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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1047_Библиотеки_им_академика_М_И_Перельмана.pdf
98
Fig. 7.1 The
Myopectineal Orice
of Fruchaud is seen
depicting the locations
of the different types of
inguinal hernias. The
direct inguinal hernia is
seen medial to the
inferior epigastric artery
while the indirect hernia
is seen lateral to the
vessel. The femoral
hernia is seen below the
inguinal ligament at the
femoral ring
R. M. F. Santos
hernia defect. However, tension is generated because
of the approximation of structures located at different planes, necessitating the need for a relaxing incision to diffuse the tension. Its primary indication
then was for the repair of femoral hernias.
These two procedures, however, have not been
used recently because of the relatively high recurrence rates compared to Shouldice and the other
types of mesh repairs. In a multicenter French
study involving 1647 hernias over 5years with a
median follow-up of more than 5years, actuarial
recurrence at 8years was 6.1% after a Shouldice,
8.6% after Bassini’s and 11.2% after Cooper’s
ligament technique [9]. The recurrence rate for
Shouldice is, however, very much higher compared to the recurrence rate at the Shouldice
Clinic in Toronto, Canada, whose reported recurrence rate is 1% [1], which has never been replicated in other institutions. This indicates therefore
the need for surgical expertise to attain the low
recurrence rate of the Shouldice clinic.
7.2 Indications
Tissue repairs are indicated principally in situations like strangulated inguinal hernias where
the local conditions in the inguinal oor is contaminated/infected or potentially contaminated/infected, and the use of foreign materials
like mesh to bridge the defect is contraindicated because of the high incidence of
infection.
7.3 Contraindications
Tissue repairs are contraindicated in situations
where tissues are too attenuated or thinned out
particularly in patients with huge hernia
defects or collagen diseases. It is also contraindicated in cases where tissues for approximation are too scarred making repair very
difficult.
7 Surgical Techniques forInguinal Hernia Repair: Open Techniques—Tissue Repairs
99
7.4 Preoperative Care
A complete history and physical examination
should be done to identify clinical ndings compatible with an inguinal hernia. Possible precipitating conditions like Benign Prostatic
Hypertrophy, COPD, and ascites should be identied and treated rst prior to the hernia repair to
prevent recurrence. Risk assessments should be
made to determine whether the patient is physically and psychologically prepared for the surgery.
The procedure and possible complications and
outcome should be explained to the patient well,
including the choice of anesthesia, whether general, regional, or local. Preoperatively, patient is
placed on NPO and urinary bladder decompressed,
without using a foley catheter, if patient is able to
urinate prior to surgery. Antibiotic prophylaxis is
generally not indicated unless you have a very
high-risk patient because of comorbidities.
7.5 Surgical Technique
7.5.1 Initial Skin Incision
1. Through an imaginary line drawn from the
anterior superior iliac spine to the pubic tuber-
cle, a 4–5cm skin incision is made 2cm above
and parallel to the inguinal crease towards the
pubic tubercle (Fig.7.2).
2. The subcutaneous tissue is incised and two
consistent branches of the supercial epigastric veins are isolated and ligated or
cauterized.
3. Incision is carried through the Scarpa’s fascia until the external oblique aponeurosis
(EOA) and supercial inguinal ring are
exposed.
7.5.2 Division andDissection
oftheExternal Oblique
Muscle
4. External oblique aponeurosis (EOA) is then
incised along its bers cutting to the superior
portion of the external inguinal ring.
Generally, the EOA is divided 3–4cm above
the inguinal ligament to allow enough EOA
left to close over the spermatic cord during
nal closure.
