2ObjectivesAssess 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.
3Objectives Choose the appropriate patient position Identify the incision used for the procedureAnalyze the procedural steps for inguinal herniorrhaphy.Describe the care of the specimenDiscuss the postoperative considerations for a patient undergoing pt w/inguinal herniorrhaphy.
4Terms and Definitions Hernioplasty or herniorrhaphy Hesselbach’s TriangleTransversalis fasciaReducible herniaIncarcerated herniaStrangulated herniaMAVCC Unit 3 INFO page 45-47
5Definition/Purpose of Procedure 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 visceraPurposeTo repair the defect and strengthen the supporting structuresAlexander p. 433
6Relevant A & P: Tissue Layers (STST p. 404 descending order)Skin and subcutaneousScarpa’s fasciaInnominate fasciaInterparietal fasciaInternal oblique muscleTransverse abdominal muscleTransverse fasciaCooper’s ligamentRectus Abdominis musclePeritoneum
7Relevant A & P: Other structures Superficial & inferior epigastric musclesIliofemoral vesselsSpermatic cord and blood supplyIlioinguinal nerveLacunar ligamentInguinal ligament (Poupart)Conjoined ligament (Falx inguinalis)Cremaster muscle & fasciaHesselbach’s TriangleFemoral canalIliopubic tract
8PathophysiologyProtrusion of an organ or part of an organ through a defect in the supporting structures which normally contain itTransverse 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.MAVCCSTST p. 405: Cooper’s Ligament is reinforced periosteum of the pubis and is important in the repair of both femoral and direct inguinal hernias.What is an aponeurosis? A flat fibrous sheet of connective tissue that attaches muscle to bone or other tissues, it may sometimes serve as a fascia.
9Abdominal Regions Where Hernias Occur MAVCC Unit 3 p These also represent the names of basic types of hernias. The only one not listed is the incisional hernia because it occurs in many abdominal regions.See # 5 Types of Hernias p. 48 MAVCC Information Sheet
10What is a Direct Hernia? Direct Acquired weaknesses in transversalis fasciaLocation: Hesselbach’s triangleCausesEmerge between the deep epigastric artery and rectus abdominus muscle and protrude into the inguinal canal but not into the spermatic cordMore difficult to repairMenp. 434 Alexander’s read this Anatomy. When a weakening or tear in the aponeurosis of the transverse abdominis and transversalis fascia occurs, the potential for the development of a direct inguinal hernia occurs.MAVCC p. 49: Have to know which it is because repair technique differs depending on which.Direct hernias are weaknesses caused by straing, such as heavy lifting, chronic coughing, straining to urinate or defecateThey rarely emerge into the scrotum and you see them more often with menB & K: A direct hernia protrudes thru a weakness in the abd wall n the region between the rectus abdominus muscle, inguinal ligament, and inferior epigastric artery. This area is a surgical landmark called Hesselbach triangle. This hernia is the most difficult type to repair. Prompt surgical intervention prevents possible discomfort and the threat of later complications.
12MAVCC # 6 Parts of Hesselbach’s Triangle; See also p. 437 Alexander Hernias that occur in this area are called DIRECT hernias—within Hesselbach’s Triangle. These structures form the Triangle:Deep epigastric vessels laterallyInguinal ligament inferiorlyRectus abdominus muscle medially
13What is an Indirect Hernia? Congenital or acquired weaknesses in transversalis fasciaLocation: lateral to deep epigastric vesselsProtrude through inguinal ring and pass with the spermatic cord structures down the inguinal canal; may descend into the scrotumMenSTST Table : 50% of inguinal hernias are indirect & inguinalThe peritoneal sac containing intestine protrudes thru the internal inguinal ring and passes down the inguinal canal. It directs lateral to the inferior epigastric vessels. It may descend all the way down into the scrotum. An indirect inguinal hernia originates from a congenital defect in the fascial floor of the inguinal canal.
14What is a pantaloon hernia? MAVCC p. 50 When both direct and indirect hernias are present. They may present as sliding hernias in which the posterior wall of the hernia sac is formed by the bowel. Pantaloon is for the French word “pants.”This is Figure 13-6 p. 438 Alexanders. It states “Defect in transversalis fascia, medial to deep epigastric vessels, gives rise to direct hernia. Defect lateral to deep epigastric vessels results in an indirect hernia. (There is a hernia sac specimen with the indirect hernia).
