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HerniaSurgerySimplied

Fig. 10.3: Original Bassini operation. The canal’s posterior

wall is opened and the deep epigastric vessels are exposed

tension,andrecurrencesresulted,primarilyinthepubic tuberclearea.us,thefailureofthisoperationinitsrst yearwasmorelikelyduetoanoverlookedsecondhernia ortopoorsurgicaltechnique,ratherthanametabolicor tissuedefectthatmightpredisposetorecurrenthernia (Fig.10.4).  erehavebeennumerousmodicationsofBassini’s originaltechnique,althoughmanyofthelessdetailed renditionshaveyieldedpoorresults.osethatavoided openingthe posterior wall,e.g.resultedinsuture-line tensionbetweentissuesatthemostmedialpartofthe inguinalcanaljustcephaladto the pubicbone.Some helpwas affordedtheBassini techniqueandother tissuerepairsbytheintroductionofrelaxingincisions bysurgeonssuchasWolfer,Halsted,Tanner,andMcVay.

Shouldice Repair

ItisbasicallyaBassinirepair.Itisapuretissuerepair.e essentialstepsinthismethodofrepairare:  1. DoublebreastingtheTF(Twolayers)  2. Approximationof conjointtendon toinguinal

ligamentintwolayers.  e operationdependson removalofcremasteric musclefromthatportion of spermaticcordwhichlies withintheinguinalcanal.isistheoptimummethod ofrepair(Fig.10.6).

Fig. 10.4: Modied Bassini. The posterior wall is not opened.

Sutures placed between the transversus arch and the inguinal ligament create tension on the tissues approximated

Fig. 10.5: Trendelenburg position

 eShouldicetechniqueforthetreatmentofinguinal hernia.

Inguinal Dissection

Acomprehensiveintraoperative examination ofthe inguinalregionisperformedinallcases.isisintegral toattainingaverylowrecurrencerate.efrequencyof secondaryherniasfoundatthetimeofsurgeryis15.4%. Theassessmentshould includethe direct, indirect, interstitialandfemoralspaces.

OpenAnteriorRepairofInguinalHerniainAdult

Fig. 10.6: Right inguinal hernia repair: dissection of cremasteric muscle. Mobilization of the spermatic cord through the

cremasteric muscle and creation of medial and lateral aps for

transection

 Theincision ismadefrom 2cm inferiomedialto theASISto thepubictubercle,paralleltothe inguinal ligament.isallowsgenerousexposuretobothinguinal canalandfemoralspace.Trendelenburg’sposition(Fig.

10.5)maybeusedtoreduceintra-abdominalpressure, facilitatingtherepair.  Dissectionisdeepenedtoexposetheexternaloblique fasciaandsupercialinguinalring.Localanesthesiais requiredatthispointpriortoopeningthecanal.Careis requiredtoidentifyandavoidinjurytotheilioinguinal andiliohypogastric nerves.eir courseusuallyruns deeptotheexternaloblique,superiortothedeepring andsupercialtothecordstructures.Inltrationofthe internalobliquemusclesuperiortothecanalcanprovide anesthesiafortheinternalobliqueandperitoneumused laterinthereconstruction.Ifthenervesaretraumatized atany point, donot hesitatetoresect thedamaged segmentsto avoidneuropathypostoperatively. The resultantnumbnessafternerveresectionisnotusually ofanyclinicalsignicance.  espermaticcordisisolatedbyalongitudinalanterior openinginthecremastericmusclebersatthemidpoint ofthe canalextendedmedially tothe pubic tubercle, creatingtwoapsofmusclemedialandlateraltothecord.  Thismaneuver allowsacomplete examinationof theposterior floor,in particularthe medialaspect.