5. The superior medial leaf of the EOA is then
dissected from the cord and the internal
oblique muscle up to the lateral anterior rectus
sheath, taking care not to injure the iliohypogastric nerve, which lies on the internal
oblique muscle superior and parallel to the
Fig. 7.2 Through an
imaginary line drawn
from the anterior
superior iliac spine to
the pubic tubercle, a
4–5cm skin incision is
made 2cm above and
parallel to the inguinal
crease towards the pubic
tubercle
100
Fig. 7.3 The superior
medial leaf of the
external oblique
aponeurosis is then
dissected from the cord
and the internal oblique
muscle up to the lateral
anterior rectus sheath,
taking care not to injure
the iliohypogastric
nerve, which lies on the
internal oblique muscle
superior and parallel to
the cord, and the
ilioinguinal nerve, which
lies anterior to the
spermatic cord
R. M. F. Santos
cord, and the ilioinguinal nerve, which lies
anterior to the spermatic cord (Fig.7.3).
6. The inferior lateral leaf is likewise dissected
from the cord until the shelving portion of the
inguinal ligament is fully exposed.
7.5.3 Isolation oftheSpermatic
Cord
7. The spermatic cord is then separated from
the posterior inguinal oor by dissecting
bluntly at the area of the pubic tubercle, taking care not to injure the genitofemoral nerve
at the lateral aspect of the cremasteric muscle, using the “blue line” corresponding to
the spermatic vessels as a landmark (Fig.7.4).
Once isolated, apply an umbilical tape or
penrose drain to apply traction on the cord to
expose fully the posterior inguinal oor.
Avoid an en masse isolation of the spermatic
cord using your nger at the area of the pubic
tubercle, to avoid bleeding and injury to the
genitofemoral nerve.
7.5.4 Isolation andHandling
oftheSac
8. The cremasteric muscle is divided anteriorly
into a medial and lateral leaf to expose the
anterolateral portion of the cord where the
indirect sac could be identied as a glistening
white surface. It is then sharply dissected from
the spermatic vessels and vas deferens until
the level of the preperitoneal fat, where a
thickened peritoneal white line is identied
when the sac is opened. All structures inside
the sac are then reduced back into the
peritoneal cavity. A purse string suture is then
applied to ligate and transect the sac (Fig.7.5).
After which, the stump spontaneously retracts
behind the transversus abdominis aponeurotic
arch. The sac may also be pushed back inside
the deep internal ring into the preperitoneal
space without being ligated. At this point, any
lipoma of the cord should be removed and
ligated. If the sac extends up to the scrotal
area, then it is transected at the middle of the
inguinal canal, keeping the distal end open to
7 Surgical Techniques forInguinal Hernia Repair: Open Techniques—Tissue Repairs
Fig. 7.4 The spermatic
cord is then separated
from the posterior
inguinal oor by
dissecting bluntly at the
area of the pubic
tubercle, taking care not
to injure the
genitofemoral nerve at
the lateral aspect of the
cremasteric muscle,
using the “blue line”
corresponding to the
spermatic vessels as a
landmark
101
Fig. 7.5 The
cremasteric muscle is
divided anteriorly into a
medial and lateral leaf
exposing the
anterolateral portion of
the cord where the
indirect sac could be
identied as a glistening
white surface. It is then
sharply dissected from
the spermatic vessels
and vas deferens until
the level of the
preperitoneal fat where a
thickened peritoneal
white line is identied
when the sac is opened.
A purse string suture is
then applied to ligate
and transect the sac after
reducing its contents
102
R. M. F. Santos
prevent formation of hydrocele. Make sure,
however, that bleeding in the sac edges is controlled by ligature or cautery. If the defect is a
direct sac with a broad base, then the sac may
just be buried with a purse string suture around
the sac, to atten the inguinal oor. If it is a
big narrow-based direct sac, then you may opt
to open the sac, dissect it, remove excess preperitoneal fat, and close it with a purse string
suture after transecting the excess sac.
9. The cord is then completely dissected around
the deep inguinal ring cutting through attachments of the cremasteric muscles and the condensed medial margin of the ring, in
preparation for the repair of the inguinal oor.
7.5.5 Repair oftheFloor
10. The oor is then repaired depending upon
the preferred type of tissue repair whether
Shouldice, Bassini’s, or Mc Vay’s.
