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218
Indirect
An indirect hernia sac lies medial to the cord and on the
anterosuperior aspect of the cord structures. In the case of
scrotal herniation, with a fixed hernia sac in the scrotum, a
transection of the empty hernia sac at the midpoint of the
canal leaving the distal part in situ is recommended to minimise the risk of postoperative ischemic orchitis. The anterior
wall of the distal sac can be incised to prevent postoperative
hydrocele formation. Further management depends on the
presence and nature of the contents of the indirect hernial
sac.
No Contents
If the sac is empty and does not extend beyond the pubic
tubercle, it is lifted and freed from the adjacent structures by
careful dissection. It is traced back to its junction with the
parietal peritoneum (a small amount of preperitoneal fat can
usually be seen at this point indicating that adequate dissection has been performed) transfixed with an absorbable
suture, which is tied around it securely, and the redundant
sac excised (Fig. 12.7). If an indirect hernia sac extends
beyond the pubic tubercle, the sac is transected and the distal
sac left in situ (Fig. 12.8).
D.L. Sanders et al.
Fig. 12.8 If the indirect sac extends beyond the inguinal canal, it
should not be dissected beyond the pubic tubercle; instead the (empty)
proximal sac is identified, dissected free from the cord and transected.
The distal sac is left in situ
Fig. 12.7 A simple sac is ligated flush to the parietal peritoneum
Small Bowel and/or Omentum, with or Without Adhesions
Unless the hernia is strangulated and the small bowel nonviable, any adhesions are divided, and the small bowel is
returned to the abdominal cavity. Strangulated omentum or
small bowel can be resected at this stage. The diagnostic
decision as to what should be done about very adherent and
frequently partially ischemic omentum is difficult. If there is
any doubt about omentum, it is best excised, because to
return omentum of doubtful viability to the peritoneal cavity
invites the formation of adhesions.
Sliding Hernia
Such a hernia may contain the cecum and appendix (on the
right side) in its wall, the sigmoid colon (on the left side) or
the bladder (in the medial wall on either side). The following
guidelines apply in these circumstances:
12 Anterior Open Repair of Inguinal Hernia in Adults
1. No attempt should be made to separate cecum or sigmoid
colon from the sac wall. This may compromise their
blood supply and lead to further unnecessary problems.
2. The appendix must not be removed unless it is acutely
inflamed, as this could introduce sepsis.
3. Appendices epiploicae must never be removed from the
sigmoid colon; they may harbour small colonic diverticula, excision of which will precipitate sepsis.
4. On the medial side of a sac, there should be no attempt to
dissect the bladder clear. If the bladder is inadvertently
opened, a two-layer closure with absorbable polymer and
urethral catheter are required for 7 days at a minimum.
A sliding hernia is dealt with by excising as much perito-
neal hernial sac as possible and then closing it using an
‘inside out’ purse-string suture. When it is closed, it is
pushed back behind the fascia transversalis (Fig. 12.9).
Direct
219
The direct sac may be either a broad-based bulge behind and
through the fascia transversalis or, less commonly, it may
have a narrow neck. In the first type, interference with the
peritoneum is not needed; the sac should be pushed behind
Fig. 12.9 Closing the sac of a sliding hernia
Fig. 12.10 The dome-shaped direct bulge; there is no need to open this
sac
the fascia transversalis, which will subsequently be repaired
(Fig. 12.10). In the case of a narrow necked hernia, which is
usually at the medial end of the canal, extraperitoneal fat is
removed, the sac carefully cleared, redundant peritoneum
excised and the defect closed with absorbable transfixion
suture. Care must be taken to avoid the bladder, which is
often in the wall of such a sac (Fig. 12.11).
Combined Direct and Indirect
Lastly, a combined direct and indirect ‘pantaloon’ sac straddling the deep epigastric vessels may be found. In such cases
the sac should be delivered to the lateral side of the deep
epigastric vessels and dealt with as described for an indirect
hernia (Hoguet’s manoeuvre) [93, 94] (Fig. 12.12).
