Hernias

Anterior Repairs

Anterior repairs are the most common operative approach for inguinal hernias. Tension-free repairs are now standard, and there are a variety of different types. Older tissue types of repair are rarely indicated, except for patients with simultaneous contamination or concomitant bowel resection, when placement of a mesh prosthesis may be contraindicated.

There are some technical aspects of the operation common to all anterior repairs. Open hernia repair is begun by making a transversely oriented linear or slightly curvilinear incision above the inguinal ligament and a fingerbreadth below the internal inguinal ring. The internal inguinal ring is located topographically at the midpoint between the anterior superior iliac spine and ipsilateral pubic tubercle. Dissection is continued through the subcutaneous tissues and Scarpa fascia. The external oblique fascia and external inguinal ring are identified. The external oblique fascia is incised through the superficial inguinal ring to expose the inguinal canal. The genital branch of the genitofemoral nerve and the ilioinguinal and iliohypogastric nerves are identified and avoided or mobilized to prevent transection and entrapment. The spermatic cord is mobilized at the pubic tubercle by a combination of blunt and sharp dissection. Improper mobilization of the spermatic cord too lateral to the pubic tubercle can cause confusion in the identification of tissue planes and essential structures and may result in injury to the spermatic cord structures or disruption of the floor of the inguinal canal.

The cremaster muscle of the mobilized spermatic cord is separated parallel to its fibers from the underlying cord structures. The cremaster artery and vein, which join the cremaster muscle near the inguinal ring, can usually be avoided but may need to be cauterized or ligated and divided. In general, minimal disruption of the cremasteric fibers and vasculature are recommended to minimize chronic groin pain. When an indirect hernia is present, the hernia sac is located deep to the cremaster muscle and anterior and superior to the spermatic cord structures. Incising the cremaster muscle in a longitudinal direction usually suffices to expose an indirect sac. The hernia sac is carefully separated from adjacent cord structures and dissected to the level of the internal inguinal ring. The sac is opened and examined for visceral contents if it is large; however, this step is unnecessary in small hernias. The sac can be mobilized and placed within the preperitoneal space, or the neck of the sac can be ligated at the level of the internal ring and any excess sac excised. If a large hernia sac is present, it can be divided with use of electrocautery to facilitate ligation. It is not necessary to excise the distal portion of the sac. If the sac is broad based, it may be easier to displace it into the peritoneal cavity rather than to ligate it. Direct hernia sacs protrude through the floor of the inguinal canal and can be reduced below the transversalis fascia before repair. To accomplish this, the weakened floor (transversalis fascia) is incised, exposing the preperitoneal fat below. This fat is mobilized from the neck of the direct defect and any other component of the direct hernia is reduced. The redundant transversalis fascia is excised and the floor can often be reapproximated using a running absorbable suture. A “lipoma” of the cord actually represents retroperitoneal fat that has herniated through the deep inguinal ring; this should be suture ligated and removed.

A sliding hernia presents a special challenge in handling the hernia sac. With a sliding hernia, a portion of the sac is composed of visceral peritoneum covering part of a retroperitoneal organ, usually the colon or bladder. In this situation, the grossly redundant portion of the sac (if present) is excised and the peritoneum reclosed. The organ and sac then can be reduced below the transversalis fascia, similar to the procedure for a direct hernia.

Tissue Repairs

Although tissue repairs have largely been abandoned because of unacceptably high recurrence rates, they remain useful in certain situations. In strangulated hernias, for which bowel resection is necessary, mesh prostheses are contraindicated and a tissue repair is necessary. Available options for tissue repair include iliopubic tract, Shouldice, Bassini, and McVay repairs.

The iliopubic tract repair approximates the transversus abdominis aponeurotic arch to the iliopubic tract with the use of interrupted sutures ( Fig. 45.5 ). The repair begins at the pubic tubercle and extends laterally past the internal inguinal ring. This repair was initially described using a relaxing incision (see later); however, many surgeons who use this repair do not perform a relaxing incision.