7.6 Shouldice Repair
(a) The transversalis fascia is incised parallel to
the inguinal ligament starting at the medial
portion of the deep inguinal ring up to pubic
tubercle, taking care not to injure the deep
epigastric vessel medial to the ring and
below the transversalis fascia (Fig.7.6). The
superior medial leaf is then dissected bluntly
away from the preperitoneal fat up to the
lateral anterior rectus sheath. The Inferior
lateral leaf is likewise dissected from the
preperitoneal fat up to the iliopubic tract.
The cribriformis fascia below the inguinal
ligament on the upper and anterior aspect of
the groin is incised from the level of the
femoral vessel and the pubis, to allow further mobilization of the EOA later in the
repair. With this area opened, exploration of
the femoral canal for a coexisting hernia
should be done to prevent a missed femoral
hernia.
Fig. 7.6 The
transversalis fascia is
incised parallel to the
inguinal ligament
starting at the medial
portion of the deep
inguinal ring up to pubic
tubercle, taking care not
to injure the deep
epigastric vessel medial
to the ring and below the
transversalis fascia
7 Surgical Techniques forInguinal Hernia Repair: Open Techniques—Tissue Repairs
103
(b) The rst suture line is started at the area of
the pubic tubercle by suturing, using a
monolament non absorbable suture, the
end of the lateral leaf to the condensed and
thickened area of the transversalis fascia,
and the transversus abdominis and internal
oblique muscles (triple layer) at the undersurface of the medial leaf, making a continuous suture with different depths to prevent
tearing up the transversalis fascia and distributing the tension evenly. This is carried
up to the medial portion of the internal ring,
taking the stump of the lateral cremasteric
muscle as it crosses over to the opposite
side, suturing the triple layer, in effect creating a new internal ring. Make sure that the
ring is being narrowed to accept only the tip
of a nger (Fig.7.7).
Fig. 7.7 The rst suture
line is started at the area
of the pubic tubercle by
suturing the end of the
lateral leaf to the
condensed area of the
triple layer at the
undersurface of the
medial leaf, making a
continuous suture to
distribute the tension
evenly. This is carried up
to the medial portion of
the internal ring, taking
the stump of the lateral
cremasteric muscle as it
crosses over to the
opposite side, suturing
the triple layer, in effect
creating a new internal
ring
(c) The second line of suture starts from the
internal ring, as a continuation of the rst
suture, by suturing the end of the medial leaf
to the shelving portion of the inguinal ligament up to the pubic tubercle, where the
suture is tied (Fig.7.8).
(d) The third line of suture starts from the inter-
nal ring by suturing the internal oblique and
transversus abdominis muscles to the external oblique aponeurosis just above the shelving portion of the inguinal ligament. This is
carried up to the pubic tubercle (Fig.7.9).
(e) The fourth line of suture begins as the previous
suture is continued by suturing again the internal
oblique and transversus abdominis muscles to
the external oblique aponeurosis above the previous suture line and carried up to the internal
ring where the suture is nally tied (Fig.7.10).
104
Fig. 7.8 The second
line of suture starts from
the internal ring, as a
continuation of the rst
suture, by suturing the
end of the medial leaf to
the shelving portion of
the inguinal ligament up
to the pubic tubercle,
where the suture is tied
R. M. F. Santos
Fig. 7.9 The third line
of suture starts from the
internal ring by suturing
the internal oblique and
transversus abdominis
muscles to the external
oblique aponeurosis just
above the shelving
portion of the inguinal
ligament. This is carried
up to the pubic tubercle
7 Surgical Techniques forInguinal Hernia Repair: Open Techniques—Tissue Repairs
Fig. 7.10 The fourth
line of suture begins as
the previous suture is
continued by suturing
again the internal
oblique and transversus
abdominis muscles to
the external oblique
aponeurosis above the
previous suture line and
carried up to the internal
ring where the suture is
nally tied
105
7.7 Bassini’s Repair
(a) In the original Bassini’s repair, the transver-
salis fascia is divided from the deep internal
ring to the pubic tubercle, and then the superior medial ap of the transversalis fascia is
dissected bluntly away from the preperitoneal fat. This allows exposure of the triple
layer of the transversalis fascia, the internal
oblique and transversus abdominis muscles.
