2. LBJ Ventral Hernia Protocol: Open VHR With Component Separation (TAR)

LBJ Ventral Hernia Protocol: Open VHR With Component Separation (TAR)

  • Preop – Weeks to Months Before Surgery
    • Selective MRSA decontamination
      • If patient has recurrent hernia, history of infection, or history of long hospitalization
      • Mupirocin ointment BID x 5 days
    • Botox – If necessary
      • Inject 4 weeks before planned surgery (range 3-5)
      • 300u divided, injected in all 3 muscle layers bilaterally
    • Chlorhexidine showers
      • Night before and morning of surgery
    • Nutrition labs – If clinically indicated
      • CBC, BMP, LFTs, ESR, CRP, prealbumin, zinc, copper, vitamin C, vitamin A, and vitamin E
    • Functional status
      • Clearly document current functional status
  • Preop – Day of Surgery
    • DVT prophylaxis – If not getting epidural, 5000u (or 7500u based on weight) SQH preoperatively
    • Regional pain – Epidural or ESP catheters unless contraindicated
    • Preop labs – Type & screen
  • Intra-op
    • Foley – Always required
    • Arterial line – Typically placed but not always
    • Surgical prophylactic antibiotics – Follow standard guidelines (typically Ancef)
    • Betadine irrigation (diluted to 1%)
    • Change gloves before handling mesh
    • TXA
      • 1 gram at the start of surgery and 1 gram at skin closure
      • Additional doses may be given at the discretion of anesthesia
    • Hemostatic agent
    • Drains
      • Typically leave 2 drains in retro-rectus space (on mesh)
        • Left drain is lower (caudal) internally, right drain is cranial internally
      • May also leave subQ drain(s) if there is a large dead space or if panniculectomy performed

IMPORTANT NOTES

  • Communication:
    • Resident team updates faculty daily after morning rounds.
    • For more urgent patient-related concerns, residents should call faculty directly.
  • These patients are at high risk for postoperative complications. The most alarming complication is abdominal compartment syndrome. Seemingly minor clinical changes (like tachypnea) may be the first evidence of a more serious underlying issue. Residents should never hesitate to contact faculty if there is concern about a patient.
    • Residents should consider escalating the following changes: hypotension, tachycardia, arrhythmia, respiratory compromise (tachypnea, new/increased O2 requirement), severe abdominal pain (see below), UOP <0.5 mL/kg/hr, mental status change, significant drop in hemoglobin, AKI, lactic acidosis, fever.
  • Abdominal pain:
    • These patients are at high risk for abdominal compartment syndrome and/or bleeding after surgery. Severe pain can be very difficult to assess after a large VHR, as the abdomen may feel rigid and it is normal to have at least moderate pain. Reports of very severe or 10/10 pain should be immediately elevated to a senior resident. Senior trainees should have a low threshold to involve attending surgeons. Associated hemodynamic changes, metabolic changes, or respiratory distress must be immediately addressed. Maintain a low threshold for increasing the patient’s level of care.
  • Urinary retention: Bladder scans are unreliable after open VHR, as the bladder is often mobilized off the abdominal wall & may be difficult to visualize. Additionally, a hematoma could easily be mistaken for a full bladder. Always maintain a low threshold to replace the Foley if AKI, oliguria, or urinary retention develop.
  • Any drain in contact with mesh must be removed prior to discharge!

