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Open repair of inguinal hernia

(click to watch video)

(Click to revise anatomy)

Inguinal hernia repair can be divided in to 2 stages:

1. Herniotomy. The cremaster muscle is divided along the length of the spermatic cord to gain access to its contents. An indirect sac is sought (often seen as a white edge of peritoneum). If present the sac is carefully freed from the other cord contents all the way back to the deep inguinal ring. The freed sac is then opened to ensure all contents have been reduced into the abdomen. If empty, the sac is then sutured closed at the level of the deep ring with an absorbable suture and the excess removed with scissors. Sometimes part of the wall of the sac is a viscus such as caecum, sigmoid colon or bladder (a sliding hernia). In this case the opened sac should merely be closed with an absorbable suture and the sac reduced back into the abdomen.
2. Herniorraphy. This is the repair of the posterior wall of the inguinal canal. A direct sac need not be opened and is merely inverted to push the contents back into the abdomen. The posterior wall is then strengthened to prevent direct herniation occurring in future. As the posterior wall of the inguinal canal is normal in children herniorraphy is not performed at hernia repair.

Methods of herniorraphy

Sutured

Darn:

• Transversalis facia plicated
• Weave/darn performed with non-absorbable suture between conjoint tendon and inguinal ring
• Tissues under tension after darn. Leads to post operative pain and ischaemia in the sutured tissues (leading to recurrence)
• Needs experience to perform properly

Shouldice repair:

• 4 layers of non-absorbable sutures required
• Transversalis facia divided from deep inguinal ring to pubic tubercle
• Transversalis facia flaps elevated and repaired in a double breasted fashion
• 2 further layers of sutures then placed from undersurface of conjoint tendon to the upturned edge of the inguinal ligament.
• Very low recurrence rate
• Needs experience ++ to do well

Mesh

Lichtenstein: (video of Lichtenstein repair)

• Most common type of repair performed
• Polypropylene mesh tailored to individual anatomy of patient.
• Slit made at lateral end of mesh to allow spermatic cord to pass through completed repair (slit made about 1/3 way from bottom of mesh)
• Mesh sutured to tissue next to pubic tubercle using non-absorbable sutures and along the upturned edge of the inguinal ligament past the deep ring.
• Medial and superior edges of mesh sutured to conjoint tendon so that the mesh overlaps it.
• Mesh shrinks by up to 20% with time so ensure mesh large enough to allow for this (most common recurrence is a direct hernia medial to the end of an inadequately sized mesh)
• No tension so little pain afterwards
• Easy to lean and low recurrence rates

Other:

• Stoppa mesh repairs
• Different shapes of mesh (e.g. with layer of mesh placed deep to transversalis facia as well as superficial to it)
• Different mesh materials (e.g. vipro - a semi absorbable mesh)

Links to other video demonstrating Lichtenstein repair

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