elarger lateralcremasteric ap,which includesthe genitalbranch,isinltratedwithlocalanesthetic,asis theinternalring.Ifalipomaispresent,thisisdissected fromthe cord towardstheinternal ringandexcised. isfacilitates identicationofthe indirectsacin its typicalanteromedialposition. Anindirect sac should beisolatedfromthecordandinternalringandexcised. estumpshould retractnaturally into theperitoneal cavity.Somesurgeonschooseonlytoreducethesacto avoidperitonealirritationanddiscomfort.Careshould betakenifthesacisthicker,containsmorefatthanusual orisbroadbased,asthismaybeanindicationofasliding hernia.ese arereducedand notopened.If asac is notidentied,thedissectionofthecordattheinternal ringmustidentifyaperitonealprotrusion,whichcanbe aidedbygentletractiononthecord.eidenticationof thisstructure,whichisinitsnormalanatomicposition, assuresthesurgeonthattheindirectherniahasnotbeen missed.Aftercompletedissectionofthecord,bothaps ofthecremastericmusclearedividedsharplyandligated. esestumps are usedto supporttherepair atalater pointintheprocedure.  eposteriorwalloftheinguinalcanalisexamined foradirectherniathenopenedbeginningattheinternal ringin paralleltothe internalobliquemuscle bers. Careshouldbetakennottoinjuretheinferiorepigastric vesselsfoundmedialtotheinternalring.elateralap shouldbewideenough,atleast1cm,toreachtheedge oftherectussheathin the rstlayer ofthe repair.Any redundanttransversalisfasciaofadirectherniashould beexcised. Preperitonealexaminationof the internal obliquemuscleandfasciacephaladtotheinternalring andtheinguinalcanal,shouldconrmthepresenceofan interstitialhernia.Ifpresent,theinternalringcanbeincised laterallytoincludeaninterstitialdefect.einternalring wouldthen bedisplacedlaterallyafter reconstruction. Dissectionbelow theinguinalligamentshould identify Cooper’sligament andthusconfirm thepresence or absenceofafemoralhernia(Figs10.7AandB).  esupercialthighfasciaorcribiformisfasciacandal totheinguinalligamentshouldbe incisedtoexamine thefemoral space fromFigure10.7. In addition,this mobilizestheinguinalligamentandexternalobliquefor useinthereconstruction.

Reconstruction

Acontinuousrepair with32to 34gaugestainless steelwire is usedfor thereconstruction.is maybe

HerniaSurgerySimplied

Figs 10.7A and B: Dissection of femoral space. (A) Cooper’s

ligament seen through the preperitoneal space, deep to the tips of the clamp; and (B) Incision of the cribiformis ligament below the inguinal ligament

substitutedwitha3-0polypropylenesuture.Itisafourlayertissuereconstructionusingtwoseparatesutures. Acontinuoustechniquedistributesthestrengthofthe repairevenlyandshouldbewithouttension.Arelaxing incisionisrarelyrequired.  The first two layersrepresent an overlapped reconstruction.Itbegins medially,anchoring overthe pubictubercle,leavingasucientendtotiethereturning sutureafterthe secondlayer. einferolateralap of transversalisfascia issuturedto thelateraledge ofthe rectussheathby reachingunderneath thesuperiormedialap.  The reconstructionthen moveslaterally tothe aponeurosisofthetransversusabdominisandtheedge

Figs 10.8A and B: Reconstruction: the rst layer. (A) Starting at

the pubic tubercle, the lateral ap of transversalis fascia is taken to the edge of rectus sheath underneath the medial ap; and (B) The layer is completed with the reconstruction of internal ring. The lateral stump of cremasteric muscle is taken with the bite

of transversalis to buttress its medial edge of the new internal

ring, prior to emerging with a full thickness bite of internal oblique

oftheinternalobliquemuscle.elateralextentofthis layerredenestheinternalringandshouldincludethe superiorstumpofthedividedlateralapofcremasteric muscle(Figs10.8Aand B). is buttressestheinternal ringand helpspreventan indirectrecurrence.The suturingisthenreversedtobeginthesecondlayer.e superiorflap oftransversalisfascia issuturedto the shelvingportionoftheinguinalligamentthentiedatthe pubictubercle.eperiosteumshouldnotbeincluded inanybiteasthiscanresultinapainfulosteitis.  enextstageofreconstructioncreatesatwo-layered imbricationtoprovidereinforcement.elayerisbegun superiorandslightlylateraltodeepring,anchoringthe suturetotheinternalobliquefascia.einferiorapof

