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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_629_Библиотеки_им_академика_М_И_Перельмана
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453
PLATE
212
INDICATIONS A McVay primary tissue repair is infrequently performed
as an initial herniorrhaphy, as it is associated with a high rate of recurrence. However in patients where mesh from a previous operation must
be removed (e.g., chronic infection), some form of primary tissue repair is
needed. e McVay procedure may be useful in these cases, especially when
the femoral space must also be obliterated.
DETAILS OF PROCEDURE Instead of approximating the transversalis fas-
cia and the aponeurotic margin of the transverse abdominal muscle to the
iliopubic tract and to Poupart’s ligament to repair either a direct or indirect
hernia, the McVay repair attaches these musculotendinous structures to
Cooper’s ligament and the lacunar ligament medially and the inguinal ligament laterally. To accomplish this, it is necessary to retract the conjoined
tendon upward and the cord downward, while the transversalis fascia adjacent to the pubic spine is freed from Cooper’s ligament (figure 1).
By blunt dissection and the use of a curved retractor (figure 2), the
region of Cooper’s ligament can be visualized, and the external iliac vessels
can be identi ed. As the conjoined tendon or internal oblique muscle is
held upward, a rm aponeurotic margin of transverse abdominal muscle is
exposed in order to facilitate the placement of interrupted sutures. As the
bulge in this region is retracted upward and medially by an appropriate
retractor, Cooper’s ligament is clearly visualized as a white, brous ridge,
deep in the wound at the innermost portion of the concavity and closely
applied to the horizontal ramus of the pubis (figure 2). Interrupted
R D I H (MV)
silk sutures approximate the aponeurotic margin of the transverse abdominal muscle and the transversalis fascia to Cooper’s ligament. e iliac
vessels may be protected by the surgeon’s le index nger or a narrow
S retractor as the innermost suture is placed. e sutures are continued
downward until the region of the pubic spine is included in the last one
(figure 3). ree to ve interrupted sutures are usually required. In obese
individuals it may be di cult to obtain an easy exposure in this location,
and constant care must be exercised to avoid injury to the iliac vessels and
to e ect a complete and solid repair (figure 4). Some operators prefer to
make an incision in Cooper’s ligament before placing the sutures in order
to ensure a better fascial approximation. A er the aponeurotic margin of
the transverse abdominal muscle has been anchored as far medially to
Cooper’s ligament as can be done safely, more super cial sutures may be
taken to approximate it to the iliopubic tract (figures 4 and 5). Some surgeons prefer to reinforce the repair to Cooper’s ligament by another row of
sutures approximating Poupart’s ligament to the aponeurosis of the transverse abdominal muscle (figure 6). e suturing of the internal oblique
muscle to Poupart’s ligament is not considered worthwhile. e type of
repair should be varied to suit the anatomic conditions encountered. A
combination of the technique described may be advantageous to ensure a
solid repair without tension upon the suture lines and an accurate approximation of fascia to fascia.
POSTOPERATIVE CARE Care is routine. (See Plate .) ■
454
McVay Repair
1
Deep epigastric vessels
Transversalis
fascia
Poupart’s ligament
Iliac vessels
2
Obturator vessel
Lacunar
ligament
Transversalis fascia
Poupart’s ligament
3
Cooper’s
ligament
Pubic spine
Transversalis fascia
1
2
3
Aponeurosis of transversus
abdominis muscle
Cooper’s
ligament
4
Lacunar
ligament
Conjoined tendon
Pubic spine
Iliac vessels
Aponeurosis
of transversus
abdominis muscle
Aponeurosis of transversus
6
abdominis muscle
5
Poupart’s ligament
Conjoined tendon
Spine of pubis
Poupart’s ligament
455
PLATE
213
R I H
M (L)
INDICATIONS Adult inguinal hernias are usually repaired in an ambula-
tory surgery setting unless coexisting medical conditions merit hospitalization for specialized monitoring or care. e use of polypropylene mesh has
become increasingly popular as it may be used for both direct and indirect
hernias and it results in a lower rate of recurrence.
PREOPERATIVE PREPARATION e obese patient should be required to
lose weight, preferably to within percent of calculated ideal weight, which
may delay the operation for a considerable time. Any open skin infections
must be healed prior to operation. Systemic causes of increased intraabdominal pressure or straining should be reviewed. A productive cough
or an upper respiratory infection will delay the procedure until resolution.
