Inguinal Hernia...Tension free mesh repair, step by step

Tension free mesh repair, step by step

1. Skin incision about 1.5 cm above and parallel to Inguinal ligament.
2. Ligation of the superficial epigastrivc vein (do not coagulate)
3. Opening Scarpa's fascia
4. Opening external aponeurosis following fibre direction. Avoid damage to the ilioinguinal nerve.
5. Isolate spermatic cord
6. Identify genitofemoral nerve (genital branche), this runs dorsal and parallel to the spermatic cord, underneath the cremaster muscle fibers
7. Isolate hernia sac and/or preperitoneal lipoma
8. Repositioning hernia (do not ligate!)
9. Lipoma can be ligated
10. In case of a large lateral hernia (scrotal) the hernia sac can be transected and proximally ligated. The distal part can remain in situ however needs to be left open widely.
11. Suture mesh with Prolene. First suture through the lateral rectus border just cranially to the pubic tubercle. Proceed along inguinal ligament with large steps and small bites.
12. Tie a knot when the internal ring has been reached (preferably an Aberbeen knot)
13. Create a new internal ring by attaching the lower edge of the upper part of the mesh to inguinal ligament.
14. Secure upper part with single sutures. Beware of the iliohypogastric nerve.
15. Close the external aponeurosis and create new external ring
16. Close Scarpa's fascia
17. Skin closure (intracutaneous resorbable)
18. Infiltrate wound with local anaesthesia

Inguinal Hernia

Risk factors
Positive family history, prolonged increased abdominal pressure (COPD, constipation, prostatism, peritoneal dialysis), aortic abdominal aneurysm, smoking.

Examination
Basically only physical examination; groin mass cranially from Poupart's ligament. Differentiate between a lateral or medial hernia with physical examination is unreliable. Describe testicles, contralateral side and reducibility. Further test are rarely necessary but in doubt a herniography, US or MRI can be considered.

Differential diagnosis
Femoral hernia, varicosis, lymph node, aneurysm, abscess, soft tissue tumor.

Treatment
Asymptomatic hernia; consider conservative treatment
Symptomatic hernia; planned surgery
Incarcerated hernia; acute surgery

Surgical technique
Unilateral; Mesh-repair.Extensive research has been done for the Lichtenstein's and the endoscopic technique. Lichtenstein's technique is recommended.
Bilateral; Mesh-repair. Lichtenstein or endoscopy if enough expertise is available. When endoscopically treated, the TEP is superior to the TAPP.
Recurrent hernia; Technique depends on earlier treatment. In case of an earlier anterior approach, a pre-peritoneal mesh or TEP should be performed. In case of an earlier posterior approach, an anterior mesh or TAPP should be performed.

 
Antibiotics
Antibiotic prophylaxis does not prevent the occurrence of wound infection after groin hernia surgery and should therefore not routinely be given. Prophylactic antibiotics is only recommended in high risk patients.