OpenAnteriorRepairofInguinalHerniainAdult

Fig. 10.9: Reconstruction: the second layer using the same suture, it is continued from the internal ring back, taking the medial ap of transversalis fascia to the shelving portion of the inguinal ligament. Overlapping layers are created

theexternaloblique,millimetersaboveandparallelto theinguinalligament,istackedtotheedgeoftheinternal obliqueandtransversusmuscles(Figs10.9to10.11).  Inaddition,onlyasmallbiteoftheinternaloblique isrequired,nomorethan5mm.Excessivelylargebites willcreatetension.Atthepubictubercle,thedirectionis reversedforthefourthlayerandtakenbacktotheinternal ringandaxed.  Theimportance ofmobilizing theinferiorflap of externalobliqueby previouslyincising thesupercial thighfascia isrealizedhere.e additionalmobility allowstheexternalobliquetobeusedinthethirdand fourthlayers to coverthe medialportion ofthe repair thatis susceptible torecurrence.The inguinalcanal isreconstructed byre-approximatingthe remaining externaloblique fascia,returningthe cordtoits anatomicalposition.e inferiorstump ofthemedial apofcremastericmuscleisincludedintherstsuture mediallyto stabilizetheposition ofthe testestothe abdominalwallandpreventdrooping.

Postoperative Course

Inthe postoperativecare,oralnarcoticanalgesia is usuallyrequiredduringtherst48hours.Ambulation isencouragedtheeveningaftertheoperationandlight

Fig. 10.10: Reconstruction: the third layer. Starting at the medial side of the internal ring, the external and internal oblique are used to imbricate the rst two layers. Small bites of external oblique are taken just above the inguinal ligament

exercisescommencetherst postoperativeday. Upon discharge,heavyliftingcanberesumedat4weeks.  Lichtensteintechniquerstdescribedabout18years ago.Itiseverysimpleeectiveandassociatedwithvery lowrecurrencerate(rangingfrom0to2%). econceptisbasedontwoimportantfacts:  1. Inguinalherniasarecausedbyametabolicdisorder,

whichleads toaprogressivedestruction ofthe broconnectivetissueofthegroin,makingthetissue unsuitableforbeingusedinherniarepair.

 2. efactthattraditionaltissuerepairsareassociated

withunduetensionatthesutureline,whichleadsto morepostoperativepain,longerrecoverytime,and

higherrateofrecurrence.  A tension-freerepairis performed under local anesthesiaandconsistsofreinforcementoftheinguinal floorusing polypropylenemesh. Theprosthesisis approximately8× 16cm toprovidesucienttissuemeshinterfacebeyond theoorof theinguinalcanal. Asa result, theentireinguinaloor iscompletelyand permanentlyprotectedfromallfuturemechanicaland degenerativeadverseeects.erefore,theprocedureis boththerapeuticandprophylactic.  Skin, subcutaneous tissuesare incisedas usualup totheexternaloblique;theanteriorwalloftheinguinal canal.Inguinalcanalisopenedbysplittingtheexternal

HerniaSurgerySimplied

Fig. 10.11: Reconstruction: the fourth layer. The second layer of imbrication using the external and internal oblique. The benet of

incising the cribiformis fascia and the mobilization of the lateral

ap of external oblique is realized as a small ap of external oblique remains after the four layers. This small ap is used to

reconstruct the inguinal canal and restore the natural anatomic position of the cord structures

