Inguinal hernia

Question 1

Open inguinal hernia repair with mesh

Answer 1

• Skin incision over the inguinal canal for exposure to pubic tubercle.
• Cord structures are dissected from the cremasteric muscle and transversalis fascia fibers and retracted off inguinal canal floor.
• Cord is explored for indirect sac or cord lipoma. The sac is ligated.
• Polypropylene mesh is secured with 2-0 Prolene suture inferiorly to shelving edge of inguinal ligament and superiorly to rectus sheath and internal oblique.
• Internal ring is reconstructed by suturing leaves of mesh together.
• The Spermatic cord is returned to its original position and aponeurosis of the external oblique is reapproximated with 2-0 absorbable suture.
• Evaluate that testicles are in proper anatomical position.

Question 2

TEP repair

Answer 2

1. Enter rectus sheath through dissection from infra-umbilical skin incision.
2. Insert dissection balloon to bluntly dissect the space between the rectus muscle anteriorly and posterior fascia, down to pubis.
3. Insert two 5 mm trocars in lower midline between rectus sheath.
4. Dissection and identify inferior epigastric vessels superiorly, Cooper’s ligament medially, and ileopubic tract laterally.
5. Hernia sac is reduced and separated off the cord structures.
6. Polypropylene mesh placed into position under cord structures, ensuring coverage of internal ring and medial coverage to Cooper’s ligament.
7. Desufflation and observation of mesh.

Question 3

TAPP repair

Answer 3

1. Arms sucked, trendelenburg, 10 mm infra-umbilical port, two lateral 5 mm ports.
2. Incision of peritoneum and development of preperitoneal space.
3. Reduction of direct/femoral hernia medially.
4. Dissection of indirect hernia sac off the cord structures and subsequent reduction of sac of direct hernias.
5. Placement of non-absorbable mesh to cover myopectineal orifice and indirect space.
6. Closure of peritoneum with tacks.