Abdominal Wall

Question 1

Open Inguinal Hernia Repair OR

Answer 1

1. Oblique skin incision 2 fingerbreadths superior to inguinal ligament
2. External oblique cut in direction of fibers; identify ilioinguinal, iliohypogastric, & genital branch of femoral nerve
3. Dissect cord structures free from hernia sac
4. Hernia & contents reduced into abdomen
5. Polypropylene mesh overlap rectus by 2 cm, cut a slit to accomodate cord and recreate internal ring; secure to pubic tubercle medially, inguinal ligament inferiorly, rectus sheath/internal oblique superiorly
6. Close external oblique, scarpas, skin

Question 2

Laparoscopic TEP OR

Answer 2

1. Infra-umbilical incision down to anterior rectus sheath and blunt dissection using balloon disector into retrorectus/preperitoneal space; 2 additional ports placed
2. Dissection to identify inferior epigastric vessels superiorly, cooper’s ligament medially, iliopubic tract laterally
3. Hernia sac is dissected from cord structures & returned to peritoneal cavity
4. Mesh is positioned to cover entire myopectineal orifice

Question 3

Laparoscopic/RA TAPP OR

Answer 3

1. First port periumbilical, two additional ports either side lateral to rectus sheath
2. Peritoneum incised from ipsilateral medial umbilical fold to ASIS
3. Preperitoneal space bluntly dissected from ASIS laterally to medial umbilical fold medially, below Cooper’s ligament inferiorly
4. Hernia sac dissected from cord structures & returned to peritoneal cavity
5. Mesh positioned over entire myopectineal orifice
6. Peritoneal defect closed

Question 4

McVay Hernia Repair OR

Answer 4

1. Oblique incision 2 fingerbreadths below inguinal ligament
2. Expose EO aponeurosis & external ring, incise EOA in direction of fibers, identifying & protecting inguinal nerve
3. Encircle spermatic cord/round ligament at external ring, reduce contents, suture ligate/reduce sac
   * If needed, incise iliopubic tract at medial femoral ring to open floor
4. Relaxing incision in anterior rectus sheath
5. Suture conjoint tendon back to cooper’s ligament with interrupted sutures, beginning at pubic tubercle & progress laterally; transition stitch at femoral canal, incorporating conjoint tendon, Cooper’s ligament, femoral sheath, & shelving edge of inguinal ligament; remaining sutures from conjoint tendon to inguinal ligament continuing laterally, leaving enough room to pass a Kelly through internal ring next to cord in M (can close completely in F)
6. Close EO & ST in layers

Question 5

Open TAR OR

Answer 5

1. Midline incision down to hernia sac; lysis of adhesions & excision of hernia sac
2. Identify rectus muscles, enter retro-rectus space to expose TA muscle
3. Divide TA medial to neurovascular rectus innervation, incise posterior lamella of internal oblique, develop preperitoneal space
4. Advance posterior sheath medially, close posterior sheath, place mesh, close anterior sheath

Question 6

Anterior component separation OR

Answer 6

1. Midline laparotomy w LOA
2. Elevate lipocutaneous flaps 2 cm lateral to linea semilunaris; incise EO fascia & separate from IO in avascular plane to 3-4 cm above costal margin down to inguinal ligament
3. Incise posterior rectus sheath making incision 1 cm lateral to linea alba
4. Develop retromusclar plane to semilunar line
5. Place mesh as underlay, redistributing tension across graft to help medialize rectus complex, place drains over mesh
6. Reapproximate fascia with interrupted figure of 8 sutures & close
   lose posterior sheath, place mesh

Question 7

ECF Management Principles

Answer 7

1. Wound care with preservation of the skin
2. Nutritional support (TPN if > 500 cc/day, tube feeds through distal end w reinfusion of chyme), PPI & somatostatin may help
3. Delayed surgical management