clean. With prolonged usage, atrophy of the spermatic cord has been reported and eventual surgical

repair is made more difficult due to fibrosis of the tissues. However, some patients do achieve

symptomatic relief.

Algorithm 72-1. Management of initial inguinal hernia.

Preoperative Considerations

Most elective groin hernias can be repaired on outpatient basis. Local anesthesia is sufficient for most

cases of open inguinal hernia repairs with or without supplemental intravenous sedation. Its greatest

advantage is the virtual elimination of urinary retention when compared to regional or general

anesthesia.59 General anesthesia is an acceptable alternative and is preferred by many surgeons. Indeed,

epidemiologic information from databases primarily in Europe disclose that local anesthesia is used in

only about 10%.60 Regional anesthesia has the highest incidence of cardiovascular complications and

should be avoided.61 Laparoscopic hernia repairs require general anesthesia and can only be performed

in patients who can safely tolerate general anesthesia and a pneumoperitoneum. Antibiotic prophylaxis

has not been shown to be of any value except in patients at high risk for infection.62 Nevertheless, it is

routinely used in the United States because of medicolegal considerations when placing prosthesis.

Surgical Treatment of Groin Hernias

6 Four developments in the latter half of the 20th century significantly decreased morbidity and

favorably influenced the recurrence rate to the currently accepted level of less than 2%: (a) the routine

use of prosthetic materials, (b) the widespread acceptance of the “tension-free” concept, (c) the

realization that the preperitoneal space can be used for hernia repair, and (d) therapeutic laparoscopy

(Algorithms 72-1 and 72-2). These concepts are discussed in this section; the treatment strategies are

divided between an open approach in the conventional anterior space and a preperitoneal approach,

either open or laparoscopic.

Open Approach

The simplest Nyhus type I indirect inguinal hernias, which include most inguinal hernias in children, are

adequately treated by obliteration of the congenital patent processus vaginalis alone. Since the inguinal

floor is otherwise normal, reconstruction is not required. Classically, the hernia sac is dissected from the

cord structures, ligated, and removed at its origin at the internal ring, the so-called high ligation of the

sac, thus the term herniotomy. The skin incision starts at the pubic tubercle and is extended laterally. The

external oblique aponeurosis is opened in the line of its fibers through the external ring and the lower

leaf is freed from the spermatic cord. The spermatic cord is freed from the floor of the inguinal canal

and the pubic tubercle. Mobilization of the cord structures is completed by means of blunt dissection,

and a Penrose drain is placed around them so that they can be retracted during the procedure.

The genital branch of the genitofemoral nerve and the spermatic vessels are included with the cord.

The ilioinguinal and iliohypogastric nerves are usually preserved. The cremasteric fibers are separated,

and the hernia sac is dissected from the cord structures to a point proximal to the internal ring. Ligation

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can be performed at this point (high ligation), followed by division of the neck of the sac. Prior to this,

the sac can be opened to allow a digital examination of the abdominal cavity and femoral ring.

Alternatively, the sac may be simply inverted. The proponents of not opening the sac feel that with this

method the patient experiences less pain because the highly innervated peritoneum has not been

violated.

The terms herniorrhaphy or hernioplasty are used when a procedure to reconstruct the inguinal floor is

added. For indirect hernias, the sac is first dealt with in an identical manner as for a herniotomy. The

only exception is large indirect inguinal scrotal hernias where complete removal of the sac might result

in too high of an incidence of cord and testicular complications because of the extensive dissection

required to completely separate them from the cord. Most authorities believe that these large sacs are

best transected at the midpoint of the canal, and the distal sac is left in situ. Direct hernia sacs are

almost never removed but instead are dissected from surrounding structures and reduced into the

preperitoneal space. Dividing the transversalis fascia circumferentially at the neck (base) of the sac will

aid in this reduction in some cases. The defect may be closed primarily at this point to maintain the

reduction while a formal repair is being performed. The latter is considered a matter of convenience and

adds nothing to the strength of the final outcome. The area of weakness in the posterior wall is then

reinforced with the patient’s own tissues.

Algorithm 72-2. Management of recurrent inguinal hernia.

The next step is to reconstruct the inguinal floor. There are two ways to do this. The first is a tissue

repair, so named because only the patient’s native tissue is used without foreign prosthetic material. The

second is the tension-free repair (TFR). This implies the use of a prosthesis to repair the weakened

inguinal floor, eliminating the need to reapproximate tissues that were not in apposition naturally.

Edoardo Bassini (1844–1924) is considered the father of modern inguinal hernia surgery because in the

latter part of the 19th century he introduced the first tissue repair based on solid anatomic principles,

which became the “gold standard” for inguinal hernia repair for most of the 20th century. His scientific

approach led to the development of several distinct steps essential for the procedure (Table 72-7).

Before Bassini’s achievements, elective herniorrhaphy was almost never recommended because the

results were so bad.

TREATMENT

Table 72-7 Essential Steps for the Inguinal Hernia Repair

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Today, there are at least 70 named tissue repairs described in the literature.63 Most are relatively

minor modifications of the Bassini, Shouldice, and McVay repairs and therefore, for the purposes of this

chapter, only these will be presented. In the Bassini repair, the transversus abdominis aponeurosis

together with the transversalis fascia is sutured to the shelving edge of the inguinal ligament with

nonabsorbable interrupted sutures (Fig. 72-24). In the Shouldice repair, the transversalis fascia is

divided from the internal ring to the pubic tubercle. The musculofascial elements laterally are then

sutured to different levels of the inferior flap of the external oblique aponeurosis with four rows of

running sutures (Fig. 72-25). Although the suture material originally used for this repair was stainless

steel wire, other nonabsorbable materials, such as Prolene, are now used. The McVay repair (Fig. 72-26)

addresses both inguinal and femoral hernias. The central attenuated portion of the inguinal floor is

excised. The Cooper ligament must be clearly identified. The inguinal floor is then repaired by

approximating the transversus abdominis aponeurosis and transversalis fascia to the Cooper ligament

between the pubic tubercle and the femoral vein. A so-called transition stitch is then necessary between

the transversalis fascia, Cooper ligament, and inguinal ligament to bring the repair above the femoral

vessels. The repair is then continued laterally along the inguinal ligament.

A relaxing incision is necessary for repairs of large indirect hernias and whenever the McVay repair is

used. Failure to make a relaxing incision has been implicated in a greater incidence of recurrence. The

relaxing incision is made in the anterior rectus sheath in a vertical direction and is extended 3 to 4 cm

above the pubis to a level opposite the internal ring (Fig. 72-26). The resulting defect in the sheath is

protected posteriorly by the body of the rectus muscle, which prevents herniation at that site.

Figure 72-24. Bassini repair.

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