Laparoscopic Hernia Repair Protocol


Outpatient Consultation
On arrival to the clinic reception and after registration, the patient will be received by and a member of the nursing staff. The patient will be greeted with professional attitude and clinic policy will be explained to the patient.

1- The patient will be given a Hernia questionnaire to fill in the required information (Appendix 1)
2- The patient will then be taken to the triage room for Vitals signs measurements including glucometer glucose check, weight in Kg and abdominal girth in centimetres.
3- The Fully filled questionnaire and vital signs will be given to Dr Enas for review.
4- The patient will be brought into Dr Enas consultation room for full history taking and examination.
5- A list of laboratory and radiology investigations will be requested (Appendix 2).

1- Before attending Dr Enas consultation room, Dr Enas will review the patient’s medical records file with all the results of requested investigations from the first visit
2- The patient will be brought into Dr Enas consultation room to discuss the results and to make a decision whether the patient qualifies for surgery or not.
3- If the patient qualifies for surgical intervention, the full procedure will be explained to the patient and information leaflets plus a DVD of live operation will be given to the patient for review (Appendix 3) (DVD 1).
4- For straight forward cases, informed consent will be obtained and a consent form will be signed, anaesthesia review date will be booked as well as surgery date.
5- Preoperative instructions sheet will be given to the patient (Appendix 4)
6- For patients who need further counselling or the results deem necessary to attend another service i.e. Endocrinology, Cardiology, Psychiatry etc appointment will be booked with the appropriate physician.
7- An appointment with Dr Enas will be booked for the third visit

THIRD VISIT (Only if necessary)
1- Further counselling and education will be given to the patient prior to booking anaesthesia review and surgery date.
2- Informed Consent will be obtained by signing a surgery consent form.

Day of Surgery
1- The First patient on the list will be admitted to the ward at 06.30 in the morning. The second patient on the list will be admitted at 08.00 and so on.
2- Antithrombotic stockings will be applied
3- BSH ward admission policy will be applied in full
4- The first patient on the list must be delivered to the operating theatre holding area by 07.30 for surgery to start at 08.00.
5- Dr Enas and the anaesthetist will meet the patient together to greet and identify the patient and check the consent form.
6- BSH theatre policy will be applied in full
7- Patient’s relatives will be instructed to wait in the room and not to come to the operating room

The operating room
1- All instruments must be prepared and sets opened prior to patient arrival into the operating room.
2- On arrival of the patient into the operating room ‘Time out’ will be done.
3- Once the patient is anesthetised positioning and urinary catheter insertion will be done
4- Diathermy pad will be applied to patient’s right thigh laterally
5- Staff and personnel who are not involved in the procedure are not allowed into the operating room
6- Number of staff entering and leaving the operating room must be minimised
7- A clear sign will be attached to the operating room entry doors stating
‘Please do not enter this operating room unless urgently necessary’
8- Phones, pagers and mobile phones must be switched to silent.
9- No distraction is allowed into the operating room

Patient positioning
1- Supine position
2- Both arms adducted alongside the patient

Required Personnel
1- One scrub nurse
2- One assistant nurse
3- One circulating nurse
4- Anaesthesia team (doctor and technician)

Nursing staff and instruments positioning
1- Scrub nurse and main instruments table on the patient’s left side
2- Assistant nurse on the patient’s right side
3- Dr Enas in between the patient’s left side
4- Laparoscopic tower on the patient’s on the patient’s right side
5- Mayo table on Dr Enas left hand side, for Trocars and fixation device
6- Ligasure Valleylab generator or diathermy machine behind Dr Enas

1- Short jaw standard shaft atraumatic forceps x2
2- Bipolar forceps x1
3- Maryland forceps x1
4- Monopolar diathermy connection standby
5- Versa port Trocars standard length smooth shaft size 10mm x1
6- Versa port Trocars 5mm x3
7- Telescopes 5mm 30degree
8- Endo scissors suture cutting
9- Endo scissors dissecting
10- Composite mesh
11- Fixation device
12- Suction catheter
13- Maryland forceps x1
14- Monocryl 3.0 x2
15- Steristrips
16- Opsites
17- Abdominal Binder

The surgical procedure
1- Preparation and draping in standard fashion
2- Laparoscopic equipment connections
3- Insertion urinary catheter
4- Insert NG tube
5- After induction of general anaesthesia the following must be administered intravenously: Omeprazol 40mg, Ceftrioxone 1g, Metronidazole 500mg
6- Small incision made in left upper quadrant mid clavicular line using size 11 blade
7- Varus needle inserted
8- Insufflation pneumoperitonium initial setup at volume 5.5 and pressure 18mmHg, Remove Varus needle
9- Insertion of Trocars as per site of hernia
10- Under optical vision insert the remaining Trocars
11- Reduce Insufflation pressure to 14mmHg
12- Identify hernia sac
13- Adhesiolysis
14- Detailed dissection depends on type of hernia
15- Measure mesh
16- Mesh fixation
17- Irrigation and suction
18- Cover bowel loops with omentum
19- Remove NG tube
20- Intravenous Gentamycin 160mg
21- Closure of port sites
22- Steristrips
23- Opsite dressing
24- Abdominal binder before termination of anaesthesia
25- Remove urine catheter
26- Insert rectal diclofenac 100mg and motilum 60mg suppositories
27- Termination of Procedure
28- Transfer patient to trolley
29- Deliver patient to recovery bay

Patient in recovery area
1- Ensure good pain control
2- Ensure antiemetics
3- Ensure normal vital signs
4- Monitor patient for at least 60 minutes in the recovery bay prior to sending back to ward
5- Continue oxygen 2L until 6pm

