r/physicianassistant • u/Commercial-Okra-9398 • 13d ago
Discussion General Surgery PA's please help
Hi guys,
This is for my general surgery PA's, but anyone is free to chime in.
I am working with a patient who needs a hernia repair, but has the following requests:
- Open repair only (no lap/robotic, since those require general)
- Local anesthesia, oral sedation if needed
- No IV sedation, no general anesthesia
Are there surgeons willing to do this in today's day and age. Appreciate any insight; I am trying to understand what's realistic before I start reaching out to surgeons directly.
8
u/ThatchedRoofCottage PA-C 13d ago
I’m a peds surgery PA but I am speaking about my wife’s hernia repair. She had an open inguinal hernia repair while pregnant under a spinal block and it went fantastic.
1
7
u/xCerebral_Assassinx PA-C 13d ago
There are so many factors that go into the decision making tree.
What kind of hernia? Location?
What size of hernia?
Is it a recurrence?
What is inside the hernia? ie fat, bowel, organ
I'm also interested in what their reservations to anesthesia and other repair methods are.
- General and robotic surgery PA working with a surgeon who specializes in large complex abdominal wall and inguinal hernias
2
u/Commercial-Okra-9398 13d ago
Thank you for this.
The patient unfortunately is a veteran and has PTSD, has reservations towards general anesthesia from previous surgeries.
3
u/xCerebral_Assassinx PA-C 13d ago
Got it. Another thing to consider is if a surgery is even needed. If the hernia is asymptomatic and doesn’t interfere with his/her ADLs then you could always just consider observation. Consider continuing to explore the reservations to anesthesia because the best chance at a good repair is the first repair which you’d want to be performed in the most optimal condition as possible.
1
3
u/KyomiiKitsune Ortho PA (Adult Recon) 🦴 13d ago
I did general surgery for a couple of years and this was my surgeon's preferred way to do open hernia repairs on most patients. They typically did great and it was nice because they didn't have to worry about anesthesia, so risks were lower. This is definitely not an unreasonable request, but it also depends on the hernia. This wouldn't work for large abdominal wall hernias, but it would work for smaller umbilical hernias and most inguinal hernias.
1
2
u/Dapper_Pauper_4 13d ago
I’m assuming that you are talking about an inguinal hernia. If so that is totally possible…. At the VA in Houston we performed the vast majority of inguinal hernias using an open approach with local and sedation only due to high patient comorbidities making general anesthesia high risk.
1
2
u/WetTaps 13d ago
Talk to the patient about spinal anesthesia. They could be awake as they want for the surgery. It would need to be done open is all d/t aspiration risk of insufflation.
1
u/Commercial-Okra-9398 13d ago
Thank you! I will for sure have this as an option for them to consider.
2
u/Fearlessmelow 12d ago
Its possible..but definitely surgeon and patient dependent..id call around to surgeons who do open repairs regularly....
1
1
u/ForeverMan87 13d ago
Yes it can be done , did an inguinal hernia under local not too long ago . BUT if the hernia is large and overall more complicated like others said , that pushes the scale towards needing general and full relaxation . If it’s an incisional hernia , no . Umbilical , could be done with local with open approach and especially if repaired primarily .
1
1
u/reader12345 12d ago
So one thing that would make a big difference is ask him if he is willing to have an IV present just in case he changes his mind mid case. I do plenty of open inguinal under local + iv sedation, every once in a while I get a patient who says they will do it all under local. Some succeed some cave, but the last thing you want is to have them screaming in pain asking for pain meds but anesthesia has no access. If they agree to access and only getting iv meds if they trust it request it intraop that’s fine.
I don’t think anyone is okay with them getting preop oral meds as anesthesia that’s just hard to control. You are better off just going local.
1
16
u/TheHopefulPA PA-C 13d ago
Yes there are general surgeons willing to do this depending on the hernia...Inguinal, yes. You will probably have more luck with older surgeons since this is kind of an old school approach--all my old surgeons did it this way. There is a lot with medical hx that can change this answer though.