Editing Inguinal hernia (section)

== '''Open techniques:''' ==

* The Bassini, Shouldice and McVey repairs are certainly not ideal for elective hernia repairs, but we should know about them for situations when you can't use mesh (contaminated fields). In that situation, Shouldice is best.
** In emergency repair for incarceration hernia WITHOUT bowel resection: benefits of mesh repair outweigh risks of infection.
** Unclear whether mesh is ok with bowel resection in these cases, but probably best to avoid it as things stand, and do a tissue repair instead.
* Open mesh repair (Liechtenstein) is best in elective setting, if going to do an open repair
* Plug-and-patch technique is not really recommended, due to increased foreign material and violation of more tissue planes. However it does have a very low recurrence rate.
* '''Recurrence rates:'''
**

{| class="wikitable"
|Procedure
|Recurrence rate
|-
|Liechtenstein
|0.8%
|-
|Shouldice
|3.6%
|-
|McVay/Bassini
|6.9%
|}


=== '''Shouldice repair:''' ===

* Modification of Bassini repair - probably the most enduring version
* Most extensively studied of open repairs, and generally recommended if non-mesh repair is taking place
* Essentially release the inguinal floor and then close it in four layers
* Method as per Gray's:
** Need to expose more than for a mesh repair, especially EO. Often need to move iliohypogastric superiorly to avoid catching it.
** Open inguinal floor (transversalis fascia opened between internal ring and pubic tubercle)
** Option to use a 'scarf' of lateral cremaster muscle sutured up to to re-create the deep inguinal ring
** Repair layers:
*** '''1: Starting from medially, suture lateral edge of rectus abdominis down to bottom flap of TA/TF''', and continue this laterally until lateral edge of rectus is reached.
*** 2: More laterally to rectus, '''fix free edge of upper flap of TA and IO to inguinal ligament to become the new medial wall of deep ring'''. Include the 'scarf' medial to internal ring, brought out behind the cord.
*** 3: moving back from deep ring towards pubic tubercle, '''bring conjoint tendon (IO and TA) together with the inguinal ligament'''. Tie back to the tail of the original suture.
*** ''Can stop there, or continue for another back and forth suture line.''
*** 4: '''Suture from lateral medial, initially just mass closure of the previous suture line, then an imbricating suture back''', tied to itself.


=== '''Iliopubic tract repair:''' ===

* Approximates transversus abdominis aponeurotic arch to the iliopubic tract with the use of interrupted sutures
* Begin at pubic tubercle and extend laterally past the internal ring
* Initially described using a relaxing incision, but not seen as necessary any more

=== '''Bassini repair:''' ===

* Developed 1887
* Reapproximation of layers of inguinal canal en masse to shelving edge of inguinal ligament
* Basically bring TA down to inguinal ligament (makes sense since IO doesn't give any strength at this level; have to use TA)
* Modified many times since then 
* Version described in Gray's:
** Reduce the indirect hernia
** Expose the aponeurosis of TA, which is sutured to the inguinal ligament using non-absorbable sutures - proceed from medial to lateral until the internal ring does not gape. Sometimes needs a few sutures lateral the cord to tighten adequately.
** Sometimes need to make a relaxing incision in anterior rectus sheath to bring TA and inguinal ligament together without tension.
** Close EO.

=== '''McVay repair:''' ===

* Similar to Bassini, but first few sutures placed between conjoint tendon/transversus abdominis arch and Cooper's ligament, transitioning to inguinal ligament when femoral vein encountered

=== '''Desarda repair:''' ===

* External oblique transposed under spermatic cord to cover inguinal floor, then incised and sutured to conjoint tendon (tension-free)
* Lacks long-term follow-up

