Abdominal Wall: Open Inguinal Hernia Repair (Herniorrhaphy)

General Approach

General Approach

  • Skin Incision 6-8 cm Parallel to Inguinal Ligament
  • Expose & Longitudinally Incise the Aponeurosis of the External Oblique to Enter the Inguinal Canal
    • Preserve Ilioinguinal Nerve
  • Isolate the Spermatic Cord & Encircle with a Penrose Drain
  • Reduce the Hernia
  • Repair
    • Tissue Repair – First Longitudinally Divide Posterior Wall/Transversalis Fascia
  • Close Aponeurosis of External Oblique
    • Avoid Injury to the Ilioinguinal Nerve
  • Close Skin

Tissue Repairs

Bassini Repair

  • Divide Inguinal Floor & Approximate Flap with Conjoined Tendon to Inguinal Ligament Mn
  • If Perceived Tension: Create a “Relaxing Incision” of the Anterior Rectus Sheath

Shouldice Repair

  • Subtype of Bassini Done in Multiple Layers (2-4)
  • Generally Considered the Best Tissue Repair
  • Original Description Used Stainless Steel Wire Suture in 4 Layers
    • Layer 1: Inferolateral Transversalis Fascia Flap to Deep Muscular Fascia
    • Layer 2: Superior-Medial Transversalis Fascia Flap to Shelving Portion of Inguinal Ligament
    • Layer 3: Conjoint Tendon to Inferolateral Transversalis Fascia Flap
    • Layer 4: Conjoint Tendon to Inguinal Ligament

McVay Repair

  • Approximate Conjoined Tendon to Cooper’s Ligament Mn
    • Interrupted Sutures from the Pubic Tubercle Laterally
    • Final Stich Includes the Inguinal Ligament (“Transition Stitch”)
  • If Perceived Tension: Create a “Relaxing Incision” of the Anterior Rectus Sheath
  • Repairs Femoral Hernias Also

Laroque Repair

  • Intraabdominal Muscle-Splitting Incision Superior to Deep Inguinal Ring
  • Assists in Reduction of Sliding Hernias
  • After Reduction Repair Can Be Through Any Other Technique

Mesh Repairs

Lichtenstein Repair

  • Uses Mesh to Decrease Tension
  • The Most Common Open Mesh Repair – Previously Considered the “Gold Standard”
  • Procedure:
    • Fix the Mesh to the Pubic Tubercle Using Nonabsorbable Monofilament Suture
      • Should Overlap 2 cm
    • Continue Running Suture Along the Inferior Shelving Edge of the Inguinal Ligament
    • Cut Mesh to Encircle the Spermatic Cord – 1/3 Below & 2/3 Above
    • Single Suture to Loosely Approximate the Mesh Tails – Recreate a New Internal Ring
    • Loosely Fix the Mesh Superiorly to the Internal Oblique Aponeurosis

Plug & Patch Repair

  • Similar to Lichtenstein Repair with the Addition of a Mesh Plug
    • Indirect Hernia: Placed Through the Internal Ring
    • Direct Hernia: Sutured to Cooper’s Ligament, Inguinal Ligament & Internal Oblique
  • Generally Discouraged Due to Complications (Contraction, Migration & Chronic Pain)

TIPP (Trans-Inguinal Preperitoneal) Repair

  • Through the Deep Inguinal Ring Bluntly Clear a Preperitoneal Space
    • Ensure the Inferior Epigastric Vessels are Against the Abdominal Wall Anterior to the Plane
  • Insert the Mesh in the Preperitoneal Plane
  • Consider Suture Fixation, Some Leave without Tacking Down
  • Repairs Both Inguinal & Femoral Hernias
  • MOPP (Minimal Open Preperitoneal) Repair
    • Subtype of TIPP Repair
    • Uses a Small (2.5-4.0 cm) Incision Immediately Over the Deep Inguinal Ring
  • Bilayer Mesh Repair
    • A Specialized Mesh is Used to Fix a Layer in the Preperitoneal Space and Another Layer in a Lichtenstein Fashion

Mnemonics

Bassini vs McVay Repairs

  • Mini Bassini – Only Down to the Inguinal Ligament
  • All the Way McVay – Down Past Inguinal Ligament to Cooper’s Ligament