Plate 213

Adult inguinal hernias are usually repaired in an ambulatory surgery setting unless coexisting medical conditions merit hospitalization for specialized monitoring or care. The use of polypropylene mesh has become increasingly popular as it may be used for both direct and indirect hernias and it results in a lower rate of recurrence.

The obese patient should be required to lose weight, preferably to within 10 percent of calculated ideal weight, which may delay the operation for a considerable time. Any open skin infections must be healed prior to operation. Systemic causes of increased intra-abdominal pressure or straining should be reviewed. A productive cough or an upper respiratory infection will delay the procedure until resolution. Chronic smokers should be encouraged to curtail their smoking. Evidence of prostatic obstruction should be evaluated in older men and the possibility of new colon lesions should be evaluated in older men and women. 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 may be given a day before the operation to ensure an empty colon. 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 with an anxiolytic, narcotic, and hypnotic (commonly midazolam, fentanyl, and propofol) is combined with a field block of local anesthesia. Lidocaine 1 or ½ % without adrenaline is preferred and the total dose is limited to less than 300 mg (30 mL of 1% lidocaine). This amount may be reduced in elderly patients. No adrenalin is used during the opening as this may obscure small bleeding vessels that should be ligated or cauterized thus lessening ecchymosis or hematoma formation. However, during the closure, when hemostasis is secured, many surgeons reinfiltrate the operative field with a long-acting local anesthetic such as bupivacaine. Adrenalin is often added except in patients with heart disease so as to extend the duration of the local anesthetic.

The patient is placed in a supine position with a pillow under the knees to lessen tension in the inguinal region.

The skin is shaved and prepared in a routine manner. In men, the penis and scrotum should be prepared, especially if the hernia extends into the scrotum or if a hydrocele is present.

After a sterile draping of the region, the local anesthetic is injected. The surgeon may perform a selective nerve block of the ilioinguinal and iliohypogastric nerves, which are just medial to the anterior superior spine (Figure 1). The incision may be made either parallel to the inguinal ligament (Figure 2, A) or more transversely along a skinfold line (Figure 2, B). Most surgeons prefer a field block with multiple injections along the incision (Figure 3) followed by further injections at each new level of fascial dissection.

Details of Procedure

The incision is carried down through Scarpa's fascia to the external oblique aponeurosis. Additional local is infiltrated beneath this fascia, especially laterally (Figure 4). The external oblique is opened in a direction parallel to its fibers down through the external ring. Care is taken to lift this fascia away from the cord and ilioinguinal nerve during the opening so as to lessen the chance of transection of the nerve.

The free edges of the external oblique fascia are grasped with a pair of hemostats medially and laterally. Using blunt dissection, the fascia is separated from the internal oblique muscle superiorly and the cord inferiorly. The cord is encircled with a soft rubber Penrose drain. Additional local anesthesia is injected along the inguinal ligament and about the pubic tubercle. The direct hernial sac is carefully separated from the cord, which is cleaned back to the level of its exit at the internal ring. It is verified that this is a direct herniation rather than a medial protrusion of an indirect herniation. The cremaster muscle about the cord is opened anteriorly. The cord structures are identified and the region of the internal ring inspected for evidence of an indirect hernia and sac. A direct hernia only is shown (Figure 5). The direct hernial sac is cleaned with blunt and sharp dissection around to its neck. This protrudes through a defect in the transversalis fascia of the canal floor. These defects may be discrete, with a finger-sized punched out hole, or may involve the entire floor as a diffuse blowout from the inguinal ligament below to the conjoint tendon above. Some surgeons prefer to open the direct sac, reduce the properitoneal fat, and excise the residual sac, as is done with indirect hernias. Almost always, however, the sac and fat are easily reduced (Figure 5) and then kept reduced with an instrument as the floor is reconstructed.

A continuous nonabsorbable 00 suture is placed for reconstruction of the canal floor. This begins at the pubic tubercle and approximates the residual transversalis fascia just above the inguinal ligament to the transversalis fascia or muscle just below the conjoint tendon so as to imbricate the herniation (Figure 6). This suture continues laterally to the level of the internal ring. Care is taken to avoid the inferior epigastric vessels. After this suture is tied, the internal ring should be snug about the cord (Figure 7). The floor of the canal is now solid and the conjoint tendon lies in its normal position. The conjoint tendon is not artificially pulled down under tension to the inguinal ligament as in the classic Bassini repair.

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