obliquealong the directionof its ber, thespermatic cordwith its cremastericcoveringis elevatedwitha Penrosedrain.Caremustbetakentoincludetheexternal spermaticvessels when elevatinganddissecting the spermaticcordfrom theoor of theinguinal femoral canal.isassuresthatthegenitalbranchofthegenito nerve,whichisalwaysinclosecontactwiththeexternal spermaticvesselsispreserved.  Nextcremastericfiber aretransverselyincised at thelevelofthedeepinguinalringtothinoutthecord. Indirectherniasacs aredissected freeupto theneck markedbycollarofextraperitonealfatandthanopened fordigital examination ofthefemoral ring.Thesac wastransxedattheneckusing1/0vicrylandexcised. Aprolene mesh 7.6× 15cm sizeused is trimmedto accommodatethevaryingsizesoftheinguinaloor.e medialendofthemeshisroundedtotheshapeofmedial corneroftheinguinalcanal.Withcordretractedupward arunningsutureof3/0prolineusedtoxthemesh.e roundedcornerissuturedrsttotheaponeurotictissue overthepubicboneby1.5to2cm(thisisacrucialstep intherepair,sincefailuretooverlapthisbonemayresult inrecurrence).eperiosteumof8theboneisavoided. en,thesuturecontinuetoattachtheloweredgeofthe meshtotheshelvingmarginoftheinguinalligamentto apointjustlateraltotheinternalring.

 Aslitismadeinthelateralendofthemeshcreating twotails,thewideron(2/3)above,thenarrowone(1/3) below.eupperwidetailisgraspedwithahemostatand passedunderneaththespermaticcord.ismaneuver positionsthecordbetweenthetwotails.ewiderupper tailisthenplacedoverthenarroweroneandheldina hemostatwiththecordretracteddownward,theupper edgeof themeshis suturedtothe internaloblique aponeurosisormuscle usinga few intercepted3/0 prolenesuture.Duringtheplacementofthesesuturesthe externalobliqueaponeurosisisretractedupwardwhen theretractionisreleased,themeshbucklesslightly.is isdesirableand‘looseness’assurestensionfreerepair andwillattenoutwhenthepatientstrainsorresumes anuprightposition.eloweredgesofthetwotailsare xedtotheshelvingmarginoftheinguinalligament.is createsanewinternalringmadeupofmesh.etails aretrimmedleavingapproximately3to 4cmofmesh beyondtheinternalring. After meticuloushemostasis aclosed suctiondrainis placedbeneath theexternal obliqueaponeurosisspeciallyinlargeinguinalhernias, whenanextensivedissectionwasperformedduringthe plasticreconstruction.eaponeurosisoftheexternal obliqueisthenclosed using absorbablesuture(Vicryl 1/0)skinclosedbysubcuticularproline(3/0).

The Repair Technique (Other Way Around)

A5to6cmtransverseincisionismadewithinaLanger’s line,beginningfrom thepubictubercle.e external obliqueaponeurosisisopened.AsitisshowninFigure

10.12,thespermaticcordwithitscremastericcovering, externalspermaticvessels, andthegenital nerveare freedfromtheinguinaloorandliftedwith aPenrose drain.Aneasilyvisiblelandmarkforthegenitalnerveis theexternalspermaticvein.Usually,referredtothisas “theblueline.”Ifthebluelineiskeptwiththespermatic cord,thesurgeoncanbesurethatthegenitalbranchof thegenitofemoralnerve,whichisalwaysadjacenttothis vein,iscompletelyprotected.espermaticcordisalso dissectedfreefromthepubicboneareaforapproximately 2cmmedialtothepubictubercleinordertomakeroom forextending the meshbeyond thepubictubercle. isdissection iseasybecause thespacebetween the cremastericsheathandthepubicboneareaisavascular. isisacriticalpartof any mesh repairbecauseifthe pubictubercleareaisnotoverlapped,thestageissetfor

