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6A
5A
443
PLATE
207
INDICATIONS Any indirect inguinal hernia should be repaired electively
unless contraindicated by the large size of the hernia or by the age or poor
physical condition of the patient. e appearance of indirect inguinal hernia in middle-aged or elderly patients requires thorough medical investigation. Before repair is advised, it is wise to rule out any other source of
pathology as a cause for the patient’s complaint rather than ascribe it to the
presence of an indirect inguinal hernia. Patients who have straining from
symptomatic gastrointestinal tract obstruction, chronic pulmonary disease,
or prostatism need appropriate diagnostic studies.
Repair of an inguinal hernia in an infant or child is indicated as soon
as practical a er the diagnosis is made. In the presence of an undescended
testicle, the repair, which includes an orchiopexy, should be delayed until
to years of age to permit maximum spontaneous descent. e orchiopexy
is indicated at any age if there is strong indication for repairing the hernia
due to incarceration.
PREOPERATIVE PREPARATION Obese persons should be refused repair
until their weight has been substantially reduced to a point within the
range of their calculated ideal weight in order to ensure a low recurrence
rate. Repair should also be delayed in patients with acute upper respiratory
infections or a chronic cough until these conditions have been remedied.
Smoking is curtailed or stopped and frequent intermittent positive-pressure
breathing, with appropriate drugs added, should be instituted several days
before surgery.
In the presence of strangulation, the operation is delayed only long
enough for uid and electrolyte balance to be established by the intravenous administration of Ringer’s lactate solution. Systemic antibiotic therapy
is instituted. Colloid solutions or blood products may be needed, especially if gangrenous bowel is suspected. A small nasogastric tube is passed,
and constant gastric suction is maintained before, during, and for several
days a er operation. Su cient time must be taken to ensure a satisfactory
urine output of at least to mL per hour, a pulse under per minute, and an appropriate blood pressure with a normal central venous pressure. Repeated electrolyte values should be approaching normal. Adequate
preparation may require from several hours to a much longer period for the
administration of several liters of uids and electrolytes, especially potassium and blood, in the patient who has had intestinal obstruction for several days. Operative intervention before stabilization may have disastrous
results.
A child years or older should be prepared psychologically in advance
for the hospital experience. Booklets that describe in simple narrative style
the various details of hospitalization and operation can be read to the child
before operation. Such preparation undoubtedly serves to diminish the
incidence of emotional trauma as a complication of elective surgery.
Uncomplicated inguinal hernias in patients of any age may be repaired as
ambulatory surgical procedures using local, regional, or general anesthesia.
ANESTHESIA Local in ltration anesthesia should be considered, since
it allows approximation of the tissues at a more normal tension and also
makes it possible for the patient to increase the intra-abdominal pressure by coughing, which will aid in identifying the sac and in testing the
adequacy of the repair. Note the position of the nerves for local anesthesia
(figure 1). If obstruction is present, general anesthesia with an endotracheal tube and cu is recommended to avoid the ever-present threat of tracheal aspiration.
Inhalation anesthesia is the method of choice in children and anxious
adults.
R I I H
POSITION e patient is placed in a supine position with a pillow beneath
the knees so that slight relaxation at the groin is achieved. e table is tilted
with the head down slightly to aid in reducing the contents of the hernia sac
and in retracting a thick abdominal wall by gravity.
OPERATIVE PREPARATION e skin preparation is routine.
TRADITIONAL EXPOSURE
INCISION AND EXPOSURE A skin incision, extending from just below
and medial to the anterosuperior iliac spine to the pubic spine, is made
to cm above and parallel to Poupart’s ligament (figure 1, a). A more
comfortable and cosmetic incision results if the major crease in the lines
of skin cleavage is followed (figure 1, b). is may be de ned by gentle
downward traction on the abdominal wall, which demarcates the natural
crease in the skin beneath the plastic drape. Either incision is carried down
to the external oblique fascia. Several blood vessels, especially the super cial epigastric vein and the external pudendal vein, are usually encountered
in the subcutaneous tissue in the lower portion of the incision. ese must
be clamped and tied (figure 2).
