1. Traditional Hernia Repair
Basic Format
Herniorrhapy

2. 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.

3. 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.

4. Terms and Definitions Hernioplasty or herniorrhaphy
Hesselbach’s Triangle
Transversalis fascia
Reducible hernia
Incarcerated hernia
Strangulated hernia
MAVCC Unit 3 INFO page 45-47

5. 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

6. 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

7. 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

8. 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.

9. Abdominal 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

10. 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.

11. Direct
STST p. 407

12. 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

13. 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 : 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.

14. 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).

15. 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.

16. 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

17. Surgical Intervention: Special Considerations
Patient Factors
Possibly in pain
Room Set-up : Routine

18. 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

19. Surgical Intervention: Positioning
Position during procedure
Supine w/arm boards
Supplies and equipment
Special considerations: high risk areas

20. 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

21. 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

22. 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)

23. 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

24. 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

25. Surgical Intervention: Equipment
General: Standard
Specific

26. 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

27. 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

28. 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

29. 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

30. 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.

31. 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

32. Summary for Hernias Dissection: Identify the structures
Repair : Reduce the hernia; Repair the defect
Closure

33. 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!

34. 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

35. Specimen & Care Identified as Peritoneal hernia sac (Indirect)
Handled: Routine in formalin fixative

36. Postoperative Care
Destination
PACU
Expected prognosis (Good)

37. 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

38. Resources Alexanders: pp. 433-439 Berry & Kohn pp. 668
Lemone and Burke Ch 24, pp
MAVCC Unit 3 pp
STST Ch 14 pp