Open Inguinal Hernia Repair with Plug and Patch Technique

Chapter 49 Open Inguinal Hernia Repair with Plug and Patch Technique



Derrick D. Cox, MD, Parag Bhanot, MD



INTRODUCTION


Groin hernias, which can be further classified as inguinal and femoral hernias, are among the most common conditions for which patients undergo surgical intervention, with approximately 800,000 cases performed annually.1 The lifetime risk of having a groin hernia repair is estimated to be 14% for men and 2% for women.2 Elective surgical repair is usually advised because of concerns regarding incarceration and/or strangulation, particularly with femoral hernias. A number of clinical studies have proved elective surgical repair to be safe and effective with a very low morbidity rate. This is in contrast to emergency operations, which are associated with a substantial morbidity and mortality; especially when concomitant bowel resections are performed.3


A number of open repairs have been described and classified depending on the type of dissection (anterior, posterior) and the use of different mesh (Lichtenstein, plug and patch, Prolene hernia system). The type of repair performed is primarily based on the type of hernia as well as the surgeon’s expertise. This chapter is dedicated to the plug and patch technique; although much of the discussion also applies to groin hernia repairs in general.



INDICATIONS AND CONTRAINDICATIONS


The most common indications for groin hernia repair are listed in Box 49-1. Repair of groin hernias in minimally symptomatic individuals is still an area of debate. A randomized clinical trial conducted by Fitzgibbons and associates4 of 720 men concluded that this cohort can be followed by delaying surgical intervention with minimal morbidity. Femoral hernias represent a different clinical entity with an increased incidence of complications and emergent operations.5 Although there are few contraindications to groin hernia repair, a number of considerations may delay repair (Box 49-2).



Box 49-1 Indications for Groin Hernia Repair



• Symptomatic hernias

• Prevention of progression of symptoms

• Prevention of complications (incarceration, strangulation)

• Treatment of complications (incarceration, strangulation)


Box 49-2 Contraindications to Groin Hernia Repair



• Uncontrollable ascites

• Soft tissue infection

• Pregnancy

• Reversible causes of increased intra-abdominal pressure (benign prostates hyperplasia [BPH], acute respiratory issues)


OPERATIVE STEPS


Although there is some variance in the technical aspects of the plug and patch repair, the operation has well-defined steps.



Step 1 Patient preparation

Step 2 Skin incision

Step 3 Dissection of subcutaneous layer and Scarpa’s fascia

Step 4 Incision of external oblique fascia

Step 5 Mobilization of spermatic cord

Step 6 Identification and reduction of hernia (direct and/or indirect)

Step 7 Mesh fixation

Step 8 Anatomic closure of abdominal wall layers


OPERATIVE PROCEDURE



Dissection of the Subcutaneous Layer and Scarpa’s Fascia



Hemorrhage



• Consequence



Significant postoperative bleeding would be very unusual from this dissection. However, ecchymosis or superficial hematoma may result from improper ligation of smaller venous branches.

Grade 1 complication


• Repair



Hematomas of significant size may need to be evacuated to prevent subsequent soft tissue infection. Other-wise, conservative measures may be employed.


• Prevention



Preoperatively, patients should be instructed to avoid antiplatelet and other anticoagulation medications. A number of small veins encountered in the subcutaneous layer can simply be cauterized. One or two prominent superficial epigastric veins are also located in the incision near the pubic tubercle, and these must be suture-ligated to prevent bleeding.


Incision of the External Oblique Fascia



Ilioinguinal Nerve Injury


The ilioinguinal nerve is solely a sensory nerve with a distribution of the upper and medial aspects of the thigh and scrotum. It is located overlying the spermatic cord directly underneath the external oblique fascia and is at risk for transection at this stage.



• Consequence



Inadvertent transaction of the ilioinguinal nerve will result in sensory deprivation in the associated dermatomes described. Inability to recognize that the nerve has been transected may also lead to a neuroma and chronic inguinal pain.

Grade 1/2 complication


• Prevention



An understanding of the anatomy of the nerve is crucial to recognizing its usual course through the field of dissection. Care should be taken when incising the external oblique fascia to ensure that the nerve has been separated from its underside. This can be accomplished by first partially transecting the fascia in the direction of the superficial ring and then lifting up on the medial and lateral leaflets to further expose the inguinal canal (Fig. 49-1).

image

Figure 49-1 A, The external oblique fascia has been transected into medial and lateral leaflets. The ilioinguinal nerve is just visible overlying the spermatic cord (tip of the forceps). B, The ilioinguinal nerve has been carefully dissected along its course from the internal ring to the pubic tubercle without the use of cautery or excessive retraction.



Mobilization of the Spermatic Cord



Ischemic Orchitis/Testicular Injury



• Consequence



Ischemic orchitis is the result of venous congestion within the testicle secondary to venous thrombosis within the spermatic cord. This process may lead to testicular atrophy. The reported incidence is less than 1%.6

Grade 3/4 complication


• Repair



The management of orchitis includes observation and use of nonsteroidal anti-inflammatory medications for several weeks. A duplex ultrasound should be performed to assess perfusion of the testicle. Ischemia and/or infarction may warrant orchiectomy.


• Prevention



This injury can be prevented by limiting dissection within the spermatic cord. This requires precise identification of the indirect hernia sac to safely mobilize it from the medial aspect of the cord (Fig. 49-2). In patients in whom the hernia sac is large and adherent, the distal portion of the sac can be left in situ with a high ligation proximally.

image

Figure 49-2 The Penrose drain encircles both the indirect hernia sac and the spermatic cord. The testicular vessels (tip of the hemostat) are directly adjacent to the hernia sac and can be easily injured.



Hemorrhage



• Consequence



Mobilization of the spermatic cord usually requires division of the cremasteric muscle fibers overlying the hernia sac. Improper recognition of bleeding from the transected muscle fibers may result in hematomas.

Grade 1/2 complication


• Repair



Hematomas of significant size may need to be evacuated to prevent subsequent soft tissue infection. Other-wise, conservative measures may be employed.


• Prevention



Division of the cremasteric muscle is necessary to fully mobilize the hernia sac from the spermatic cord. Cautery is usually sufficient to prevent bleeding from the muscle fibers, but it must be done before retraction occurs.


Mesh Fixation



Mesh Infection and/or Exposure



• Consequence



Mesh infection accounts for over 40% of all adverse events, as reported by the U.S. Food and Drug Administration.7 An increased risk is associated with incarcerated and femoral hernias. The sequela of an infection is dependent upon the source of infection, the degree of infection, and the type of mesh placed for the repair. Exposed mesh is considered to be contaminated and is included in the same algorithm.

Grade 3/4/5 complication


• Repair



The majority of plug and patch meshes are constructed from polypropylene. This type of mesh can resist bacterial colonization and has the ability to incorporate into native tissue. This accounts for a higher likelihood of being able to salvage the mesh with long-term antibiotic administration and/or drainage of any associated abscess. However, if the source of infection is an enteric fistula, mesh removal is required. In the presence of sepsis, aggressive measures are instituted with immediate operative exploration and systemic antibiotics.

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Jun 21, 2017 | Posted by in GENERAL SURGERY | Comments Off on Open Inguinal Hernia Repair with Plug and Patch Technique

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