The Shouldice repair emphasizes a multilayer imbricated repair of the posterior wall of the inguinal canal with a continuous running suture technique. After completion of the dissection, the posterior wall of the inguinal canal is reconstructed by superimposing running suture lines progressing from deep to more superficial layers. The initial suture line secures the transversus abdominis aponeurotic arch to the iliopubic tract. Next, the internal oblique and transversus abdominis muscles and aponeuroses are sutured to the inguinal ligament. The Shouldice repair is associated with a very low recurrence rate and a high degree of patient satisfaction in highly selected patients.

The Bassini repair is performed by suturing the transversus abdominis and internal oblique musculoaponeurotic arches or conjoined tendon (when present) to the inguinal ligament. This once popular technique is the basic approach to nonanatomic hernia repairs and was the most popular type of repair done before the advent of tension-free repairs.

Cooper ligament repair, also known as the McVay repair, has traditionally been popular for the correction of direct inguinal hernias, large indirect hernias, recurrent hernias, and femoral hernias. Interrupted nonabsorbable sutures are used to approximate the edge of the transversus abdominis aponeurosis to Cooper ligament. When the medial aspect of the femoral canal is reached, a transition suture is placed to incorporate Cooper ligament and the iliopubic tract. Lateral to this transition stitch, the transversus abdominis aponeurosis is secured to the iliopubic tract. An important principle of this repair is the need for a relaxing incision. This incision is made by reflecting the external oblique aponeurosis cephalad and medial to expose the anterior rectus sheath. An incision is then made in a curvilinear direction, beginning 1 cm above the pubic tubercle throughout the extent of the anterior sheath to near its lateral border. This relieves tension on the suture line and results in decreased postoperative pain and hernia recurrence. The fascial defect is covered by the body of the rectus muscle, which prevents herniation at the relaxing incision site. The McVay repair is particularly suited for strangulated femoral hernias because it provides obliteration of the femoral space without the use of mesh.

Tension-free Anterior Inguinal Hernia Repair

Tension-free repair has become the dominant method of inguinal hernia repair ( Fig. 45.6 ). Recognizing that tension in a repair is the principal cause of recurrence, current practices in hernia management use a synthetic mesh prosthesis to bridge the defect, a concept popularized by Lichtenstein. There are several options for placement of mesh during anterior inguinal herniorrhaphy, including the Lichtenstein approach, plug and patch technique, and sandwich technique, with both an anterior and preperitoneal piece of mesh.

In the Lichtenstein repair, a piece of prosthetic nonabsorbable mesh is fashioned to fit the canal. A slit is cut into the distal lateral edge of the mesh to accommodate the spermatic cord. There are various preformed, commercially available prostheses available for use. The periosteum overlying the pubic tubercle is exposed and this dissection is extended medially toward the midline of the pubis for at least 15 to 20 mm. Fixation of mesh to the pubic tubercle itself should be avoided to minimize the risk of chronic groin pain. The inferolateral edge of the mesh is sutured to the shelving edge of the inguinal ligament starting just adjacent (but not into) the pubic tubercle) using a nonabsorbable suture. The medial aspect of the mesh is allowed to generously overlap the pubic tubercle by at least 15 mm. This suture is taken to a point just lateral and superior to the internal inguinal ring and tied. Interrupted sutures are then placed affixing the superomedial aspect of the mesh to the conjoined tendon. Great care is taken to visualize the ilioinguinal and iliohypogastric nerves to avoid injury or entrapment. In addition, adequate medial overlap of the mesh medial to the pubic tubercle is ensured. At this point, the tails created by the slit are sutured together around the spermatic cord, snugly forming a new internal inguinal ring. It is important to protect the ilioinguinal nerve and genital branch of the genitofemoral nerve from entrapment by placing them with the cord structures as they are passed through this newly fashioned internal inguinal ring or avoiding their enclosure in the repair.

