Open Inguinal Hernia Repair

Practice Essentials
Inguinal hernia repair is one of the most commonly performed surgical procedures in the world. Most surgeons now prefer to
perform a tension-free mesh repair. The Lichtenstein tension-free hernioplasty is currently one of the most popular techniques
for repair of inguinal hernias.
The image below depicts the anatomy of the inguinal canal.

Anatomy of inguinal canal.

Indications and contraindications

The existence of an inguinal hernia has traditionally been considered sufficient reason for operative intervention. However, the
following considerations should be taken into account:

Some studies have shown that the presence of a reducible hernia is not, in itself, an indication for surgery and that the
risk of incarceration is less than 1%

Symptomatic patients should undergo repair

Even asymptomatic patients who are medically fit should be offered surgical repair

Because of the higher frequency of femoral hernias in women, procedures that provide coverage of the femoral space
(eg, laparoscopic repair) at the time of initial operation may be better suited for women as primary repairs
Inguinal hernia repair has no absolute contraindications. However, the following considerations should be taken into account:

Any medical issues should be fully addressed beforehand and the operation delayed accordingly
Patients with elevated American Society of Anesthesiologists (ASA) scores and high operative risk should undergo a full
preoperative workup and determination of the risk-to-benefit ratio

Recurrences after a primary posterior technique may be treated with Lichtenstein hernioplasty; recurrences after a
primary anterior technique should be treated with TEP, TAPP, or open posterior repair

Asymptomatic reducible direct inguinal hernia in an elderly patient with multiple uncontrollable comorbidities and an
elevated ASA score does not require repair and may be left alone for close observation and follow-up
See Overview for more detail.

Preparation
No special equipment is required for inguinal hernia repair. Instruments and materials on hand may include the following:

Syringe
25-Gauge needle
Surgical knife with blade

Mosquito forceps
Dissecting scissors
Polypropylene or polyester mesh
Langenbeck retractors
Adson thumb forceps
Needle holder
Sutures (absorbable or nonabsorbable)
Penrose drain or umbilical tape
Inguinal hernia repair can be performed with the following types of anesthesia:

General
Regional (spinal epidural)
Local (infiltration field block)
For Lichtenstein hernioplasty, local anesthesia is safe and generally preferable. Antibiotic prophylaxis is not routinely indicated in
low-risk cases but may be considered when risk factors are present.
See Periprocedural Care for more detail.

Procedure
Inguinal hernia repairs are of the following three general types:

Herniotomy (removal of the hernial sac only)

Herniorrhaphy (herniotomy plus repair of the posterior wall of the inguinal canal)
Hernioplasty (herniotomy plus reinforcement of the posterior wall of the inguinal canal with a synthetic mesh)
The Lichtenstein tension-free mesh repair, which is an example of hernioplasty and is currently one of the most popular open
inguinal hernia repair techniques, includes the following components:

Opening of the subcutaneous fat along the line of the incision

Opening of the Scarpa fascia down to the external oblique aponeurosis and visualization of the external inguinal ring
and the lower border of the inguinal ligament
Opening of the deep fascia of the thigh and exposure of the femoral canal to check for a femoral hernia
Division of the external oblique aponeurosis from the external ring laterally for up to 5 cm, safeguarding the ilioinguinal
nerve
Mobilization of the superior (safeguarding the iliohypogastric nerve) and inferior flaps of the external oblique
aponeurosis to expose the underlying structures
Mobilization of the spermatic cord, along with the cremaster, including the ilioinguinal nerve, the genitofemoral nerve,
and the spermatic vessels; all of these structures may then be encircled in a Penrose drain or tape
Opening of the coverings of the spermatic cord and identification and isolation of the hernia sac
Inversion, division, resection, or ligation of the sac, as indicated
Placement and fixation of mesh to the edges of the defect or weakness in the posterior wall of the inguinal canal to
create a new artificial internal ring, with care taken to allow some laxity to compensate for increased intra-abdominal pressure
when the patient stands
Resection of any nerves that are injured or of doubtful integrity
In males, gentle pulling of the testes back down to their normal scrotal position
Closure of spermatic cord layers, the external oblique aponeurosis, subcutaneous tissue, and the skin
Other approaches to open inguinal hernia repair include the following:

