Inguinal hernia repair

General remarks

Risk factors

Positive family history, prolonged increased abdominal pressure (COPD, constipation, prostatism, peritoneal dialysis), aortic abdominal aneurysm, smoking.

Examination

Basically only physical examination; groin mass cranially from Poupart's ligament. Differentiate between a lateral or medial hernia with physical examination is unreliable. Describe testicles, contralateral side and reducibility. Further test are rarely necessary but in doubt a herniography, US or MRI can be considered.

Differential diagnosis

Femoral hernia, varicosis, lymph node, aneurysm, abscess, soft tissue tumor.

Treatment

Asymptomatic hernia; consider conservative treatment
Symptomatic hernia; planned surgery
Incarcerated hernia; acute surgery

Surgical technique

Unilateral; Mesh-repair.Extensive research has been done for the Lichtenstein's and the endoscopic technique. Lichtenstein's technique is recommended.
Bilateral; Mesh-repair. Lichtenstein or endoscopy if enough expertise is available. When endoscopically treated, the TEP is superior to the TAPP.
Recurrent hernia; Technique depends on earlier treatment. In case of an earlier anterior approach, a pre-peritoneal mesh or TEP should be performed. In case of an earlier posterior approach, an anterior mesh or TAPP should be performed.

Antibiotics

Antibiotic prophylaxis does not prevent the occurrence of wound infection after groin hernia surgery and should therefore not routinely be given. Prophylactic antibiotics is only recommended in high risk patients.

Step by step

1. Skin incision about 1.5 cm above and parallel to Poupart's ligament.
2. Ligation of the superficial epigastrivc vein (do not coagulate)
3. Opening Scarpa's fascia
4. Opening external aponeurosis following fibre direction. Avoid damage to the ilioinguinal nerve.
5. Isolate spermatic cord
6. Identify genitofemoral nerve (genital branche), this runs dorsal and parallel to the spermatic cord, underneath the cremaster muscle fibers
7. Isolate hernia sac and/or preperitoneal lipoma
8. Repositioning hernia (do not ligate!)
9. Lipoma can be ligated
10. In case of a large lateral hernia (scrotal) the hernia sac can be transected and proximally ligated. The distal part can remain in situ however needs to be left open widely.
11. Suture mesh with Prolene. First suture through the lateral rectus border just cranially to the pubic tubercle. Proceed along Poupart's ligament with large steps and small bites.
12. Tie a knot when the internal ring has been reached (preferably an Aberbeen knot)
13. Create a new internal ring by attaching the lower edge of the upper part of the mesh to Poupart's ligament.
14. Secure upper part with single sutures. Beware of the iliohypogastric nerve.
15. Close the external aponeurosis and create new external ring
16. Close Scarpa's fascia
17. Skin closure (intracutaneous resorbable)
18. Infiltrate wound with local anaesthesia

References

Kark A, Kurzer M, Waters KJ. Accuracy of clinical diagnosis of direct and indirect inguinal hernia. Br J Surg 1994;81(7):1081-2 McIntosh A, Hutchinson A, Roberts A, Withers H. Evidence-based management of groin hernia in primary care - a systematic review. Fam Pract 2000;17(5):442-7 Ralphs DN, Brain AJ, Grundy DJ, Hobsley M. How accurately can direct and indirect inguinal hernias be distinguished? Br Med J 1980;280(6220):1039-40. Taylor EW, Byrne DJ, Leaper DJ, Karran SJ, Browne MK, Mitchell KJ. Antibiotic prophylaxis and open groin hernia repair. World J Surg 1997;21(8):811-4; discussion 814-5 T. J. Aufenacker, M. J. W. Koelemay, D. J. Gouma, M. P. Simons. Systematic review and meta-analysis of the effectiveness of antibiotic prophylaxis in prevention of wound infection after mesh repair of abdominal wall hernia. Br J Surg 2006 Jan;93(1):5-10 The EU Hernia Trialists Collaboration. Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials. Ann Surg 2002;235(3):322-32