OpenAnteriorRepairofInguinalHerniainAdult

Fig. 10.12: The external oblique aponeurosis is opened. The

spermatic cord with its cremasteric covering,external spermatic

vessels, and the genital nerve are freed from the inguinal oor

and lifted with a Penrose drain

Fig. 10.13: The medial side of the mesh, shaped to the patient’s

anatomy. The rst anchoring suture of the mesh xes the mesh

to the anterior rectus sheath where it inserts into the pubic bone

oneofthemostcommoncausesofrecurrenceafterany meshrepair,openorlaparoscopic.  Next,the externalobliqueaponeurosisis dissected fromthe underlying internaloblique muscle and aponeurosishighenoughtomakeroomforaprosthesis

thatis6 to7 cminheight.e iliohypogastricnerve comesintotheview duringthispartof the dissection. Identicationofthisnerveprotectsitfromincorporation duringsuturingofthemesh.  Forindirectinguinalhernias,thecremastericsheathis incisedlongitudinallyforapproximately3cm.Removal ofthecremastericmuscleisunnecessary.Approximately, 15%of thetime,the ilioinguinalnerve iswithin the cremastericmuscleand,therefore,removalofthemuscle caninjurethenerveaswellasinjuringthepampiniform plexus.  e sacisthen dissectedfrom the cordbeyond its neckandinvertedintotheproperitonealspacewithout ligationorexcision.Ifthesacisverylarge,asinascrotal hernia,thesacisdividedatthemidpointoftheinguinal canal.eproximalendisclosed,dissectedawayfrom thecordstructures,andinvertedintothepreperitoneal space.edistalendisleftbehindinordertoreducethe possibilityof testicularcomplication.Of course,if the herniaisaslidingtype,thiscannotbeachieved.  Nospecialpreparationisneededfordirectinguinal herniasif itisnot toolarge.When thedirecthernia bulgeislarge,itisinvertedutilizingapurse-stringora continuoussutureon thetransversalisfascia without incorporatingtheiliopubictractortheinguinalligament. isisonlytomaketheoorof the inguinalcanalat inordertofacilitateplacementofthemesh.Itaddsno strengthtotherepair.  emedialsideofthemesh,asseeninFigure10.13, isshapedtothepatient’sanatomy.erstanchoring sutureofthemeshxesthemeshtotheanteriorrectus sheathwhereitinsertsintothepubicbone.issutureis placedapproximately2cmmedialtothepubictubercle inordertobesurethatareaiscoveredbythemesh.While doingthis,care mustbetaken nottopass theneedle throughtheperiosteumoftheboneorthroughthepubic tuberclebecausethisisoneofthemostcommoncauses ofchronicpostoperativepain.eloweredgeofthemesh issuturedtotheinguinalligamentusingthesamesuture inacontinuousfashionwithnotmorethan4passages. issutureendsatthelateralborderoftheinternalring.  Atthis point,a slit ismadeon thelateralendofthe mesh,asseeninFigure10.14,creating2tails—2/3above and1/3below.euppertailisthenpassedunderthe cordandpulledtowardtheheadofthepatient,placing thespermaticcordinbetweenthe2tails.  euppertailisthencrossedovertheloweroneand heldwithapairofhemostatasseeninFigure10.15.e tailsarelater suturedtogetherand tuckedunderthe

HerniaSurgerySimplied

Fig. 10.14: At this point, a slit is made on the lateral end of the mesh, creating 2 tails—2/3 above and 1/3 below. The upper tail is then passed under the cord and pulled toward the head of the patient, placing the spermatic cord in between the 2 tails

externalobliqueaponeurosis,leaving5to6cmofmesh lateraltotheinternalring.Leavingthis muchof mesh lateralto theinternalring isveryimportantbecauseif thetailsaretooshort,thereisapossibilityofrecurrence inthatarea.Also,failuretocrossthe2tailsofthemeshis anothersourceofinternalringrecurrence.And,infact, thisisthesubjectofarecentarticlefromSpain,showing thatiftheedgesofthetailsaresimplysuturedtogether withouthavingoverlapor withoutbeingcrossed,then anindirectrecurrentherniacanoccuratinternalring.  Whilethe upperedge of themesh isxedin place, careistakentokeepthemeshslightlyrelaxed.islaxity producesadome-likerippleinthemeshtocompensate forincreased intra-abdominal pressurewhen the patientstandsup fromhis or herrecumbentposition duringtheoperation.Itisparticularlyimportanttohave thisconvexity tocompensatefor theinevitable future shrinkageof themesh,which, accordingtoour study reported6 or7years agoduringone ofthe American CollegeofSurgeonmeetings,isapproximately20%.Ifthe meshiskeptcompletelyat,itbecomessubjecttotension whenthepatientstandsup.Wecanseethispullingeect onthemeshandthetissue,whenthemeshiskeptatin

