Inguinal Hernia Repair: Open

Anatomy

The inguinal canal is formed by the aponeurosis of the external oblique muscle anteriorly, the transversalis fascia, and the transversus abdominis muscles posteriorly ( Figs. 53B.1 and 53B.2 ). The canal is approximately 4 cm in length and is located cephalad to the inguinal ligament running between the internal (deep) inguinal and external (superficial) inguinal rings. In men, the inguinal canal contains the spermatic cord and, in women, it contains the round ligament. During open inguinal hernia repair, the iliohypogastric, ilioinguinal, and genital branches of the genitofemoral nerves are encountered ( Fig. 53B.3 ). The ilioinguinal and iliohypogastric nerves can be identified as they pass between the external and internal oblique muscles. The genital branch of the genitofemoral nerve is generally found outside the area of dissection behind the cord structures.

Inguinal hernias are classified anatomically as direct or indirect. Indirect inguinal hernias are the most common type of hernia in both sexes. Indirect hernias are a protrusion of the hernia sac at the internal ring, lateral to the inferior epigastric vessels. Indirect inguinal hernias are the result of a patent processus vaginalis. In contrast, the sac of a direct inguinal hernia protrudes medial to the inferior epigastric vessels, within Hesselbach triangle. Hesselbach triangle is formed by the inguinal ligament (Poupart ligament) inferiorly, the inferior epigastric vessels laterally, and the rectus abdominis muscle medially. Direct hernias are a result of weakness in the floor of the inguinal canal.

Conventional Anterior Open Approach

Open anterior inguinal hernia repairs generally follow the same initial steps: skin incision along the lines of Langer, deepening of the incision through Camper and Scarpa fascia to the external oblique aponeurosis, and incision of the external oblique through the external ring. Once the external oblique aponeurosis has been incised, the superior flap is created by bluntly sweeping off the internal oblique muscle. The ilioinguinal and iliohypogastric nerves are identified and preserved. Selective use of neurectomy is advocated in cases of inadvertent trauma or presumed injury due to mesh entrapment. Inferiorly, the cord structures are separated from the inferior flap of the external oblique aponeurosis and blunt dissection is carried onto the pubic tubercle. Using both index fingers, the surgeon creates a window behind the cord structures at the pubic tubercle to allow for passage of a Penrose drain. Once the Penrose is placed for retraction, dissection of the cord is performed in order to identify an indirect hernia sac. The indirect hernia sac is then dissected free from the cord structures up to the level of the internal ring. The sac can either be high-ligated with division and suture closure or it can simply be inverted and reduced into the preperitoneal space. If a direct hernia is present, a purse-string suture can be placed in the transversalis fascia at the base of the hernia to allow for inversion and closure of the hernia.

Lichtenstein Repair

Initial steps of the Lichtenstein repair are similar to the steps described previously ( Fig. 53B.4 ). High ligation is performed after incising the cremasteric muscle longitudinally to fully mobilize the sac. Similarly, direct hernias are circumferentially dissected and reduced back into the preperitoneal space. A large mesh prosthesis is then tailored to the shape and size of the patient's anatomy to facilitate overlap of 2 cm onto the pubic tubercle, 4 cm above Hesselbach triangle, and 5 to 6 cm lateral to the internal ring. The mesh is sutured to the pubic tubercle on either side and then secured in a continuous fashion along the shelving edge of the inguinal ligament inferiorly until it is at least 1 cm lateral to the insertion of the internal oblique muscle into Poupart ligament. Similarly, the mesh is secured superiorly to the rectus sheath and subsequently to the internal oblique aponeurosis with interrupted sutures. Two tails are created in the mesh by incising it from the lateral edge to create a slit that encircles the spermatic cord and reconstructs the internal ring. The mesh tails encircling the cord are anchored in a fashion that overlaps the superior and inferior tails in a manner that creates a new internal ring fitting snugly around the spermatic cord. This is accomplished by suturing the tails together and tucking the ends of the tails under the external oblique aponeurosis. Creation of this shutter valve at the internal ring is a critical step for preventing indirect hernia recurrence. The superior and inferior tails can then be secured to the underlying internal oblique and fascia. Care should be taken not to entrap the ilioinguinal, iliohypogastric, or genital branches of the genitofemoral nerves when placing sutures. The main limitation of this technique is that it does not address femoral hernias.