If you need a hernia repair, you may be asked whether you'd prefer to have it done while you are awake or asleep. This is an important factor to discuss before your operation with your anesthesiologist, who will talk to you about the best way to control your pain.
Anesthesiologists work alongside surgeons on both routine and highly complex hernia repairs to make sure patients are comfortable and safe. “We take care of the patient so that the surgeon can concentrate on just repairing the hernia,” says Yale Medicine's anesthesiologist Robert Stout, MD.
What types of hernia repair procedures are done at Yale Medicine?
There are several different kinds of hernias, including:
Inguinal hernia: It occurs when a section of the intestine or bladder pushes through a weak spot in the abdominal wall down into the groin area.
Ventral hernia: This occurs where the muscles meet in the midline of your abdomen; you may have a congenital weakness there that can split open when strained.
Umbilical hernia: This is most common in children and women who have gone through childbirth. This hernia occurs when a part of the small intestine pushes through the abdominal wall near the belly button (navel).
Hiatal hernia: This type of hernia happens when a section of the stomach passes through a hole in the diaphragm that the esophagus goes through.
Incisional hernia: This can result when scar tissue from a previous surgery breaks down, and the incision reopens, allowing organs to poke through.
What types of anesthesia are available for hernia surgery?
The method of anesthesia depends on many factors, including the type, size and location of the hernia, and whether a section of the bowel is being incarcerated (unable to move back into place) or strangulated (pinched off so blood can’t flow to it) in the hernia. It also depends on the surgical technique planned by the surgeon, as well as the patient’s health and preferences.
In addition to the type of procedure the surgeon plans to perform, It's important to consider any potential alternatives the surgeon may use if the initial technique is not sufficient to complete the repair, Dr. Stout says.
Hernia surgery may be traditional open surgery or laparoscopic surgery, which involves smaller incisions through which the surgeon passes several thin tubes, small surgical instruments and a camera.
The different levels of anesthesia include:
Local anesthesia: Only used for the most superficial, easily repaired hernias, local anesthesia is injected at the site of the repair. It can theoretically can be done in the surgeon’s office with just a nurse in attendance, but it is usually done in an operating room or a “special procedure” room.
Monitored anesthesia care: This is used for “relatively simple cases," such as an inguinal hernia or some of the smaller ventral or umbilical hernias, where the surgeon thinks he can do the procedure with little or no sedation, Dr. Stout says. The patient is given a local anesthetic to numb the area where the surgery is performed, and some sedatives to help him remain relaxed and calm, but remains fully awake during the procedure.
Standard monitors such as an electrocardiogram (EKG) and blood pressure cuff are used, and medication is administered intravenously. “We start with low levels of sedation, but can raise it to a higher level if the patient is not tolerating the discomfort or the surgeon needs to extend the length of the incision," Dr. Stout says. "We can also take over the patient’s breathing if we feel we need to transition to deep sedation or a general anesthetic.” Using this method, the level of sedation can range anywhere from almost wide awake to fast asleep.
General anesthesia: This may be required for complicated repairs. In the operating room, the patient is hooked up to monitors, and given oxygen through a mask. Then the patient is given medication through an I.V., which causes unconsciousness. While the patient is asleep, a breathing tube may be inserted in his or her mouth so that the anesthesiologist can protect the airway if there’s concern about aspiration (inhaling the stomach’s contents back up into the airway); otherwise, the patient may simply breathe through a mask. Patients remember nothing about the surgery when they wake up.
Who decides what level and type of anesthesia to give for hernia surgery?
The patient will have an opportunity to discuss options with the anesthesiologist, either at a pre-admission clinic a week or two before the surgery, or on the morning of the procedure. “We give the patient our best guess at what we think is going to happen based on having worked with the surgeon before and the technique being used,” Dr. Stout says.
"We’ll also give an array of options depending on the size and severity of the hernia. We will talk about what is safe and reasonable, and go over various scenarios of what may happen during the surgery and what the side effects of different types of anesthesia may be.”
If it’s deemed safe and appropriate, the anesthesiologist will ask whether the patient prefers to be awake or completely asleep during surgery. “Patients have different opinions on that,” Dr. Stout says. “Some would rather have no knowledge at all of what’s going on, while others don’t want to feel nauseous or groggy when they wake up.” But for some complicated surgeries, general anesthesia is required, and the anesthesiologist will simply use this meeting to explain what the patient may expect.
How does the anesthesiologist help control pain after surgery?
Postoperative pain can vary depending on the type of surgery, Dr. Stout says. “If someone has a large incision from an open procedure, there may be a lot of sharp pain in the area of the incision, and that can be managed well with I.V. opioid medications as well as non-narcotic analgesics,” he says. The surgeon will also inject more local anesthetic into the site of the incision just before he or she closes it up.
With laparoscopic surgery, there is minimal pain at the incisions, because the incisions are all tiny. But because the abdomen is filled up with gas during surgery, so the surgeon can see what’s going on inside, the sensitive lining of the abdomen is stretched out and sore.
“It can sometimes feel like someone punched you really hard in the stomach,” Dr. Stout says. That pain is less intense and localized than incisional pain, but also a little harder to control. “We tell the patient what to expect after surgery,” Dr. Stout says, “and it’s important for them not to be a hero and bear the pain, but to tell us exactly what it feels like and how intense it is so we can manage it with medications before it gets out of control.”
Dr. Stout points out that the anesthesiologist can usually tell before the anesthesia wears off what the patient’s comfort level will be, based on his or her vital signs. “By the time they wake up, we’ve already given them pain medication through their I.V. that will keep them comfortable through the first part of their recovery,” he says.
If there is additional postoperative pain, and the patient has already maxed out on opioid medicines, the anesthesiologist can perform a transversus abdominis plane (TAP) block. This method uses ultrasound to guide an injection of anesthetic between the abdominal muscles and the location of nerves that send pain signals to the central nervous system. Because that anesthetic is not systemically absorbed like opioids, there are few side effects, such as grogginess or nausea.
What are some factors that might complicate anesthesia for hernia repair?
Different types of monitoring and anesthesia may be required for people who have additional, complicating health conditions such as heart disease, pulmonary disease, extensive gastrointestinal disease, or a neuromuscular condition such as Parkinson’s disease or multiple sclerosis, or who are morbidly obese, Dr. Stout says.
What makes Yale Medicine’s approach to anesthesiology for hernia repair unique?
Yale Medicine excels at performing the most complicated hernia surgeries, often treating patients who are referred from other parts of the country and the world. These include patients who are told they need surgery, but because of their other health conditions—such as pulmonary or cardiac disease—are at too high of a risk to safely undergo surgery at their local hospitals, Dr. Stout says.
"With the right team in the operating room and the right team taking care of them postoperatively, high-risk patients can do very well after surgery and experience vast improvements in their quality of life,” he says.