Herniorrhaphy has become an outpatient surgical procedure, regardless of the age of the patient. The Shouldice repair has been advocated for some years as the procedure of choice for adults with inguinal hernias.
The obese patient should be required to lose weight, preferably to within 10% of calculated ideal weight. This may delay the operation for a considerable time. Any infections of the skin should be cleared up before operation. A productive cough or an upper respiratory infection delays the procedure. Chronic smokers should be encouraged to curtail their smoking. Evidence of prostatic obstruction should be sought in older men. 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 should be given a day before the operation to ensure an empty colon. A mild laxative or 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 plus local anesthesia is commonly used. The type of sedation will vary, but may include midazolam, fentanyl or meperidine, and propofol. Local anesthesia is limited to 30 mL of 1% lidocaine without epinephrine (total lidocaine dose <300 mg). The amount is reduced in elderly patients.
The skin is carefully inspected for any evidence of localized infection. All hair of the lower abdomen and pubis is removed with an electric hair clipper. In patients with scrotal hernias, the skin of the scrotum should be included in the usual skin preparation with topical antiseptics.
The legs should be slightly flexed, with pillows under the knees, and the patient placed in a modified Trendelenburg position to assist in the reduction of the hernia sac. Following the draping of the patient, the local anesthetic is injected. Keeping in mind the location of the ilioinguinal and iliohypogastric nerves, the original injection of a few milliliters of anesthetic agent is made, using a fine needle (No. 25), just medial to the anterosuperior spine. Approximately 10 mL of (lidocaine) anesthetic solution is injected subcutaneously with a No. 25 needle above and parallel to the inguinal ligament. About 5 mL is injected medial to the anterosuperior spine deep into the external oblique aponeurosis to anesthetize the ilioinguinal nerve. Another 5 mL is injected about the internal ring to eliminate painful impulses from the peritoneum and from the genital branch of the genitofemoral nerve. In elderly patients, less anesthetic solution is used. Epinephrine is not used in the elderly or in patients with cardiovascular disease.