Traditional Hernia Repair

Basic Format

Herniorrhapy

Objectives

• Assess the anatomy, physiology, and pathophysiology of the abdomenal wall.

• Analyze the diagnostic and surgical interventions for a patient undergoing a herniorrhapy.

• Plan the intraoperative course for a patient undergoing inguinal herniorrhapy.

• Assemble supplies, equipment, and instrumentation needed for the procedure.

Objectives

• Choose the appropriate patient position• Identify the incision used for the procedure• Analyze the procedural steps for inguinal

herniorrhaphy.• Describe the care of the specimen• Discuss the postoperative considerations for a

patient undergoing pt w/inguinal herniorrhaphy.

Terms and Definitions

• Hernioplasty or herniorrhaphy

• Hesselbach’s Triangle

• Transversalis fascia

• Reducible hernia

• Incarcerated hernia

• Strangulated hernia

Definition/Purpose of Procedure

• Definition– A sac lined by peritoneum that protrudes thru a defect n

the layers of the abdominal wall; congenital, acquired, traumatic; generally covered by tissues, a peritoneal sac, and any contained viscera

• Purpose– To repair the defect and strengthen the supporting

structures

Relevant A & P: Tissue Layers

• (STST p. 404 descending order)– Skin and subcutaneous– Scarpa’s fascia– Innominate fascia– Interparietal fascia– Internal oblique muscle– Transverse abdominal muscle– Transverse fascia– Cooper’s ligament– Rectus Abdominis muscle– Peritoneum

Relevant A & P: Other structures

• Superficial & inferior epigastric muscles

• Iliofemoral vessels

• Spermatic cord and blood supply

• Ilioinguinal nerve

• Lacunar ligament

• Inguinal ligament (Poupart)

• Conjoined ligament (Falx inguinalis)

• Cremaster muscle & fascia

• Hesselbach’s Triangle

• Femoral canal

• Iliopubic tract

Pathophysiology

• Protrusion of an organ or part of an organ through a defect in the supporting structures which normally contain it

• Transverse fascia is the man focus of groin herniation and separates the abdominal musculature from the preperitoneal fat. It is a continuation of the fascia completely containing the abdominal cavity and is inherently weak in the area of Cooper’s Ligament and the iliopubic tract, lending to inguinal herniation.

Abdominal Regions Where Hernias Occur

What is a Direct Hernia?

• Direct– Acquired weaknesses in transversalis fascia– Location: Hesselbach’s triangle– Causes– Emerge between the deep epigastric artery and

rectus abdominus muscle and protrude into the inguinal canal but not into the spermatic cord

– More difficult to repair– Men

Direct

What is an Indirect Hernia?

• Congenital or acquired weaknesses in transversalis fascia

• Location: lateral to deep epigastric vessels

• Protrude through inguinal ring and pass with the spermatic cord structures down the inguinal canal; may descend into the scrotum

• Men

What is a pantaloon hernia?

Femoral

Diagnostics

• Exams: asked to stand and cough during physical exam: can see outpouched area; fingertip palpation –can feel edges of external ring and or abd wall. Pt most likely will have pain; may be described as burning. Compare both sides for protrusions.

• Preoperative Testing: Routine CBC, ECG or chest as applicable; can employ CT, herniography, & std radiography if dx not confirmed

Surgical Intervention:Special Considerations

• Patient Factors– Possibly in pain

• Room Set-up : Routine

Surgical Intervention: Anesthesia

• Method: Various: General, Spinal, Epidural, Regional w/sedation, Local– *Surgeon may ask for pt to cooperate by coughing or bearing

down

• Equipment

Surgical Intervention: Positioning

• Position during procedure– Supine w/arm boards

• Supplies and equipment

• Special considerations: high risk areas

Surgical Intervention: Skin Prep

• Method of hair removal—at least on side of hernia down to groin—ask

• Anatomic perimeters—table side to table side; upper abdomen to mid thigh

• Solution options—Routine (Betadine vs Hibclens)

Surgical Intervention: Draping/Incision

• Types of drapes: Lap Sheet

• Order of draping: 4 towels & sheet

• Special considerations

• State/Describe incision: Anterior Groin/oblique inguinal incision

Surgical Intervention: Supplies

• General– Lap pack, gowns, raytex, disposamag

• Specific– Suture: Various (Mayo and Ferguson taper type needles)

