Care of patients undergoing day case inguinal hernia repair

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Module overview

Inguinal hernia repair is a common operation often performed as a day case procedure. Day surgery is popular with patients and offers many benefits. This module outlines the most common forms of hernia repair and discusses the need for general or local anaesthesia. Basic principles of day surgery management, including patient selection criteria, pain relief, post-operative information, nurse-led discharge and subsequent aftercare are described, many of which are applicable to other day surgery procedures.
after care, anaesthesia, anaesthetics, day surgery, follow up, pain, pain relief, patient education, patient information, post-operative care, surgical

Aims

The aim of this module is to provide an overview of the pathology of an inguinal hernia and the indications for surgical repair.

Intended learning outcomes

After reading this module and completing the time out activities you should be able to:
  • Describe the pathology of an inguinal hernia and reasons for surgical repair.
  • Outline the most common methods of inguinal hernia repair, including open surgery and laparoscopic surgery.
  • List the benefits of performing hernia repair under local anaesthesia.
  • Discuss why day surgery is appropriate for the majority of patients undergoing inguinal hernia repair.
  • Describe the basic principles of day surgery, in particular regarding analgesia, which can be applied to other procedures.
  • Explain the importance of providing patient information to aid early detection and treatment of post-operative complications.

  • Introduction

    An inguinal hernia is a protrusion of abdominal contents through the muscle of the abdominal wall at the level of the inguinal canal in the groin (Figure 1).
    It is most commonly seen in men (Purkayastha et al 2008), because they have an inherent weakness in the abdominal wall where the spermatic cord passes through the inguinal canal, but it can also occur in women. It is also increasingly common with ageing because the muscles in the abdominal wall become weaker.














Figure 1. Inguinal hernia anatomy

©Peter Lamb


  • The protrusion may be an out-pouching of peritoneum, but it often contains peritoneal fat or bowel (Purkayastha et al 2008), and can appear as a swelling or lump. If the lump appears intermittently, usually on standing or on straining, and then disappears on lying down or can be pushed back into the abdominal cavity, then the hernia is said to be reducible.
  • A lump that remains permanently outside the abdominal cavity and which cannot be pushed back is said to be irreducible (Purkayastha et al 2008).
  • If a loop of bowel becomes trapped in an irreducible hernia, it can compromise the blood supply to the bowel, leading to intense pain, perforation and peritonitis.
  • Preventing this life-threatening condition is one of the main reasons for electively repairing an inguinal hernia. Patients may also request repair because the hernia is uncomfortable or painful.
  • A hernia may occur on one (unilateral) or both (bilateral) sides of the body. It is said to be primary on its first occurrence and recurrent if it returns after repair (Purkayastha et al 2008).
More than 80,000 inguinal hernia repairs were performed from April 1 2011 to March 31 2012 in England (Health & Social Care Information Centre 2013). Overall, about two thirds of all inguinal hernia repairs are performed on a day case basis (British Association of Day Surgery (BADS) 2012a), with the remainder of patients spending at least one night in hospital, although there is considerable variation between individual hospital trusts (BADS 2012a, NHS Institute for Innovation and Improvement 2013).
BADS (2012b) believes that more patients with inguinal hernia could benefit from day surgery if current selection criteria were applied consistently and patients followed an appropriate ambulatory pathway. Up to 95% of primary and 70% of recurrent hernia repairs could be performed without an overnight stay in hospital (BADS 2012b).
  1. An inguinal hernia is a protrusion of abdominal contents through the muscle of the abdominal wall at the level of the inguinal canal in the groin. It is most commonly seen in men.
  2. The protrusion may be an out-pouching of peritoneum, but it often contains peritoneal fat or bowel, and can appear as a swelling or lump.
  3. If the lump appears intermittently, usually on standing or on straining, and then disappears on lying down or can be pushed back into the abdominal cavity, then the hernia is said to be reducible. If it is not possible to push the lump back then it is termed irreversible.
  4. About two thirds of all inguinal hernia repairs are performed on a day case basis. More than 80,000 inguinal hernia repairs were performed from 2011 to 2012 in England.

Open inguinal hernia repair

A range of operations has been described for inguinal hernia repair (Purkayastha et al 2008). Most of these used sutures to pull the patient’s tissues, which could be muscles, ligaments or tendons, tight across the defect. Recurrence rates associated with these procedures were relatively high and with lack of agreement over which techniques were best, many surgeons suggested that none of these operations were particularly effective (Purkayastha et al 2008).
Lichtenstein (1964) began performing tension-free repairs in the 1960s. With the development of appropriate materials, the technique evolved to include a synthetic mesh (Amid et al 1996) and has since become the gold standard for inguinal hernia repair, primarily because the recurrence rate is significantly lower than that following sutured repairs (Purkayastha et al 2008, Amato et al 2012). Because the mesh is placed without tension, post-operative pain is reduced (Purkayastha et al 2008) and manageable with oral analgesia. This in turn leads to earlier ambulation and shorter hospital stays (Purkayastha et al2008).

Figure 2. Tension-free repair


Laparoscopic inguinal hernia repair

Laparoscopic inguinal hernia repair involves the placement of a sheet of mesh into the abdomen through the laparoscope to cover the hernia orifice from the inside. The mesh is fixed in place, without tension, using sutures or tacking devices. Early results showed a high recurrence rate (Bhandarkar et al 2006), however the technique has evolved and recurrence rates have reduced (Schmedt et al2005, Bhandarkar et al 2006).
Currently, two main laparoscopic techniques are used:
  1. The first of these is the transabdominal preperitoneal (TAPP) repair, in which the hernia is approached through the peritoneal cavity. A mesh is placed over all possible hernia sites in the inguinal region and the peritoneum is then closed over this.
  2. The second technique is the totally extraperitoneal (TEP) repair, in which the hernia opening is reached without going through the peritoneal cavity, and instead is approached via the preperitoneal plane (a plane developed in front of the peritoneum) by separating it from the abdominal wall. Although technically more difficult than TAPP repair, the TEP technique may reduce the risk of damage to intra-abdominal organs (National Institute for Health and Care Excellence (NICE) 2004).

Figure 3. Totally extraperitoneal (TEP) repair and transabdominal preperitoneal (TAPP) repair

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