Fig. 10.15

Figs 10.15 and 10.16: Pulling effect on the mesh and the tissue, when the mesh is kept at in Figure 10.16. The mesh becomes

subject to even more tension after shrinkage of the mesh is completed. Failure to keep the mesh slightly convex is the second

most common cause of recurrence after mesh repair

Fig. 10.16

OpenAnteriorRepairofInguinalHerniainAdult

Figure10.16.e meshbecomes subjecttoeven more tensionaftershrinkageofthemeshiscompleted.Failure tokeep themeshslightly convexisthe secondmost commoncauseofrecurrenceaftermeshrepair.

Advantages and Disadvantages

eLichtensteinoperation,includingtheadministration oflocal anesthesia,takesbetween 20and 40minutes, dependingonthecomplexityofthehernia.Patientsare dischargedafter 1or2 hourspostoperatively,and no restrictionofactivityisimposedonthem.Postoperative painisminimal,and,infact,accordingtoameta-analysis ofallreportedrandomizedstudies,isequallycomparable withthe postoperativepainafter laparoscopicrepair. Basedonmorethan150articlesinthesurgicalliterature, therecurrencerateisconsistentlylessthan1%,ranging between0%and0.7%.  Thecomplicationsof theprocedureare not life threateningandincludelessthana2%rateofinfection, hematoma,orseroma.Usingmeshdoesnotincreasethe riskofinfection,providedthatthemeshismonolament andmicroporous.Ifthe woundgetsinfected forother reasons,sucha meshdoes not havetobe removed. emost signicantcomplicationsafter Lichtenstein repairaretesticular atrophyand chronicneuralgia witha reportedrateof lessthan1%. To summarize, theoperationissimple,canbeperformedunderlocal anesthesia,iseasytolearn,andiseconomical.

 ePHSbilayerpatchdevicehasacombinedonlay graft(likeaLichtensteinrepair)andunderlaygraft(like aStoppaor Kugelpatch);these areheldtogetherby a connector(likeaplug)(Figs10.18and10.19).

Equipment

 • Standardoperatingroom anesthesiaequipment,

outttedforpossibleconversiontogeneralanesthesia

andendotrachealintubation,isrequired.  • A standard opensurgicaltray,including self-

retainingretractors,a Penrose drain, anddierent

sizemeshes,shouldbeavailableonstandby.  • Mesh: The meshmust bea permanentmaterial

largeenough toproducea wideoverlapbeyond

thedefects edges.Apolypropyleneor polyester

mesh(5×10–7×15cm)isgenerallyused.Recently,

manufacturershave shiftedtowardlighter, more

porousconstructionsthatmaintainthestrengthof

therepairbut putativelyreducethe inammatory

response. Differentmeshconfigurationsmay be

chosen,primarily basedon surgeonpreference

andtraining.Nonehavebeenshowntobebetterat

preventingrecurrence(Fig.10.17).  • equestionofabsorbableversuspermanentsutures

tosecurethemeshisbasedonsurgeonpreference;

