Abdominal Wall: Open Inguinal Hernia Repair (Herniorrhaphy)
General Approach
General Approach
- Skin Incision 6-8 cm Parallel to Inguinal Ligament
- Expose & Longitudinally Incise the Aponeurosis of the External Oblique to Enter the Inguinal Canal
- Preserve Ilioinguinal Nerve
- Isolate the Spermatic Cord & Encircle with a Penrose Drain
- Reduce the Hernia
- Repair
- Tissue Repair – First Longitudinally Divide Posterior Wall/Transversalis Fascia
- Close Aponeurosis of External Oblique
- Avoid Injury to the Ilioinguinal Nerve
- Close Skin
Tissue Repairs
Bassini Repair
- Divide Inguinal Floor & Approximate Flap with Conjoined Tendon to Inguinal Ligament Mn
- If Perceived Tension: Create a “Relaxing Incision” of the Anterior Rectus Sheath
Shouldice Repair
- Subtype of Bassini Done in Multiple Layers (2-4)
- Generally Considered the Best Tissue Repair
- Original Description Used Stainless Steel Wire Suture in 4 Layers
- Layer 1: Inferolateral Transversalis Fascia Flap to Deep Muscular Fascia
- Layer 2: Superior-Medial Transversalis Fascia Flap to Shelving Portion of Inguinal Ligament
- Layer 3: Conjoint Tendon to Inferolateral Transversalis Fascia Flap
- Layer 4: Conjoint Tendon to Inguinal Ligament
McVay Repair
- Approximate Conjoined Tendon to Cooper’s Ligament Mn
- Interrupted Sutures from the Pubic Tubercle Laterally
- Final Stich Includes the Inguinal Ligament (“Transition Stitch”)
- If Perceived Tension: Create a “Relaxing Incision” of the Anterior Rectus Sheath
- Repairs Femoral Hernias Also
Laroque Repair
- Intraabdominal Muscle-Splitting Incision Superior to Deep Inguinal Ring
- Assists in Reduction of Sliding Hernias
- After Reduction Repair Can Be Through Any Other Technique
Mesh Repairs
Lichtenstein Repair
- Uses Mesh to Decrease Tension
- The Most Common Open Mesh Repair – Previously Considered the “Gold Standard”
- Procedure:
- Fix the Mesh to the Pubic Tubercle Using Nonabsorbable Monofilament Suture
- Should Overlap 2 cm
- Continue Running Suture Along the Inferior Shelving Edge of the Inguinal Ligament
- Cut Mesh to Encircle the Spermatic Cord – 1/3 Below & 2/3 Above
- Single Suture to Loosely Approximate the Mesh Tails – Recreate a New Internal Ring
- Loosely Fix the Mesh Superiorly to the Internal Oblique Aponeurosis
- Fix the Mesh to the Pubic Tubercle Using Nonabsorbable Monofilament Suture
Plug & Patch Repair
- Similar to Lichtenstein Repair with the Addition of a Mesh Plug
- Indirect Hernia: Placed Through the Internal Ring
- Direct Hernia: Sutured to Cooper’s Ligament, Inguinal Ligament & Internal Oblique
- Generally Discouraged Due to Complications (Contraction, Migration & Chronic Pain)
TIPP (Trans-Inguinal Preperitoneal) Repair
- Through the Deep Inguinal Ring Bluntly Clear a Preperitoneal Space
- Ensure the Inferior Epigastric Vessels are Against the Abdominal Wall Anterior to the Plane
- Insert the Mesh in the Preperitoneal Plane
- Consider Suture Fixation, Some Leave without Tacking Down
- Repairs Both Inguinal & Femoral Hernias
- MOPP (Minimal Open Preperitoneal) Repair
- Subtype of TIPP Repair
- Uses a Small (2.5-4.0 cm) Incision Immediately Over the Deep Inguinal Ring
- Bilayer Mesh Repair
- A Specialized Mesh is Used to Fix a Layer in the Preperitoneal Space and Another Layer in a Lichtenstein Fashion
Mnemonics
Bassini vs McVay Repairs
- Mini Bassini – Only Down to the Inguinal Ligament
- All the Way McVay – Down Past Inguinal Ligament to Cooper’s Ligament