The technique described below is for the repair of inguinal hernias in males. In female patients, the procedure is different because the content of the inguinal canal is the round ligament rather than the spermatic cord.

Indirect inguinal hernia
Technique

The aim of the operation is to reduce the hernia, ligate the sac and repair the defect in the posterior inguinal canal.

1	Make an incision in the inguinal region in a skin crease 1–2 cm above the inguinal ligament, centred midway between the deep ring and the pubic symphysis (Figure 8.1). Divide and ligate the veins in the subcutaneous tissue.
Figure 8.1
2	Visualize the external oblique aponeurosis with its fibres running in a downward and medial direction. Incise the aponeurosis along its fibres, holding the cut margins with forceps (Figures 8.2 and 8.3). Use these forceps to lift and retract the edges while extending the incision to the full length of the wound. The process of extending the wound also opens the external ring. Identify the ilio-inguinal nerve and protect it during surgery by holding it away from the operating field.
Figure 8.2
Figure 8.3
3	Using blunt dissection, deliver the spermatic cord together with the hernial sac as one mass and pass a finger around it (Figure 8.4). It is easiest to mobilize the mass by starting medially in the inguinal canal. Secure the mass with a latex drain or gauze (Figure 8.5). Using blunt dissection, separate the sac from the cord (vas deferens and vessels), layer by layer. Do not devascularize the cord. The hernia sac is located in the anteromedial aspect of the cord.
Figure 8.4
Figure 8.5
4	Continue to free the hernia sac from the cord (or round ligament in women) up to the internal inguinal ring. Open the sac between two pairs of small forceps and confirm its communication with the abdominal cavity by introducing a finger into the opening (Figure 8.6).
Figure 8.6
5	Twist the sac to ensure that it is empty (Figure 8.7). Suture ligate the neck with 2/0 suture, hold the ligature and excise the sac (Figures 8.8 and 8.9). If there is adherent gut in the sac, it may be a sliding hernia (see page 8--–5). In this situation, do not excise the entire sac.
Figure 8.7
Figure 8.8
Figure 8.9
6	Inspect the stump to be sure that it is adequate to prevent partial slipping of the ligature. When the ligature is finally cut, the stump will recede deeply within the ring and out of view (Figure 8.10).
Figure 8.10
7	If there is a defect in the posterior inguinal wall, stitch the conjoined muscle and tendon to the inguinal ligament. Do not place sutures too deep medially as the femoral vein will be injured.

Begin the repair medially using No. 1 nylon. Insert stitches through the inguinal ligament at different fibre levels, as the fibres tend to split along the line of the ligament.

Insert the first stitch to include the pectineal ligament (Figure 8.11). Insert the next stitch through the conjoined tendon and the inguinal ligament and continue laterally to insert stitches in this manner (Figure 8.12). Leave the stitches untied until all have been inserted. Test the final stitch adjacent to the ring before you start to tie the stitches; it should just allow the tip of the little finger to be passed through the ring along the cord. Then tie the stitches, beginning medially, and cut loose ends (Figure 8.13). As the final stitch is tied, adjust its tension so that the internal ring just admits the tip of your little finger (Figure 8.14). Finally, check the soundness of the repair, inserting additional stitches where necessary.

Figure 8.11

Figure 8.12

Figure 8.13

Figure 8.14

8 Close the external oblique aponeurosis with continuous 2/0 absorbable suture (Figure 8.15). Stitch the skin with interrupted 2/0 suture (Figure 8.16). Apply a layer of gauze and hold it in place.

Figure 8.15

Figure 8.16

Direct inguinal hernia

A direct hernia will appear as a bulge, often covered by fascia transversalis and with a wide neck in the posterior inguinal wall. Once recognized at operation, reduce the hernia but do not open or excise the sac. Cover the reduced sac by completing the repair of the posterior wall of the inguinal canal as described above for indirect hernia (Figures 8.17 and 8.18).

Figure 8.17

Figure 8.18

Sliding hernia

Diagnosis of a sliding hernia is often intraoperative, becoming apparent once you open the inguinal canal and the hernia sac. A portion of the gut will appear to adhere to the inside wall of the sac: the caecum and appendix if the hernia is in the right groin, and the sigmoid colon if the hernia is on the left. The colon or caecum (depending on where the hernia is located) actually forms part of the posterior wall of the hernia sac. Occasionally the bladder forms part of the sac in a sliding hernia.

Excise most of the sac, leaving a rim of sac below and lateral to the bowel (Figures 8.19 and 8.20). Close the sac with a purse-string suture (Figures 8.21 and 8.22). While tying the suture, push the hernial mass up within the deep inguinal ring. If the hernia fails to reduce completely, make a curved incision below and lateral to the caecum to allow the mass to slide back. The skin incision may have to be extended laterally to improve access. Repair the posterior inguinal wall as described for indirect hernia.

Figure 8.19

Figure 8.20

Figure 8.21

Figure 8.22

Inguinoscrotal hernia

Attempts to excise the scrotal part of the sac can predispose the patient to developing scrotal haematoma. Transect the sac in the inguinal canal and deal with the proximal part as described for indirect inguinal hernia. Leave the distal sac in place, but ensure haemostasis of the distal cut end of the sac.

Recurrent hernia

Operate to repair a recurrent hernia only if it is strangulated; otherwise, refer the patient to a surgeon. Because of previous operations, the inguinal anatomy is often distorted, which makes repair difficult and the risk of further recurrence is increased.