1. Most inguinal hernias are repaired.

2. Repair techniques: There are several open and laparoscopic techniques described to repair an inguinal hernia:

3. Selecting the correct approach to repair an inguinal hernia.

1. The diagnosis of groin swellings is notoriously difficult. Experienced as well as inexperienced surgeons make frequent mistakes. Do not accept the diagnosis of the referring doctor, but take a fresh history and carry out a complete examination. Is there another possible cause for the patient’s symptoms apart from the hernia? If a clear history of a reducible intermittent lump in the groin is accompanied by a negative examination, a hernia will be found on exploration; if in doubt, consider herniography.

2. Palpation is not the only or even the most important method of examination. Look with the patient standing and again with the patient supine. If you see a lump, ask yourself ‘Where is it?’ If it is reducible, where does it first reappear on coughing or straining? A cough impulse may be absent, especially over a femoral hernia in which a small sac is covered by much fatty extra-peritoneal tissue. Conversely, a cough impulse is present over Malgaigne’s (Parisian surgeon 1806–1856) bulging, or a saphena varix.

3. Always examine the scrotum and its contents in male patients. If there is a swelling, ask yourself the fundamental question ‘Can I get above it?’ Occasionally you discover undescended testes; deal with them at the same procedure.

4. Finally, examine the other hernial orifices.

1. Obtain the patient’s signed consent, warning of the possible complications of haematoma (especially for large inguinoscrotal hernias), ischaemic orchitis, persistent groin pain, hernia recurrence, wound and mesh infection, and damage to local structures, which can be more significant with a laparoscopic approach. In laparoscopic surgery obtain consent for conversion to open repair if necessary. Discuss with the patient what action you should take, if, at operation for unilateral hernia, an unexpected, asymptomatic contralateral hernia is revealed. Record the agreed consent on the form.

2. Mark the hernia side.

Local anaesthesia for inguinal hernia repair

1. Start the incision a finger’s breadth above the palpable pubic tubercle within the skin crease which is often present (as opposed to parallel to the inguinal ligament) and extend this to two-thirds of the way to the anterior superior iliac spine. Incise the fascia to expose the external oblique aponeurosis, ligating and dividing two or three large veins that cross the line of the incision. Avoid cutting into the hernial sac and spermatic cord at the medial end of the incision.

2. Expose the glistening fibres of the external oblique aponeurosis and identify the external inguinal ring, which confirms the line of the inguinal canal.

3. With a scalpel split the external oblique aponeurosis in the line of the fibres. Enlarge the split medially and laterally by pushing the half-closed blades of the scissors in the line of the fibres. At the medial end of the split you open the external inguinal ring. Ensure that you do so. Do not allow curved blades of scissors to skirt around the crura of the ring. Preserve the ilioinguinal nerve, lying under the external oblique, to minimize the risk of postoperative numbness and pain.

4. Apply artery forceps to the edges of the aponeurosis and gently elevate each side. As you evert the upper leaf, look for the arching lower border of internal oblique muscle, with the cord below it. As you evert the lower leaf, sweep loose tissue from the deep surface of the inguinal ligament.

1. Start to mobilize the cord by incising, just above and lateral to the public tubercle, the ‘mesentery’ of fascia and fibres of cremasteric muscle that extends downwards from the medial part of the conjoint tendon to envelop the cord. Deepen this small incision behind the cord, drawing the latter downwards while passing the index finger from below against the pubic tubercle, to develop a plane to encircle the cord and apply a hernia ring.

2. Now dislocate the cord laterally and downwards by incising the coverings along lines just above and below it. This exposes a direct hernia, which can be freed from the cord.

3. Carefully divide the fibres of cremaster just distal to the internal ring, ensuring haemostasis.

4. Even though a direct hernia is evident, examine the cord. Normally it is about the thickness of a pencil. It is markedly distended by an unreduced, sometimes adherent or sliding, hernia. A thickened sac results from a longstanding indirect hernia. Cord lipomata produce thickening, as does an encysted hydrocele of the cord (in females a hydrocele of the canal of Nuck). To exclude an indirect sac, open the spermatic fascia covering the cord and identify the edge of the peritoneum deep to the internal ring.

5. Identify the lower arching fibres of the internal oblique muscle, becoming tendinous at the conjoint tendon, and examine the posterior wall below this. A direct hernia may be a large bulge, a diffuse weakness of the whole posterior wall or, less often, a funicular hernia through a small localized defect (Ogilvie’s hernia).

6. If you have any concern that a femoral hernia may be present, incise the transversalis fascia to expose the upper aspect of the femoral canal. If a femoral sac is present, deal with it via a High approach repair (Lothiesen procedure, see later).

7. The cremasteric vessels pass medially from the inferior epigastric vessels adjacent to the cord. If the internal ring is enlarged it may be necessary to carefully identify, isolate, ligate and then divide the cremasteric vessels to facilitate a snug repair at the internal ring. If they are injured more medially, ligate them proximally and distally to the damage.