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 bed with a minimum of discomfort and advised to practice this. Sensitivity to drugs, including local anesthetics, should be ascertained. A mild cathartic may be given a day before
the operation to ensure an empty colon. 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 with an anxiolytic, narcotic, and hypnotic
(commonly midazolam, fentanyl, and propofol) is combined with a eld
block of local anesthesia. Lidocaine or ½ without adrenaline is preferred
and the total dose is limited to less than mg ( mL of lidocaine).
is amount may be reduced in elderly patients. No adrenalin 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
rein ltrate the operative eld with a long-acting local anesthetic such as
bupivacaine. Adrenalin is o en added except in patients with heart disease
so as to extend the duration of the local anesthetic.
POSITIONING e patient is placed in a supine position with a pillow
under the knees to lessen tension in the inguinal region.
OPERATIVE PREPARATION e skin is shaved and prepared in a routine
manner. In men, the penis and scrotum should be prepared, especially if the
hernia extends into the scrotum or if a hydrocele is present.
INCISION AND EXPOSURE A er a sterile draping of the region, the local
anesthetic is injected. e surgeon may perform a selective nerve block of
the ilioinguinal and iliohypogastric nerves, which are just medial to the
anterior superior spine (figure 1). e incision may be made either parallel to the inguinal ligament (figure 2a) or more transversely along a
skinfold line (figure 2b). Most surgeons prefer a eld block with multiple
injections along the incision (figure 3) followed by further injections at
each new level of fascial dissection.
DIRECT INGUINAL HERNIA
DETAILS OF PROCEDURE e incision is carried down through Scarpa’s
fascia to the external oblique aponeurosis. Additional local is in ltrated
beneath this fascia, especially laterally (figure 4). e external oblique is
opened in a direction parallel to its bers down through the external ring.
Care is taken to li this fascia away from the cord and ilioinguinal nerve
during the opening so as to lessen the chance of transection of the nerve.
e free edges of the external oblique fascia are grasped with a pair of
hemostats medially and laterally. Using blunt dissection, the fascia is separated from the internal oblique muscle superiorly and the cord inferiorly.
e cord is encircled with a so rubber Penrose drain. Additional local
anesthesia is injected along the inguinal ligament and about the pubic
tubercle. e direct hernial sac is carefully separated from the cord, which
is cleaned back to the level of its exit at the internal ring. It is veri ed that
this is a direct herniation rather than a medial protrusion of an indirect
herniation. e cremaster muscle about the cord is opened anteriorly. e
cord structures are identi ed and the region of the internal ring inspected
for evidence of an indirect hernia and sac. A direct hernia only is shown
(figure 5). e direct hernial sac is cleaned with blunt and sharp dissection around to its neck. is protrudes through a defect in the transversalis
fascia of the canal oor. ese defects may be discrete, with a nger-sized
punched out hole, or may involve the entire oor as a di use blowout from
the inguinal ligament below to the conjoint tendon above. Some surgeons
prefer to open the direct sac, reduce the properitoneal fat, and excise the
residual sac, as is done with indirect hernias. Almost always, however, the
sac and fat are easily reduced (figure 5) and then kept reduced with an
instrument as the oor is reconstructed.
A continuous nonabsorbable suture is placed for reconstruction
of the canal oor. is begins at the pubic tubercle and approximates the
residual transversalis fascia just above the inguinal ligament to the transversalis fascia or muscle just below the conjoint tendon so as to imbricate
the herniation (figure 6). is suture continues laterally to the level of the
internal ring. Care is taken to avoid the inferior epigastric vessels. A er this
suture is tied, the internal ring should be snug about the cord (figure 7).
e oor of the canal is now solid and the conjoint tendon lies in its normal
position. e conjoint tendon is not arti cially pulled down under tension
to the inguinal ligament as in the classic Bassini repair.
CONTINUES
456
457
PLATE
214
R I H
M (L)
DIRECT CONTINUED, INDIRECT INGUINAL HERNIA Once
the continuity of the direct oor is restored, the repair continues in the same
manner as that for an indirect inguinal herniorrhaphy for a Lichtenstein
indirect inguinal herniorrhaphy. e cremaster muscle is opened anteriorly. e vital cord structures are identi ed and the indirect sac is freed
from the cord using electrocautery and gentle traction. e key landmark
is the vas, which is directly posterior to the sac. A er the sac is opened and
examined, a trans xing nonabsorbable suture is placed through its neck
and ligated (figure 8). e excess sac is then excised, as is any signi cant
lateral lipoma of the cord. Alternatively some surgeons do not open the
hernia sac and merely return it to the preoperational space.