The inferior ap of the transversalis fascia is
likewise dissected from the preperitoneal fat
up to the iliopubic tract. This also facilitates
the exploration of the femoral canal to rule
out a femoral hernia (Fig.7.6).
(b) The rst stitch in the repair of the posterior
inguinal oor using nonabsorbable suture is
placed superiorly and medially encompassing the triple layer and part of the anterior
rectus sheath and the shelving portion of the
inguinal or Poupart’s ligament at the area of
the pubic tubercle. Interrupted stitches using
also nonabsorbable sutures are then applied
laterally encompassing the triple layer and
the shelving portion of the inguinal ligament
until the medial portion of the deep inguinal
ring, narrowing it to admit only the tip of a
nger. The sutures are then tied but should
not be too tight to avoid ischemia or cutting
through tissues (Fig.7.11).
106
Fig. 7.11 The rst
stitch in the repair of the
posterior inguinal oor
is placed superiorly and
medially encompassing
the triple layer and part
of the anterior rectus
sheath and the shelving
portion of the inguinal
ligament at the area of
the pubic tubercle.
Interrupted stitches are
then applied laterally
encompassing the triple
layer and the shelving
portion of the inguinal
ligament until the medial
portion of the deep
inguinal ring, narrowing
it to admit only the tip of
a nger
R. M. F. Santos
7.8 Mc Vay’s Repair
(a) The transversalis fascia is divided from the
internal ring to the pubic tubercle, taking care
not to damage the inferior epigastric vessel
located deep and medial to the internal ring. The
preperitoneal space is bluntly dissected to
expose the Cooper’s or Iliopectineal ligament,
taking care not to damage the corona mortis or
anastomotic vessels between the obturator and
epigastric arteries located usually anterior to the
Cooper’s ligament. The femoral canal is then
explored to look for a femoral hernia. If a femoral sac is noted, then an attempt to reduce it is
done. If the sac could not be reduced, then the
inguinal ligament above the sac could be transected to allow reduction and inspection of the
contents to assess viability of organs within,
since a femoral hernia is prone to strangulation.
(b) Repair of the oor is initiated by suturing
with multiple interrupted nonabsorbable
sutures the triple layer of transversalis fascia,
transversus abdominis and internal oblique
muscles to the Cooper’s ligament from the
pubic tubercle to the femoral vein as it crosses
the Cooper’s ligament laterally (Fig.7.12).
(c) 2–3 interrupted transition sutures using non-
absorbable sutures are then placed encompassing the triple layer, the anterior femoral
sheath and the shelving portion of the inguinal ligament (Fig.7.12).
(d) Additional interrupted monolament nonab-
sorbable sutures are then placed to approximate the triple layer to the shelving portion
of the inguinal ligament proceeding laterally
up to the deep internal ring, which must
admit only the tip of a nger.
(e) Before the sutures are tied, a relaxing inci-
sion on the anterior rectus sheath, which may
extend from the deep inguinal ring to the
pubic tubercle, must be made to decrease the
tension brought about by the approximation
of structures not on the same plane
(Fig.7.13).
7 Surgical Techniques forInguinal Hernia Repair: Open Techniques—Tissue Repairs
Fig. 7.12 Repair of the
oor is initiated by
suturing with multiple
interrupted sutures the
triple layer to the
Cooper’s ligament from
the pubic tubercle to the
femoral vein as it
crosses the Cooper’s
ligament laterally. About
2–3 interrupted
transition sutures are
then placed
encompassing the triple
layer, the anterior
femoral sheath, and the
shelving portion of the
inguinal ligament
107
Fig. 7.13 Before the
sutures are tied, a
relaxing incision on the
anterior rectus sheath,
which may extend from
the deep inguinal ring to
the pubic tubercle, must
be made to decrease the
tension brought about by
the approximation of
structures not on the
same plane