Plate 211

Herniorrhaphy has become more and more an outpatient surgical procedure, regardless of the age of the patient. The Shouldice repair has been advocated for some years as the procedure of choice for adults with inguinal hernias.

The obese patient should be required to lose weight, preferably to within 10 percent of calculated ideal weight. This may delay the operation for a considerable time. Any infections of the skin should be cleared up before operation. A productive cough or an upper respiratory infection delays the procedure. Chronic smokers should be encouraged to curtail their smoking. Evidence of prostatic obstruction should be sought in older men. All patients should be taught how to get out of bed with a minimum of discomfort and advised to practice this. Sensitivity to drugs, including local anesthetics, should be ascertained. A mild cathartic should be given a day before the operation to ensure an empty colon. A mild laxative or mineral oil may be given to ensure bowel action without excessive straining after operation. A thorough medical evaluation is essential in older patients. A hernia should be relatively asymptomatic unless it becomes incarcerated. Any other symptoms must be evaluated, because they may be due to causes other than hernia.

Deep sedation plus local anesthesia is commonly used. The type of sedation will vary, but may include midazolam, fentanyl or meperidine, and propofol. Local anesthesia is limited to 30 mL of 1% lidocaine without epinephrine (total lidocaine dose <300 mg). The amount is reduced in elderly patients.

The skin is carefully inspected for any evidence of localized infection. All hair of the lower abdomen and pubis is removed with an electric hair clipper. In patients with scrotal hernias, the skin of the scrotum should be included in the usual skin preparation with topical antiseptics.

The legs should be slightly flexed, with pillows under the knees, and the patient placed in a modified Trendelenburg position to assist in the reduction of the hernia sac. Following the draping of the patient, the local anesthetic is injected. Keeping in mind the location of the ilioinguinal and iliohypogastric nerves, the original injection of a few milliliters of anesthetic agent is made, using a fine needle (No. 25), just medial to the anterosuperior spine. Approximately 10 mL of (lidocaine) anesthetic solution is injected subcutaneously with a No. 25 needle above and parallel to the inguinal ligament. About 5 mL is injected medial to the anterosuperior spine deep into the external oblique aponeurosis to anesthetize the ilioinguinal nerve. Another 5 mL is injected about the internal ring to eliminate painful impulses from the peritoneum and from the genital branch of the genitofemoral nerve. In elderly patients, less anesthetic solution is used. Epinephrine is not used in the elderly or in patients with cardiovascular disease.

A 10-cm incision is made parallel to the inguinal ligament, although some prefer a more transverse or skinfold incision. The external pudendal vessels are spared, especially in bilateral repairs, in an effort to minimize postoperative edema.

The external oblique aponeurosis is divided along the line of its fibers. Great care is exercised to avoid possible injury to the underlying ilioinguinal nerve. The aponeurosis of the external oblique is divided from the level of the internal ring down through the external ring, and both flaps are mobilized (Figure 1). Mobilization of the lower flap should involve some division in the superficial fascia of the thigh to allow inspection of the femoral area for evidence of a femoral hernia. The cremaster muscle is carefully divided longitudinally, with the lateral side being made the larger, since it contains the cremaster vessels and the genital branch of the genitofemoral nerve in its base.

The internal ring is freed from attachments, and evidence of a hernial sac is sought. If no indirect hernial sac is found, a small crescent reflection of peritoneum (processus vaginalis) is visible proximally. When an obvious hernial sac is found, it is freed by blunt and sharp dissection. When the sac is large, it can be filled with gauze sponge to provide counterpressure, which simplifies the pushing away of other tissues. The sac is opened and the index finger inserted medially under the inferior epigastric vessels in an effort to determine the presence or absence of a direct hernial defect. The neck of the hernial sac is freed from the surrounding tissue. Following this, the sac is ligated (Figure 2). Some believe an effort for a high ligation of the sac is unnecessary. If a lipoma of the cord is found, it is carefully excised, but the cord is not stripped of interstitial fat. Even large sliding hernia sacs can be freed and reduced without opening the sac.

The two cremaster muscles are excised with double ligation of the stumps. The posterior inguinal wall should now be fully visible. The posterior inguinal wall is palpated for an area of weakness or general bulge. The transversalis fascia is divided starting on the medial aspect of the internal ring but avoiding the inferior epigastric vessels and proceeding to the pubic tubercle (Figure 2). The femoral ring is evaluated for evidence of a femoral hernia.

If the transversalis fascia has been stretched by the diffuse bulge of a direct hernia, the excess from each flap is excised. The upper flap (A) is usually narrower than the lower flap (B). It is extremely important to develop an adequate lower flap if the repair is to have the best chance of success. The latter tends to be 1 to 2 cm wide and somewhat stronger. The lower flap is completely freed by careful dissection. The development of the flaps of the transversalis is very important in the subsequent steps of the Shouldice repair (Figure 2). The subsequent repair involves the development of a four-layered closure, using either two different continuous sutures of 34-gauge monofilament stainless steel wire or a nonabsorbable suture material. Absorbable suture or mesh is not used. Continuous sutures are preferred for distributing the stresses evenly.

The repair of the posterior inguinal wall must be carefully performed, using small, even bites without tension on the suture. Retaining sutures are not used. The first suture anchors the free edge of the lower flap (B) of the transversalis to the posterior aspect of the lateral edge of the rectus close to its insertion (Figure 2A). The placement of the suture must be accurate, and the knot securely tied without leaving a defect in this area. Only a short distance from the edge of the rectus sheath is included before the suture is continued laterally to include the deep underneath surface of the upper flap (A) of the transversalis and the internal oblique (Figure 3). The inferior epigastric vessels are carefully avoided as the suture line is extended to include the upper lateral cremasteric stump. The suture is now reversed at the internal inguinal ring (Figure 4), extending medially as it unites the free edge of the upper transversus flap (A) to the edge of Poupart's ligament. The suture is continued down to the pubic bone and tied. The space medial to the femoral vein may be obliterated by including the lacunar ligament if necessary.

Another continuous suture line is used to reinforce the second suture line just completed. The third suture line starts at the internal ring and includes bites of the internal oblique and transversalis muscles as well as the deep surface of the inguinal ligament as it continues medially to the pubic bone (Figure 5). The fourth suture line returns from the pubic bone, bringing together the same structures at a slightly more superficial plane up to the internal ring, where it is tied (Figure 6).

The spermatic cord is tested to determine that it can be freely moved and the veins are not engorged. The cord is returned to its normal position and the external oblique fascia approximated without constricting the vein in the region of the external inguinal ring (Figure 7).

The subcutaneous tissues are carefully approximated with interrupted sutures. The skin can be closed with interrupted or a continuous subcutaneous suture of absorbable material reinforced with skin tapes of a “butterfly” nature. Some prefer metal staples. A small dressing is applied to cover the wound.

The patient may return home several hours after the operation with full written instructions concerning activities, signs of bleeding or infection, or any other unusual reaction. Oral narcotic is supplied, and an ice pack may be applied locally for several hours. The patient should rest in bed except for voiding in the bathroom on the day of surgery. A suspensory for men is optional. Physical activity is restricted for an additional few days. Many experience improvement after 3 days, and some may drive or return to light duty work after 7 to 10 days. Vigorous exertion, as in sports, is limited for 4 weeks, and extreme exertion should be avoided. See also Plate 208.