A rectangular piece of polypropylene mesh approximately ½ to cm by
to cm in size is cut with a lateral slit for the cord and a medial blunt oval
for the pubis (figure 9). e mesh is positioned on the oor of the canal
with the tails overlapping lateral to the internal ring and cord. A nonabsorbable suture anchors the mesh to the pubic tubercle. is continuous
suture secures the inferior edge of the mesh to the inguinal ligament while
interrupted absorbable sutures anchor the superior edge to the internal
oblique muscle (figure 10). Care is taken in the placement of the superior
suture so as to avoid any nerve branches. Additional care is needed in the
placement of sutures laterally so as to avoid the ilioinguinal nerve, which
lies upon the internal oblique muscle just lateral to the cord. e two tails
of the mesh are overlapped and then sewn together. It is important that the
mesh not be stretched tightly. e superior suture placements are chosen
such that the mesh is not stretched but rather is loose and almost wrinkles
longitudinally. e importance of this maneuver becomes apparent when
the patient is asked to cough or strain (an advantage possible with the use
of local anesthesia). e wrinkles disappear as the abdominal wall tightens.
If the mesh had been placed without slack, the suture lines would now be
under tension. A few interrupted sutures are placed to further close the
lateral slit and create an appropriate size for the internal ring opening. Currently, only a few ( or ) loops of each continuous suture are placed on the
inferior and superior edges of the mesh by Lichtenstein surgeons.
An alternate pattern for the mesh may be used where the slit is placed
inferior to the cord (figure 11). e mesh is sewn in place with the same
continuous nonabsorbable suture, which begins at the pubic tubercle.
Additional interrupted sutures are used to anchor the superior edge of
the mesh to the internal oblique muscle and to close the inferior slit about
the cord (figure 12). A modi cation described in the classic Lichtenstein
repair is shown for males in this illustration where the spermatic cord has
been thinned and partitioned. e superior bundle of cremasteric muscle
has been transected and ligated at the internal ring. e cord is then partitioned into a major portion containing ilioinguinal nerve, vas, and major
vessels and a minor portion containing the intact inferior cremaster muscle bundle with the external spermatic vessels and the genital branch of
the genitofemoral nerve. e major cord exits through the internal ring
and is shown encircled with a so rubber Penrose drain. e minor portion is le undisturbed, with minimal dissection or disruption in the oor
of the canal near the internal ring. is minor portion now exits through
a separate opening le between the inferior edge of the mesh and the
inguinal ligament. It is important to use a double loop or locking stitch
on either side of this opening such that the minor portion of the cord will
not be compressed.
e external oblique fascia is reapproximated with a running suture,
which may begin at either end of the incision and which creates a snug
de ned external ring (figure 13). Scarpa’s fascia is approximated with
interrupted absorbable sutures and the skin is approximated with subcutaneous absorbable sutures reinforced with skin tapes. A small dressing is
applied to cover the incision.
POSTOPERATIVE CARE e patient may return home several hours
a er the operation with 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 a few weeks, and extreme exertion
should be avoided. ■
458
459
PLATE
215
R I H M
(R R)
INDICATIONS e repair of inguinal hernias in adults has shi ed from
pure tissue repairs (e.g., Bassini) to “tension-free” repairs using polypropylene mesh. e Lichtenstein repair, shown in Plates and , represents the rst widely accepted method for repair of an inguinal hernia using
mesh. Since , however, multiple new con gurations of mesh have been
invented. A frequently used variation is the “plug and patch,” popularized
by Drs. Rutkow and Robbins. is technique has results equivalent to those
of the Lichtenstein method. e mesh cone or “plug” brings a new approach
to the correction of the actual hernial defect. is technique may be used
for recurrent as well as primary inguinal hernias.
PREOPERATIVE PREPARATION e patient is evaluated for general med-
ical and anesthesia risks, as discussed in Chapter , Ambulatory Surgery,
and in the preceding plates concerning hernia repair. As most operations
are elective and performed in an ambulatory setting, su cient time should
be available to optimize the management of any medical diseases. Chronic
coughing, new constipation with straining, and symptoms of prostatism
require a specialty evaluation prior to surgery. Any active infections, including intertrigo, must be controlled. Although mono lament polypropylene
mesh and sutures do not harbor bacteria, an infection may become established or chronic in the presence of mesh, thus requiring its removal.