Indirect sac

Large indirect sac

Sliding indirect sac

Direct sac

Combined direct and indirect sac

1. The mesh should have overall dimensions of 11 cm × 6 cm. To accommodate this, separate the external oblique aponeurosis from the deeper layers superiorly and medially and from the muscular part of internal oblique laterally to create an adequate pocket to receive the mesh.

2. Prepare the polypropylene mesh as indicated in Figure 6.2A. The lower medial corner is slightly rounded, the upper medial corner rather more so. The mesh is then incised from its lateral margin, placing the cut one-third of the distance from the lower edge. The cut extends for approximately half the length of the mesh, depending upon the size of the patient; it may need to be extended when the mesh is in place. In small patients the upper edge may need to be trimmed slightly.

3. Place the mesh in its final position (Fig. 6.2B). Lift the cord and bring the narrow lower tail through under it, below the internal ring. Then tuck the lateral end under the external oblique; the lower edge of the mesh now lies along the inguinal ligament. Now insert the upper two-thirds of the mesh so that it lies under the external oblique aponeurosis superiorly and medially, ensuring that there is a good overlap on the rectus sheath medially. Tuck the wide upper tail under the external oblique laterally, with its lower edge over the lower tail. Insert your fingers under external oblique superiorly and laterally to ensure that the mesh lies quite flat in the peripheral part of the pocket, though there may be a slight bulge centrally.

4. The mesh does need to be secured in place across the posterior wall of the inguinal canal. Although most use polypropylene sutures, it is possible to use staples or glue. Start the fixation by passing a 2/0 polypropylene stitch through the mesh and the tissues overlying the pubic tubercle and tying this. Use this to form a continuous locking suture between the lower edge of the mesh and the inguinal ligament, working from medial to lateral, extending to at least 2 cm lateral to the internal ring. Take irregular bites of the inguinal ligament to avoid splitting it and do not allow the lower leaf of the external oblique to roll in and be included in the sutures; if this happens, there will be no external oblique left to close. For the medial part of this suture line it is best to retract the cord downwards. Then, as the suture approaches the internal ring, move the cord cephalad and pass the needle under it to continue laterally. When suturing immediately in front of the femoral vessels be careful to take only the ligament and not a bite of a major vessel!

5. If the slit in the mesh is too short extend it so that the cord passes directly from the internal ring to the opening in the mesh. A bulky cord may be accommodated by making a small cut in the mesh at right-angles to the slit. If you made too long a cut, all is not lost; simply shorten the slit with one or two sutures.

6. Overlap the tails of the mesh by bringing the lower edge of the upper portion in front of the lower tail and securing it to the inguinal ligament with two interrupted sutures (or by including it in the lateral part of the continuous suture). The resulting opening in the mesh should be a snug, but not a tight, fit around the cord (Fig. 6.2B).

7. Now secure the medial and upper margins of the mesh with about six interrupted sutures, avoiding the nerves (Fig. 6.2B). These are most conveniently placed 0.5 cm away from the edge, so that the mesh lies flat on the underlying aponeurosis or muscle. The medial sutures are particularly important as there is less overlapping of the mesh there, making it a potential site for recurrence.

8. The mesh repair is now completed. It appears slightly redundant centrally but that does not matter.

9. Replace the cord in the inguinal canal.

10. Wash the inguinal canal with any remaining local anaesthetic, making sure not to remove it too quickly.

11. Close the external oblique aponeurosis with a synthetic absorbable suture, starting laterally and ending medially to reform the external ring snugly but not tightly around the emerging cord. Once again, take care to take bites at unequal distances from the edges; otherwise you will pull from the cut edges a strip of aponeurosis.

12. Appose the subcutaneous fascia with fine absorbable stitches and close the skin wound (see above).

1. Following repair of inguinal hernia under local anaesthesia, allow the patient to leave the operating theatre on foot. This is good for confidence.

2. Encourage patients to mobilize immediately after recovery from general anaesthesia.

3. Activities should be limited only by the patient’s comfort.

1. Scrotal complications: Ischaemic orchitis is an uncommon complication presenting as pain and swelling in the first few days after hernia repair. In a proportion of cases it results in testicular atrophy. Damage to the vas should be recognized and repaired at the time of hernia repair. Hydrocele formation is more common after transection of the sac and resorbs spontaneously in most cases. Genital oedema, relatively common in the first 3 days, settles spontaneously, requiring reassurance only.

2. Haematoma: Bruising can be significant, often involving the scrotum, to the alarm of the patient, developing a couple of days after surgery. Even significant haematomas can be left to resolve, although this may take months and does increase the risk of orchitis, mesh infection and possibly recurrence and groin pain.

3. Wound infections: Reddening of the wounds is not uncommon, but frank purulent discharge is. If this persists, be concerned about a mesh infection and consider removing the mesh.

