Editing Inguinal hernia (section)

=== '''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)