DETAILS OF PROCEDURE e external oblique is carefully cleaned of all
fat by sharp dissection throughout the length of the wound, and the external ring is visualized (figure 2). A er the margins of the wound have
been covered with gauze moistened in isotonic saline, a small incision is
made in the direction of the bers of the external oblique, which extend
into the medial side of the external inguinal ring (figure 2). e edges
of the external oblique are held away from the internal oblique muscle to
avoid injury to the underlying nerves as the incision is continued through
the medial side of the external ring (figure 3). e nerves are most commonly injured at the external ring. e lower side of the external oblique
is freed by blunt dissection down to include Poupart’s ligament. e upper
margin is similarly freed for some distance. As the ilioinguinal nerve is
dissected free from the adjacent structures, a bleeding point is commonly
encountered as it passes over the internal oblique (figure 4). is bleeding vessel, if encountered, must be tied carefully; otherwise a hematoma
may develop in the wound. When the ilioinguinal nerve has been carefully
dissected free, it is pulled to one side over a hemostat placed at the edge of
the incision (figure 5). e cremasteric bers are grasped with toothed
forceps and divided in order to approach the sac (figure 6). e sac itself
is seen as a de nite white membrane that lies in front and toward the inner
side of the cord; it is usually easily di erentiated from surrounding tissues.
If the hernia is small, the sac lies high in the canal. e vas deferens can
be recognized by palpation because it is rmer than the other structures
of the cord. e wall of the sac is li ed up gently and opened with care to
avoid possible injury to its contents (figure 7). While the margins of the
opened sac are grasped with hemostats, the contents are replaced within
the peritoneal cavity. With the index nger of the le hand introduced into
the sac to give counter-resistance, the surgeon frees the sac with the right
hand by either blunt or sharp dissection (figure 8). If the dissection is
kept close to the sac, an avascular cleavage plane will be found. Sharp dissection is advisable to separate the vas deferens and adjacent vessels from
the sac (figure 9). If this is done carefully, fewer bleeding points will be
encountered than if an e ort is made to sweep these structures away from
the sac by means of blunt dissection with gauze. e dissection is then continued until the properitoneal fat is displaced and the peritoneum beyond
the narrow neck of the sac is visualized.
CONTINUES
444
Anterior superior
spine of ilium
1
B
Internal
inguinal ring
Iliohypogastric
nerve
A
Deep epigastric
artery and vein
Rectus muscle
Aponeurosis of
2
external oblique
muscle
Incision
3
Internal
oblique muscle
Incision
Ilioinguinal
nerve
Poupart’s ligament
Cremaster muscle
(lateral bers)
External inguinal ring
4
Bleeding
point
Spermatic cord
Iliohypogastric
nerve
Bulging
of hernia
Cremaster
muscle,
median bers
Pubic spine
5
Supercial
external
pudendal vein
External ring
Ilioinguinal nerve
External ring
6
Hernia sac
Ilioinguinal
nerve
7
Cremaster
muscle
Hernia sac
Hernia sac
Ilioinguinal
nerve
8
Vas
Cremaster muscle
Conjoined tendon
9
Hernia sac
Vas
445
Spermatic vessels
PLATE
208
DETAILS OF PROCEDURE e sac is opened within to
cm of its neck, and exploration is carried out with the index nger to
rule out the presence of a “pantaloon” or secondary direct or femoral hernia (figure 10). To ensure obliteration of the sac, a purse-string suture
is placed at the inner side of the neck (figure 11), or several trans xing sutures may be used if preferred. e lumen of the neck of the sac
must be visualized as sutures are placed or tied to avoid possible injury to
omentum or intestine. is suture should include the transversalis fascia
with the peritoneum. e neck of the sac can sometimes be identi ed as
a slightly thickened white ring. e sac should be ligated proximal to this
ring. A er the purse-string suture is tied, the excess sac is amputated with
scissors (figure 12).
If desired, the ligated sac may be anchored to the overlying muscle. In
this instance the long ends of the suture used to close the neck of the sac
are rethreaded. e needle is inserted beneath the transversalis fascia and
brought up in the edge of the internal oblique muscle, the two ends being
brought through separately and tied (figure 13). Care should be taken to
avoid injuring the inferior deep epigastric vessels.
ALTERNATE TECHNIQUES FOR SAC Although the classic inguinal her-
nia operations utilize high ligation with division of the hernia sac, two
alternate methods have gained popularity with mesh repair. In small to
medium-sized indirect hernias, the sac is le intact as it is dissected from
the posterior cord structures. Electrocautery is used along the edge of the
sac while gentle traction is applied. is minimizes bleeding and ecchymosis a er surgery. Any entry into the sac is used for nger exploration and
guidance of further dissection well up into the internal ring. Any opening
in the sac is closed using absorbable suture, and the entire sac, along
with any lipoma of the cord, is returned to the preperitoneal space behind
the abdominal muscular wall.