The indirect sac is completely freed from the vas, spermatic vessels and the adjacent fascia transversalis at the deep
ring. It is best then to mobilise the fascia transversalis medially so that the whole of the sac can be drawn laterally.
Whether or not the direct sac should be opened at this stage
is a question of judgement. The hazard of wounding the
bladder must be acknowledged. Any opening into a direct
220
D.L. Sanders et al.
sac must be commenced laterally; care must be taken to
identify the bladder margin medially, and any peritoneal
incision must stop short of this. Alternatively the direct sac
can be opened; a finger inserted into the peritoneal cavity
through the indirect sac will identify the dimensions of the
direct sac and facilitate dissection and mobilisation.
Once the indirect and direct sacs are mobilised, redundant
peritoneum is excised and the peritoneal defect closed.
The Reconstruction
After the preparation an assessment of the hernial orifice is
possible. This is also the moment to look for the femoral
orifice to rule out a concomitant femoral hernia.
The repair of the defect can be achieved by an impressive
variety of different procedures. The main differentiation is a
repair by suture or by augmentation with non-absorbable
mesh prosthesis, in an anterior or posterior position:
• Anterior flat mesh repair
– Lichtenstein
• Open suture repair
– Shouldice
– Marcy/Zimmermann (for historical interest only)
– McVay technique (for historical interest only)
The Open Anterior Mesh Repair (Lichtenstein Tension-Free Hernioplasty)
Fig. 12.11 The narrow-necked medial direct hernia. The (empty) sac
is isolated, closed and excised
The incision, exposure, dissection of the canal and cord and
the method of dealing with indirect hernial sacs are identical
for that described above.
The upper leaf of the external oblique aponeurosis needs
to be lifted up and dissected from the underlying internal
Beware
bladder
Fig. 12.12 Hoguet manoeuvre. The combined direct/indirect sac (pantaloon hernia) is delivered lateral to the deep epigastric vessels. Any redundant peritoneum is excised and the sac closed
12 Anterior Open Repair of Inguinal Hernia in Adults
221
oblique muscle and aponeurosis high enough to accommodate a 6–8-cm-wide patch. Between these two layers, the
anatomical cleavage is avascular and the dissection can be
performed as described above. A sufficient overlap is
required of Hesselbach’s triangle, the pubic tubercle and laterally beyond the internal ring. Medially this dissection
should be taken beyond the pubic tubercle to the midline
(Fig. 12.13).
In the case of large direct sacs, in order to flatten the pos-
terior inguinal wall to facilitate placement of the mesh, a
Fig. 12.13 Wide dissection of the posterior wall of the canal
running, inverting, absorbable suture is applied to the transversalis fascia.
A non-absorbable mesh prosthesis precut to 12 cm × 8 cm
is now tailored to the individual patient’s requirements. This
will involve trimming 1–2 cm of the patch’s width and the
upper medial corner so that it will tuck itself between the
external oblique and internal oblique muscles without
wrinkles.
The cord is now retracted downwards and the mesh
aligned into the inguinal canal such that its inferior border
lies parallel with the inguinal ligament and its medial border
overlaps the pubic tubercle by 1–2 cm. Using a nonabsorbable monofilament running suture beginning at the
upper, medial, rounded border of the mesh, the suture is
placed into the tough aponeurotic tissue of the midline and
secured with a knot. This suture then continues around the
edge of the mesh taking bites of firm connective tissue under
direct vision but avoiding the periosteum of the bone.
As the suture continues, it picks up the lower edge of the
shelving margin of the inguinal ligament. Having secured the
mesh medially and also secured it to 1–2 cm of inguinal ligament, this suturing is temporarily halted (Fig. 12.14). A slit
is now made at the lateral end of the mesh creating two tails,
a wider one (two-thirds above) and a narrow one (one-third
below) (Fig. 12.15). The lower, narrower tail together with
the needle and its running suture are now passed behind the
cord, which is then retracted upwards (Fig. 12.16). The wider
upper tail and the narrow lower tail are overlapped and
grasped in a haemostat to retract the mesh and prevent unnecessary wrinkles.