• After the hernia repair, finer sutures will be used for other layers of tissue

• Examples: 3-0 silk ties, 2-0 silk SH (GI), 3-0 silk, 0 silk (GI needle); 3-0 vicryl ; Other possible: 2-0 Prolene SH, 0 Ethibond, 4-0 Vicryl undyed

• For mesh: 0 Prolene CT-1 or CT-2

– Kittners– Blades: # 10 x 2– 35 R stapler (hold)

Surgical Intervention: Supplies cont’d

– Medications on field (name & purpose)• For local: Example: Xylocaine .5%

w/Marcaine .25% w/epi

• 20 cc syringe, 25 g needle, possibly 22 g spinal needle

– Catheters & Drains: A ½ in penrose drain is used to retract spermatic cord structures

Surgical Intervention: Instruments

• General– Minor set

• Specific– A hemostat is placed on the penrose drain before

passing to the surgeon

– Med debakeys

– Med rt angles

– Gelpies x 2

Surgical Intervention: Equipment

• General: Standard

• Specific

Procedure Highlights

• 1. Layers of the abdominal wall are incised

• 2. The spermatic cord is identified & dissected free

• 3. The hernia sac is identified

• 4. The sac is ligated and removed.

• 5. Layers of the wound are closed individually.

Surgical Intervention: Procedure Steps• After prep, pt is draped with groin area exposed on

affected side• Incision is made over hernia site and electrocautery used

for hemostasis• Surgeon incises fascia lying over the spermatic cord and

retracts w/several hemostats on the edge of the incised fascia

• Surgeon identifies spermatic cord and separates it from the surrounding tissue

• STSR mounts moistened Penrose drain on a med clamp & passes it to the surgeon, who passes it around the spermatic cord for retraction

Surgical Intervention: Procedure Steps Cont’d

• Dissection continues until hernia is located

• Hernia repair– Direct

• Surgeon sutures transversalis fascial defect using heavy interrupted sutures as STSR initiates first closing count

• Surgeon closes external oblique fascia as SRST initiates second closing count

Surgical Intervention: Procedure Steps Cont’d

• Hernia repair– Indirect

• Surgeon dissects sac away from the spermatic cord using Metzenbaum scissors

• The sac is opened & edges grasped with hemostats

• Surgeon pushes contents of sac back toward the abdomen w/ a finger or a small sponge on instrument

Surgical Intervention: Procedure Steps Cont’d

• Surgeon ligates small sac, uses purse-string suture, or oversews to close large sac as STSR initiates first closing count

• Surgeon sutures transversalis fascial defect using heavy (0, 2-0) interrupted sutures as STSR initiates second closing count.

Classic Procedures

• Marcy repair– Closure of inguinal ring

• Bassini or Bassini-Shouldice Repair– A new inguinal canal is made by uniting the edge of the

internal oblique muscle to the inguinal ligament

• McVay/Lotheissen– The transverse abdominis muscle & its associated

fasciae (transverse layer) are sutured to the pectineal ligament (Cooper’s ligament repair)

Summary for Hernias

• Dissection: Identify the structures

• Repair : Reduce the hernia; Repair the defect

• Closure

Counts

• Initial

• First closing

• Final closing– Sponges– Sharps– Instruments

The peritoneal cavity may be entered when the hernia sac is opened—Counts must be done!

Dressing

• Types & sizes– 2x2 or 4x4, ½ in steri strips, Small Tegaderm

• Type of tape or method of securing– May use Mastisol or Benzoin

Specimen & Care

• Identified as Peritoneal hernia sac (Indirect)

• Handled: Routine in formalin fixative

Postoperative Care

• Destination– PACU

• Expected prognosis (Good)

Postoperative Care

• Potential complications– Hemorrhage

– Infection

– Other: Damage to…neural and vascular structures

– Recurrence

– Ischemic orchitis & testicular atrophy

– Loss of bowel function

• Surgical wound classification: 1

Resources

• Alexanders: pp. 433-439

• Berry & Kohn pp. 668

• Lemone and Burke Ch 24, pp. 677-679

• MAVCC Unit 3 pp. 45-81

• STST Ch 14 pp. 405-407