What are the preoperative, intraoperative, and postoperative considerations for a patient undergoing a bilateral herniotomy, particularly with regards to anticoagulant medications, antibiotic prophylaxis, and management of potential complications?

Bilateral Herniotomy: Perioperative Management

Antibiotic Prophylaxis

Administer a first-generation cephalosporin (cefazolin 2g IV) within 30-60 minutes before surgical incision as a single dose. 1, 2

• For patients with beta-lactam allergy, use clindamycin 900 mg IV slow infusion as a single dose, combined with gentamicin 5 mg/kg IV 1, 3
• Re-inject cefazolin 1g if the procedure duration exceeds 4 hours 1, 2
• Discontinue prophylactic antibiotics within 24 hours postoperatively to prevent antimicrobial resistance and C. difficile infection 1, 4
• Pediatric herniotomy does not require antibiotic prophylaxis, as the surgical site infection rate is approximately 2.89% without antibiotics 5

Anticoagulation Management

Continue antiplatelet therapy (aspirin or clopidogrel) perioperatively without interruption, as this does not increase bleeding complications in inguinal hernia repair. 6

For Patients on Warfarin:

• Proceed with surgery if INR < 3.0 on the day before surgery 7
• INR > 3.0 significantly increases postoperative hematoma risk (P = 0.03), requiring surgical management in 6.1% of cases 7
• If INR > 3.0, hold warfarin 3 days preoperatively and consider bridging with low-molecular-weight heparin for high-risk patients (mechanical mitral valve, recent thromboembolism within 1 year, or ≥3 risk factors including atrial fibrillation, prior embolism, hypercoagulable state, mechanical prosthesis, or LVEF <30%) 1
• Resume warfarin postoperatively once hemostasis is assured 1

VTE Prophylaxis:

• Administer mechanical prophylaxis (compression stockings and/or intermittent pneumatic compression) intraoperatively 1
• For high-risk patients (age >60, obesity, prolonged immobility, cancer, prior VTE), add pharmacologic prophylaxis with low-molecular-weight heparin or unfractionated heparin 1
• Low-molecular-weight heparin should be dosed twice daily in obese patients (BMI >30) to achieve therapeutic anti-factor Xa levels 1

Preoperative Optimization

Screen for and optimize the following conditions before elective surgery: 1

• Cardiovascular: Assess for hypertension, coronary artery disease, heart failure, and valvular disease; continue beta-blockers and statins perioperatively 1
• Pulmonary: Screen for smoking (cessation recommended), COPD, and sleep apnea 1
• Metabolic: Optimize diabetes control and correct anemia (hemoglobin <10 g/dL) 1
• Nutritional: Assess nutritional status and provide supplementation if malnourished 1

Fasting Guidelines:

• Clear fluids until 2 hours before induction 1
• Light meal until 6 hours before induction 1
• Full meal (meat, fatty foods) requires 8+ hours fasting 1
• Administer carbohydrate drink (400 ml with 50g CHO) 2 hours preoperatively for elective patients 1

Intraoperative Management

Use the WHO Surgical Safety Checklist with all 19 items and three pause points. 1

• Maintain core temperature ≥36°C with active warming for procedures >30 minutes 1
• Employ multimodal opioid-sparing analgesia with short-acting agents and local/regional blocks 1
• Use lung-protective ventilation and ensure complete reversal of neuromuscular blockade 1
• Maintain near-zero fluid balance; avoid routine nasogastric tubes and drains 1

PONV Prophylaxis:

• Assess all patients for PONV risk 1
• High-risk patients require 2-3 antiemetics administered prophylactically and continued postoperatively as needed 1

Postoperative Care

Initiate oral fluids as soon as the patient is lucid and solid food after 4 hours. 1

• Mobilize patients for 30 minutes on the day of surgery and 6 hours daily thereafter 1
• Continue multimodal analgesia with paracetamol and NSAIDs (avoid NSAIDs in elderly with renal dysfunction) 1, 8
• Use opioids only as a last resort and in low doses 1
• Remove urinary catheters as early as possible to reduce infection risk 1, 8
• Discontinue IV fluids on postoperative day 1 1

Delirium Prevention (Age >65):

• Perform regular postoperative delirium screening 1
• Implement non-pharmaceutical interventions: regular orientation, sleep hygiene, cognitive stimulation 1
• Minimize medication triggers (avoid anticholinergics like cyclizine) 8

Critical Pitfalls to Avoid

• Do not continue prophylactic antibiotics beyond 24 hours, as this increases antimicrobial resistance without benefit 1, 4
• Do not operate on patients with INR >3.0 due to significantly increased hematoma risk requiring surgical intervention 7
• Do not discontinue antiplatelet therapy (aspirin/clopidogrel), as continuation does not increase bleeding complications 6
• Do not administer antibiotics too early or too late; timing within 30-60 minutes before incision is critical for tissue levels 1, 4
• Do not use codeine postoperatively in elderly patients due to constipation, emesis, and cognitive dysfunction risk 8