- Recent literature suggests that patients who are asymptomatic or "minimally symptomatic" may be managed without surgical intervention.
- All symptomatic inguinal hernias (pain, neurologic symptoms) should be repaired unless a specific contraindication exists.
- Inguinal hernias that are incarcerated and are reduced in a timely fashion should be repaired on an urgent basis.
- Hernias that are unable to be reduced should be treated as a surgical emergency and repaired expeditiously.
- There are no absolute contraindications.
- In the event the patient cannot undergo general or spinal anesthetic, the repair can be performed under local anesthetic with sedation.
- Infection (potentially requiring reoperation to remove infected mesh).
- Damage to nerves resulting in loss of inner thigh skin sensation.
- Damage to the vas deferens or testicular vessels potentially leading to decreased fertility.
- Nothing by mouth for 6 hours before surgery.
- Blood thinners should be discontinued with adequate time for normalization of coagulation.
- Foley catheter insertion is required for laparoscopic procedures only.
- The patient should be supine.
Open Inguinal Hernia Repair
- The operation may be performed under spinal, local, or general anesthesia.
- Figure 40–1: Inguinal hernia locations.
- Figure 40–2A: Landmarks for skin incision are the anterior superior iliac spine and pubic tubercle.
- The incision should be superior to the inguinal ligament and, if possible, hidden in a natural skin crease.
- Figure 40–2B: The subcutaneous tissue should be divided until the external oblique fascia is encountered.
- A regional local anesthetic block may be placed at this time (10 mL of 0.5% bupivacaine infiltrated subfascially into the deep muscular layers and retroperitoneum along the iliac fossa region 2 cm medial and cephalad to the anterior superior iliac spine).
- The external oblique fascia is then divided sharply to expose the underlying cord and hernia.
- Figure 40–3: The hernia sac is dissected free from the associated cord structures.
- Care should be taken to identify the ilioinguinal nerve and retract it away from the area of dissection to avoid injury.
- Indirect hernias originate from the internal ring and are located anteromedial to the cord structures.
- Direct hernias come directly through the floor and push the cord structure superficially.
- Sliding hernias arise lateral to the cord.
- Figure 40–4: The hernia sac is opened and the contents are visualized to ensure that no incarcerated bowel is present. The sac is then amputated and ligated with a suture ligature.
- If the internal ring is widely dilated, sutures may be placed to tighten it medially, laterally, or in both directions.
- A large direct hernia may be navigated by sutures in the inguinal floor.
- Figure 40–5: A piece of polypropylene mesh is then cut to a keyhole shape and sewn medially to the pubic tubercle with a 2-cm overlap on the tubercle, inferiorly to the shelving edge of the inguinal ligament, and superiorly to the internal oblique fascia.
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