12.1. Hernia Repair: Patient Positioning and Operating Room Setup
David S. Thoman, M.D.
Edward H. Phillips, M.D.
A. Room and Equipment Setup
1. Inguinal hernia repair
a. An adjustable operating table capable of Trendelenburg position- ing is required.
b. A movable cart with the following equipment is placed at the patient’s feet:
i. Large color monitor ii. Processing unit for camera iii. Light source
iv. Insufflator
v. Video cassette recorder (optional) vi. Color printer (optional)
c. The monitor should be at a comfortable height facing the patient.
d. The camera cord, light cord, and insufflation tubing are fastened to the drapes at the patient’s knees and run directly to the instru- ment cart.
e. The electrocautery unit and suction are best placed near the head and brought off either side. This allows the surgeon and assistant to change sides without negotiating cords and tubing.
f. A mayo stand with instruments is placed over the patient’s lower legs and appropriately adjusted for Trendelenburg positioning.
g. Basic instruments:
i. 30° 10-mm or 5-mm laparoscope
ii. Veress needle, Hasson cannula, or an optical nonbladed trocar
iii. Dissecting balloon (totally extraperitoneal approach only) iv. Fine laparoscopic grasping forceps with electrocautery
potential
v. Blunt locking atraumatic graspers vi. Laparoscopic scissors
vii. Long laparoscopic needle for local anesthetic injection viii. Hernia mesh stapler
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ix. One or two sheets of permanent mesh
x. Three working ports (diameter based on technique) 2. Incisional hernia repair
a. Monitor position will vary based on hernia location and size.
Likely to require repositioning during case because mesh must be anchored or sutured circumferentially.
b. The position of the surgeon, first assistant, and cameraperson (if utilized) about the table will also vary during the case.
c. Supine position again is utilized.
d. Foley catheter is selectively used.
e. As explained in next chapter, the number of ports required will vary.
B. Patient Preparation and Positioning
1. All patients should have had nothing to eat or drink for at least 6 hours before induction of anesthesia.
2. Bowel preparation may be considered for patients with multiple prior abdominal procedures but is generally not necessary.
3. Venous thromboembolism prophylaxis is not routinely used, although some surgeons routinely use pneumatic compression boots or subcu- taneous heparin. There is little available information; however, the risk seems to be minimized with the short operative time and the liberal use of Trendelenburg. Patients at high risk may benefit from prophylaxis.
4. The patient voids before surgery, making routine bladder catheteri- zation unnecessary unless there are bilateral hernias.
5. Nasogastric drainage is unnecessary, unless peritonoscopy is per- formed and gastric dilatation is present.
6. A first-generation cephalosporin, or equivalent, is given 30 minutes before incision.
7. The supine position is uniformly utilized for inguinal and incisional hernia repair. It is important to pad all bony prominences.
8. The arms should be padded and tucked at the sides if possible.
9. A retaining strap is placed at the midthigh level.
10. The abdomen is shaved from umbilicus to pubis.
11. An electrocautery grounding pad is placed on the patient away from the field.
12. Antiseptic skin preparation of the entire abdomen, genital region, and upper thighs is performed, in case scrotal manipulation is necessary.
13. Draping is done to limit the amount of lower abdominal skin exposed.
This helps prevent inadvertent contact of the mesh with skin before implantation.
14. For unilateral inguinal hernias, the operating surgeon stands on the contralateral side. For bilateral hernias, the surgeon may remain on the left side or can switch sides (Figure 12.1.1).
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12.1. Hernia Repair: Patient Positioning and Operating Room Setup 115
Figure 12.1.1. Typical operating room setup for laparoscopic inguinal hernia repair (surgeon positioned for a left inguinal hernia repair).
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116 D S Thoman and E H Phillips
15. As mentioned, for incisional hernia repair the staff positions around the table will vary.
C. Selected References
Airan MC. Equipment setup and troubleshooting. In: Scott-Conner CEH, ed. The SAGES Manual. New York: Springer-Verlag, 1999:1–11.
Crawford DL, Phillips EH. Totally extraperitoneal laparoscopic herniorrhaphy. In: Zucker KA, ed. Surgical Laparoscopy. Philadelphia: Lippincott Williams & Wilkins, 2001:
571–584.
Fallas MJ, Phillips EH. Laparoscopic near-total preperitoneal hernia repair. In: Phillips EH, Rosenthal RJ, eds. Operative Strategies in Laparoscopic Surgery. New York:
Springer-Verlag, 1995:88–94.
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