The running suture between the lower edge of the mesh
and the shelving margin of the inguinal ligament is now
completed to a point just lateral to the internal ring
(Fig. 12.17). The upper leaf of the external oblique aponeurosis is now retracted strongly upwards, and the upper edge
Fig. 12.14 Securing the
mesh to the inguinal ligament,
ensuring good medial
coverage; use a nonabsorbable or slowly
reabsorbable suture
222
Fig. 12.15 A slit is cut in the mesh (one-third below, two-thirds
above), up to the medial margin of the deep ring
D.L. Sanders et al.
Fig. 12.16 The lower ‘tail’ of the mesh is flipped behind the cord, followed by the continuous suture with needle, and the cord is retracted
upwards
of the mesh is sutured to the underlying internal oblique
aponeurosis or muscle with a series of interrupted sutures
approximately 2–3 cm apart. Care is taken to avoid underly-
Fig. 12.17 The continuous suture line along the inguinal ligament is
now continued to the lateral border of the deep ring
ing blood vessels and sensory nerves, especially the iliohypogastric nerve which has an intramuscular portion
(Fig. 12.18). In order to prevent inadvertent damage to the
iliohypogastric nerve, the sutures are tied loosely with ‘air
knots’ over a haemostat thus preventing nerve compression.
The mesh should not be completely flattened but should be
seen to have some degree of anterior convexity in order to
remain tension-free. The last fixation suture is placed laterally at approximately the same level as the internal ring.
According to Lichtenstein the lower edges of each of the
two tails are now fixed to the inguinal ligament at a point just
lateral to the completion knot of the lower running suture
(some surgeons do not complete this step). A point is chosen
in the lower edge of the upper tail approximately 1 cm
beyond the lateral margin of the internal ring to avoid unnecessary buckling of the mesh (Fig. 12.19). Having created a
new internal ring with crossover and overlap of the two tails,
excess patch on the lateral side is now trimmed in order to
leave approximately 3–4 cm of mesh beyond the internal
ring. This lateral tail is now tucked underneath the external
oblique aponeurosis and may be prevented from movement,
curling up or wrinkling by placing sutures between it and the
underlying muscle. The size of the new internal ring is now
tested with a haemostat, which should pass easily between
the cord and the mesh. If this gap is too wide it may be closed
loosely with a non-absorbable suture (Fig. 12.20).
12 Anterior Open Repair of Inguinal Hernia in Adults
Fig. 12.18 Lateral fixation of
the mesh with ‘air knots’
223
Fig. 12.19 The ‘tails’ are overlapped and crossed and a single suture
placed to create a new deep ring
Having completed the repair of the posterior inguinal wall
with non-absorbable mesh prosthesis, the cord is placed back
into the canal. The wound closure is preformed; see below.
The original Lichtenstein technique as described above
has seen many modifications over the years. The main focus
is today directed on the mesh and the fixation technique. The
advances in mesh technology provide a great variety of different meshes (see Chap. 7).
Fig. 12.20 An artery clip is run down between the mesh and the cord
to ensure adequate aperture
Mesh Fixation
Lichtenstein used a non-absorbable polypropylene suture for
mesh fixation. In a recent survey of the Swedish Hernia
Registry, different sutures were investigated. The data of
over 80.000 Lichtenstein repairs were analysed in respect of
the suture material, non-absorbable, long-term or short-term
absorbable suture. There was no difference in the recurrence
224
D.L. Sanders et al.
rate between the first two groups but a significant increase in
the short-term absorbable suture group [95].
Today there is a great variety of suture- and tack-free
mesh fixation options available. In experimental studies the
strength of glue or fibrin sealant in comparison to sutures has
been demonstrated [96]. Fibrin sealant for mesh fixation was
first introduced by Chevrel and Rath in 1997 for the treatment of open onlay meshes in incisional hernia repair and is
now also used for inguinal open Lichtenstein repair. Negro
and colleagues have performed an observational multicentre
study including 520 patients over a 12-month period. They
found significantly less intense pain, numbness and discomfort in the fibrin sealant group [97].
