inguinal herniorrhaphy

INGUINAL HERNIORRHAPHY

DR BASHIR YUNUS

SURGERY RESIDENT

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OUTLINE

• DEFINITION

• INDICATIONS

• TYPES

• PREOPERATIVE PREP

• PROCEDURE

• COMPLICATIONS

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DEFINITION

• Surgical repair of a hernia

• INDICATIONS– Emergency

• Obstruction• Strangulation

– Elective • Risk of complication• Cosmesis• Discomfort- pain, pressure necrosis • Career choice

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• TYPES

– OPEN

– LAPAROSCOPIC

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PRE-OP PREPARATION

• Treatment of exacerbating factors- causes of chronic straining- Chronic cough, constipation, bladder outlet obstruction– CXR, ABD USS,

• Weight reduction• Hernia with loss of domain requires intermittent

abdominal pneumoperitoneum to prevent post-op respiratory embarrassment.

• Obstructed or strangulated requires resuscitation- iv fluids, iv antibiotics, NG tube and urethral catheterization

• Obtain an informed consent.

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PROCEDURE

• POSITION– Supine

• Routine cleaning(nipple line to mid-thigh) and draping(exposing the umbilicus, ASIS, pubic symphysis)

• Surgeon stand on the side of the hernia and the assistant at the opposite• ANAESTHESIA

– local anasthesia (60ml of 0.5%lidocain + adrenaline) with sedation for elective • Ilioinguinal and hypogastric nerve block• Intradermal and the subcutaneous tissues are infiltrated at the site of the proposed

incision• At the deep ring (peritoneal pain)• Pubic tubercle medially

– General anasthesia for emergency – Spinal for elderly with co-morbidity OR bilateral, recurrent hernia

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Local anasthesia

• Ilioinguinal and iliohypogastric blocks

• Surface landmarks for ilioinguinal block. The point of needle insertion ismarked 2 cm medial and 2 cm superior from the anterior superior iliac spine.

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•

• Needle maneuvers to block to ilioinguoinal nerve. Shown is perpendicular needle insertion (1), lateral (2), and medial (3) redirections (fan technique)

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• INCISION

– An incision is usually made parallel to and approximately 2 cm above the inguinal ligament.

– Extend from the level of the pubic tubercle to the internal ring at the level of the femoral pulse. (medial two-third of the inguinal ligament)

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• EXPOSURE

– The subcutaneous tissue is incised

– The blood vessels – superficial Epigastric vein and external pudenda vein- are ligated and divided

– A self-retaining Weitlaner retractor is placed

– The external oblique aponeurosis is exposed

– Further local anesthetic agent is infiltrated beneath the external obligue.

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• Small incision is made on the direction of the fibers of the external oblique and extended into the medial side of the external ring. The cut edges of the external oblique held away to prevent injury to the underlying nerves.

• The two nerves (ilioinguinal and genitofemoral nerves) are then preserved and retracted out of the way

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• The cord is then freed from the floor of the canal(best started from the pubic tubercle)and held with a hernia ring.

• The crimaster muscle is grasped with toothed forceps and divided to approach the sac.

• The sac is white membrane anteriomedial to the cord.

• Vas difference can be felt by palpation because is firmer than other structures of the cord.

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• The crimaster is dissected of the off the sac and dissect the sac and cord apart.

• The sac separated upto the deep ring, with exposure of preperitoneal fat or inferior Epigastric vessels

• The wall of the sac is picked is lifted up gently and opened at the apex with care to avoid injury to the content.

• The content is inspected and reduced.• Transfix the sac at the deep ring and excise the

redundant sac.

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Re-enforcement of the posterior wall• Bassini Repair

– The conjoined tendon is retracted upward– The aponeurosis of the transversus abdominis muscle is

approximated to the iliopubic tract that lies adjacent to the inguinal ligament with several interrupted 3-0 silk sutures.

– The second layer of the repair involves suturing the conjoined tendon to the inguinal ligament with interrupted 2-0 silk sutures.

– Tanner slide can be made to reduce tension– Lytle’s repair; tighting the internal ring on the medial side if

it is too wide.

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• Shouldice repair; four layered repair

• Lichtenstein repair; mesh repair

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CLOSURE

• The external oblique fascia is reapproximated starting at the external ring using 2-0 absorbable sutures.

• The subcutaneous tissue is irrigated, and any debris is removed. The skin is approximated with subcuticular 4-0 absorbable sutures, and the testis is gently drawn into the scrotum to avoid iatrogenic undescended testis.

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COMPLICATION

• INTRA-OPERATIVE– Injury to the external iliac or femoral vessels– Injury the vas deferens– Injury to the bladder and colon esp in sliding hernia– Injury to the inferior epigastric vessel– Injury to the content of the sac– Injury to the testicular artery

• EARLY POST-OP– Retention of urine – Haematoma of cord and scrotum– Wound infection

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• LATE POST-OP – Recurrence

– Sinuses

– Neuralgic pain- ilioinguinal nerve – hyperasthesia over the medial side of the inguinal canal

– Painful scar

– Atrophy of the testis due to injury to testicular artery

– Ostetis pubis

– Mesh extrusion with or without foreign body reaction

– Epidermoid cyst

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Causes of recurrence

• Inadequate pre-op preparation– Persistent causes of straining – Infection

Intra-operative– Tension repair– Low ligation of sac – Inadequate lytle’s repair (in huge long standing

hernia)

Treatment of recurrence is via preperitonealrepair(there is fibrosis of the previous site). Can be open or laparoscopic(gold standard).

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Special situations

• Sliding hernia

• Strangulated hernia

• Madyl’s hernia(hernia N-W)

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References

• Vijay P chatri; operative surgery manual. 1st

edition 2003

• Zollinger ; atlas of surgical operations. 9th edition

• Graeme J Poston. Principles of operative surgery. 2nd edition

• S.K Bhattacharya; short cases in surgery. Sixth edition

• Youtube .

• www.nysora.com

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