Adapting the principles of tension-free repair, Gilbert has reported using a cone-shaped plug of polypropylene mesh that, when inserted into the internal inguinal ring, would deploy like an upside-down umbrella and occlude the hernia. This plug is sewn to the surrounding tissues and held in place by an additional overlying mesh patch. This patch may not need to be secured by sutures; however, to do so requires dissection to create a sufficient space between the external and internal oblique muscles for the patch to lie flat over the inguinal canal. This so-called plug and patch repair, an extension of the Lichtenstein original mesh repair, has now become the most commonly performed primary anterior inguinal hernia repair. Although this repair can be done without suture fixation by some experienced surgeons, most secure plug and patch with several monofilament nonabsorbable sutures, especially for very weak inguinal floors or large defects.

The sandwich technique involves a bilayered device, with three polypropylene components. An underlay patch provides a posterior repair similar to that of the laparoscopic approach, a connector functions similar to a plug, and an onlay patch covers the posterior inguinal floor. The use of interrupted fixating sutures is not mandatory, but most surgeons place three or four fixation sutures in this repair.

Another option for a tension-free mesh repair involves a preperitoneal approach using a self-expanding polypropylene patch. A pocket is created in the preperitoneal space by blunt dissection, and then a preformed mesh patch is inserted into the hernia defect, which expands to cover the direct, indirect, and femoral spaces. The patch lies parallel to the inguinal ligament. It can remain without suture fixation, or a tacking suture can be placed.

The Stoppa-Rives repair uses a subumbilical midline incision to place a large mesh prosthesis into the preperitoneal space. Blunt dissection is used to create an extraperitoneal space that extends into the prevesical space, beyond the obturator foramen, and posterolateral to the pelvic brim. This technique has the advantage of distributing the natural intra abdominal pressure across a broad area to retain the mesh in a proper location. The Stoppa-Rives technique is particularly useful for large, recurrent, or bilateral hernias.

Preperitoneal Repair

The open preperitoneal approach is useful for the repair of recurrent inguinal hernias, sliding hernias, femoral hernias, and some strangulated hernias. A transverse skin incision is made 2 cm above the internal inguinal ring and is directed to the medial border of the rectus sheath. The muscles of the anterior abdominal wall are incised transversely, and the preperitoneal space is identified. If further exposure is needed, the anterior rectus sheath can be incised and the rectus muscle retracted medially. The preperitoneal tissues are retracted cephalad to visualize the posterior inguinal wall and the site of herniation. The inferior epigastric artery and veins are generally beneath the midportion of the posterior rectus sheath and usually do not need to be divided. This approach avoids mobilization of the spermatic cord and injury to the sensory nerves of the inguinal canal, which is particularly important for hernias previously repaired through an anterior approach. If the peritoneum is incised, it is sutured closed to avoid the evisceration of intraperitoneal contents into the operative field. The transversalis fascia and transversus abdominis aponeurosis are identified and sutured to the iliopubic tract with permanent sutures. Femoral hernias repaired by this approach require closure of the femoral canal by securing the repair to Cooper ligament. A mesh prosthesis is frequently used to obliterate the defect in the femoral canal, particularly with large hernias.

Laparoscopic Repair

Laparoscopic inguinal hernia repair is another method of tension-free mesh repair based on a preperitoneal approach. The laparoscopic approach provides the mechanical advantage of placing a large piece of mesh behind the defect, covering the myopectineal orifice, and using the natural forces of the abdominal wall to disperse intra abdominal pressure over a larger area to support the mesh in place. Proponents have touted quicker recovery, less pain, better visualization of anatomy, and usefulness for fixing all inguinal hernia defects. Critics have emphasized longer operative times, technical challenges, increased risk of recurrence, and increased cost. Laparoscopic repair is also associated with an approximately 0.3% risk of visceral or vascular injury. Although controversy exists about the usefulness of laparoscopic repair for primary unilateral inguinal hernias, most agree that this approach has advantages for patients having bilateral or recurrent hernia repairs. Adopting practice guidelines for the performance of laparoscopic hernia repairs could help control costs.

