MANAGEMENT OF HERNIA

The treatment of choice for majority of patients with symptomatic inguinal hernias is surgery.
However a third of patients presenting with a groin hernia will have minimal or no symptoms, the risk of
a hernia accident in these patients is small. Whether or not these patients should undergo surgery is not
clear. Studies were done and concluded that the repair of an asymptomatic inguinal hernia does not
affect the rate of long-term chronic pain and may be beneficial to patients in improving overall health
and reducing potentially serious morbidity. It would seem therefore that with minimally symptomatic
inguinal hernias, while a watch and wait policy is a reasonable and safe strategy, symptoms are likely to
progress and an operation will eventually be needed. In light of the demonstrated improvement in
quality of life following surgery, all medically fit patients with an inguinal hernia should have a repair.
Patients who have significant co-morbidities and who do not want to undergo surgical repair can be
managed conservatively in the community, with reassurance that strangulation and incarceration are
extremely rare events. These patients should be counseled on the symptoms of the aforementioned
complications and to seek prompt assessment if these occur.

In uncomplicated Indirect inguinal hernia, the first step in the open approach is to open the
inguinal canal, free the hernia sac from the spermatic cord and excise it after transfixing and ligating
its neck. Herniotomy or simple excision of the sac is all that is needed in young children. In older
children and adults, the inguinal ring is usually stretched and widened, and therefore after
herniotomy it is necessary to tighten the deep ring and/or strengthen the posterior wall with a mesh.

In cases of direct hernia, following mobilization from the spermatic cord, it is not normally
excised and it is simply invaginated by sutures placed in the transversalis fascia. Insertion of a
sythnetic mesh is used to reinforce the posterior wall of the inguinal canal.

PREOPERATIVE PROCEDURE

An obese patient is required to lose weight, ideally ten percent of calculated ideal body weight.
Open skin infections must be healed prior to operation. Systemic causes of increased intraabdominal
pressure or straining should be reviewed. Ensure resolution of productive cough or an upper respiratory
infection prior to procedure. Chronic smokers should be encouraged to curtail their smoking. Evidence
of prostatic obstruction should be evaluated in older men and the possibility of new colon lesions should
be evaluated in older men and women. All patients should be taught how to get out of the bed with a
minimum discomfort and advised to practice this. Sensitivity to drugs, including local anesthetics, should
be ascertained. A mild cathartic may be gicen a day before the operation to ensure an empty colon. A
thorough medical evaluation is essential in older patients, including a cardiopulmonary clearance. A
hernia should be relatively asymptomatic unless it becomes incarcerated. Any other symptoms must be
evaluated, because they may be due to causes other than hernia.

ANESTHESIA
 Deep sedation with anxiolytic, narcotic, and hypnotic is combined with field block of local
anesthesia. Lidocaine 1 or 1/2% without epinephrine is preferred and the total dose is limited to less
than 300mg (30ml of 1% Lidocaine). This amount may be reduced in elderly patients. No epinephrine is
used during the opening as this may obscure small bleeding vessels that should be ligated or cauterized
thus lessening ecchymosis or hematoma formation. However, during the closure, when hemostasis is
secured, many surgeons reinfiltrate the operative field with a long-acting anesthetic. Epinephrine is
often added excepth in patients with heart disease so as to extend the duration of local anesthetic.

OPEN HERNIA REPAIR

Open inguinal hernia repairs are subdivided into techniques that employ prostheses to create a
tension-free repair and those that reconstruct the inguinal floor using native tissue. Tissue repairs are
indicated when the use of prosthetic material is contraindicated, such as in contamination or
strangulation. The option to administer locoregional anesthesia is an advantage of the open approach. A
regional block is an option for patients who cannot tolerate general anesthesia, and it exerts a broader
effect than local anesthesia alone. Exposure of the anterior inguinal region is common to the open
approaches. An oblique or horizontal incision is performed over the groin two fingerbreadths inferior and
medial to the anterior superior iliac spine then extended medially for approximately 6 to 8 cm.
Subcutaneous tissue is dissected using electrocautery to expose the external oblique aponeurosis. A small
incision is then made in the external oblique aponeurosis parallel to the direction of the muscle fibers.
Metzenbaum scissors are introduced and spread beneath the fibers to separate adhesions to the
underlying ilioinguinal nerve. The scissors are then used to incise the aponeurosis superior to the inguinal
ligament, splitting the external inguinal ring. The flaps of the external oblique aponeurosis are elevated
with Hemostat clamps. The interior oblique fibers are dissected bluntly from the overlying external
oblique flaps. The iliohypogastric and ilioinguinal nerves are identified and preserved. The pubic tubercle
is identified and the cord structures are atraumatically dissected off of the pubis, encircled, and elevated
with a Penrose drain. The cord is elevated 2 cm over the pubic symphysis in an avascular plane, and
cremasteric fibers are preserved to avoid injuring cord structures. An indirect hernia sac will generally be
found on the anterolateral surface of the spermatic cord after division of the cremasteric muscle in the
direction of its fibers. In addition to sac identification, the vas deferens and vessels of the spermatic cord
must be identified to allow dissection of the sac from the cord. At the leading edge of the sac, the two
layers of peritoneum will fold upon themselves and reveal a white edge, which may help in the
identification of the sac. The sac can then be grasped with a tissue forceps and bluntly dissected from the
cord. The dissection is carried proximally toward the deep inguinal ring. Viable contents may be reduced
into the peritoneal cavity, while nonviable contents should be resected, and synthetic prostheses should
be avoided in the repair. The inguinal canal is then reconstructed, either with native tissue or with
prostheses.

