Chapter 111: Repair of Inguinal Hernia with Mesh (Plug and Patch)

INDICATIONS

The repair of inguinal hernias in adults has shifted from pure tissue repairs (e.g., Bassini) to tension-free repairs using synthetic mesh. The Lichtenstein repair, shown in Chapter 110, represents the first widely accepted method for repair of an inguinal hernia using mesh. Since 1990, however, multiple new configurations of mesh have been invented. A frequently used variation is the plug and patch popularized by Rutkow and Robbins. This technique has results equivalent to those of the Lichtenstein method. The mesh cone, or plug, brings a new approach to the correction of the actual hernia defect. This technique may be used for recurrent as well as primary inguinal hernias.

PREOPERATIVE PREPARATION

Patients are evaluated for general medical and anesthesia risks, as discussed in Chapter 4 and in the preceding chapters concerning hernia repair. Because most operations are elective and performed in an ambulatory setting, sufficient time should be available to optimize the management of any medical diseases. Chronic coughing, new constipation with straining, and symptoms of prostatism require a specialty evaluation prior to surgery. Any active infections, including intertrigo, must be controlled. Although synthetic mesh and sutures do not harbor bacteria, an infection may become established or chronic in the presence of mesh, thus requiring its removal.

ANESTHESIA

Most patients can be managed effectively with deep sedation plus local anesthesia. The use of anxiolytic drugs followed by a narcotic and hypnotic (typically midazolam, fentanyl, or propofol) allows a pleasant induction. Dilute 0.5% lidocaine without epinephrine is placed by intradermal infiltration. This produces instant skin anesthesia, which lessens the discomfort of deeper injections. At the same time, the swelling serves as a marker for the skin incision. Epinephrine is not used with the entry local anesthetic because it may obscure bleeding points. Later, during closure, when hemostasis has been fully secured, epinephrine may be added to the long-acting local anesthetic to prolong its duration of action. Epinephrine is not used in older patients or in those with cardiovascular disease. Alternatively, some surgeons prefer epidural anesthesia for their patients because they believe that there is a significant interval of hyperesthesia during recovery. Finally, general anesthesia may be required for very anxious patients.

POSITION

Patients are placed in a comfortable supine position. A pillow is often put under the knees to lessen tension in the inguinal region, and some older patients may require an additional pillow under the head and neck.

OPERATIVE PREPARATION

Skin hair is clipped, and the skin is prepared in the usual manner. In men, the penis and scrotum should be prepared, especially if the hernia extends into the scrotum or if a hydrocele is present. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.

INCISION AND EXPOSURE