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 MAVCC Unit 3 INFO page 45-47

Definition/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 viscera Purpose To repair the defect and strengthen the supporting structures Alexander p. 433

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. MAVCC STST 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.

Abdominal Regions Where Hernias Occur MAVCC Unit 3 p. 47 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

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 p. 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 defecate They rarely emerge into the scrotum and you see them more often with men B & 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.

Direct STST p. 407

MAVCC # 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 laterally Inguinal ligament inferiorly Rectus abdominus muscle medially

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 STST Table 14-14 : 50% of inguinal hernias are indirect & inguinal The 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.

What 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).

Femoral STST 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.

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 Alexander p. 439

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) MAVCC Unit 3 p. 50

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. Fuller p. 308

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 Bassini or Bassini-Shouldice 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) STST p. 405

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 Type of tape or method of securing 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