Inguinal hernia - open mesh repair

Question 1

What is the key principle of open mesh repair of inguianl hernia?

Answer 1

Dissection of hernia sac, assessment and reduction of hernia contents and reinforcing the repair with tension free lightweight mesh

This outlines the fundamental steps involved in hernia repair surgery.

Question 2

What are the preoperative preferences for the mesh repair?

Answer 2

Light weight polypropylene mesh 10x15cm, 2’0 Prolene sutures, 2’0 Vicryl suture

These materials are chosen for their effectiveness and compatibility in hernia repair surgery.

Question 3

What is the positioning for the inguinal hernia repair procedure?

Answer 3

GA/LA/Spinal. Supine. Arms out

This positioning ensures optimal access and safety during the surgery.

Question 4

What type of incision is made for the hernia repair?

Answer 4

Skin crease incision 2cm above the inguinal ligament

This incision is strategically located to minimize scarring and facilitate access.

Question 5

What should be done when the superficial epigastric veins are encountered?

Answer 5

Ligate the superficial epigastric veins

Question 6

How is the external oblique aponeurosis incised?

Answer 6

Sharp incision with scalpel, extended with scissors along the fibers of external oblique and open to the Superficial ring

Question 7

What is a key consideration when dissecting an indirect hernia sac?

Answer 7

Look for indirect sac and free sac off cord structures

Question 8

What should be done for large congenital inguinal scrotal hernias?

Answer 8

Divide the sac and leave the distal end free

This prevents the formation of a hydrocele post-surgery.

Question 9

How is the medial edge of the mesh secured?

Answer 9

To pubic tubercle with 2/0 Prolene with 2cm medial overlap

Question 10

What type of suture is used for the upper edge of the mesh?

Answer 10

Interrupted absorbable 2/0 Vicryl

Absorbable sutures help reduce the need for suture removal and minimize irritation.

Question 11

What is the closure method for the external oblique?

Answer 11

Continuous 2/0 Vicryl

Question 12

What is included in the post-operative plan?

Answer 12

E+D, Analgesia: Paracetamol and NSAIDs, no heavy lifting 6 weeks

Question 13

True or False: It is normal to have discomfort for 6-8 weeks post hernia repair.

Answer 13

True

Question 14

Summarise the steps of exposure for open inguinal repair

Answer 14

Divide subcutaneous tissue, ligate the superficial epigastric veins if encountered

Once the EO is reached, sharp incision with scalpel, the extented with scissors along the fibers of EO towards the Superfical ring

Note to look out for ingioinguinal nerve as it lays Infront of the cord

Attach two artery forceps on the cut edges of EO aponeurosis, I then use a self-retaining retractor

Develop plan around the cord at the level of pubic tubercle , sling cord with Penrose 10Fr

Question 15

Summarise the landmarks for incision and local anaesthetic infiltration in inguinal hernia repair

Answer 15

• Incision Skin crease incision 2cm above the inguinal ligament. From pubic tubercle extending towards the deep inguinal ring approx 2/3 ASIS. Infiltrate LA in point 2cm lateral ASIS and into the skin incision

Question 16

Verbalise the key steps for dissecting out the sac of an indirect, and direct inguinal hernias. What needs to be done when the sac has been defined?

Answer 16

Dissection of sac: Indirect Hernia sac - Open coverings of spermatic cord - look for indirect sac. Blunt and sharp dissection free sac off cord structures, work up towards the Deep ring. NB: For large congential inguinal scrotal hernia it connects to scrotum and testicle. Therefore is no distal edge to sac. So have to divide the sac. Leave the distal end free. Otherwise it can form hydrocele

Direct Hernia: Check for indirect sac as well! Usually associated with general weakening. Push hernia back → pilcate post-wall with 2’0 Vicryl

Assessment of reduction of sac contents: Open hernia sac. Check hernia contents. Suture tranfix base with 2/0 Vicryl

Question 17

Summarise the steps for repairing an inguinal hernia defect

Answer 17

Repair of Defect: Mesh repair to reinforce post wall of inguinal canal. 8x15cm mesh cut to size, medial corner rounded edge and trouser ledge 2-3cm (1/3) from the lower edge. Secured medial → lateral

Inferior
Medial edge mesh to pubic turbcle with 2/0 Prolene with sufficient overlap
Continuous running suture 2/0 prolene lower edge of inguinal ligament towards deep ring

Superiorly
Interrupted absorable 2/0 vicryl to upper edge of mesh to internal oblique
Reapprox internal ring loosly with trouse ledge of the mesh