These are few notes regarding the mesh plug technique for inguinal hernia repair
Pre-op:
Less than 40 year old require no investigations while greater than 40 years require ECG and Hb levels and if there are some preexisting respiratory or CVS problem then consult a Medical Specialist for clearance regarding ambulatory anaesthesia. Shave the area just before surgery. Even the pre-op antibiotic is not required as the Marlex mesh is resistant to infection. Only anti-HTN or IHD drugs are taken on morning.
Anaesthesia:
Regional anaesthesia or epidural with chloroprocaine and midazolam 1mg and 2ml of fentanyl injection lead to preserved motor function but absent sensory function except peritoneal function. Thus able to walk after operation.
Technique:
6cm incision starts at pubic tubercle over inguinal canal towards ASIS. Only epidermis is cut with scalpel and remaining with electrocautery. Blood loss should be less than 5ml. Open the canal from external ring to internal ring by cutting the external oblique aponeurosis and separate the medial and lateral leaf from underlying structures. Put the spermatic cord in a rubber drain at the level of pubic tubercle.
Now for Indirect hernia Only separate and not cut the cremasteric muscle longitudinally from the spermatic cord. The sac is and lipoma of cord are dissected and cleared from the surrounding structures by pulling on it and clearing it till the internal ring till the preperitoneal fat pad is visualized. Except in case of strangulation or incarceration the sac is not opened and simply retuned.
While for Direct hernia the transversalis fascia is lifted with an Allis clamp and cleared upto the pre-peritoneal fat pad and care is taken not to dissect anything other than attenuated transversalis fascia.
The Mesh plug is inserted after reducing both sacs. The narrow end is inserted first and the petals are stitched at least at two locations. However if the internal ring is grossly attenuated than fix the mesh plug with multiple interrupted stitches and then check via cough or straining to make sure that it is intact.
Similarly the transversalis fascia and transverses abdominis muscle is invaginated and mesh plug in inserted in direct hernia and sutured to the margins of the defect and checked for patency. For further strength On lay patch is applied in the shape shown below:
It is placed on posterior wall of inguinal canal from pubic tubercle to above the internal ring, the slit is for internal ring and it stitched after placement. The mesh has a Velcro like effect.
The cord is placed back in the canal and external oblique aponeurosis is approximated with continuous stitches and scarpa’s stitched and skin with subcuticular. And transparent dressing applied.
Recurrent Hernia:
Minimal dissection is done, spermatic cord is not mobilized, the key is pearly white edge of sac of the hernia and it is dissected upto the internal ring or margins of defect in case of indirect and direct hernia respectively until the preperitoneal fat pad is seen. The integrity of previous repair as well as femoral canal is determined via inserting a finger and the sac reduced and plug inserted in internal ring or the defect and stitched with multiple interrupted sutures. Onlay mesh is only applied if there is enough space and spermatic cord has been mobilized.
Femoral Hernia:
After the sac has been identified, it is reduced and if big it is excised and ligated and then reduced followed by inserting a petals cut Perfix mesh with its narrow end first and stitching it t the margins of the defect, followed by closure. The patency is checked by cough and straining.
Post-op:
60 mg of IM ketorolac is given in recovery and than propoxyphene and paracetamol is advised as analgesia if required. 9-10 kg weight lifting is allowed while heavy weight lifting after 2 weeks.
Pre-op:
Less than 40 year old require no investigations while greater than 40 years require ECG and Hb levels and if there are some preexisting respiratory or CVS problem then consult a Medical Specialist for clearance regarding ambulatory anaesthesia. Shave the area just before surgery. Even the pre-op antibiotic is not required as the Marlex mesh is resistant to infection. Only anti-HTN or IHD drugs are taken on morning.
Anaesthesia:
Regional anaesthesia or epidural with chloroprocaine and midazolam 1mg and 2ml of fentanyl injection lead to preserved motor function but absent sensory function except peritoneal function. Thus able to walk after operation.
Technique:
6cm incision starts at pubic tubercle over inguinal canal towards ASIS. Only epidermis is cut with scalpel and remaining with electrocautery. Blood loss should be less than 5ml. Open the canal from external ring to internal ring by cutting the external oblique aponeurosis and separate the medial and lateral leaf from underlying structures. Put the spermatic cord in a rubber drain at the level of pubic tubercle.
Now for Indirect hernia Only separate and not cut the cremasteric muscle longitudinally from the spermatic cord. The sac is and lipoma of cord are dissected and cleared from the surrounding structures by pulling on it and clearing it till the internal ring till the preperitoneal fat pad is visualized. Except in case of strangulation or incarceration the sac is not opened and simply retuned.
While for Direct hernia the transversalis fascia is lifted with an Allis clamp and cleared upto the pre-peritoneal fat pad and care is taken not to dissect anything other than attenuated transversalis fascia.
The Mesh plug is inserted after reducing both sacs. The narrow end is inserted first and the petals are stitched at least at two locations. However if the internal ring is grossly attenuated than fix the mesh plug with multiple interrupted stitches and then check via cough or straining to make sure that it is intact.
Similarly the transversalis fascia and transverses abdominis muscle is invaginated and mesh plug in inserted in direct hernia and sutured to the margins of the defect and checked for patency. For further strength On lay patch is applied in the shape shown below:
It is placed on posterior wall of inguinal canal from pubic tubercle to above the internal ring, the slit is for internal ring and it stitched after placement. The mesh has a Velcro like effect.
The cord is placed back in the canal and external oblique aponeurosis is approximated with continuous stitches and scarpa’s stitched and skin with subcuticular. And transparent dressing applied.
Recurrent Hernia:
Minimal dissection is done, spermatic cord is not mobilized, the key is pearly white edge of sac of the hernia and it is dissected upto the internal ring or margins of defect in case of indirect and direct hernia respectively until the preperitoneal fat pad is seen. The integrity of previous repair as well as femoral canal is determined via inserting a finger and the sac reduced and plug inserted in internal ring or the defect and stitched with multiple interrupted sutures. Onlay mesh is only applied if there is enough space and spermatic cord has been mobilized.
Femoral Hernia:
After the sac has been identified, it is reduced and if big it is excised and ligated and then reduced followed by inserting a petals cut Perfix mesh with its narrow end first and stitching it t the margins of the defect, followed by closure. The patency is checked by cough and straining.
Post-op:
60 mg of IM ketorolac is given in recovery and than propoxyphene and paracetamol is advised as analgesia if required. 9-10 kg weight lifting is allowed while heavy weight lifting after 2 weeks.
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