Notes on Hernia Repair with Mesh using Local anesthetic repair technique

In this post i have written some notes regarding the local mesh repair technique for inguinal hernia.

Pre-op preparation:

• NPO for 4 Hours
• shave hair with razor on admission. 
• Walk to table. 
• Prophylactic antibiotic is given. 
• 100 mg diclofenac rectal suppository is inserted before operation. 
• Sedation is achieved with dormicum (preferred)/diazepam and an opioid. 
• Monofilament mesh like Marlex or Prolene and Monofilament synthetic sutures are used for fixation.
• Trendelenburg position is used, cross arms over chest and no screening of head is required.

Anesthesia:

• Local Anaethetic technique is “infiltration as you proceed”. This technique is preferred over the ilioinguinal and iliohypogastric block because that may cause femoral nerve palsy.
• Solution used is 0.5 percent lignocaine with 1/200000 adrenaline (40ml) and 0.5 percent bupivacaine with 1/200000 lignocaine (20ml). If bilateral than the solution is diluted with equal amounts of normal saline.

Technique:

• The sac is reduced. 
• Incision is marked with non-removable pental pen. 
• Infiltrate along the line of incision with a 23 G needle. 
• After incision infiltrate deep to scarpa’s fascia before exposing external oblique aponeurosis. 
• After external oblique has been exposed infiltrate 10ml of anesthetic into lateral part of aponeurosis to fold the canal. This will anaesthetize the nerves and separate the cord structures from the boundaries. 
• Sometimes ilioinguinal nerve is found outside the canal, it has to be identified and saved.
• Once the canal is opened, infiltrate in the internal ring and dissect the medial and lateral leaves of the external oblique aponeurosis. 
• Now if the direct or indirect sac is small than the whole spermatic cord is mobilized. 
• In case of large indirect hernia open cord by incising the cremasteric muscles and find the pearly white sac and dissect it free from vas deferens and vessels, infiltrate between the sac and cord structure to assist in dissection. 
• Once the sac had been dealt with and sliding hernia reduced than mobilize the cord. 
• The cord with its cremasteric muscle covering is elevated and its medial attachments to conjoint area divided and cremasteric vessels and genital branch of genitofemoral nerve are identified just beneath the bulk of the cord and infiltration is done between them and the inguinal ligament to create a space and then open this space and mobilize the cord upto 2cm beyond and medial to pubic tubercle. 
• Few vessels here have to be coagulated to stop bleeding. 
• The cord with its covering and the nerves is retracted via a rubber drain. 
• Skeletonization of cremasteric muscle is never done. 
• Now deal with the sac and check the posterior wall, internal ring and femoral canal.
• If Gilbert Type I; small internal ring and intact anal floor than a simple Onlay mesh is placed. 
• If Gilbert Type II; 1-2 fingers can be inserted in the internal ring and attenuated transversalis fascia is there than a mesh shaped like an umbrella is inserted in internal ring and sutures to the edges and an Onlay mesh applied afterwards. For large indirect hernia the distal sac is cut and opened anteriorly to prevent the formation of hydrocele and proximal portion is transfixed and excised. Distal sac is not dissected as it may lead to bleeding, testicular ischemia hematoma. 
• For Gilbert Type III; internal ring two finger breadths or more and large scrotal or sliding hernia, reinforcement of posterior wall as well as internal ring will be required. There are two options for that: one is a preperitoneal inlay mesh and second is imbrications or plication of posterior wall. 
• Now the dissection of the canal is done beyond, above and medial to pubic tubercle. We can also obliquely cut external oblique aponeurosis upwards and medially to release most medial part of its fibers where they are attached to rectus aponeurosis. The mesh is cut in the shape of inguinal canal:

• With cord retracted insert the mesh and fix it to pubic tubercle, inguinal ligament, while superiorly internal ring, rectus sheath, internal oblique aponeurosis and reflected part of external oblique aponeurosis. 
• Fixation is done with thread because staples are dangerous on inguinal ligament. Also fixation with inguinal ligament is done side to side and not side to end or end to end. 
• The trousers of the mesh are overlapped and stitched and a new internal ring about 1.5cm is made followed by closure of external oblique and skin.

Tumescent Technique for Recurrent Inguinal Hernia:
Pre-op:

• Note down the size and state of testis, because of multiple operations it may be atrophied so take consent for orchidectomy. 
• Tension free-mesh will still be performed. 
• Information on previous repair should be obtained.

Technique:

• Infiltrate as you go technique is used. 
• The incision is along the inguinal canal irrespective of previous incision, followed by dissection in the subcutaneous tissue superiorly in the virgin area until the external oblique is reached. 
• Infiltrate at the most lateral position of external oblique aponeurosis to flood the canal and anesthetize and separate the cord from its walls.
• After canal is opened further dissection is carried out by continuously infiltration between the important structures of cord to dissect them. 
• Determine the type of defect Gilbert I, II or III. 
• Deal with the sac and either tension free plication or an inlay mesh is placed. 
• Vacuum drain is required after excessive dissection.

Extraperitoneal Approach:

• If anterior approach proves difficult then convert to extraperitoneal one.
•  For operating on multirecurrent and prevascular hernia pre-peritoneal approach is required. 
• In extraperitoneal space the mesh covers the Hasselbachs triangle. 
• In the preperitoneal space the mesh is fixed medially to pectineal ligament and laterally to iliopubic tract while the upper edge is fixed to anterior abdominal wall.

Femoral Hernia:

• Again infiltrate as you go technique is used. 
• Incision is just below the femoral hernia. 
• The external oblique aponeurosis is exposed near pubic tubercle and is followed down to where inguinal ligament fuses with scarpa’s fascia as it is here that femoral canal lies. 
• The scarpa’s fascia is opened. The sac requires removal of surrounding fat and it is either excised or reduced. The margins are defined and a prosthetic rolled mesh is inserted and fixed circumferentially with 4 stitches followed by another mesh over it and this is covered by a flap of pectineal ligament. 
• If any difficulty arises then open inguinal canal and access femoral canal after opening the transversalis fascia and then apply mesh.

Mesh repair of small Epigastric and umbilical hernia:

• The defect should be 5cm or less to use this technique. 
• For larger hernia Apposition closure is preferred over Mayo Repair. 
• Incision is given radial below the hernia, flaps dissected and sac dissected out, the fascial edges of rectus muscle are identified, local anesthetic is infiltrated deep to muscle in the extraperitoneal space as well as in the muscle, 
• Space is created in the extraperitoneal space by separating the extraperitoneal tissue from posterior rectus sheath and sac dealt with if excised repair the peritoneum. 
• Place the mesh in preperitoneal space, it should be 2cm larger than the defect. 
• Close the wound.

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