Tissue-based herniorrhaphy is a suitable alternative when prosthetic materials cannot be used

safely. Indications for tissue repairs include operative field contamination, emergency surgery, and when
the viability of hernia contents is uncertain.
 The Bassini repair involves dissection of the hernia sac with high ligation and extensive
reconstruction of the inguinal canal. It is performed for direct and indirect inguinal hernias, but has a
higher rate of recurrence compared to other types. After exposing the inguinal floor, the transversalis
fascia is opened. Preperitoneal fat is bluntly dissected then reconstruction of posterior wall is done by
suturing the transversalis fascia, the transversus abdominis muscle, and the internal oblique muscle
medially to the inguinal ligament laterally.

The Shouldice repair recapitulates principles of the Bassini repair and the procedure of choice
for adults. With the posterior inguinal floor exposed, an incision in the transversalis fascia is made
between the pubic tubercle and internal ring. At the pubic tubercle, the iliopubic tract is sutured to the
lateral edge of the rectus sheath. This continuous suture progresses laterally, approximating the edge of
the inferior transversalis flap to the posterior aspect of the superior flap. At the internal inguinal ring, the
suture continues back in the medial direction, approximating the edge of the superior transversalis fascia
flap to the shelving edge of the inguinal ligament. At the pubic tubercle, this suture is tied to the tail of
the original stitch. The next suture begins at the internal inguinal ring, and it continues medially,
apposing the aponeuroses of the internal oblique and transversus abdominis to the external oblique
aponeurotic fibers. At the pubic tubercle, the suture doubles back through the same structures laterally
toward the tightened internal ring. This multilayer reconstruction allows redistribution of tension over
several tissue layers which results in lower recurrence rates.

McVay Repair also known as Cooper Ligament repair can be used for both inguinal (direct &
indirect) and femoral ring defects. This may also be indicated for femoral hernias when a prosthetic
material is contraindicated. The technique sutures the conjoined (transversus abdominis and internal
oblique) tendon to the cooper’s ligament laterally which may result in increased postoperative pain and
higher risk of ventral abdominal herniation. Due to its high rate of recurrence, it is infrequently
performed as an initial herniorrhaphy. However, it may be useful in cases where mesh from a previous
operation must be removed and some form of primary tissue repair is needed.

Mesh-based hernioplasty is the most commonly performed general surgical procedure, owing
to the technique’s efficacy and improved outcomes. The techniques of the most commonly performed
prosthetic repairs are Lichtenstein Tension-Free Repair, Plug and Patch Technique, and Prolene Hernia
System.

Lichtenstein Tension-Free Repair expands the domain of the inguinal canal by reinforcing the
inguinal floor with a prosthetic mesh, thereby minimizing tension in the repair. The inguinal canal is
dissected to expose the shelving edge of the inguinal ligament, the pubic tubercle, and sufficient area for
mesh. The mesh is a 7 × 15 cm rectangle with a rounded medial edge, and it must be large enough to
extend 2 to 3 cm superior to Hesselbach’s triangle. The lateral portion of the mesh is split such that the
superior tail comprises two thirds of its width, and the inferior tail comprises the remaining one third.
The medial edge of the mesh is affixed to the anterior rectus sheath such that it overlaps the pubic
tubercle by 1.5 to 2 cm. This refinement to the original Lichtenstein technique minimizes medial
recurrence. For fixation of the inferior margin of the mesh, a permanent, synthetic, monofilament suture
is used, taking care to avoid placing sutures directly into the periosteum of the pubic tubercle. Fixation is
continued along the shelving edge of the inguinal ligament from medial to lateral, ending at the internal
ring. The upper tail of the mesh is then fixed to the internal oblique aponeurosis and the medial edge to
the rectus sheath using a synthetic, absorbable suture.

Plug and Patch Technique is a modification of Lichtenstein repair wherein prior to placing the
prosthetic mesh patch over the inguinal floor, a three dimensional prosthetic plug is placed in the space
previously occupied by the hernia sac. In the case of an indirect hernia, the plug is placed alongside the
spermatic cord through the internal ring. Prosthetic plugs of various sizes are available, and one of
appropriate size is fixed to the margins of the internal ring with interrupted sutures. For direct hernias,
the sac is reduced, and the plug is sutured to Cooper’s ligament, the inguinal ligament, and the internal
oblique aponeurosis. This technique may be used for recurrent as well as primary inguinal hernias.