15FemoralSTST p. 405: Femoral hernias are more common in females than males due to anatomical differences in the femoral area.B & K p. 668 Femoral herniorrhaphy involves repairing the defect in the transversalis fascia below the inguinal ligament, as well as removing the peritoneal sac protruding thru the femoral ring. The transversalis fascia is normally attached to Cooper’s ligament, which prevents the peritoneum from reaching the femoral ring. To repair this defect, it is necessary to reconstruct the posterior wall and close the femoral ring.
16DiagnosticsExams: 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 confirmedAlexander p. 439
17Surgical Intervention: Special Considerations Patient FactorsPossibly in painRoom Set-up : Routine
18Surgical Intervention: Anesthesia Method: Various: General, Spinal, Epidural, Regional w/sedation, Local*Surgeon may ask for pt to cooperate by coughing or bearing downEquipment
19Surgical Intervention: Positioning Position during procedureSupine w/arm boardsSupplies and equipmentSpecial considerations: high risk areas
20Surgical Intervention: Skin Prep Method of hair removal—at least on side of hernia down to groin—askAnatomic perimeters—table side to table side; upper abdomen to mid thighSolution options—Routine (Betadine vs Hibclens)MAVCC Unit 3 p. 50
21Surgical Intervention: Draping/Incision Types of drapes: Lap SheetOrder of draping: 4 towels & sheetSpecial considerationsState/Describe incision: Anterior Groin/oblique inguinal incision
22Surgical Intervention: Supplies GeneralLap pack, gowns, raytex, disposamagSpecificSuture: Various (Mayo and Ferguson taper type needles)After the hernia repair, finer sutures will be used for other layers of tissueExamples: 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 undyedFor mesh: 0 Prolene CT-1 or CT-2KittnersBlades: # 10 x 235 R stapler (hold)
23Surgical Intervention: Supplies cont’d Medications on field (name & purpose)For local: Example: Xylocaine .5% w/Marcaine .25% w/epi20 cc syringe, 25 g needle, possibly 22 g spinal needleCatheters & Drains: A ½ in penrose drain is used to retract spermatic cord structures
24Surgical Intervention: Instruments GeneralMinor setSpecificA hemostat is placed on the penrose drain before passing to the surgeonMed debakeysMed rt anglesGelpies x 2
26Procedure Highlights 1. Layers of the abdominal wall are incised 2. The spermatic cord is identified & dissected free3. The hernia sac is identified4. The sac is ligated and removed.5. Layers of the wound are closed individually.Fuller p. 308
27Surgical Intervention: Procedure Steps After prep, pt is draped with groin area exposed on affected sideIncision is made over hernia site and electrocautery used for hemostasisSurgeon incises fascia lying over the spermatic cord and retracts w/several hemostats on the edge of the incised fasciaSurgeon identifies spermatic cord and separates it from the surrounding tissueSTSR mounts moistened Penrose drain on a med clamp & passes it to the surgeon, who passes it around the spermatic cord for retraction
28Surgical Intervention: Procedure Steps Cont’d Dissection continues until hernia is locatedHernia repairDirectSurgeon sutures transversalis fascial defect using heavy interrupted sutures as STSR initiates first closing countSurgeon closes external oblique fascia as SRST initiates second closing count
29Surgical Intervention: Procedure Steps Cont’d Hernia repairIndirectSurgeon dissects sac away from the spermatic cord using Metzenbaum scissorsThe sac is opened & edges grasped with hemostatsSurgeon pushes contents of sac back toward the abdomen w/ a finger or a small sponge on instrument
30Surgical Intervention: Procedure Steps Cont’d Surgeon ligates small sac, uses purse-string suture, or oversews to close large sac as STSR initiates first closing countSurgeon sutures transversalis fascial defect using heavy (0, 2-0) interrupted sutures as STSR initiates second closing count.
31Classic Procedures Marcy repair Bassini or Bassini-Shouldice Repair Closure of inguinal ringBassini or Bassini-Shouldice RepairA new inguinal canal is made by uniting the edge of the internal oblique muscle to the inguinal ligamentMcVay/LotheissenThe transverse abdominis muscle & its associated fasciae (transverse layer) are sutured to the pectineal ligament (Cooper’s ligament repair)STST p. 405
32Summary for Hernias Dissection: Identify the structures Repair : Reduce the hernia; Repair the defectClosure
33Counts Initial First closing Final closing Sponges Sharps Instruments The peritoneal cavity may be entered when the hernia sac is opened—Counts must be done!
34Dressing Types & sizes Type of tape or method of securing 2x2 or 4x4, ½ in steri strips, Small TegadermType of tape or method of securingMay use Mastisol or Benzoin
35Specimen & Care Identified as Peritoneal hernia sac (Indirect) Handled: Routine in formalin fixative