Plug-and-patch repair - This adds a polypropylene plug shaped as a cone, which can be deployed into the internal ring
after reduction of an indirect sac
Prolene Hernia System (PHS) - This consists of an anterior oval polypropylene mesh connected to a posterior circular
component
McVay repair - In this approach, the conjoined (transversus abdominis and internal oblique) tendon is sutured to the
inguinal ligament with interrupted nonabsorbable sutures
Bassini repair - This approach involves suturing the transversalis fascia and the conjoined tendon to the inguinal
ligament behind the spermatic cord, as well as placing a vertical relaxing incision in the anterior rectus sheath
Shouldice repair - This is a four-layer procedure in which transversalis fascia is incised from the internal ring laterally to
the pubic tubercle medially, upper and lower flaps are created and then overlapped with two layers of sutures, and the
conjoined tendon is sutured to the inguinal ligament (again in two overlapping layers)
Darn repair - This is a pure-tissue tensionless technique that is performed by placing a continuous suture between the
conjoined tendon and the inguinal ligament without approximating the two structures

Background

Hernias are abnormal protrusions of a viscus (or part of it) through a normal or abnormal opening in a cavity (usually the
abdomen). They are most commonly seen in the groin; a minority are paraumbilical or incisional. In the groin, inguinal hernias
are more common than femoral hernias.
Inguinal hernias occur in about 15% of the adult population, and inguinal hernia repair is one of the most commonly performed
surgical procedures in the world.[1]Approximately 800,000 mesh hernioplasties are performed each year in the United States,
[2]
100,000 in France, and 80,000 in the United Kingdom.
There is morphologic and biochemical evidence that adult male inguinal hernias are associated with an altered ratio of type I to
type III collagen.[3] These changes lead to weakening of the fibroconnective tissue of the groin and development of inguinal
hernias. Recognition of this process led to acknowledgment of the need for prosthetic reinforcement of weakened abdominal
wall tissue.
Given the evidence that the use of mesh lowers the recurrence rate, [4, 5] as well as the availability of various prosthetic meshes for
the reinforcement of the posterior wall of the inguinal canal, most surgeons now prefer to perform a tension-free mesh repair.
Accordingly, this article focuses primarily on the Lichtenstein tension-free hernioplasty, which is one of the most popular
techniques used for inguinal hernia repair.[6, 7]

Types of hernia
An indirect hernia is defined as a defect protruding through the internal or deep inguinal ring, whereas a direct hernia is a defect
protruding through the posterior wall of the inguinal canal. To put it in a more anatomic way, an indirect hernia is lateral to the
inferior epigastric artery and vein, whereas a direct hernia is medial to these vessels. The Hesselbach triangle is the zone of the
inguinal floor through which direct hernias protrude, and its boundaries are the epigastric vessels laterally, the rectus sheath
medially, and the inguinal ligament inferiorly.[8]
An incomplete hernia is confined to the inguinal canal, whereas a complete hernia comes out of the inguinal canal through the
external or superficial ring into the scrotum. Direct hernias are always incomplete, whereas indirect hernias can also be
complete.
A sliding inguinal hernia is one in which a portion of the wall of the hernia sac is made up of an intra-abdominal organ. As the
peritoneum is stretched and pushed through the hernia defect and becomes the hernia sac, retroperitoneal structures such as
the colon or bladder are dragged along with it and thus come to make up one of its walls.
Bilateral pediatric hernias are most commonly indirect hernias and arise because of the patency of the processus vaginalis.
Simple ligation of the hernia sac (herniotomy) alone is enough. Surgical treatment of indirect hernias in adults, unlike that in
children, requires more than simple ligation of the hernia sac. This is because the patent processus is only part of the story. With
time, the internal ring dilates, leaving an adult with what can be a sizable defect in the floor of the inguinal canal; this must be
closed in addition to division or reduction of the indirect hernia sac.
A hydrocele is a commonly encountered pathology related to hernias. A communicating hydrocele is, by definition, a form of
indirect hernia, albeit with an extremely small defect through which only peritoneal fluid enters the sac but no viscus (eg,
omentum or bowel) comes out.

Types of hernia repair

Inguinal hernia repairs may be divided into the following three general types:

Herniotomy (removal of the hernial sac only) - This, by itself, is adequate for an indirect inguinal hernia in children in
whom the abdominal wall muscles are normal; formal repair of the posterior wall of the inguinal canal is not required
Herniorrhaphy (herniotomy plus repair of the posterior wall of the inguinal canal) - This may be suitable for a small
hernia in a young adult with good abdominal wall musculature; the Bassini and Shouldice repairs are examples of
herniorrhaphy
Hernioplasty (herniotomy plus reinforcement of the posterior wall of the inguinal canal with a synthetic mesh) - This is
required for large hernias and hernias in middle-aged and elderly patients with poor abdominal wall musculature; the
Lichtenstein tension-free mesh repair is an example of hernioplasty

