Plate 213
###### Figure 7

Adult inguinal hernias are usually repaired in an ambulatory surgery setting unless coexisting medical conditions merit hospitalization for specialized monitoring or care. The use of polypropylene mesh has become increasingly popular as it may be used for both direct and indirect hernias and it results in a lower rate of recurrence.

The obese patient should be required to lose weight, preferably to within 10 percent of calculated ideal weight, which may delay the operation for a considerable time. Any open skin infections must be healed prior to operation. Systemic causes of increased intra-abdominal pressure or straining should be reviewed. A productive cough or an upper respiratory infection will delay the procedure until resolution. Chronic smokers should be encouraged to curtail their smoking. Evidence of prostatic obstruction should be evaluated in older men and the possibility of new colon lesions should be evaluated in older men and women. All patients should be taught how to get out of bed with a minimum of discomfort and advised to practice this. Sensitivity to drugs, including local anesthetics, should be ascertained. A mild cathartic may be given a day before the operation to ensure an empty colon. Mineral oil may be given to ensure bowel action without excessive straining after operation. A thorough medical evaluation is essential in older patients. A hernia should be relatively asymptomatic unless it becomes incarcerated. Any other symptoms must be evaluated, because they may be due to causes other than hernia.

Deep sedation with an anxiolytic, narcotic, and hypnotic (commonly midazolam, fentanyl, and propofol) is combined with a field block of local anesthesia. Lidocaine 1 or ½ % without adrenaline is preferred and the total dose is limited to less than 300 mg (30 mL of 1% lidocaine). This amount may be reduced in elderly patients. No adrenalin is used during the opening as this may obscure small bleeding vessels that should be ligated or cauterized thus lessening ecchymosis or hematoma formation. However, during the closure, when hemostasis is secured, many surgeons reinfiltrate the operative field with a long-acting local anesthetic such as bupivacaine. Adrenalin is often added except in patients with heart disease so as to extend the duration of the local anesthetic.

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