Inguinal hernia, elective (core) | Groin bulge, groin pain Ask about obstructive symptoms, incarceration events, enlargement over time Examine patient and look for inguinal hernia while standing and sitting | Typically diagnosed on exam but can get groin U/S if diagnosis is unclear | Repair symptomatic inguinal hernias Watchful waiting is safe for asymptomatic or minimally symptomatic inguinal hernias in male patients; however, symptoms often progress and patients seek repair Repair can be done open or minimally invasive - Open preferable in patients who will not tolerate general anesthesia and/or pneumoperitoneum - Laparoscopic repair may be preferable in morbidly obese patients, patients with bilateral hernias, and female patients due to higher risk of femoral hernia (not addressed by Lichtenstein repair) - If patient has recurrent hernia, typically prefer to fix it with a method that was not previously used Minimally invasive options for repair include TAPP (transabdominal preperitoneal) vs TEP (totally extraperitoneal) | Open Lichtenstein repair (core): - Inguinal incision made between pubic symphysis and ASIS, overlying the cord, dissect down to external oblique - Open external oblique aponeurosis to superficial ring - Preserve or sacrifice ilioinguinal nerve - Encircle the cord with a Penrose drain - Locate indirect hernia sac and dissect it off the cord, ligate or reduce sac - Examine floor of canal for direct defect - Secure mesh to pubic tubercle then run this stitch along the shelving edge of the inguinal ligament - Lay tails of mesh on either side of the cord and then tuck tails of mesh under the external oblique - Place interrupted sutures medially in the conjoint tendon - Close tails of the mesh around the cord by suturing them together (tight enough to accommodate only a fingertip) - Close external oblique aponeurosis, Scarpa’s, and skin Laparoscopic TEP inguinal hernia ... |