POSTOPERATIVE PATHWAY

  • Postop Day 0 (Evening of Surgery)
    • Communication
      • The operating resident is expected to communicate the following information to the resident group and ICU team: patient info, relevant history (including home meds that have been restarted or held), operative details (procedure, case duration, EBL, intra-op concerns, relevant details such as extent of lysis), drains (and whether on mesh versus subQ), postop plan (and any planned deviation from protocol), any special concerns.
        • Residents are expected to pass on this information to the night team.
    • Admit to SICU
    • DVT prophylaxis – Lovenox (trauma dosing) starts on night of surgery, followed by BID
      • Use heparin in setting of AKI or CKD
    • Recommended pain regimen
      • Acetaminophen, Ketorolac, Methocarbamol, & Gabapentin scheduled
      • Oxycodone PRN
      • Note: regional pain team follows for catheter management
    • IV fluids – All patients receive maintenance isotonic fluids
      • Monitor hourly UOP à titrate fluid rate & administer boluses as indicated
        • Urine output should be maintained at >0.5mL/kg/hr
          • This requires actively checking urine output, not waiting for notification
          • The longer the case duration, the more likely the patient will require additional fluids due to high insensible losses
    • Diet – Typically order clear liquid diet (CLD)
      • May keep NPO except meds if lysis was extensive
    • Mobilization
      • Abdominal binder
      • Out of bed to chair the night of surgery
      • Consult PT & OT
    • Medications
      • Pain regimen & DVT ppx as above
      • Bowel regimen: milk of magnesia BID
      • Hold anticoagulation/antiplatelet therapy
      • Continue rate control meds (beta blockers, CCBs) if hemodynamically appropriate
      • Hold ACEi & ARBs, initiate on/after POD 1 as appropriate based on renal function & hemodynamic status
      • Diabetics:
        • Sliding scale insulin (low/med/high based on home dose), target glucose 120-160 mg/dL
        • Hold oral hypoglycemics until tolerating regular diet
        • Blood glucose >300 on 2 checks should prompt initiation of insulin drip
      • Typically resume all home psych medications
        • If patients take scheduled benzodiazepines at home, continue inpatient. Otherwise, try to avoid benzodiazepines (even PRN) to prevent delirium.
      • Resume other medications as appropriate
    • Labs
      • Order stat post-op CBC, BMP, Mg, PO4, and VBG with lactate (to be drawn in PACU)
      • Order early AM CBC, BMP, Mg & PO4 on POD 1
    • Lines/Tubes/Drains
      • Keep Foley in place
      • Measure drain output at least Q12H
      • May keep arterial line if going to SICU
    • Postop check
    • The patient should be examined 4-6 hours postop (with documentation), and current orders should be reviewed
  • Day 1
    • Consider downgrading to IMU or floor status
    • Diet – Advance as appropriate, based on extent of lysis & clinical status
      • Discuss IV fluid changes with faculty prior to placing orders
    • Mobilization – PT/OT, ambulate at least once, out of bed to chair TID (with all meals)
    • Regional pain – Assess whether epidural/catheters are working
    • Pain regimen – As above
    • Labs – Morning CBC, BMP, Mg & PO4
      • Obtain more frequent labs if there is clinical concern (e.g., low UOP, AKI, significant Hgb drop from postop to AM labs, etc.)
    • Lines/Tubes/Drains
      • Can consider removal of Foley, but typically keep > 24 hours postop
      • Measure drain outputs Q12H
      • Consider removal of arterial line, CVC if present
    • Discharge planning
      • Engage case management early if patient might require placement after discharge
  • Day 2
    • Diet – Advance diet as appropriate
      • Discuss IV fluid changes with faculty prior to placing orders
    • Mobilization – Up out of bed in chair unless sleeping, ambulate TID
    • Regional pain – Assess whether epidural/catheters working &/or still necessary
    • Medications
      • If anticoagulated at baseline and drain output serosanguinous, can consider re-initiation of anticoagulation if clinically high risk. Decisions to anti-coagulate should be made on a case-by-case basis & discussed with the attending.
      • Resume home medications as able
      • Consider diuresis
    • Labs – Morning CBC, BMP, Mg, PO4
    • Lines/Tubes/Drains
      • Daily drain outputs
      • Consider removal of CVC, foley, etc. if present
    • Remove dressing for wound check; incisional vac stays in place until POD 7
    • Discharge planning
  • Day 3
    • Diet – Advance diet as appropriate
    • Mobilization – Out of bed unless sleeping
    • Regional pain – Assess whether epidural/catheters still necessary
    • Medications – Resume home medications as able, start to wean pain medications as able
    • Consider diuresis
    • Labs – CBC, BMP, Mg, PO4
    • Lines/Tubes/Drains
      • Discuss with the faculty prior to removing any drains
        • Typically remove the right drain (cranial drain internally) on POD 3
      • Consider removal of CVC, foley, etc. if present
    • Discharge planning
  • Day 4+
  • `Diet – As above
  • Mobilization – As above
  • Regional pain – Assess whether epidural/catheters are still necessary
  • Medications – Resume home medications as able, start to wean pain medications as able
  • Consider diuresis
  • Labs – As clinically indicated
  • Lines/Tubes/Drains
    • Discuss with faculty prior to removing any drains
      • Typically remove the left drain (caudal drain internally) on POD 4
      • Note: Any drain in contact with mesh MUST be removed prior to discharge
    • Consider removal of CVC, foley, etc. if present
  • Remove incisional vac on POD 5 (KCI) or 7 (Prevena), or prior to discharge
  • Discharge planning