A new mesh modification that addresses the problem of
fixation and mesh structure has gained popularity amongst
hernia surgeons. Absorbable microhooks on the fasciafacing side of the mesh induce a ‘self-gripping’ or Velcrolike property, negating any additional type of fixation [98].
Recent publications have shown some advantages in total
length of operation time and less acute pain, though longterm results need to be awaited (see Chap. 7).
Suture Repairs
the fascia is separated from the underlying structures, particularly the deep epigastric vessels. If there is no direct herniation and no gross distortion of the deep ring, only the
margin of the deep ring, the ‘sling’ of the deep ring, needs
dividing; if there is a direct hernia and attenuation of the fascia transversalis, the fascia transversalis is now divided along
the length of the canal, beginning at the deep inguinal ring
and continuing down to the pubic tubercle. The upper medial
flap is lifted up away from the underlying fat. Attention is
now turned to the lower flap. If it is penetrated by cremasteric vessels arising from the deep epigastric vessels, these
should now be divided and ligated close to their origin. If
care is not taken with the cremasteric vessels, they may be
torn off the deep epigastric vessels, and troublesome haemorrhage will follow. If a direct hernia is present, it will bulge
forward at this time and must be pushed back in order to free
the lower lateral flap of the fascia transversalis. This flap
must be freed down to its continuation as the anterior femoral sheath deep to the inguinal ligament. The lower, condensed fascia transversalis as it merges to the anterior
femoral sheath is the iliopubic band. Any grossly attenuated
fascia transversalis about a direct sac is excised. With the
fascia transversalis opened and developed, the femoral canal
should be checked again (Fig. 12.21).
In Table 12.1 the most common suture techniques are
enlisted. A description of each technique would certainly go
beyond the scope of this chapter. Therefore, only the most
common current and historical techniques are described.
Shouldice Repair
In 1945 it was Earl E. Shouldice who described this novel
method of inguinal hernia repair. It is an open, transinguinal
suture technique to repair defects in the posterior wall of the
inguinal canal. In the same year, he founded the Shouldice
Hospital, but it took until 1952 and the support of his assistants
E.A. Ryan and N. Obney that after several modifications of the
initial technique led to the development of today’s classical
‘Shouldice repair’ also known as the ‘Canadian repair’ [99].
Dissection of Fascia Transversalis
The most essential part of the Shouldice operation is the
repair of the fascia transversalis. This structure should
already have been identified at its condensation around the
cord forming the deep inguinal ring. The condensed medial
margin of the deep inguinal ring is freed from the emerging
cord by sharp dissection. When this is completed, the medial
margin of the ring is grasped in a dissecting forceps or a
haemostat and lifted up off the underlying extraperitoneal
fat. Dissecting scissors are now passed through the ring
between the fascia and the underlying fat. By this manoeuvre
Repair of Fascia Transversalis
If the previous dissection has been carried out carefully, and
if haemostasis is now complete, the repair with the reconstruction of the inguinal floor commences. First, the fascia
Fig. 12.21 Dissection of the fascia transversalis
12 Anterior Open Repair of Inguinal Hernia in Adults
transversalis is reapproximated, and the deep ring is carefully reconstituted using a ‘double breasting’ technique. The
posterior wall of the canal must be reconstituted so that all of
the peritoneum and the stump of a hernial sac are retained
behind it. To do this, the lower lateral flap of the fascia transversalis is sutured to the deep surface of the upper medial
flap. The repair is begun towards the medial end of the canal.