Post operative care in the ward
1- Continue nasal oxygen 2L until 6pm
2- Patient must be allowed to sleep for 4 hours after arrival to ward
3- Mobilise patient at 6pm, sit out of bed, walk to the toilet and if tolerated walk in the ward accompanied by a nurse and a relative
4- Inpatient medication chart (Appendix 5)
5- Ceftrioxone 1g intravenous 8 hourly
6- Metronidazole 500mg intravenous 8 hourly
7- Gentamycin 80mg intravenous 12 hourly
8- Normal saline 100mls per hour
9- Parfalgan 1g intravenous 4hourly
10- Motilium suppository 60mg 8 hourly
11- Stemetil 12.5mg intramuscular 8 hourly PRN
12- Omeprazole 40mg intravenous 24 hourly
13- Diclofenac suppository 100mg 12 hourly
14- Start oral fluids 4 hours after arrival to ward then soft and normal diet as tolerated
15- Abdominal binder in situ
16- If oral diet is tolerated, patient discharged home at 8pm with post operative instructions sheet (Appendix 6)

Discharge Medications
1- Cefuroxime 500mg BID for 10 days
2- Panadol extra as required
3- Nurofen liquid capsules as required

OPD Clinic follow up (post operative)
1- Post operative follow up after 5 days of discharge from hospital
2- Full body suite / abdominal binder encouraged

OPD Clinic follow up (monthly)
1- Final follow up after 6 weeks
Appendix 1
    Patient Name:

1. Since when have you been complaining of Hernia?

2. Where is the hernia and which on which side?

3. Is there family history of Hernia?

4. Is there family history of any diseases?

5. What do you work as?

6. Do you do any weight lifting exercises?

7. Did you have any surgery in the past? What Kind and when?

8. Do you suffer from diabetes? (Yes / No)

9. Are you taking any medication?

10. If yes, what are the medications names and dosage

11. What other diseases do you suffer from?

12. Do you smoke, if yes, what do you smoke and how many

Appendix 2



Appendix 3
Laparoscopic Surgery for Hernia Repair

What is a hernia?
A hernia occurs when the inside layers of the abdominal wall weaken then bulge or tear. The inner lining of the abdomen pushes through the weakened area to form a balloon-like sac. This, in turn, can cause a loop of intestine or abdominal tissue to slip into the sac, causing severe pain and other potentially serious health problems.
Men and women of all ages can have hernias. Hernias usually occur either because of a natural weakness in the abdominal wall or from excessive strain on the abdominal wall such as strain from heavy lifting, substantial weight gain, persistent coughing, or difficulty with bowel movements or urination. Eighty percent of all hernias are located near the groin. Hernias might also be found below the groin (femoral), through the navel (umbilical), and along a previous incision (incisional).

What are the symptoms of hernias?
• A noticeable protrusion in the groin area or in the abdomen
• Feeling pain while lifting
• A dull aching sensation
• A vague feeling of fullness
• Nausea and constipation

How is a laparoscopic hernia repair performed?
Laparoscopic surgery uses a thin, telescope-like instrument known as an endoscope that is inserted through a small incision at the umbilicus (belly button). Usually, this procedure is performed under general anesthesia. This requires an evaluation of your general state of health, including a history and physical exam, possibly including lab work and EKG.
You will not feel pain during this surgery. The endoscope is connected to a tiny video camera, smaller than a dime, which projects an "inside view" of the patient's body onto television screens in the operating room. The abdomen is inflated with a harmless gas (carbon dioxide) to allow your doctor to view your internal structures. The peritoneum (the inner lining of your abdomen) is cut to expose the weakness in the abdominal wall. A mesh patch is attached to secure the weak area under the peritoneum. The peritoneum is then stapled or sutured closed. Following the procedure, the small abdominal incisions are closed with a stitch or two, or with surgical tape. Within a few months, the incision are barely visible.

What are the benefits of laparoscopic hernia surgery?
• Three tiny scars rather than one large abdominal incision
• Short hospital stay (You might leave the day of surgery or the first day after surgery)
• Reduced post-operative pain
• Low hospital costs
• Faster return to work
• Shorter recovery time and earlier resumption of daily activities (a recovery time of days instead of weeks)

What can I expect after surgery?
It is important to follow your doctor's instructions after surgery. Many people feel better in just a few days. However, you might need to take it easy for a week or two.
Dr Enas Al-Alawi M.D FRCSI
Consultant General & Laparoscopic Surgeon

Appendix 4
Preoperative instructions
1- Anaesthesia team review
2- Read information leaflets and watch operation DVD
3- Contact a provided list of previous hernia patients for further information and expectations
4- Purchase abdominal binder
5- Start Glycerine suppositories one every 12 hours 24 hours before surgery until the morning of the surgery
6- Start fasting from 10pm the night before surgery

Appendix 5
Inpatient medications

Ceftrioxone 1g intravenous 8 hourly
Metronidazole 500mg intravenous 8 hourly
Gentamycin 80mg intravenous 12 hourly
Normal saline 100mls per hour until normal diet is commenced
Parfalgan 1g intravenous 4hourly
Motilium suppository 60mg 8 hourly
Stemetil 12.5mg intramuscular 8 hourly PRN
Omeprazole 40mg intravenous 24 hourly
Diclofenac suppository 100mg 12 hourly
Glycerine suppositories one 12 hourly

Appendix 6
Post operative instructions

1- Ware the abdominal binder over a vest or a t-shirt continuously throughout the day for the first week
2- Ware the abdominal binder during the day and when doing anything strenuous for 6 weeks after the surgery
3- Avoid strenuous activity for 6 weeks after the surgery
4- You can drive from day 3 after surgery
5- Take your discharge medication as prescribed



Copyright© Dr Enas Al-Alawi , All rights reserved.


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