In very large inguinoscrotal hernias, the indirect sac is transected and
suture-ligated near the internal ring. Only the proximal sac is dissected
free into the internal ring. e distal very large sac is le untouched, as the
extensive dissection from the cord vessels and the mobilization of the testicle up and out of the scrotum may result in venous thrombosis or possible
ischemic orchiditis. A residual hydrocele rarely occurs.
CLOSURE There are various methods of repair after the sac has been
removed. Large or recurrent hernias in older persons or hernias in
patients doing very heavy work may be corrected by a method that
either partially or completely transplants the cord and narrows the
internal ring.
R I I H
REPAIR IN CHILDREN
A short (-cm) skin incision is made in the suprapubic crease above the
inguinal ligament and centered over the internal inguinal ring.
A er the incision has been made through the skin, a small curved
mosquito hemostat is placed in the subcutaneous tissue on either side of
the midportion of the incision for traction. Scarpa’s fascia is exposed and
divided. e underlying aponeurosis of the external oblique is cleared down
to the external inguinal ring. e aponeurosis of the external oblique is then
opened upward from the external inguinal ring. If there is no associated scrotal hydrocele, the incision through the external oblique aponeurosis may be
placed just above rather than through the external ring. Superior and inferior aps of the aponeurosis of the external oblique are developed with the
scalpel handle, and a small right-angle retractor is placed under the superior
ap to expose the inguinal canal. e cremasteric muscle bers are separated
by blunt dissection. e hernia sac is identi ed on the anteromedial aspect
of the cord structures, li ed up, and gently separated in the midportion of
the inguinal canal from the vas and the vessels. e cord structures themselves should not be mobilized from the inguinal canal. e sac is divided
between two straight mosquito hemostats in the mid-portion of the inguinal
canal, and the proximal portion is freed well above the level of the internal
ring. e neck of the sac then is closed with a suture ligature of ne silk and
the sac amputated. Ordinarily, it is not necessary to open the sac during this
process. However, if omentum or a loop of intestine is within the sac, the sac
is opened, and these structures are returned to the peritoneal cavity before
the neck of the hernia sac is closed. e distal portion of the sac is freed
below the level of the external ring and excised.
e testis and cord structures are repositioned into their normal anatomic bed if they have been disturbed, and an anatomic closure is performed. e aponeurosis of the external oblique and Scarpa’s fascia are
closed with interrupted sutures of ne silk. A subcuticular closure with ne
absorbable suture is used in children. Because of the high incidence of a
patent processus vaginalis on the opposite side in instances of a clinical
inguinal hernia in infants, it is common practice to perform an inguinal
exploration on the opposite side in infants but not older children.
In female children, the incision and initial stages of the procedure are as
described above. However, in a high proportion of cases a congenital indirect hernia in a female is a sliding type of hernia, with the fallopian tube and
its mesenteric attachments making up a portion of the hernia sac. In such
instances the hernia sac and round ligament are closed with a suture ligature of ne silk distal to the attachment of the mesosalpinx. e remainder
of the procedure is identical with that done in the male.
NONTRANSPLANTATION OF CORD
(FERGUSON REPAIR)
e cremasteric bers, which may or may not be well developed, are
approximated with interrupted silk sutures (figure 14). is covers the
raw surface remaining a er removal of the sac and restores the structures
to a normal appearance. e cremaster muscle is pulled beneath the conjoined tendon to relieve strain on the next layer of sutures and to increase
the e ciency of the repair (figure 15). Sutures are then placed to approximate the conjoined tendon and the internal oblique muscle to Poupart’s ligament, the sutures being tied anterior to the cord (figure 16). e sutures
in Poupart’s ligament are placed from below upward, unequal portions of
the ligament being taken to avoid fraying. e rst suture should be tied
loosely enough so that the cord is not constricted and there is su cient
space about the cord to permit an instrument tip to pass; moreover, care
should be taken to avoid injury to or inclusion of the ilioinguinal nerve by
the sutures. e external oblique fascia is approximated with interrupted
sutures (figure 17). Here again, the external ring should not constrict the
cord (figure 18). e subcutaneous tissue is carefully approximated with
interrupted absorbable sutures to (figure 19). A continuous subcutaneous closure with absorbable suture may be used, followed by adhesive
skin strips and a dry sterile dressing.