Prolene Hernia System provides reinforcement to the anterior and posterior aspects of the
abdominal wall. With an indirect hernia, the sac is dissected from the spermatic cord, and the
preperitoneal space is bluntly dissected through the internal ring. With a direct hernia, the transversalis
fascia is opened at the defect, and the preperitoneal space is bluntly dissected to create space for the
mesh. The mesh has an underlay flap and an onlay flap, joined by a short cylindrical connector. The
underlay portion of the mesh is then placed through the hernia defect into the preperitoneal space. The
advantage of the preperitoneal mesh position is that increased intra-abdominal pressure pushes the
mesh into closer apposition to the abdominal wall. The overlay flap reinforces the inguinal floor similar
to a tension-free repair. The spermatic cord is placed through a slit in the onlay portion of the mesh.
Three to four circumferential interrupted sutures anchor the anterior layer of the mesh to the inguinal
canal floor. Once the reconstruction of the inguinal canal is complete, the cord contents are returned to
their anatomic position. The external oblique aponeurosis is then reapproximated continuously from
medial to lateral using an absorbable suture. The external ring should be reconstructed in close
apposition to the spermatic cord to avoid the appearance of recurrence on future examination. Scarpa’s
fascia and skin are appropriately closed.

LAPAROSCOPIC HERNIA REPAIR

The laparoscopic approach reinforces the abdominal wall in posterior approach. Indications are
similar to open approach. It is superior to open approach in repairing bilateral or recurrent inguinal
hernias. The three methods commonly used by surgeons are transabdominal preperitoneal repair
(TAPP), Totally extraperitoneal (TEP) repair and Intraperitoneal Onlay Mesh (IPOM) repair.

Transabdominal preperitoneal approach is advantageous for an intraperitoneal perspective and

is useful for bilateral hernias, large hernia defects, and scarring from previous lower abdominal surgery.
In this procedure, the bladder, median and medial umbilical ligaments, external iliac, inferior epigastric
vessels are visualized.

Totally extraperitoneal procedure grants access to preperitoneal space without intraperitoneal

infiltration. This approach minimizes risk of injury to intraabdominal organs and port site herniation
through the iatrogenic defect in the wall. This is also indicated for repair of bilateral inguinal hernias or
unilateral hernias when scarring makes the anterior approach challenging. A small horizontal incision is
made inferior to the umbilicus. Subcutaneous tissue is dissected to the level of the anterior rectus
sheath, which is then incised lateral to the linea alba. The rectus muscle is retracted
superolaterally, and a dissecting balloon is advanced through the incision toward the pubic symphysis.
Under direct visualization with a 30° laparoscope, the balloon is inflated slowly to bluntly dissect the
preperitoneal space. The dissecting balloon is replaced with a 12-mm balloon trocar, and
pneumopreperitoneum is achieved by insufflation to 15 mmHg. A second port is placed inferior to the
umbilical port and a third port is placed suprapubically in the midline. These ports are for instruments
used to separate attachments of the hernial sac. Once detached, it is gently pulled out of the inguinal
canal and returned to the abdomen. A mesh is the placed and fixed over the opening of the inguinal
canal. Incisions will then be closed with sutures.

Intraperitoneal Onlay Mesh Procedure permits the posterior approach without prepritoneal
procedure. It is useful in cases where the anterior approach is unfeasible, in recurrent hernias that are
refractory to other approaches, or where extensive preperitoneal scarring would make other
approaches challenging. The lateral cutaneous nerve of the thigh and the genitofemoral nerve are prone
to injury. Intraperitoneal mesh migration can also lead to postoperative morbidity, recurrence and
reoperation.

Transabdominal Laparoscopy carries complications. Urinary retention is mostly caused by

routine general anesthesia. Other risk factors for postoperative urinary retention include pain, narcotic
analgesia and perioperative bladder distention. Decompression of the bladder with short-term
catheterization is the initial treatment. A higher incidence of ileus and bowel obstruction is also
observed. This is self-limited but needs inpatient observation, IV fluid maintenance, and possible NGT
decompression. In TAPP, obstruction occurs secondary to herniation of bowel loops through peritoneal
defects or large trocar insertion sites. Visceral injury of the small bowel, colon and bladder are at also at
risk. This may be due to intraabdominal adhesions from previous surgeries. The most commonly injured
vessels in laparoscopic hernia repair include the inferior epigastrics and external iliacs. Injury to
spermatic cord vessels may result in a scrotal hematoma. They are dark blue discolorations and are self-
limited. Intermittent warm and cold compression aids in resolution. Hematomas are common in the
retroperitoneum, rectus sheath, and peritoneal cavity. Seromas are loculated fluid collections that most
commonly develop within 1 week of synthetic mesh repairs. Treatment consists of reassurance and
warm compression to accelerate resolution. To avoid secondary infection, seromas should not be
aspirated unless they cause discomfort or they restrict activity for a prolonged time.