ANESTHESIA Most patients can be managed e ectively with deep seda-
tion plus local anesthesia. e use of anxiolytic drugs followed by a narcotic
and hypnotic (typically midazolam, fentanyl, and propofol) allows a pleasant induction. Dilute . lidocaine without adrenaline is placed by intradermal in ltration. is produces instant skin anesthesia, which lessens the
discomfort of deeper injections. At the same time, the swelling serves as a
marker for the skin incision. Adrenaline is not used with the entry local
anesthetic as it may obscure bleeding points. Later during the closure, when
hemostasis has been fully secured, adrenaline may be added to the longacting local anesthetic to prolong its duration of action. Adrenaline is not
used in older patients or in those with cardiovascular disease. Alternatively,
some surgeons prefer epidural anesthesia for their patients, as they believe
there is a signi cant interval of hypesthesia during recovery. Finally, general anesthesia may be required for the very anxious patient.
POSITIONING e patient is placed in a comfortable supine position. A
pillow is o en put under the knees to lessen tension in the inguinal region,
and some older patients may require an additional pillow under the head
and neck.
OPERATIVE PREPARATION e skin is shaved and prepared in the usual
manner. In men, the penis and scrotum should be prepared, especially if the
hernia extends into the scrotum or if a hydrocele is present.
INCISION AND EXPOSURE e area is draped in a sterile manner and
local anesthesia is injected along the planned -cm incision. e incision
is placed directly over the inguinal canal and extends obliquely and laterally from the external ring. In very obese patients, a more transverse
incision may be required because of a major skinfold crease. In general,
these incisions are placed below and parallel to the crease. Alternatively, a
recurrent hernia may be approached through the old or original incision.
It may be prudent to make a longer incision that extends laterally into an
area that has not been scarred from the previous operation, as recurrences
are best approached laterally through new tissue planes. A er the skin is
opened, the dissection proceeds down through Scarpa’s fascia to the level
of the external oblique fascia. More local anesthesthetic is injected deeply
beneath the fascia, especially laterally toward the origin of the nerves. e
external oblique fascia is opened in a direction parallel to its bers from
laterally to the midportion of the external ring. Some surgeons prefer to
make a small lateral opening and li the external oblique fascia away from
the cord and ilioinguinal nerve. Scissors are inserted into the opening and
the fascia is cut under direct vision from lateral to medial with avoidance
of the nerve.
INDIRECT INGUINAL HERNIA
DETAILS OF PROCEDURE e inferior leaf of the external oblique fascia is
grasped with two hemostats, one lateral and the other at the external ring. Using
blunt dissection with the peanut on a Kelly, the wispy attachments between
the cord and inguinal ligament are swept from lateral to medial, exposing the
clean shelving edge of the inguinal ligament and the pubic tubercle. Additional local anesthetic is injected along the ligament and at the pubic tubercle.
e superior leaf of the external oblique fascia is grasped by two hemostats.
e cord is dissected free, again beginning laterally. e pubic tubercle is
cleaned. Further extension of this dissection from above, out along the rst
centimeter or so of inguinal ligament lateral to the pubic tubercle, ensures
an easy mobilization of the cord. e surgeon’s nger is placed around the
cord and a so rubber Penrose drain is placed around it for inferior retraction
(figure 1). e cremaster muscle is opened anteriorly and longitudinally for a
few centimeters in its proximal region. e sac is identi ed anterior to the vas
deferens and is carefully dissected away from the vas and blood vessels. is
dissection is performed using electrocautery at the edge of the sac while gentle
traction is applied to the fat and vessels. Historically, this dissection was done
bluntly with smooth forceps or with a sweeping motion using a gauze sponge;
however, careful dissection with electrocautery along the edge of the sac minimizes bleeding. e sac is freed up well into the internal ring (figure 2). If
the sac is entered, the opening is closed with a absorbable suture. When an
extremely large sac associated with an inguinoscrotal hernia is present, it may
be prudent to perform a high transection and ligation of the proximal sac. is
leaves the distal sac intact and minimizes potential trauma of the cord veins,
with consequent testicular complications.
e hernia sac in this example of an indirect hernia is not divided but
rather is invaginated back up through the internal ring with an instrument
(figure 3). e internal ring may be sized with the surgeon’s nger, which
then guides the polypropylene cone or “plug” into the opening. e cone is
secured to the con-joint tendon (external oblique muscle) with one or more
absorbable sutures. It is important that the cone be positioned behind the
muscle and that a su cient number of sutures be placed such that the sac or
preperitoneal fat cannot get out around the perimeter of the cone (figure 4).
