomy, 2nd edition. Lippincott Williams & Wilkins, Philadelphia: 2003.) |
Patient Population Characteristics
|
Age range |
1–90 yr |
|
Male:Female |
85:15 |
|
Incidence |
15/1000 |
|
Etiology |
Congenital variants; reduced collagen synthesis in adults |
|
Associated conditions |
Chronic cough; urinary retention; chronic constipation |
Anesthetic Considerations
See Anesthetic Considerations following Repair of Abdominal Dehiscence, p. 641.
Suggested Readings
P.638
Femoral Herniorrhaphy
Surgical Considerations
Description: The hernia sac is exposed as it exits the preperitoneal space through the femoral canal (Fig. 7.9-5). If the hernia cannot be reduced, the possibility of strangulation needs to be kept in mind. The peritoneal sac in most cases should be opened proximal to the femoral canal in order to gain control of the intestine before it reduces itself into the peritoneal cavity. If the bowel is ischemic, it may require resection. The repair consists of suturing the iliopubic tract to Cooper's ligament, taking care not to compromise the femoral vein (McVay repair).
Usual preop diagnosis: Bulging of tissues over femoral canal
Summary of Procedures
|
Position |
Supine |
|
|
Incision |
Oblique |
|
|
Antibiotics |
Cefazolin 1 g iv |
|
|
Surgical time |
1–1.5 h |
|
|
EBL |
25–50 mL |
|
|
Postop care |
PACU → room |
|
|
Mortality |
< 1% (6–20%, if strangulated) |
|
|
Morbidity |
Recurrence: 6% |
|
|
Pain score |
5–6 |
|
|
Figure 7.9-5. Femoral hernia repair. (Reproduced with permission from Scott-Conner CEH, Dawson DL: Operative Anatomy, 2nd edition. Lippincott Williams & Wilkins, Philadelphia: 2003.) |
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Patient Population Characteristics
|
Age range |
Adults; rare in children |
|
Male:Female |
1:4 |
|
Incidence |
1.5% of all groin hernias |
|
Etiology |
Failure of preformed peritoneal sac to obliterate; muscle atrophy in older age group |
Anesthetic Considerations
See Anesthetic Considerations following Repair of Abdominal Dehiscence, p. 641.
Suggested Readings
Repair of Incisional Hernia
Surgical Considerations
Description: Incisional hernias can occur after any abdominal incision, but are most common following midline incisions. Factors leading to herniation are: wound infection, trauma, inadequate suturing, and ischemia. Following skin incision, the skin edges and subcutaneous fat are retracted and the dissection is carried down to the hernia defect. The redundant hernia sac is excised and the fascia is freed up on both sides of the wound. Primary closure is preferred, if possible.
Variant procedure or approaches: In addition to primary repair, the latter may be reinforced by an onlay mesh prosthesis, or the prosthesis may be used to fill the hernial defect or placed behind the muscle layer. In the repair of incisional hernias, laparoscopic tacking of mesh is gaining in popularity.
Usual preop diagnosis: Incisional hernia
Summary of Procedures
|
Position |
Supine |
|
Incision |
Vertical or transverse |
|
Special instrumentation |
Mesh prosthesis (when indicated) |
|
Antibiotics |
Cefoxitin 1 g iv |
|
VTE prophylaxis |
Heparin 5000 units sq |
|
Surgical time |
1–2 h |
|
Closing considerations |
Retention sutures |
|
EBL |
100–200 mL |
|
Postop care |
NG decompression; abdominal binder; PACU → ward |
|
Mortality |
< 1% |
|
Morbidity |
Ileus: 5–10% |
|
Pain score |
5–6 |
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Patient Population Characteristics
|
Age range |
20–70 yr |
|
Male:Female |
1:1 |
|
Incidence |
3–5% of midline abdominal incisions |
|
Etiology |
Wound infection; trauma; inadequate suturing; weak tissues |
|
Associated conditions |
Obesity; malnutrition |
Anesthetic Considerations
See Anesthetic Considerations following Repair of Abdominal Dehiscence, p. 641.
Suggested Readings
Repair of Abdominal Dehiscence
Surgical Considerations
Description: Dehiscence implies a “splitting apart” or “bursting open” of the abdominal wall fascia. A complete dehiscence is a separation of all layers of the abdominal wall and often is associated with an extrusion of abdominal viscera. If incomplete, the separation of fascial and muscular layers results in an incisional hernia or an obstruction of a herniated loop of intestine. The earliest sign of a wound dehiscence is the presence of serosanguineous drainage from the wound. Minimal disruptions may be treated conservatively with occlusive dressings and an abdominal binder. Major dehiscence requires operative repair using retention sutures.
Variant procedure or approaches: Variations in the type of closure depend on surgeon's preference. Interrupted, nonabsorbable sutures and skin bridges are often used.