REPAIR IN ADULT FEMALES
e round ligament is usually closely attached to the sac, making sharp
dissection necessary for separation. A er the neck of the sac is freed and
ligated, the repair proceeds as in the operation on the male, except that the
round ligament may be included in the sutures that bring the conjoined
tendon to Poupart’s ligament. If the round ligament is divided, it must
be ligated, since it contains a small artery, and the proximal end must be
anchored in order to give support to the uterus.
POSTOPERATIVE CARE Adult e patient is placed at in bed with the
thighs somewhat exed either by a pillow beneath the knees or, if in an adjustable bed, with the lower part of the bed somewhat elevated in order to prevent
undue tension upon the sutures in the wound. Support to the scrotum may be
furnished by suspensory. An ice pack may be applied to the scrotum. Coughing must be controlled by sedation. Laxatives are given in su cient dosage to
avoid undue straining at stool. Patients should ambulate and void as soon as
possible. Normal activities are resumed as tolerated. However, several weeks
should elapse before the patient is permitted to perform heavy physical work.
Special abdominal supports usually are not necessary.
Child e infant or child is fed to hours a er operation and, by the
evening of operation, should be taking a normal diet.
CONTINUES
446
Purse-string suture
Sac
13
10
Iliohypogastric
nerve
Cremaster
muscle
Transxing
suture
11
Junction of
peritoneum and
hernia sac
Ferguson repair
14
12
Sac
Vas
Vas
15
16
Iliohypogastric
nerve
Cremaster
muscle
Vas
Cremaster muscle
17
Poupart’s ligament
Cremaster muscle
Cord
19
18
Aponeurosis of
external oblique
muscle
Poupart’s ligament
Cord
Ilioinguinal
nerve
447
Testing size of
reconstructed external ring
PLATE
209
R I I H
MODIFIED BASSINI REPAIR
DETAILS OF PROCEDURE e cord is visualized by the
approach described in Plate . Since the structures of the cord are to be
transplanted, it may be easier to separate the cord from the surrounding
structures before the hernia sac is identi ed and opened. e index nger
may be inserted beneath the cord from the medial side just above the pubic
tubercle in order to assist in the blunt dissection and freeing of the cord
from the underlying Poupart’s ligament (figure 20). A curved half-length
clamp directed over Poupart’s ligament and toward the pubic spine is then
passed beneath the cord and guided by the index nger (figure 21). A tube
of so rubber (Penrose drain) is drawn through beneath the cord for traction (figure 22). Many times blood vessels that course downward beneath
the cord must be clamped and tied to ensure a dry eld. e cremaster
muscle is divided, and the hernial sac is grasped with toothed forceps preliminary to opening it (figure 23). Some prefer to completely divide the
cremaster muscle near the internal oblique muscle, leaving the vas and its
accompanying vessels exposed. e sacri ce of the cremaster muscle at this
level permits a more accurate closure of the internal ring. e hernia sac is
opened, and traction is maintained by curved or straight hemostats applied
to its margin. With the surgeon’s index nger in the hernia sac, the vas
deferens and accompanying vessels are dissected free by sharp and blunt
dissection (figure 24). With the surgeon’s nger in the neck of the hernia
sac to ensure that all abdominal contents are completely reduced, a pursestring suture is placed at the inner side proximal to the neck of the sac or
several trans xing mattress sutures are used, as preferred (figure 25). Care
must be taken that the adjacent epigastric vessels are not injured.