=== '''Liechtenstein repair -''' open, tension-free, mesh ===

* '''Overview'''
** Dissect down to identify inferior edge of inguinal ligament
** Expose external ring
** Open external oblique
** Delineate anatomy - isolate cord structures
*** Reduce direct hernia
*** Dissect free and ligate indirect hernia
** Place mesh
** Plicate external oblique
** Close
* '''Developed by Irvin Liechtenstein'''
* Supine, GA, IV Abx (although technically not evidence-based for low-risk patients), TT, TEDs, prep+drape
* Palpate inguinal ligament, pubic tubercle, and ASIS
* Incision a few centimetres superior to, and parallel with, the inguinal canal 
** Some surgeons do a transverse incision at the medial half of the IL
* Divide subcutaneous layer. Ligate superficial epigastric vein (found around level of internal ring) and superficial circumflex iliac vein (found laterally), and superficial external pudendal (medially). May also encounter superficial epigastric artery and superficial external pudendal artery. Dissect down to external oblique aponeurosis, then dissect subcutaneous tissue free from it to expose external ring.
* Incise the aponeurosis with metz scissors a few centimetres superior to inguinal ligament, moving laterally (protect ilioinguinal nerve, which is often adherent to the inner surface of EO) as far as the internal ring
** Expose internal oblique fibres and identify ilioinguinal nerve.
** Some surgeons suggest always dividing ilioinguinal nerve - which seems to reduce incidence of chronic pain in systematic reviews
* Men: dissect spermatic cord free from underlying transversalis fascia in region of Hesselbach's triangle (medially), and put the hernia ring forceps around it. Doing this laterally can injure the posterior wall.
* Identify the hernia
** Indirect herniae will be anterior and medial to cord (look for a whitish membranous layer, which is normally sharply demarcated from the cord). These should be dissected out to the level of the internal ring by putting artery forceps on the sac and pushing other structures away using gauze, and diathermy as needed. Note that they will be contained within the cremasteric muscle, which needs to be opened parallel to its fibres to get directly onto the sac. Large indirect sacs will need to be opened to check for visceral contents. Sacs can then either be mobilised and returned to the pre-peritoneal space, or ligated and divided. The easiest thing to do is open, divide, suture ligate
** Examine the floor of canal even if an indirect hernia is present (can have a pantaloon hernia). If a direct hernia is present, do a purse-string around it, invert it, and tie. May need to incise the transversalis fascia to facilitate return of a direct sac to pre-peritoneal space.
** In women, division of round ligament may facilitate the hernia repair (ligate it as high and then as low as possible)
* Don't routinely skeletonise the cord (risk of ischaemic orchitis) beyond the level of pubic tubercle, but do explore it and check whether a hernia is present. Close the peritoneum at level of inguinal ring.
* Liechtenstein repair: polypropylene mesh covers inguinal region, cut to fit, anchor at pubic tubercle, with the mesh overlapping the pubic tubercle to cover 15mm medially too. Suture from medial to lateral to the inguinal ligament (with small bits of both mesh and ligament to stop bunching). Suture the two mesh tails together lateral to internal ring. Superiorly suture to internal oblique/transversus abdominis (the IO is muscular fibres at this level and not useful in holding - need to go deeper to get to aponeurosis of TA, which is actually strong at this level).
** Careful not to make rings too tight - risk of ischaemic orchitis
** Women - don't need to create an opening in the mesh, if the round ligament was divided.
** VARIATION - plug and patch repair ('Rutkow and Robbins') - never been shown definitively to reduce recurrence rates. The plug may lead to complications such as chronic pain or issues with the intra-abdominal component of it. So plug and patch is not recommended by Cameron's. Polypropylene mesh plug is sutured into internal ring, in the pre-peritoneal space.
** Prolene Hernia System - anterior oval polypropylene mesh (similar to Liechtenstein) connected to a smaller circular component which is deployed into a bluntly created preperitoneal space. Good early results.
** Stoppa repair - posterior preperitoneal placement of mesh covering both groins.
* Make a neo-inguinal ring, which should be placed just medial to the true inguinal ring, to create obliquity of the cord in the canal.
* Close external oblique (vicryl)
* Close Scarpa's fascia (vicryl)
* Close skin (monocryl)