When considering the laparoscopic approach for repair of inguinal hernias, the surgeon has several options. The most popular techniques are totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) approaches. The main difference between these two techniques is the sequence of gaining access to the preperitoneal space. In the TEP approach, the dissection begins in the preperitoneal space using a balloon dissector. With the TAPP repair, the preperitoneal space is accessed after initially entering the peritoneal cavity. Each approach has its merits. With the TEP approach, the preperitoneal dissection is quicker, and the potential risk for intraperitoneal visceral damage is minimized. However, the use of dissection balloons is costly, the working space is more limited, and it may not be possible to create a working space if the patient has had a prior preperitoneal operation. Also, if a large tear in the peritoneum is created during a TEP approach; the potential working space can become obliterated, necessitating conversion to a TAPP approach. For these reasons, knowledge of the transabdominal technique is essential in performing laparoscopic inguinal hernia repairs. The transabdominal approach allows identification of the groin anatomy before extensive dissection and disruption of natural tissue planes. The larger working space of the peritoneal cavity can make early experience with the laparoscopic approach easier.

There are no absolute contraindications to laparoscopic inguinal hernia repair other than the patient’s inability to tolerate general anesthesia. Patients who have had extensive prior lower abdominal surgery can require significant adhesiolysis and may be best approached anteriorly. In particular, in patients who have had a radical retropubic prostatectomy with the preperitoneal space previously dissected, accurate and safe dissection can be challenging.

In the TEP approach, an infraumbilical incision is used. The anterior rectus sheath is incised, the ipsilateral rectus abdominis muscle is retracted laterally, and blunt dissection is used to create a space beneath the rectus. A dissecting balloon is inserted deep to the posterior rectus sheath, advanced to the pubic symphysis, and inflated under direct laparoscopic vision ( Fig. 45.7 ). After it is opened, the space is insufflated, and additional trocars are placed. A 30-degree laparoscope provides the best visualization of the inguinal region (see Fig. 45.3 ). The inferior epigastric vessels are identified along the lower portion of the rectus muscle and serve as a useful landmark. Cooper ligament must be cleared from the pubic symphysis medially to the level of the external iliac vein. The iliopubic tract is also identified. Care must be taken to avoid injury to the femoral branch of the genitofemoral nerve and lateral femoral cutaneous nerve, which are located lateral to and below the iliopubic tract (see Fig. 45.4 ). Lateral dissection is carried out to the anterior superior iliac spine. Finally, the testicular vessels and vas deferens are identified and mobilized away from the peritoneum.

In the TAPP approach, an infraumbilical incision is used to gain access to the peritoneal cavity directly. Two 5-mm ports are placed lateral to the inferior epigastric vessels at the level of the umbilicus. A peritoneal flap is created high on the anterior abdominal wall, extending from the median umbilical fold to the anterior superior iliac spine. The remainder of the operation proceeds similar to a TEP procedure.

A direct hernia sac and associated preperitoneal fat are gently reduced by traction if not already reduced by balloon expansion of the peritoneal space. A small, indirect hernia sac is mobilized from the cord structures and reduced into the peritoneal cavity. A large sac may be difficult to reduce. In this case, the sac is divided with cautery near the internal inguinal ring, leaving the distal sac in situ. The proximal peritoneal sac is closed with a loop ligature or clips to prevent pneumoperitoneum from occurring. After all hernias are reduced, a 12 × 14-cm piece of polypropylene mesh is inserted through a trocar and unfolded. It covers the direct, indirect, and femoral spaces and rests over the cord structures. It is imperative that the peritoneum be dissected at least 4 cm off the cord structures to prevent the peritoneum from encroaching beneath the mesh, which can lead to recurrence. The mesh is carefully secured with a fixation device to Cooper ligament medially, anteriorly to the posterior rectus musculature and transversus abdominis aponeurotic arch at least 2 cm above the hernia defect, and laterally to the iliopubic tract. The mesh extends beyond the pubic symphysis and below the spermatic cord and peritoneum ( Fig. 45.8 ). The mesh is not fixed in this area and tacks are not placed inferior to the iliopubic tract beyond the external iliac artery. Fixation placed in this area may injure the femoral branch of the genitofemoral nerve or lateral femoral cutaneous nerve. Fixation is also avoided in the so-called triangle of doom, bounded by the ductus deferens medially and spermatic vessels laterally, to avoid injury to the external iliac vessels and femoral nerve. As long as one can palpate the tip of the tacking device, these structures are not likely to be injured.