Hernia Repair

What preparation?
Ensure site and side are marked pre-op with pt awake
- may be difficult to find later.
Correct cough if possible
- lessens recurrence risk.
Ensure hernia is the cause of their problems.
If very obese, defer until weight lost.

Selection.
"Many surgeons accept the challenge of repairing recurrent diffuse hernias in obese patients with stretched fat-infiltrated tissues or chronic coughs.  We are reluctant to do so.  These pts are not at risk of strangulation and recurrence is likely." (Kirk)

Bilateral repairs?
Yes, makes economic sense, but consider doing it laparoscopically

Local or GA?
Local is effective and probably better if reducible elective case
Results in less anaesthetic time, reduced hospital stay, less narcotic use, less complications (primarily urinary retention) compared to GA (RCTs)
[In general pre-incision local is highly advisable anyway, ie even if doing under GA]
Can be augmented by sedatives by the anesthetist to decrease situational anxiety and decrease local requirement (esp. for bilateral repairs).
A combination of xylocaine and bupivocaine allows rapid onset, slow offset, and higher doses of total agents without reaching side effect thresholds.

Technique : Lichtenstein Mesh Repair

1. Place supine
- antibiotic prophylaxis with 1g cephazolin pre-op.

2. Local anaesthetic and sedation method
- use 30-40 ml of .25% marcaine and 1% lignocaine mixed solution with or without adrenaline
- inject 5 ml in subdermal plane along line of planned incision using a long 25-gauge needle ; blocks subdermal plane
- inject ~3ml intradermally (raising a skin bleb), blocks skin.
- deep subcutaneous injection 10ml, inserting perpendicular (vertical) through skin along line of incision, at 2cm intervals.
- subfascial infiltration 8-10mL in underneath aponeurosis, viewed through subcut adipose tissue on first view; floods inguinal canal while still closed
- may need extra injection around level of pubic tubercle, around neck and inside of an indirect sac to achieve adequate anaesthesia.
- splashing remainder around canal before closing and into sub cut space can augment duration of coverage.

3. Make a skin crease incision 2cm above the inguinal ligament.
- from level of pubic tubercle to ~level of femoral pulse (two finger-breadths medial of ASIS.
- dissect through subcutaneous tissues
- clamp divide and ligate (or diathermy) the superficial branches of inferior epigastric veins.

4. Place a self retaining retractor.
- identify the external oblique fascia laterally
- incise rest of subcut tissue down to external oblique level and replace retractor.
- be wary of cutting into cord structures medially where they exit external ring.

5. Identify the external ring medially.
- define the rolled edge of the inguinal ligament to establish anatomical landmarks
- with scalpel, nick the external oblique in line with fibres
- open fascia and external ring carefully with scissors (be sure to enter ring, not skirt around crura)
- grasp EO edges with artery forceps.
- carefully dissect away underlying areolar tissue, place a self-retainer
- preserve and retract / or cut the ilioinguinal nerve on anterior aspect of cord
- evidence probably supports preservation depending on what you read; i try to preserve but do not hesitate to sacrifice it if compromised by the operation

6. Mobilize the cord from the floor of the inguinal canal, starting at the level of the pubic tubercle.
- combination of blunt and sharp dissection, holding the cord in the left hand.
- deepen dissection down to bone, and develop a plane to encircle cord with finger.
- place a quarter-inch penrose drain around the cord to facilitate retraction.
- delineate the internal ring, avoiding injury to the inferior epigastrics medially.

7. Carefully divide fibres of cremaster just distal to the internal ring, ensuring haemostasis.
- to identify the indirect sac, begin dissection on anterolateral aspect of the cord
- spermatic coverings from internal oblique and transversus (internal spermatic fascia) are divided and split up to level of internal ring.
- identify the shiny white sac, grasp it with haemostats
- now dissect it free of the cord structures with combination of paired forceps, scissors where adherent, and wiping with gauzed finger
- grasp dissected sac with Lanes or other non-traumatic forceps.
- if the distal end is visualized, this is also grasped so that the entire sac can be resected.
- else transect it where convenient, leaving the distal end open.
The cord structures are: vas deferens and accompanying vessels, testicular artery and veins, genital branch of genitofemoral nerve, autonomic nerves, cremasteric artery.