todate,noevidencesupportsoneovertheother.A

theoreticaladvantageof absorbablesutureisthat,

ifnerve impingementis inadvertently caused,the

suturematerialdisappears withtime.e authors

Currently Used Other Tension-Free Techniques

Atrecenttimes thespecialmesh instrumentcalled as proleneherniasystem(PHS)orultraproherniasystem (UHS)areusedincreasingly.eseinstrumentsprovide astrongsupporttotheinguinaltissuesandpreventsthe recurrence(Fig.10.16).  Theprolene herniasystem (PHS, Fig.10.16) isan innovativemethodoftreatinghernias.emeshismade upofthreeelements.ereisanunderlaymesh,which slipsbehindthemuscle,an onlay mesh whichlayson topof themuscle,and acylinder whichconnectsthe twolayers.ecylinderts throughthe hernia defect, andit isheldin placeprimarily byitsshape. Stitches maybeusedtoholditinposition,butusuallyonlyafew arenecessaryandtheydonothaveasmuchtensionon themasstitchesintheoldertypesofrepair.ismeans lesspaininthepostoperativeperiod.

Fig. 10.17: Polypropylene hernia system–I

HerniaSurgerySimplied

Fig. 10.18: Polypropylene hernia system–II

Fig. 10.19: The PHS repair gains its strength

from the patients tissues healing into the patch

prefertouseabsorbable(2-0polyglactin)suturefor meshxation.

Positioning

 • Confirmand markthecorrect surgicalsitepre-

operativelyintheholdingarea.

 • Positionthepatientsupine,comfortablysecuringthe

upperextremities.

 • Forlargedefects,slightTrendelenburgpositioning

mayhelpexposurebyreducingthevisceralcontents

intotheabdomen.  • Shavethesurgicalsitewithelectricclippers.  • Prepare anddrapethe surgicalsitein standard

surgicalfashion, exposingonly theintended

operativegroinsite.

Technique

Afternalvericationofthecorrectsideofsurgeryand theinfiltrationof localanesthesia,make anoblique skinincision(oralongtheLangerlines)approximately 2ngerbreadths(2cm)superiortoandparalleltothe thighcrease(Fig.10.20),andextendit5cmtowardthe anteriorsuperioriliacspine,startingfromjustlateralto thepubictubercle.Inthinpatients,theexternalringcan actuallybepalpated justlateralandslightlyabovethe pubictubercleandshouldbethemedialstartingpoint ofincision.  • Continue thedissection deeper throughthe

subcutaneoustissue untiltheaponeurosis ofthe

externalobliqueisidentied.Duringdissection,take

noteofthesupercialvesselsthatcanbeligatedand

dividedwhenencountered.  • Identify theexternal oblique aponeurosis.The

followingthree landmarks mustalso be identied

beforeincisingtheexternaloblique:  1. Firstly,theScarpafasciacanmimictheexternal

oblique,asit iswell developedandthickened in somepatients. Avoiding this mistake, especiallyinpatientswhoareoverweight,canbe accomplishedifthebersoftheexternaloblique aponeurosis(Fig.10.21)are alwaysvisualized, sincetheScarpafasciadoesnothavethesebers.

 2. Secondly,theinguinalcanalshouldbeentered

atits apex.Tocorrectly identifythe apex of thecanal, identifythelower wallof the canal, whichis wheretheexternaloblique aponeurosisdisappears into thefat ofthethigh. Approximatelyone ngerbreadth abovethis pointisagoodentrysiteintothecanal.

 3. Thirdly,the externalringmust beidentified.

isis importantbecausethe externalringis ultimatelythe end pointof thedivisionto be madeintheexternaloblique aponeurosisand denestheorientationofthiscut.

OpenAnteriorRepairofInguinalHerniainAdult

Fig. 10.20: Skin incision

Fig. 10.21: Division of the external oblique aponeurosis

Fig. 10.23: Hernia sac separated from the cord structures

Fig. 10.22: Cord structures and hernia sac encircled

by a Penrose drain

Fig. 10.24: Development of the preperitoneal space

 • Oncetheexternalobliqueaponeurosisisidentied,

thoroughlyexposeitandmakeagentlestabincision initsmid-portionalongtheorientationofitsbers. Extendthisincisionsuperiorly,andmediallydownward,throughthesupercialring,thusexposingthe inguinalcanalandthecordstructures.

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