4. Nerve injury: Some degree of transient numbness below and medial to the incision is very common and may persist with little disability. Of much more significance is the incidence of chronic residual pain that occurs in at least 3% of conventional hernia repairs.

5. Urinary problems: Make sure you are aware of the possibility of bladder injury and recognize it at the time of surgery. Treat it by primary repair and insert an indwelling catheter until a cystogram demonstrates healing. Postoperative urinary retention becomes more common with age, after general anaesthesia and following bilateral hernia repair and usually resolves following a 24-hour period of catheterization.

6. Impotence: This is an occasional complaint for which there does not appear to be an organic basis.

1. Consider laparoscopic repair to avoid the adherent tissues.

2. For open operations, take considerable time to define the anatomy. This is difficult as there is distortion from the previous repair and all structures tend to be encased in fibrous tissue.

3. Once the anatomy is defined, secure the posterior wall and undertake a mesh repair as described.

4. Orchidectomy need not be considered, but warn the patient of the increased risk of ischaemic orchitis.

1. Incise or excise the previous skin scar.

2. Deepen the incision at a higher or more lateral level than the previous approach, so that unscarred external oblique aponeurosis is encountered first.

3. Display the external oblique aponeurosis downwards to the inguinal ligament.

4. Re-open the inguinal canal through the scar in the external oblique aponeurosis. Avoid damaging the contents of the canal, which will be adherent.

5. Elevate the upper and lower leaves of the external oblique aponeurosis until you reach unscarred tissue.

6. Isolate the spermatic cord below the pubic tubercle and follow it up to the internal ring. It may lie in an unusual place or be adherent and the vas may have been separated from the vessels.

1. Look for an indirect recurrence. If you find a sac, isolate it, empty it, then transfix, ligate and divide it at the neck.

2. Look for a direct recurrence. If the recurrence is funicular, isolate it, empty it, then transfix, ligate and divide it at the neck. If it is a diffuse bulge, invert the sac with a running suture to maintain the invagination.

1. Almost always, the repair should be a mesh repair as outlined above.

2. Occasionally, for a small well defined direct defect, a ‘plug’ repair can be undertaken. Insert a bunched-up piece of polypropylene mesh through the small defect into the extra-peritoneal space and secure it with a few sutures across the open defect.

1. Most operations listed as strangulated hernia are carried out for painful, irreducible or obstructed hernias.

2. An open approach to the strangulated inguinal hernia repair is easiest and most common,

3. Strangulation results from venous obstruction, a rise in capillary hydrostatic pressure, transudation of fluid, exudation of protein and cells, and eventual arterial obstruction. Alternatively, the pressure of a sharp constriction ring at the neck of the sac may cause local necrosis of the bowel wall.

4. Once diagnosed, try to reduce the hernia, making emergency surgery unnecessary and allowing for an early elective operation. The effect of reassuring the patient, who is laid supine in the head-down position, encourages spontaneous reduction. Try to gently reduce the hernia, making sure not to hurt the patient. There is a slight but real risk that you may reduce the hernia en masse: that is, the hernia remains within the peritoneal sac, the neck of which remains as a constriction, so the strangulation is not relieved. Some hernias reduce spontaneously when the patient is sedated prior to operation, or when anaesthesia is induced.

1. Do not rush patients with strangulated hernias to the operating theatre. Make sure you know any reason (such as urinary outflow obstruction or a chest infection) why the patient has developed strangulation now. Identify coincidental disease that may make general anaesthesia and operation hazardous.

2. If strangulation has been present for some time, the patient requires fluid and electrolyte replacement. This takes priority over the operation. It is likely, in such cases, that bowel in the hernia will already be irreversibly ischaemic, so little is lost by the delay.

1. The approach is open and identical to that for an elective operation.

1. If the history was short, the sac will frequently be empty by the time you expose it. The relaxation produced by the anaesthetic often succeeds when other conservative methods have failed to reduce a hernia. There is then no merit in exploring the abdomen. Repair the hernia as though this were an elective operation.

2. If bowel is present in the sac, do not let it slip back into the abdomen but gently draw it down into view. The bowel is likely to have suffered the greatest damage where it was trapped at the neck of the sac.

3. Feel the margins of the neck of the sac with a fingertip.

4. In Richter’s hernia, a knuckle of the bowel wall is trapped. The bowel lumen is thus not obstructed but the knuckle may become gangrenous and perforate.

5. Maydl’s strangulation is very rare. Two loops lie in the sac but the blood supply to an intermediate loop within the abdomen may be prejudiced so that it is gangrenous.

1. If the neck of the hernia sac is constricted, first draw down healthy bowel, then place an index fingertip on each side of the contents, nails facing outwards. Gently dilate the neck of the sac (Fig. 6.3). Make sure the bowel does not slip back. Draw it out to ensure that there is no peritoneal constriction and to expose healthy bowel.

2. If the bowel is viable, return it to the abdomen.

3. If necessary, resect a gangrenous segment of bowel, performing an end-to-end anastomosis.