CLOSURE (TRANSPLANTATION OF CORD, BASSINI) e rst step in
the closure is to provide adequate retraction of the cord as well as the internal oblique muscle, so that the deep-lying aponeurosis of the transversus
abdominis and the transversalis fascia can be identi ed (figure 26). It is
important to reinforce the weakened area over the ligated hernia sac by
approximating the thickened fascia just below the free edge of Poupart’s
ligament, the so-called iliopubic tract, and the edge of the aponeurosis of
the transverse abdominal muscle (figure 26, suture X). e remaining
opening in the cremaster muscle is closed with interrupted sutures unless
it has been completely divided adjacent to the internal oblique muscle.
e transversalis fascia may appear to be very thinned out adjacent to
Poupart’s ligament, but an aponeurosis, the strong white membrane
forming the inferior margin of the transversus abdominis, is exposed
(figure 26) by retracting the internal oblique sharply upward. e hernial repair is strengthened if an e ort is made to approximate the latter
structure to the iliopubic tract beyond the margins of Poupart’s ligament.
e conjoined tendon is retracted upward so that each bite of the needle
includes a good portion of the aponeurosis of the transversus muscle
(figure 27) and the thickened fascia adjacent to the margin of Poupart’s
ligament. Several sutures between the iliopubic tract and the aponeurosis
of the transversus muscle are taken lateral to the cord to close the redundancy of the internal ring (figure 28).
CONTINUES
448
Bulge
of hernia
20
Cremaster
muscle
Ilioinguinal nerve
Bassini Repair
Internal
oblique muscle
21
Poupart’s ligament
24
Spine of pubis
Cord
22
Poupart’s ligament
Penrose
drain
Cord
23
Extent of
hernia sac
X
26
Pubic branch
of inferior
epigastric
artery
Dividing
cremaster
Neck of sac
Vas
Spermatic
vessels
27
Hernia sac
A
25
Peritoneum
Aponeurosis transversus
abdominis muscle
Conjoined
tendon
28
Neck of
hernial sac
Deep
epigastric
vessels
Vas
Poupart’s ligament
Transversus
abdominis
muscle
Transversalis
fascia
Spine of pubis
Iliopubic
band
Poupart’s
ligament
Conjoined tendon
Spine of pubis
Poupart’s ligament
Aponeurosis transversus
abdominis muscle
Conjoined tendon
449
PLATE
210
CLOSURE (TRANSPLANTATION OF CORD, BASSINI) A sec-
ond layer of nonabsorbable sutures includes unequal portions of the shelving edge of Poupart’s ligament and a bite of the conjoined tendon. is suture
line extends from the pubic tubercle outward over the deep epigastric vessels until the cord appears to be angulated laterally. Before these sutures are
placed, the mobility and composition of the tendon should be determined. In
many instances the conjoined tendon cannot be brought down to Poupart’s
ligament except under a great deal of tension. A preliminary trial should be
carried out by attempting to approximate the conjoined tendon to Poupart’s
ligament at the proposed suture line to determine the amount of tension that
will be present (figure 29). e medial leaf of the external oblique fascia is
retracted medially, and by blunt dissection the underlying sheath of the rectus is exposed (figure 30). If the tension appears to be excessive, relaxation
of the fascia with retained support of the underlying rectus muscle is achieved
by multiple incisions in the rectus sheath (figure 31). e relaxing incisions
can be made about cm apart and cm in length. Eight or ten or even more
may be required to produce the desired relaxation (figures 31 and 32). e
number required can be judged by the spread of the tissues as the incisions
are made and as traction on the fascia is maintained. e conjoined tendon
is sutured to the lower edge of Poupart’s ligament adjacent to the suture line
that has approximated the aponeurosis of the transverse abdominal muscle
to the iliopubic tract. e initial suture should include the periosteum of the
pubic spine and the medial portion of the conjoined tendon. Several sutures
are taken to approximate the muscle to Poupart’s ligament above the point
R I I H
of exit of the cord, but these must not constrict the cord, especially if its size
has been decreased markedly by the excision of some of the dilated veins and
the cremaster muscle (figure 33). e ilioinguinal nerve is replaced, and
the external oblique aponeurosis is closed over the cord, either by imbricating the mesial ap of the external oblique muscle over the lower ap by two
rows of mattress sutures (figures 34 and 35) or by a simple approximation
of the edges of the external oblique with a running suture. e newly constructed external ring should be tested to make certain that the cord is not
unduly constricted.
TRANSPLANTATION OF CORD (HALSTED)
Some surgeons prefer the method of transplanting the cord to the subcutaneous fatty layer (figure 36). Here, the cord is brought out through the
upper third of the incision in the external oblique fascia (figure 36) and
the fascia is closed beneath the cord, leaving it entirely in the super cial fatty
tissue (figure 37). e size of the cord is usually decreased by the excision
of many of the spermatic veins as well as the cremaster muscle; however,
su cient blood supply to the testicle must be retained. e cord must not be
constricted, or atrophy of the testicle may occur. e size of the external ring
is tested with a curved clamp, and, if necessary, a small incision is made just
through the margin to release the constriction about the cord (figure 36).
