How to perform an Open Inguinal Hernia Mesh Repair: (Hernioplasty or Herniorrhaphy) in a Male.
1. Prior to surgery ensure you have taken an adequate history and examination. Confirm a hernia is present and you have identified the correct side. Is it reducible? (Important if to be done under LA as not really possible if not reducable) Does it extend into the scrotum. Is there an associated hydrocoele etc.
2. Ensure patient is correctly consented and marked. Following administration of general anaesthetic or a local block + infiltration, the patient may need to be shaved to expose the skin.
3. The region should be prepared with antisteptic soloution. The patient should be draped in order to expose the anterior superior iliac spine to the midline, and from below the pubic symphysis / base of penis in males, to below the umbilicus. And sterile towel can be placed over the genitals to protect from “prep” solution and adhesion from drapes.
4. The landmarks of the anterior superior iliac spine (ASIS) to the pubic tubercle should be palpated. This marks the line of the inguinal ligament. An oblique incision parallel to this line should be made above - approximately 3-4 cm.
5. The skin is divided using a sharp blade. Diathermy can then be used to dissect the underlying superfical fatty layer (Camper’s fascia). A self retaining retractor can be inserted. The retraction helps separates the structures and aids finding the anatomical plane. The retractor is a dynamic tool, and should regularly be adjusted to help the surgeon.
6. The superficial inferior epigastric vein lies relatively superficially and should be ligated and divided if encountered.
7. Dissection using a combination of tension from the retractor, elevator and use of diathermy allows the tissues to be divided through the fatty layer, then the deeper fibrous layer (Scarpa’s fascia) down onto the external oblique tendon.
8. Once the fibres of the external oblique have been identified, the dissection should be continued in the direction towards the inguinal ligament, using a combination of blunt dissection/ dry gauze. Once the edge of the inguinal ligament has been visualized it confirms the correct anatomical landmarks.
9. The next step is to incise external oblique, above the superifical inguinal ring. A blade is used to make a small incision running in parallel with the fibres of the tendon above the ring. Dissecting scissors can initially be passed under the tendon closed to create a safe passage, before being used to cut and split the external oblique tendon laterally to beyond the length of the incision and medially to open the superficial ring.
10. A clip should be attached to the external oblique tendon on each side. The hernia sack or cord structures may adhere to the inferior aspect of the divided tendon and should be carefully dissected away. Blunt dissection with a finger or dry gauze can help. Enough space should be created at this stage to facilitated placement of the mesh later.
11. The cord and hernia should be dissected to expose the inguinal ligament edge inferiorly and the pubic tubercle medially. A finger should be able to pass freely around the spermatic cord indicating it is also free posteriorly. A small window in the fascia may need to be made using dissection scissors if this is not possible using blunt dissection techniques.
12. Next the important cord structures of the vas deferens, testicular artery and veins, lymph vessels, autonomic nerves, cremasteric artery, artery of the vas and the genital branch of the genito-femoral nerve , need to be identified, separated from the hernial sac and preserved.
13. Non-traumatic forceps (eg Lanes) may be used to safely retract and separate the cord structures when identified.
14. The hernia sac should now be separated from the spermatic cord structures. Tissue adherent to the hernia sac should be dissected and divided away from the sac, in the direction of the inguinal canal. (The path of descent). A combination of blunt and sharp dissection may need to be used.
15. Once the hernial sac is identified, it can be dissected to confirm its contents. Two clips can be used to pick up the “white” peritoneal layer. The sac contents can be carefully opened, remembering that the hernia may contain bowel! The hernia may comprise of retroperitoneal fat, bowel, bladder, omentum or any combination. Ensure the contents is fully reducible inside the abdominal cavity, through the deep inguinal ring (indirect hernia) or the defect on the conjoint tendon (direct).
16. Following reduction of the hernia sac, the defect in the conjoint tendon may be plicated. Care should be taken to ensure the hernia sac does not protrude prior to the completion of this posterior wall repair. An assistant can be useful to prevent this using the blunt end of forceps to retract the hernia sac.
17. Following successful reduction of the hernia +/- plication - the mesh is ready to be inserted. There are a variety of synthetic meshes available, some with self retaining properties.
18. In principle the mesh should be correctly sized for the patient. It should be trimmed and shaped to fit the space created at the initial stages of the operation under the external oblique tendon. The inferior edge of the mesh should be split to match the distance the deep ring lies from the inside edge of the inguinal ligament. This allows an inferior “tail” of the mesh to be passed under the spermatic cord using a clip from medial to lateral, and lie inline and parallel to the inguinal ligament.
19. The edge of the mesh inferior “tail” can then be secured to the edge of the inguinal ligament. The apex of the mesh should lie over the pubic tubercle. It should be secured with a suture to the underlying pubic tubercle using a single suture. The mesh should be Tension Free and cover the defect in the posterior wall.
20. Ensure the mesh gives adequate medial coverage at the tubercle, as recurrence can often happen here. Further sutures can be used to secure the top of the mesh to fibres of the underlying conjoint tendon.
21. The superior “tail” of the mesh should overlap the inferior tail, around the spermatic cord at the deep inguinal ring. Enough space should be left for the spermatic cord to pass through, but not loose enough that an indirect hernia might recur.
22. The superior and inferior “tails” of the mesh should be secured to each other as well as the inferior edge of the inguinal canal. Once the mesh is secure, depending on type used, the external oblique can be closed.
23. Using an monofilament suture, a continuous suture can be used to close the external oblique layer. Use your assistant to ensure that the underlying mesh is not picked up in closing this layer. An inverted retractor on blunt end of forceps can be used.
24. Interrupted or continuous sutures using an absorbable suture can be used to close the deep fascial layer (Scapa’s fascia).
25. The skin can then be closed using a subcuticular absorbable suture or interrupted sutures or staples.
26. A suitable dressing should be applied.
Post op instructions:
The patient should be advised on wound care in the initial period, i.e. don't soak in a bath 2/52; avoid public swimming baths for 2/52 and keep wound dry.
Advice should be given with regard to driving. Generally one week is advised, but also advise patient to attempt emergency stop whilst stationary before driving and probably wise to consult insurance company.
Advise to avoid strenuous activity and heavy lifting for up to 6 weeks, give the appropriate "doctors note".