e onlay “patch” of polypropylene mesh is placed with the pointed or
shield end overlapping the pubic tubercle. e cord is passed through the
lateral slit and the two tails are joined together with absorbable suture
(figure 5). A suture is placed near the cord, thus determining the diameter
of the new internal ring. Traditionally, this opening has been sized for easy
passage of the cord plus an instrument tip. It is important that the onlay
patch be of su cient size to overlap the inguinal ligament inferiorly, the
pubic tubercle medially, and the entire oor centrally, as shown in the cross
section (figure 5a). Additionally, the mesh should reach well lateral to the
internal ring. is may require the custom cutting of a sheet of polypropylene mesh for large indirect hernias.
e perimeter of the incision, both deep and super cial, is in ltrated
with a long-acting local anesthetic. e external oblique fascia is reapproximated above the level of the cord using an absorbable suture. e closure
begins at the external ring with observation of the cord, the ilioinguinal
nerve, and the path of each edge of the oblique fascia. Starting the closure
here allows the surgeon to size the external ring. e closure is continued
laterally as a running suture (figure 6). Scarpa’s fascia is approximated
with a few or absorbable sutures and the skin is closed in a subcuticular manner with a ne absorbable suture. Adhesive skin strips and a dry
sterile dressing are applied.
POSTOPERATIVE CARE Patients operated upon in an ambulatory surgery
setting are observed for about an hour until discharge criteria are met. ey
may take liquids by mouth and are encouraged to void. e homegoing
instructions detailing activities and the signs of bleeding or infection are
reviewed with the patient and caregiver. Most patients require pain medications for a day or two. Normal activities are resumed as tolerated. ■
460
461
PLATE
216
R I H M
(R R)
DIRECT INGUINAL HERNIA
DETAILS OF PROCEDURE e incision and exposure is the same as that
utilized for the indirect hernia (Plate ). e external oblique fascia is
opened and the superior and inferior edges are grasped with pairs of hemostats. e shelving edge of the inguinal ligament is cleared rst with blunt
dissection using a peanut on a Kelly. However, as the surgeon begins the
superior exposure, the direct oor is not apparent as a structure separate
from the cord. It appears as though the cord and hernial process covered
both areas (figure 1). As the cremaster is opened anteriorly, the cord is
identi ed as separate from the direct herniation. e cord is dissected free
and isolated for retraction with a so rubber Penrose drain. e direct hernial sac, which is o en quite large compared to its defect in the oor, is
cleaned carefully back to its junction with the oor or transversalis fascia
and muscle. A suitable zone approximately cm above the junction of the
direct sac with the oor is chosen for incision with the electrocautery. As
the sac is cut, the preperitoneal fat literally pops into view (figure 2). is
circumscription is carried for degrees about the entire neck of the sac.
is allows the tethered sac and its content of preperitoneal fat to be easily
returned into the preperitoneal space. e actual size of the direct defect is
o en smaller than anticipated. On palpation of the defect, there is usually a
clearcut rim of transversalis fascia and muscle that persists, although these
layers are o en quite thin. e polypropylene cone or “plug” is placed into
the direct opening such that its rim is directly ush with the transversalis oor. Multiple interrupted absorbable sutures are used to secure the
perimeter of cone to the transversalis tissues (figure 3). Usually eight or
more sutures are placed such that none of the preperitoneal fat can protrude
between the edge of the cone and the rim of the transversalis. e cremaster is opened anteriorly (figure 4) and a search is made for any indirect
hernia, which may require a second cone for repair. e cord structures
including the vas are identi ed and the cremasteric opening is not closed.
e onlay “patch” of polypropylene mesh is placed over the entire direct
oor in the same manner as described in the preceding plate for indirect
hernia. e two tails of mesh are joined together producing the new internal ring (figure 5). e same precautions apply—namely, the mesh must
clearly overlap the inguinal ligament inferiorly, the pubic tubercle medially,
the entire direct oor and cone centrally, and the internal ring laterally.
If this coverage is in doubt, a custom-cut piece of polypropylene mesh is
prepared. In their original description, Rutkow and Robbins do not suture
down the perimeter of the onlay mesh “patch,” as in the Lichtenstein
repair. However, some surgeons prefer to suture the inferior edge of the
patch to the inguinal ligament and the superior edge to the internal oblique
muscle, thus creating a hybrid procedure that Rutkow has humorously
named the “plugstein.”
POSTOPERATIVE CARE e perimeter of the incision is in ltrated with
long-acting local anesthetic and the external oblique is reapproximated
above the level of the cord using a running absorbable suture that begins
at the external ring. Scarpa’s fascia may be approximated with absorbable
sutures. e skin is approximated with a ne absorbable subcuticular suture.
Adhesive skin strips and a dry sterile dressing are applied. e postoperative care is the same as that described in relation to Plate . ■
462
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