POSTOPERATIVE CARE e usual p ostoperative care is given, as des cribed
on Plate . ■
450
Poupart’s
ligament
Ilioinguinal
nerve
29 30
Aponeurosis of
external oblique
muscle
Conjoined
tendon
Cord
33
Iliohypogastric
32
nerve
Internal
oblique
muscle
Component of
anterior rectus sheath
34
31
Incisions in
component of
anterior rectus
sheath
External
oblique
muscle
Aponeurosis of
external oblique
muscle
35
Rectus
muscle
Pyramidalis
muscle
Conjoined
tendon
Aponeurosis of
external oblique
muscle
Halstead Repair
36
Incision
Poupart’s ligament
Testing size
of opening
37
Incision
Cord
Cord
Aponeurosis of
external oblique
muscle
Reconstructed
external ring
Cord emerging
from internal ring
451
Cord
PLATE
211
R I I
H (S)
INDICATIONS Herniorrhaphy has become more and more an outpatient
surgical procedure, regardless of the age of the patient. e Shouldice repair
has been advocated for some years as the procedure of choice for adults
with inguinal hernias.
PREOPERATIVE PREPARATION e obese patient should be required
to lose weight, preferably to within percent of calculated ideal weight.
is may delay the operation for a considerable time. Any infections of
the skin should be cleared up before operation. A productive cough or an
upper respiratory infection delays the procedure. Chronic smokers should
be encouraged to curtail their smoking. Evidence of prostatic obstruction
should be sought in older men. All patients should be taught how to get out
of bed with a minimum of discomfort and advised to practice this. Sensitivity to drugs, including local anesthetics, should be ascertained. A mild
cathartic should be given a day before the operation to ensure an empty
colon. A mild laxative or mineral oil may be given to ensure bowel action
without excessive straining a er operation. A thorough medical evaluation
is essential in older patients. 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 plus local anesthesia is commonly used. e
type of sedation will vary, but may include midazolam, fentanyl or meperidine, and propofol. Local anesthesia is limited to mL of lidocaine
without epinephrine (total lidocaine dose < mg). e amount is reduced
in elderly patients.
SKIN PREPARATION e skin is carefully inspected for any evidence of
localized infection. All hair of the lower abdomen and pubis is removed
with an electric hair clipper. In patients with scrotal hernias, the skin of
the scrotum should be included in the usual skin preparation with topical
antiseptics.
POSITION e legs should be slightly exed, with pillows under the knees,
and the patient placed in a modi ed Trendelenburg position to assist in
the reduction of the hernia sac. Following the draping of the patient, the
local anesthetic is injected. Keeping in mind the location of the ilioinguinal and iliohypogastric nerves, the original injection of a few milliliters of
anesthetic agent is made, using a ne needle (No. ), just medial to the
anterosuperior spine. Approximately mL of (lidocaine) anesthetic solution is injected subcutaneously with a No. needle above and parallel to
the inguinal ligament. About mL is injected medial to the anterosuperior
spine deep into the external oblique aponeurosis to anesthetize the ilioinguinal nerve. Another mL is injected about the internal ring to eliminate
painful impulses from the peritoneum and from the genital branch of the
genitofemoral nerve. In elderly patients, less anesthetic solution is used.
Epinephrine is not used in the elderly or in patients with cardiovascular
disease.
INCISION AND EXPOSURE A -cm incision is made parallel to the ingui-
nal ligament, although some prefer a more transverse or skinfold incision.
e external pudendal vessels are spared, especially in bilateral repairs, in
an e ort to minimize postoperative edema.
