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INGUINAL HERNIA
SURGERY
Faisal Azmi
Hernia repair
• Hernioplasty when herniotomy is combined with a reinforced repair
of the posterior inguinal canal with autogenous ;patieŶtĶ›s oǁ Ŷ tissueĶæ
or heterogenous material such as prolene mesh.
• Herniorraphy is somewhat like hernioplasty only that no autogenous
or heterogenous material is used for reinforcement.
• Herniotomy is a surgical operation where the hernia sac is removed
without any repair of the inguinal canal.
• Indications
• All hernia require Sx unless they are eldely /unfit for Sx
• Due to risk of complications of hernia
• Preparation
• Treat the predisposing cause
• c/c cough constipation BPH
• Anaesthesia
• General
• Spinal
• Local } point block field block } anaesthesia of choice
• Position
• Supine
• Cleaning & draping the area
• Incision
• ½ ĶšĶ› aďoĒ€e & parallel to ŵedial to Ļ®/ĻÆrd of inguinal ligament
• Structures cut
• skin
• 2 layers of superficial fascia
• Ligate superficial epigastric & superficialexternal pudendal
• External oblique along the direction of fibres directed towards apex of superficial
inguinal ring
• Ilioinguinal nerve is thus identified and preserved
Herniotomy
• Search for sac (pearly white in colour)
• Indirect – inside the spermatic cord anterolateral to it
• Direct– outside the cord & posteromedial to it (therefore spermatic cord is not
opened)
• Incase of indirect hernia Incise cremasteric fascia & inrenal spermatic fascia
• Expose the sac from fundus to neck separate from spermatic cord
• Divide the fundus of the sac in the inguinal canal and reduce the contents
by opening it and with fingers
• Identify the neck with
• Constriction /narrowness
• Inferior epigastric A
• Presence of extraperitoneal fat
Alone is sufficient in childrens
• Transfix and ligate the neck by needle passing technique through the
tissue to prevent slipping
• Excise the redundant sac
• Closure of the wound
Herniorraphy *(repair of posterior wall)
• Indication for In children only when there is collagen vascular
disease,severe anemia,severe malnutrition,CRF
• ďassiŶiĶ›s repair
• The conjoined muscle of the transversus abdominis and the internal oblique
muscles is sutured to the inguinal ligament by 3-5 interrupted sutures (non
absorbable suture)
• Drawbacks
• Undue tension to relieve it tanners slide operation (transverse incision on rectus sheath)
• Recurrence due to approximation of muscle to a ligament & thick distant bites
• Modified ďassiŶiĶ›s repair
• Conjoint tendon to inguinal ligament with continuous sutures
• shouldice repair
• 6 layers
• 1st &2nd } double breasting of fascia transversalis
• 3rd & 4th } approximate conjoint tendon to inguinal ligament in 2 layers
• 5th & 6th } double breast external oblique aponeurosis
• Spermatic cord is superficial ļƒ†more chance of trauma
• Modified shouldice
• Only 4 layers
• 1st &2nd } double breasting of fascia transversalis
• 3rd } approximate conjoint tendon to inguinal ligament in 1 layer
• Coopers ligament repair/mc vays repair
• inguinal and femoral canal defects
• The ĐoŶjoiŶed teŶdoŶ is sutured to CooperĶ›s ligaŵeŶt froŵ the puďiĐĐuďiĐle laterally
Hernioplasty
• Lichenstein tension free mesh repair
• Rives repair
• Preperitoneal mesh is kept with out suturing by incising transversalis fascia
• GPRVS/giant prosthetic reinforcement of visceral sac/stoppas repair
• By pfannensteil incision/midline vertical
• Size of mesh
• Breadth = distance B/W 2 ASIS -2cm
• Length = b/w umbilicus to pubic symphysis
• Desaradas technique
• Dynamic repair
• Closure
• External oblique is sutured with chromic catgut or silk.
• Subcutaneous fat absorbable catgut suture.
• Skin with silk.
• Post -op
• NPO fro 6-8 hours, oral fluids and soft diet later.
• Analgesics
• Antibiotics
• Scrotal support if the dissection is more(complete hernia)
• Suture removal after 7-10days.
• Post-op complications
• Haematoma
• Wound infection
• Severe peritonitis pubis
• nerve entrapment causing pain.
Thank You