Where the medial margin of the deep ring only has been
divided and the more medial aspect of the posterior wall of
the canal shown to be sound, no direct herniation, only the
divided fascia transversalis at the medial margin of the deep
ring, the ‘sling’, will need careful two-layered reconstruction
with a non-absorbable suture (Fig. 12.22). If there is a direct
hernia, the whole of the posterior wall of the canal will have
been divided and will need repair, the first suture being
placed in fascia transversalis where that structure becomes
condensed into the aponeurosis and periosteum on the pubic
tubercle. The lower lateral flap of the fascia transversalis is
then sutured to the undersurface of the upper flap at the point
where the upper flap is just deep to the tendon of the transversus abdominis (conjoint tendon). At this point there is a
thickening or condensation of the fascia transversalis (the
‘white line’ or ‘arch’), which holds sutures easily (Fig. 12.23).
Care must be taken with the closure of the fascia transversalis as it approaches the lateral rectus sheath, which must be
adequately repaired to the fascia transversalis and the pubic
Fig. 12.22 After the neck of the sac has been divided at the deep inguinal ring, the fascia transversalis of the deep ring is identified and
assessed. If the ring is normal sized, the stump of the sac is reduced and
no more need be done. If the ring is marginally dilated (stretched), it
should be carefully distracted and possibly divided slightly (inset) and
then sutured tightly around the medial side of the cord with polypropylene to reconstitute a competent deep inguinal ring
225
Fig. 12.23 Suturing the lower lateral flap of fascia transversalis to the
under surface of the upper medial flap along the ‘white line’ or ‘arch’
tubercle. The anatomy here is variable and the falx inguinalis
should be included in the repair. The fascia is sutured laterally until the stump of an indirect hernia lies behind it and it
has been snugly fitted around the spermatic cord (Fig. 12.24).
The direction of suturing is then reversed. The free margin of
the upper medial flap is brought down over the lower lateral
flap and sutured to the fascia transversalis at its condensation
(the iliopubic tract), just above the upturned deep edge of the
inguinal ligament in the floor of the canal. Suturing is continued back to the pubic tubercle, where the suture is tied. By
this manoeuvre the fascia transversalis is ‘double breasted’
on itself, and the ‘direct area’ of the canal is reinforced and
the internal ring carefully reconstituted and tightened. It is
important not to split the fascial fibres. Sutures should be
placed about 2–4 mm apart and bites of different depth taken
with each so that an irregular ‘broken saw tooth’ effect is
produced. The repair of the fascia transversalis is the crucial
part of the operation. The fascia must be dissected and handled with care if its structure is to be maintained.
A ‘trick of the trade’ sometimes facilitates this suturing of
the fascia transversalis: after the upper medial and lower lateral leaflets of fascia transversalis have been developed to
clearly show the ‘white line’ of the transversus tendon
through the fascia above and the iliopubic tract below, a
loose swab (sponge) is pushed into the dissection to keep the
extraperitoneal fat out of the way when the first sutures are
introduced (Fig. 12.25). When these sutures are loosely in
place, the swab is removed and the suture tension adjusted to
give tissue closure.
226
a
D.L. Sanders et al.
Reinforcement with the Conjoint Tendon
The conjoint tendon is now used to reinforce the repair of
the fascia transversalis medially. A suture is started laterally through the upturned deep edge of the inguinal ligament medial to the margin of the reconstituted deep
inguinal ring and continued to the deep tendinous surface
of the conjoint tendon, which is directly to the medial side
of the deep ring. Sometimes, particularly if the cord is
bulky, it is easier to proceed in reverse by passing the needle first through the undersurface of the conjoint tendon
and then under the cord and through the upturned edge of
the inguinal ligament. At the point where this suture is
inserted, the deep surface of the conjoint tendon is just
beginning to become aponeurotic (the tendon of the transversus muscle), and it should hold sutures easily. The
suture is continued in a medial direction, picking up the
b
Fig. 12.24 Completing the overlap of the fascia transversalis repair.
