Enhanced Recovery in Abdominal Hernia Repair

Abstract

While there is no question that operative technique is important in achieving good patient outcomes, increasing evidence suggests that a coordinated and systematic approach to pre-operative patient preparation, intra-operative management, and post-operative care may be an even more critical contributor. Collectively, this approach has come to be known as “Enhanced Recovery After Surgery,” or ERAS, and represents a multidisciplinary approach to patient selection, pre-operative nutrition and optimization, intra-operative fluid management, advanced pain control, and early diet and mobilization. Originated and best studied in colorectal surgery, ERAS protocols have been shown to reduce length of stay, reduce the rates of post-operative complications by up to 40%, and significantly reduce costs. In fact, by one estimate, every dollar spent in implementation of ERAS protocols results in a $3.8 savings. ERAS protocols are now being adapted and extended to other types of surgery including bariatric, hepatobiliary, gynecologic, and recently to hernia surgery.

“A surgeon can do more for the community by operating on hernia cases and seeing that [their] recurrence rate is low than [they] can by operating on cases of malignant disease.”

—Sir Cecil Wakely, 1948

Appendices

Appendix 1: UW Medicine Hernia ERAS Protocol

Complex Hernia Clinical Pathway

Activities Before Surgery
	Week-4 to -6	Day-5 to -6	Day-1
Clinic Visit	• Implement strong for surgery pre-hospital clinical interventions • RN teach class: Patient CareMap and reference Med Consult note  – Tell patient to bring most current medication list to hospital for review and bring home medication bottles for review (cannot take in hospital) • Clinic provide patient with 2 × 8 oz of apple juice and directs patient to drink 1 × 8 oz before midnight night prior to surgery and 1 × 8 oz after parking at hospital day of surgery • PCC schedules follow-up visit for 2 weeks post-op (encourage patient to schedule 1-week post-op with PCP immediately following call) • Consent signed • MRSA/MSSA screen	• Impact drink 6 days prior (optional) • If MRSA/MSSA positive, Intranasal Mupirocin for 5 days prior
Diet			• Drink 1 × 8 oz of apple juice before midnight • No food after midnight, clear liquids as instructed
Medications
Other			• Patient to follow pre-surgery shower and shaving instructions • Patient to bring 1 × 8 oz bottles of apple juice to hospital

Complex Hernia Clinical Pathway

Day 0: Pre-, Intra-, and Post-Operative Milestones
	Pre-OP	Intra-OP
Pain	• 1000 mg Acetaminophen po (then po or IV q6h until discharge) • Gabapentin 300 mg po (continued once tolerating pills again) • Thoracic Epidural—aimed at upper level of incision (tested with 3 mL 1.5% Lidocaine w/Epi 1:200K)	• Pain: 1/16% Bupivacaine plus Fentanyl 2 μg/mL infused at 10 mL/h started ASAP after anesthesia induction. Avoid systemic opiates (especially Morphine and Dilaudid)
Diet	• Carbo loading: apple juice 2–3 h prior to surgery; patient directed to drink 1 × 8 oz immediately after parking at the hospital
Fluids	• If IV in place, LR at 50 mL/h	• Induction period—7 mL/kg of LR over 30 min • During surgery—5 mL/kg/h of LR. Target a urine output of 0.3–0.5 mL/kg/h • Blood loss—replace with colloid (5% Albumin) mL for mL
Mobility
Medications	• Abx per standard pre-op orders  – If MRSA positive; administer Vancomycin and abx per standard pre-op orders • For Bowel Resection ONLY (5% of cases); minimum of 30 min prior: Alvimopan 12 mg po q12h until first B.M. or discharge  – Unless chronic opioid user (on narcotics within 1 week of surgery) • Heparin 5000 units subcu	• Abx per standard intra-op orders
Vitals/Monitoring	• Blood glucose check. If >100, recheck 30–60 min after incision. If >140 start insulin GTT	• Continue glucose management
Equipment	• Portable sequential compression devices on in pre-op	• Place Foley • No nasogastric tubes (remove at end of case if placed for gastric decompression) • Abdominal binder for comfort per surgeon discretion
Support Services
Other	• Patients should be admitted in inpatient status • Have sleeve patients void prior to moving back to OR

Complex Hernia Clinical Pathway

Day 0: Pre-, Intra-, and Post-Operative Milestones
	PACU
Pain	• Changed to PCEA with 6 mL/h infusion • Breakthrough pain: Epidural Fentanyl (25–50 μg) (followed by 3 cm3 NS) and infusion increased, by 2 mL/h—followed by increased Bupivacaine concentration (1/10% then 1/8%) if BP okay  – If BP low or marginal or pressors ongoing talk with surgeons about ketorolac (vs. bleeding vs. nephrotoxic risks vs. anastomotic risk). If BP unable to be controlled with low dose pressors or fluid bolus (500 cm3) “split” epidural (take fentanyl out of epidural infusion and add IV opiate PCA) in preparation for, or as start of, stopping epidural
Diet
Fluids	• LR at 1 mL/kh/h • Target urine output of 0.3–0.5 mL/kg/h
Mobility
Medications
Vitals/Monitoring	• Continue glucose management
Equipment
Support Services
Other

Complex Hernia Clinical Pathway

Inpatient Milestones: Target Post-op LOS = 3–4 Days
	Day 0	Day 1
Pain		• PCEA and acetaminophen PO continued. After clear liquid lunch, start ibuprofen 600 mg po q6h (consider ketorolac 15 mg q6h if opiate side effects and NPO)
Diet	• Ice chips and sips of clears	• Advance diet as tolerated. General diet, if patient has no nausea, no distention, no belching/hiccups
Fluids		• LR at 1 mL/kg/h. Cease IV fluids asap. Saline lock IV fluids when oral intake greater than 500 or adequate urine output. Aim for early oral fluid intake
Mobility	• Edge of bed after last set of post-op VS (usually 6 h) with orthostatic VS	• OOB for all meals. Walk 3–4 times in the hall—Goal 9 laps. OOB 6 h/day
Medications	• Heparin 5000 units subcu q8h	• Start 17g Mirolax 1× daily
Vitals/Monitoring	• Continue glucose management	• Labs Days 1–4, as clinically indicated
Equipment	• Incentive spirometer 10×/h while awake until discharge • Sequential compression devices on, unless ambulating until discharge	• DC Foley (just pull)
Support Services		• PT visit on day 1, latest
	Day 2	Day 3–4
Pain	• Epidural stopped and oxycodone started after breakfast tolerated (epidural pulled 4 h later)	• Gabapentin discontinued on day 3 • Do not prescribe Gabapentin at discharge • Acetaminophen and ibuprofen continued at discharge  – Unless chronic opioid user (on narcotics within 1 week of surgery)
Diet	• Advance diet as tolerated. General diet, if patient has no nausea, no distention, no belching/hiccups	• Advance diet as tolerated. General diet, if patient has no nausea, no distention, no belching/hiccups
Fluids
Mobility	• OOB for all meals. Walk 3–4 times in the hall—Goal 18 laps. OOB 6 h/day until discharge	• OOB for all meals. Walk 3–4 times in the hall—Goal 18 laps. OOB 6 h/day until discharge
Medications		• DC Alvimopan (if bowel movement) • Med rec on day before discharge
Vitals/Monitoring
Equipment	• JP drain teaching
Support Services

Appendix 2: Patient-Friendly Hernia Care Map