[7a. For a direct hernia:
- examine the conjoint tendon, looking for a large bulge, diffuse weakness or sometimes a small localised hernia.
- may need to ask pt to cough / anaesthetist to valsalva pt.]

8. Open the indirect sac, inspect its contents and exclude a sliding hernia.
- stick in a finger and ensure free mobility / reduction back into peritoneum
- when devoid, hold up ends with clips, twist it, then suture ligate it at level of internal ring with 2-0 vicryl.
- stump should retract back into abdomen.
- else, if a siding hernia, trim it to the level of the sliding structure and close with continuous 2-0 vicryl; or reduce the lot

9. If the internal ring is widened, reconstruct it with interrupted 3-0 vicryl to barely admit the tip of your index finger.
- not too tight or testicular blood supply threatened.
- avoid the inferior epigastric vessels medially.

10. Repair the floor / posterior wall of the inguinal canal.
- plicate the floor of the inguinal canal with 2-0 vicryl using a continuous suture without tension.

11. Fashion an appropriate piece of prolene mesh.
- including a linear cut near the bottom to pass around the cord structure near the internal ring level.
- secure it to the floor with 2-0 nylon starting well over (2cm) the pubic tubercle ~midline.
- fix to lacunar ligament and run infero-laterally to past internal ring.  Fishtail around cord at ring. secure laterally and medially with few more interrupted sutures.
- place the retracted ilioinguinal nerves over the mesh.

12. Irrigate, achieve haemostasis, particularly of the cord structures.

13. Close starting at the external ring, using 2-0 vicryl.
- ensure can get a finger through at external ring
- close skin with subcuticular 4-0.
- ensure the testis is carefully drawn into the scrotum.

Notes on Repair

Pitfalls
Suturing over the nerve
- chronic post op pain >3mo minimized by carefully identifying nerves.
Damage to vas (0.3%)
- located posteriorly, identify and preserve.
Stitching periosteum
- a point of maximal post-op tenderness.
- be mindful taking the bite over the pubic tubercle.
Vascular injury
- rare but disastrous; respect the proximity of the femoral vessels.
Haematoma
- injury to inferior epigastrics or failure to ligate the superficial subcutaneous veins.
Recurrence
- tend to recur medially.
- ensure good mesh coverage medially 2 cm over the pubic tubercle.
- 3-4 cm above Hesselbach triangle
-
and 5 cm lateral to internal ring.
- do not lay it under tension; should be slightly domed at the center; compensates for forward protrusion of transversalis when standing and progressive shrinking over time.
Pull testes back into position afterwards.

Local anaesthetic use.

Use monitoring.
Do not exceed safe dose.

Post op analgesia.
Rectal diclofenac in OT useful.
Post-op regular diclofenac and paracetamol +/- codeine is effective.

What suture?
Monofilament non-absorbable most popular: strong repair.
Remember to knot well and handle with care to maintain strength.
Do not tie too tightly, do not take even bites of fascias; toilet-paper tearing effect.

What mesh?
Prolene commonly used (polypropylene), e.g. 8x16cm
- stiff enough to lie flat, needs only tacking sutures.
- rapid incorporation into fibrous tissue, strong
Polyester preferred by some (Mersilene).
- softer, needs full suturing, more dependent on sutures than fibrous reaction.

Sliding hernia?
Will see fat encroachment on the side (and possibly other contents) inside a chunky sac.
Effectively is a prolapse of the retroperitoneal tissues
Don't go dividing and removing the sac - can damage contents.
Just reduce the whole sac without entering it

What follow-up?
Best to give one six week visit.  Some leave this to reliable GPs.
Can follow complications eg nerve injury, pain, infection.

Other Repairs

Darn repair
Now largely abandoned.

Shouldice Repair
Long learning curve.
No mesh (see notes)