Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

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3. CLOSING

For multiple, complex fistula-in-ano, place a 2-0 silk suture through those fistulous tracts that circumscribe an anal sphincter yet cannot be incised. Tie the ends of this suture together loosely to create a seton. With time the seton will incite sufficient granulation and fibrosis that the fistulous tract can be incised at a second operation or allowed to erode through the fistulous tract.

STEP 4: POSTOPERATIVE CARE

Sitz baths

Stool softeners

Repeat doses of mineral oil given orally

STEP 5: PEARLS AND PITFALLS

It is sometimes difficult to assert with confidence the path of the fistula-in-ano. Goodsall’s rule relates that if the external opening is anterior to an imaginary line drawn across the midpoint of the anus and less than 3 cm from the anus, the fistula usually runs directly into the anal canal. If the external opening is anterior to but greater than 3 cm from the anus, then the fistulous tract may curve posteriorly to the posterior midline. If the external opening is posterior to this line, the tract will usually curve to the posterior midline.

SELECTED REFERENCE

1. Zollinger RM Jr, Zollinger RM: Atlas of Surgical Operations, 5th ed. New York, Macmillan, 1983, p 420.

C H A P T E R 71

HERNIA REPAIR: GENERAL

PRINCIPLES—TENSION-FREE

VERSUS TENSION

Thomas D. Kimbrough

STEP 1: SURGICAL ANATOMY

Although the widespread adoption of mesh to repair hernias may lead the inexperienced and reckless to presume otherwise, a comprehensive understanding of the anatomy of the inguinal region is of paramount importance in inguinal hernia repairs.

See Figures 71-1 and 71-2 for surface and superficial anatomic structures. The typical location of each of the three inguinal hernia types is shown in Figure 71-2.

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Figure 71-3 is a parasagittal representation of the various layers at a point midway in the right inguinal canal.

Peritoneum

Transversalis fascia

Skin

External oblique aponeurosis

Transversus abdominis Spermatic cord and aponeurosis arch

cremaster muscle

Cooper’s ligament

Inguinal ligament

Superior ramus of pubis

Pectineus muscle and fascia

A

Plane of section (A)

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STEP 2: PREOPERATIVE CONSIDERATIONS

The actual incidence of dangerous complications of untreated hernias is quite low, and the mortal risk from these complications, when they do occur, is similarly low.

The few deaths that result from hernia repair are far more likely to be due to complications of comorbidities than operative complications, so any evaluation of a candidate for repair should include careful attention to other medical problems. Appropriate evaluation and referral for evaluation and treatment of other significant medical problems should take precedence over a recommendation for operative repair in elective cases.

On the other hand, the probable natural course of an untreated inguinal hernia over time is an increase in size and symptoms, so it is not unreasonable to offer repair to a young individual with no other medical problems.

The classic recommendation to evaluate and treat those conditions that might chronically increase intra-abdominal pressure, including chronic cough, constipation, and difficulty with urination, fits under the previous admonition to evaluate comorbidities and does not otherwise bear special consideration.

In the final analysis, the recommendation for a hernia repair requires of the surgeon a careful balance and consideration of the natural history of untreated hernias, their symptoms and complications, the patient’s age and comorbidities, and the presence of symptoms and their immediate and anticipated effect on quality of life.

TENSION VERSUS TENSION-FREE

A basic precept of surgery is that wounds closed under tension are less likely to heal well than those closed with little or no tension.

All of the classic tissue repairs require the approximation of tissues that do not exist in that state naturally and thereby to one degree or another create tension on wound closures.

Recognition of this has led to the use of mesh to bridge hernia defects and reinforce what has been increasingly recognized as an often attenuated, hernia-prone portion of the abdominal wall, even in those areas away from the actual hernia defect at the time of operation.

The purported advantages of the tension-free repairs obtained with mesh include the following:

Mesh repairs have lower recurrence rates than tissue repairs.

Postoperative pain is less, and recovery to full activity is faster.

Long-term morbidity is the same as with tissue repairs.

Although there are case reports of complications arising from the mesh itself, these are sufficiently rare to not preclude its use.

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Before the incision is made, 0.25% bupivacaine with epinephrine should be injected medial to the anterior superior iliac spine and deep to the external oblique aponeurosis. Approximate areas of injection are marked with an “X” on Figure 71-5. An additional 10 mL should be injected at the site of the incision.

The skin incision should be carried through the superficial subcutaneous fat, Scarpa’s fascia, and the deep subcutaneous fat until the easily recognized oblique fibers of the external oblique aponeurosis are identified.

2. DISSECTION

The surgeon should then find the external inguinal ring, obtaining exposure as illustrated in Figure 71-6. Such exposure can be achieved with hand-held retractors or, as shown, with self-retaining ones.

As shown in Figure 71-6, the aponeurosis of the external oblique should be divided in the line of its fibers through the external inguinal ring. Some advocate the use of a knife for the initial incision through the aponeurosis. I prefer scissors because they are less likely to injure underlying structures.

Using a combination of blunt and sharp dissection, the external oblique aponeurosis should be freed superiorly and laterally from the underlying internal oblique muscle and fascia. Inferiorly and laterally, the cord structures should be swept off the undersurface of the external oblique aponeurosis down to the shelving edge of the inguinal ligament.

The next step is longitudinal division of the fibers of the cremaster muscle that invests the structures of the spermatic cord as shown in Figure 71-7. Care should be taken to divide the cremaster away from the ilioinguinal nerve.