Open vs laparoscopic repair

Although numerous surgical approaches have been developed to treat inguinal hernias, the Lichtenstein tension-free meshbased repair remains the criterion standard.[1] In a Cochrane review comparing mesh with nonmesh open repair, the evidence
was sufficient to conclude that the use of mesh was associated with a reduced rate of recurrence. [2]
Laparoscopic approaches are feasible in expert hands, but the learning curve for laparoscopic hernia repair is long (200-250
cases), the severity of complications is greater, detailed analyses of cost-effectiveness are lacking, and long-term recurrence
rates have not been determined.[9] The role of laparoscopic inguinal hernia repair in the treatment of an uncomplicated, unilateral
hernia is yet to be resolved.

Nevertheless, transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP) laparoscopic inguinal hernioplasty may offer
specific benefits for some patients, such as those with recurrent hernia after conventional anterior open hernioplasty, those with
bilateral hernias, and those undergoing laparoscopy for other clean operative procedures.
A 2014 meta-analysis of seven studies comparing laparoscopic repair with the Lichtenstein technique for treatment of recurrent
inguinal hernia concluded that despite the advantages to be expected with the former (eg, reduced pain and earlier return to
normal activities), operating time was significantly longer with the minimally invasive technique, and the choice between the two
approaches depended largely on the availability of local expertise. [10]

Medication Summary
The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Local Anesthetics
Class Summary
Local anesthetic agents are used to increase patient comfort during the procedure.

Lidocaine and epinephrine (Lignospan Forte, Xylocaine with Epinephrine)

Lidocaine is an amide local anesthetic used in a 0.5-1% concentration in combination with bupivacaine (50:50 mixture). This
agent inhibits depolarization of type C sensory neurons by blocking sodium channels. Epinephrine prolongs the duration of the
anesthetic effects from lidocaine by causing vasoconstriction of the blood vessels surrounding the nerve axons.
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Bupivacaine (Marcaine, Sensorcaine)

Bupivacaine 0.25% may be used in combination with lidocaine plus epinephrine (50:50 mixture). It decreases permeability to
sodium ions in neuronal membranes. This results in the inhibition of depolarization, blocking the transmission of nerve impulses.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Class Summary
These agents have analgesic, anti-inflammatory properties and antipyretic activities. Their mechanism of action is not known,
but they may inhibit cyclo-oxygenase activity (COX) and prostaglandin synthesis. Other mechanisms may exist as well, such as
inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell
membrane functions.
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Diclofenac (Voltaren-XR, Cataflam, Zipsor, Cambia)

Diclofenac inhibits prostaglandin synthesis by decreasing COX activity, which, in turn, decreases formation of prostaglandin
precursors.
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Ibuprofen (Advil, Ultraprin, I-Prin, Motrin IB)

Ibuprofen is the drug of choice for patients with mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing
prostaglandin synthesis.

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Sulindac (Clinoril)
Sulindac decreases the activity of COX and, in turn, inhibits prostaglandin synthesis. Its action results in the decreased
formation of inflammatory mediators.
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Naproxen (Anaprox, Aleve, Naprosyn, Naprelan)

Naproxen is used for the relief of mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing the activity of
the enzyme COX, which results in prostaglandin synthesis.
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Meloxicam (Mobic)
Meloxicam decreases COX activity, and this, in turn, inhibits prostaglandin synthesis. These effects decrease the formation of
inflammatory mediators.
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Ketoprofen
Ketoprofen is used for relief of mild to moderate pain and inflammation. Small dosages are indicated initially in small patients,
elderly patients, and patients with renal or liver disease. Doses higher than 75 mg do not increase the therapeutic effects.
Administer high doses with caution, and closely observe the patient's response.
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Flurbiprofen
Flurbiprofen may inhibit COX, thereby inhibiting prostaglandin biosynthesis. These effects may result in analgesic, antipyretic,
and anti-inflammatory activities.

Analgesics
Class Summary
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy
regimens. Many analgesics have sedating properties that benefit patients who experience moderate to severe pain.
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Acetaminophen and codeine (Tylenol #3)

This combination is indicated for the treatment of mild to moderate pain.
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Hydrocodone bitartrate and acetaminophen (Vicodin ES, Lortab, Lorcet Plus, Norco, Maxidone)
This agent is indicated for the relief of moderately severe to severe pain.

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Tramadol (Ultram, Ryzolt)

Tramadol is an analgesic that probably acts over monoaminergic and opioid mechanisms. Its monoaminergic effect is shared
with tricyclic antidepressants. Tolerance and dependence