The margin of the upper medial flap is sutured to the anterior surface of
the lower lateral flap (a). A neat closure up to the cord makes a new
deep ring (b)
upturned edge of the inguinal ligament and the undersurface—the aponeurotic part—of the conjoint tendon down
to the pubic tubercle (Fig. 12.26). The direction is then
reversed, suturing the aponeurotic part of the conjoint tendon, the internal oblique tendon now, loosely to the external oblique aponeurosis about 0.5 cm above the inguinal
ligament. The ‘broken saw tooth’ technique previously
mentioned is again used, and as it is done, the suture is
gently pulled snug, not tight, so that the conjoint tendon
and rectus sheath are rolled down onto the deep surface of
the external oblique aponeurosis. Suturing is continued
laterally until the conjoint tendon ceases to be aponeurotic
Fig. 12.25 If the subjacent extraperitoneal fat and peritoneum is bulging, a ‘trick of the trade’ is to pack it down with a gauze swab. This must
be removed before the sutures are snugged tight
Fig. 12.26 The aponeurotic, white part of the internal oblique tendon
and the conjoint tendon is used to reinforce the repair
12 Anterior Open Repair of Inguinal Hernia in Adults
Fig. 12.27 The anterior aponeurotic surface of the internal oblique
aponeurosis is loosely sutured to the aponeurosis of the external oblique
medially
at the medial edge of the emergent spermatic cord. The
suture is then tied. The reconstruction of the posterior wall
and the floor of the inguinal canal are now complete. The
cord is now placed back in the canal (Fig. 12.27).
Marcy/Zimmermann Suture Repair
The first description of a narrowing of the deeper inguinal
hernia ring by suture was by Marcy in 1887 [8] and later by
Zimmermann [100]. Indications for his simple repair are
small, indirect inguinal hernias (EHS classification L1) with
a stable fascia transversalis. In these cases a further incision
of the posterior wall is neglected, and a reduction of the hernial orifice by suture is performed.
A prerequisite for this repair is a sufficient preparation
of the internal inguinal ring, with identification of the fascia transversalis, complete dissection of the spermatic
cord from the internal inguinal ring and removal of preperitoneal fatty tissue. The suture repair starts medial to
lateral. The narrowing of the internal hernia ring should
accomplish a remaining orifice of 5–8 mm, admitting just
the tip of a finger, to guarantee a sufficient blood supply
for the testis. To standardise the size of the ring, the use of
an 11.5 Hegar dilator has proved to be helpful. The closing sutures are placed medial to the spermatic cord. To
achieve a secure placement of the sutures, the fascia transversalis, the aponeurosis of the m. transversus and the
caudal fibres of the iliopubic tract are included into the
suture.
After sufficient narrowing of the internal hernia ring, the
posterior wall of the inguinal canal is augmented by a single
continuous suture fixation of the internal oblique and transverse muscles to the inguinal ligament.
227
McVay Repair
The initial indication for the McVay/Cooper’s ligament
repair was for patients with a large direct hernia and an
absent caudal margin of the fascia transversalis. It is also
useful in the management of concomitant femoral and inguinal hernias. Today the McVay repair has lost most of its initial relevance. The advantages of the different mesh
techniques have reduced the indication and propagation of
this technique.
The McVay repair is therefore described only in summary.
The incision, exposure and dissection of the canal and cord are
identical to the above-mentioned. The transversalis fascia is
incised, preserving the inferior epigastric vessels, and the preperitoneal space opened. The dissection is then taken deeper to
expose and free the iliopectineal (Cooper’s) ligament. Great
care must be taken here to preserve the anastomosis between
the obturator and epigastric arteries (‘the corona mortis’). The
hernia sac can be dissected bluntly away from the superior
pubic ligament. The main principle of this procedure is a triple-layer repair, attaching the fascia transversalis, the m. transversus abdominis and the m. oblique internus to Cooper’s
ligament. To reduce possible tension on the suture line, a
relaxing incision is made as medial as possible in the internal
oblique aponeurosis—anterior rectus sheath—deep to the
external oblique aponeurosis before the two aponeuroses fuse
(Fig. 12.28). The repair is now initiated by bringing the transverse abdominis arch down to the inguinal ligament. This is
best achieved with a layer of interrupted sutures, beginning at
Fig. 12.28 McVay/Cooper’s ligament operation, clearing the anterior
femoral sheath