The use of mesh in hernia repair, risk management and the advantages of day surgery - 
Part 2 - Hernia Repair under Local anaesthesia

Skin Preparation
Shaving may be performed in the ward or in the theatre immediately pre-operatively. Too early shaving can lead to colonisation of the small nicks with bacteria resulting in wound infection. Depilatory creams are becoming increasingly used.

An antiseptic body wash is recommended pre-operatively to reduce the risk of infection.

The skin is prepped again with antiseptic in theatre. The antiseptic can be warmed so that the patient does not get a fright with the cold solution. The patient should be informed of any movements that are to take place as well as when the injection will be administered. An alcoholic solution should not be used near the scrotum because it can sting and irritate the sensitive skin. If diathermy is being used and alcohol is splashed nearby ignition can occur.

Alternatively, Povodine iodine solution can be used. The colour makes it more difficult to see where the local anaesthetic has been administered. There is a similar problem when drapes are applied. While both these problems can be overcome by marking, injection into this mark can cause tattooing.

Diathermy
Diathermy may be used for haemostasis. However the whole procedure can be performed without its use. Diathermy has the disadvantage of having to place a sticky plate on the patient who, often needs additional shaving.

There is a small incidence of complications from diathermy, such as burns, particularly is alcoholic skin preps are used. There is a smell and noise. Tissue necrosis can result in infection. Diathermy is not as certain a method  as haemostasis as ligature for larger vessels and should not be relied upon solely. Bruising is more common with the use of local anaesthesia making haemostasis vital.

Techniques of Local Anaesthesia

The surgeon usually injects the local anaesthetic after the skin is prepped and the site draped. Some anaesthetists or surgeons do this earlier, either in the pre-op area or in theatre, to allow the local anaesthetic to take effect longer.

1                    Nerve Block

For inguinal hernia repair, a ilio-inguinal and ilio-hypogastric nerve block is performed. These are approximately 1.5 cm supero-medially to the anterior superior iliac spine. The nerves are situated deep to the external oblique and the resistance to this muscle can be felt during the injection. The ilio-inguinal nerve supplies the sensory fibres to the skin where an incision is to be made.

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