Open VHR Without Component Separation (Rives Stoppa)

• 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 (sometimes used to avoid need for component separation)
    • 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
  • Functional status – Clearly document current functional status

• Preop – Day of Surgery
  • DVT prophylaxis –5000u (or 7500u based on weight) subQ heparin preoperatively
  • Regional pain – Typically perform regional blocks only

• Intra-op
  • Foley
  • Surgical prophylactic antibiotics following 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 – if indicated
  • Drains – Do not routinely leave drains in the absence of a component separation

IMPORTANT NOTES

• Communication:
  • Resident team updates faculty daily after morning rounds.
  • For more urgent patient-related concerns, residents should call faculty directly.
• 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: patient info, relevant history (including important 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 during sign out
  • Admit to IMU vs. floor
  • DVT prophylaxis – Lovenox starts on night of surgery, followed by BID
    • Use heparin in setting of AKI or CKD
  • Recommended pain regimen
    • Acetaminophen, ketorolac/naproxen, & methocarbamol scheduled
    • Oxycodone PRN
  • IV fluids – All patients receive maintenance isotonic fluids (i.e., LR or Isolyte)
    • Monitor UOP à titrate fluid rate & administer boluses as indicated
      • The longer the case duration, the more likely the patient will require additional fluids due to high insensible losses
  • Diet – Clear liquid diet (CLD)
  • Mobilization
    • Abdominal binder
    • Out of bed to chair the night of surgery
    • Consult PT & OT
  • Medications
    • Pain regimen & DVT ppx as above
    • Milk of magnesia BID
    • Continue rate control meds (beta blockers, CCBs) if hemodynamically appropriate
    • Hold other anticoagulation/antiplatelet therapy
    • 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
    • Stat postop labs only as indicated (very long case or underlying comorbidities)
    • Order early AM CBC, BMP, Mg & PO4 on POD 1
  • Lines/Tubes/Drains
    • Remove Foley unless clinical indication to keep
    • If present, measure drain outputs Q12H
  • Postop check
    • The patient should be examined 4-6 hours postop (with documentation), and current orders should be reviewed
• Day 1
  • Consider downgrading to floor status if in IMU
  • Diet – Advance diet as appropriate, based on extent of adhesiolysis & clinical status
    • Discuss IV fluid changes with faculty prior to placing orders
  • Mobilization – PT/OT, out of bed to chair TID with all meals
  • Pain regimen – As above
  • Labs – CBC, BMP, Mg & PO4
  • Lines/Tubes/Drains
    • Consider removal of Foley if present
    • If present, measure drain output Q12H
• Day 2
  • Diet – Advance diet & decrease or stop IVF as appropriate
  • Mobilization – Up out of bed in chair unless sleeping, ambulate at least 3x
  • 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
  • Labs – Morning CBC, BMP, Mg, PO4
  • Lines/Tubes/Drains
    • If present, measure drain output daily
  • Remove dressing for wound check; incisional vac stays in place until POD 7
• Day 3
  • Diet – As above
  • Mobilization – As above
  • Medications – Resume home medications as able, start to wean pain medications as able
  • Labs – As clinically indicated
  • Lines/Tubes/Drains
    • If present, consider drain removal
• Day 4+
  • Diet – As above
  • Mobilization – As above
  • Medications – Resume home medications as able, start to wean pain medications as able
  • Labs – As clinically indicated
  • Lines/Tubes/Drains
    • If present, consider drain removal
  • Remove incisional vac on POD 7 or prior to discharge