Usual preop diagnosis: Wound dehiscence
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Summary of Procedures
|
Position |
Supine |
|
Incision |
Closure of previous incision |
|
Unique considerations |
Adequate muscle relaxation essential |
|
Antibiotics |
Cefoxitin 1–2 g iv |
|
VTE prophylaxis |
Heparin 5000 units sq |
|
Surgical time |
1–2 h |
|
EBL |
50–100 mL |
|
Postop care |
Abdominal binder to relieve tension on suture line; PACU → ward |
|
Mortality |
5–10% |
|
Morbidity |
Recurrent incisional hernia: 5–10% |
|
Pain score |
4–5 |
Patient Population Characteristics
|
Age range |
25–90 yr |
|
Male:Female |
1:1 |
|
Incidence |
1.3% in patients < 45 yr |
|
Etiology |
Wound infection; excessive coughing or sneezing; excessive abdominal distention; weak tissue; poor nutrition; hematoma formation; poor surgical technique with tissue ischemia |
|
Associated conditions |
Malnutrition (25–30%); ascites (20–25%); hypoproteinemia (20%); chronic anemia (5–10%); vitamin C deficiency (< 5%) |
Anesthetic Considerations
Procedures covered: inguinal herniorrhaphy; femoral herniorrhaphy; incisional hernia repair; repair of abdominal dehiscence
Preoperative
Predisposing factors for hernia often include increased abdominal pressure 2° chronic cough, bladder outlet obstruction, constipation, pregnancy, vomiting, ↑BMI, and acute or chronic muscular effort. These factors should ideally be managed preop to avoid postop recurrence. The patient population may range from premature infants to the elderly, who have the potential for presenting with multiple medical problems.
|
Musculoskeletal |
Pain is likely to be present in area of hernia; evaluate bony landmarks if regional anesthesia is planned. |
|
Gastrointestinal |
Hernias may become incarcerated, obstructed, or strangulated, requiring emergency surgery. Fluid and electrolyte imbalance is likely. |
|
Hematologic |
For regional anesthesia, [check mark] patient's coagulation status, if indicated from H&P. |
|
Laboratory |
Other tests as indicated from H&P |
|
Premedication |
If necessary, standard premedication (see p. B-2). |
P.642
Intraoperative
Anesthetic technique: GA, regional, or local anesthesia ± iv sedation (MAC) may all be appropriate anesthetic techniques for uncomplicated cases (e.g., without incarceration or obstruction). Choice depends on factors such as site of incision, patient physical status, and preference of both patient and surgeon. Profound muscle relaxation may be necessary to facilitate exploration and repair.
Regional anesthesia:
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Spinal |
Single-shot vs continuous: Patient in sitting or lateral decubitus position (operative site down) for placement of hyperbaric subarachnoid block. Doses of local anesthetics are as follows for T4-T6 level: 0.75% bupivacaine in 8.25% dextrose (10–15 mg); 0.5% tetracaine in 5% dextrose (12–16 mg). Consider adding fentanyl (10–20 mcg). |
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Epidural |
Patient in sitting or lateral decubitus position for placement of epidural catheter. After locating the epidural space, administer a test dose (e.g., 3 mL of 1.5% lidocaine with 1:200,000 epinephrine) to determine whether the catheter is subarachnoid or intravascular. Titrate local anesthetic (e.g., 1–2% lidocaine or 0.5% bupivacaine or ropivacaine) until desired surgical level is obtained (5–7 mL at a time), usually 20 mL. Consider adding fentanyl (25–100 mcg). |
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Local |
Requires gentle surgical technique. Surgical field block, plus ilioinguinal and iliohypogastric nerve blocks, using 0.5% bupivacaine with 1:200,000 epinephrine. Usually performed by surgeon. |
General anesthesia:
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Induction |
LMA vs ETT: Standard induction (see p. B-2). LMA may be suitable for the patient who presents with a simple chronic hernia. If there is obstruction, incarceration, or strangulation, however, a rapid-sequence induction (see p. B-5) with ET intubation is indicated. GETA also may be indicated in the patient with wound dehiscence. |
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Maintenance |
Standard maintenance (see p. B-3). Muscle relaxants may be necessary to facilitate surgical repair. |
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Emergence |
Consider extubating the trachea while patient is still anesthetized to prevent coughing and straining. Patients who are at risk for pulmonary aspiration and require awake intubation or rapid-sequence induction (see p. B-4) are not candidates for deep extubation. |
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Blood and fluid requirements |
Minimal blood loss |
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Monitoring |
Standard monitoring (see p. B-2). |
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Positioning |
[check mark] and pad pressure points |
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Complications |
↓↓ HR + ↓ BP |
Vagal reflex evoked by bowel traction. |
P.643
Postoperative
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Complications |
PDPH after neuraxial block |
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Pain management |
PO analgesics: Acetaminophen and codeine (Tylenol #3 1–2 tab q 4–6 h) or oxycodone and acetaminophen (Percocet 1 tab q 6 h) |
Surgical field block or regional anesthesia should provide sufficient analgesia postop. |
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