DETAILS OF PROCEDURE e external oblique aponeurosis is divided
along the line of its bers. Great care is exercised to avoid possible injury to
the underlying ilioinguinal nerve. e aponeurosis of the external oblique
is divided from the level of the internal ring down through the external
ring, and both aps are mobilized (figure 1). Mobilization of the lower
ap should involve some division in the super cial fascia of the thigh to
allow inspection of the femoral area for evidence of a femoral hernia. e
cremaster muscle is carefully divided longitudinally, with the lateral side
being made the larger, since it contains the cremaster vessels and the genital
branch of the genitofemoral nerve in its base.
e internal ring is freed from attachments, and evidence of a hernial
sac is sought. If no indirect hernial sac is found, a small crescent re ection
of peritoneum (processus vaginalis) is visible proximally. When an obvious
hernial sac is found, it is freed by blunt and sharp dissection. When the
sac is large, it can be lled with gauze sponge to provide counterpressure,
which simpli es the pushing away of other tissues. e sac is opened and
the index nger inserted medially under the inferior epigastric vessels in an
e ort to determine the presence or absence of a direct hernial defect. e
neck of the hernial sac is freed from the surrounding tissue. Following this,
the sac is ligated (figure 2). Some believe an e ort for a high ligation of the
sac is unnecessary. If a lipoma of the cord is found, it is carefully excised,
but the cord is not stripped of interstitial fat. Even large sliding hernia sacs
can be freed and reduced without opening the sac.
e two cremaster muscles are excised with double ligation of the
stumps. e posterior inguinal wall should now be fully visible. e posterior inguinal wall is palpated for an area of weakness or general bulge. e
transversalis fascia is divided starting on the medial aspect of the internal
ring but avoiding the inferior epigastric vessels and proceeding to the pubic
tubercle (figure 2). e femoral ring is evaluated for evidence of a femoral
hernia.
If the transversalis fascia has been stretched by the di use bulge of a
direct hernia, the excess from each ap is excised. e upper ap (a) is usually narrower than the lower ap (b). It is extremely important to develop
an adequate lower ap if the repair is to have the best chance of success.
e latter tends to be to cm wide and somewhat stronger. e lower
ap is completely freed by careful dissection. e development of the aps
of the transversalis is very important in the subsequent steps of the Shouldice repair (figure 2). e subsequent repair involves the development
of a four-layered closure, using either two di erent continuous sutures of
-gauge mono lament stainless steel wire or a nonabsorbable suture material. Absorbable suture or mesh is not used. Continuous sutures are preferred for distributing the stresses evenly.
e repair of the posterior inguinal wall must be carefully performed,
using small, even bites without tension on the suture. Retaining sutures are
not used. e rst suture anchors the free edge of the lower ap (b) of the
transversalis to the posterior aspect of the lateral edge of the rectus close to
its insertion (figure 2a). e placement of the suture must be accurate,
and the knot securely tied without leaving a defect in this area. Only a short
distance from the edge of the rectus sheath is included before the suture
is continued laterally to include the deep underneath surface of the upper
ap (a) of the transversalis and the internal oblique (figure 3). e infe-
rior epigastric vessels are carefully avoided as the suture line is extended to
include the upper lateral cremasteric stump. e suture is now reversed at
the internal inguinal ring (figure 4)
free edge of the upper transversus ap (A) to the edge of Poupart’s ligament.
e suture is continued down to the pubic bone and tied. e space medial
to the femoral vein may be obliterated by including the lacunar ligament if
necessary.
Another continuous suture line is used to reinforce the second suture
line just completed. e third suture line starts at the internal ring and
includes bites of the internal oblique and transversalis muscles as well as
the deep surface of the inguinal ligament as it continues medially to the
pubic bone (figure 5). e fourth suture line returns from the pubic bone,
bringing together the same structures at a slightly more super cial plane up
to the internal ring, where it is tied (figure 6).
e spermatic cord is tested to determine that it can be freely moved
and the veins are not engorged. e cord is returned to its normal position
and the external oblique fascia approximated without constricting the vein
in the region of the external inguinal ring (figure 7).
e subcutaneous tissues are carefully approximated with interrupted
sutures. e skin can be closed with interrupted or a continuous subcutaneous
suture of absorbable material reinforced with skin tapes of a “butter y” nature.
Some prefer metal staples. A small dressing is applied to cover the wound.
POSTOPERATIVE CARE e patient may return home several hours a er
the operation with full written instructions concerning activities, signs of
bleeding or infection, or any other unusual reaction. Oral narcotic is supplied, and an ice pack may be applied locally for several hours. e patient
should rest in bed except for voiding in the bathroom on the day of surgery.
A suspensory for men is optional. Physical activity is restricted for an additional few days. Many experience improvement a er days, and some may
drive or return to light duty work a er to days. Vigorous exertion, as in
sports, is limited for weeks, and extreme exertion should be avoided. See
also Plate . ■
, extending medially as it unites the
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