This document discusses inguinal herniorrhaphy, including definitions, indications for surgery, types of procedures, preoperative preparation, the surgical procedure, and potential complications. Inguinal herniorrhaphy is the surgical repair of an inguinal hernia, which can be performed as an emergency procedure for complications like obstruction or strangulation, or electively to prevent future risks. The procedure involves accessing the hernia sac through an incision above the inguinal ligament, reducing the herniated contents, and reinforcing the posterior wall using techniques like Bassini repair or Lichtenstein mesh repair. Potential complications include injury to surrounding structures during surgery and issues like recurrence, infection, or neuralgia

1. INGUINAL HERNIORRHAPHY
DR BASHIR YUNUS
SURGERY RESIDENT
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2. OUTLINE
• DEFINITION
• INDICATIONS
• TYPES
• PREOPERATIVE PREP
• PROCEDURE
• COMPLICATIONS
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3. DEFINITION
• Surgical repair of a hernia
• INDICATIONS
– Emergency
• Obstruction
• Strangulation
– Elective
• Risk of complication
• Cosmesis
• Discomfort- pain, pressure necrosis
• Career choice
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4. • TYPES
– OPEN
– LAPAROSCOPIC
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5. PRE-OP PREPARATION
• Treatment of exacerbating factors- causes of chronic
straining- Chronic cough, constipation, bladder outlet
obstruction
– CXR, ABD USS,
• Weight reduction
• Hernia with loss of domain requires intermittent
abdominal pneumoperitoneum to prevent post-op
respiratory embarrassment.
• Obstructed or strangulated requires resuscitation- iv
fluids, iv antibiotics, NG tube and urethral
catheterization
• Obtain an informed consent.
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6. PROCEDURE
• POSITION
– Supine
• Routine cleaning(nipple line to mid-thigh) and draping(exposing the
umbilicus, ASIS, pubic symphysis)
• Surgeon stand on the side of the hernia and the assistant at the opposite
• ANAESTHESIA
– local anasthesia (60ml of 0.5%lidocain + adrenaline) with sedation for
elective
• Ilioinguinal and hypogastric nerve block
• Intradermal and the subcutaneous tissues are infiltrated at the site of the proposed
incision
• At the deep ring (peritoneal pain)
• Pubic tubercle medially
– General anasthesia for emergency
– Spinal for elderly with co-morbidity OR bilateral, recurrent hernia
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7. Local anasthesia
• Ilioinguinal and iliohypogastric blocks
• Surface landmarks for ilioinguinal block. The point of needle insertion ismarked 2 cm medial
and 2 cm superior from the anterior superior iliac spine.
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8. •
• Needle maneuvers to block to ilioinguoinal nerve. Shown is perpendicular needle insertion (1),
lateral (2), and medial (3) redirections (fan technique)
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9. • INCISION
– An incision is usually made parallel to and
approximately 2 cm above the inguinal ligament.
– Extend from the level of the pubic tubercle to the
internal ring at the level of the femoral pulse.
(medial two-third of the inguinal ligament)
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10. • EXPOSURE
– The subcutaneous tissue is incised
– The blood vessels – superficial Epigastric vein and
external pudenda vein- are ligated and divided
– A self-retaining Weitlaner retractor is placed
– The external oblique aponeurosis is exposed
– Further local anesthetic agent is infiltrated
beneath the external obligue.
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11. • Small incision is made on the direction of the
fibers of the external oblique and extended
into the medial side of the external ring. The
cut edges of the external oblique held away to
prevent injury to the underlying nerves.
• The two nerves (ilioinguinal and
genitofemoral nerves) are then preserved and
retracted out of the way
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12. • The cord is then freed from the floor of the
canal(best started from the pubic tubercle)and
held with a hernia ring.
• The crimaster muscle is grasped with toothed
forceps and divided to approach the sac.
• The sac is white membrane anteriomedial to the
cord.
• Vas difference can be felt by palpation because is
firmer than other structures of the cord.
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13. • The crimaster is dissected of the off the sac and
dissect the sac and cord apart.
• The sac separated upto the deep ring, with
exposure of preperitoneal fat or inferior
Epigastric vessels
• The wall of the sac is picked is lifted up gently and
opened at the apex with care to avoid injury to
the content.
• The content is inspected and reduced.
• Transfix the sac at the deep ring and excise the
redundant sac.
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14. Re-enforcement of the posterior wall
• Bassini Repair
– The conjoined tendon is retracted upward
– The aponeurosis of the transversus abdominis muscle is
approximated to the iliopubic tract that lies adjacent to
the inguinal ligament with several interrupted 3-0 silk
sutures.
– The second layer of the repair involves suturing the
conjoined tendon to the inguinal ligament with
interrupted 2-0 silk sutures.
– Tanner slide can be made to reduce tension
– Lytle’s repair; tighting the internal ring on the medial side if
it is too wide.
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15. • Shouldice repair; four layered repair
• Lichtenstein repair; mesh repair
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16. CLOSURE
• The external oblique fascia is reapproximated
starting at the external ring using 2-0
absorbable sutures.
• The subcutaneous tissue is irrigated, and any
debris is removed. The skin is approximated
with subcuticular 4-0 absorbable sutures, and
the testis is gently drawn into the scrotum to
avoid iatrogenic undescended testis.
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17. COMPLICATION
• INTRA-OPERATIVE
– Injury to the external iliac or femoral vessels
– Injury the vas deferens
– Injury to the bladder and colon esp in sliding hernia
– Injury to the inferior epigastric vessel
– Injury to the content of the sac
– Injury to the testicular artery
• EARLY POST-OP
– Retention of urine
– Haematoma of cord and scrotum
– Wound infection
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18. • LATE POST-OP
– Recurrence
– Sinuses
– Neuralgic pain- ilioinguinal nerve – hyperasthesia over
the medial side of the inguinal canal
– Painful scar
– Atrophy of the testis due to injury to testicular artery
– Ostetis pubis
– Mesh extrusion with or without foreign body reaction
– Epidermoid cyst
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19. Causes of recurrence
• Inadequate pre-op preparation
– Persistent causes of straining
– Infection
Intra-operative
– Tension repair
– Low ligation of sac
– Inadequate lytle’s repair (in huge long standing
hernia)
Treatment of recurrence is via preperitoneal
repair(there is fibrosis of the previous site). Can be
open or laparoscopic(gold standard).
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20. Special situations
• Sliding hernia
• Strangulated hernia
• Madyl’s hernia(hernia N-W)
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21. References
• Vijay P chatri; operative surgery manual. 1st
edition 2003
• Zollinger ; atlas of surgical operations. 9th edition
• Graeme J Poston. Principles of operative surgery.
2nd edition
• S.K Bhattacharya; short cases in surgery. Sixth
edition
• Youtube .
• www.nysora.com
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