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General inguinal hernia repair is a surgical operation. The operation site is the abdomen. The anesthesia method is inhalation anesthesia, general anesthesia, and the operation method is surgery.

General inguinal hernia repair

General inguinal hernia repair is a surgical operation. The operation site is the abdomen. The anesthesia method is inhalation anesthesia, general anesthesia, and the operation method is surgery.

Chinese name

General inguinal hernia repair

Fully revealed

The incision must be above the inferior abdominal artery

Inner ring

Complete separation of the hernia sac at the inner ring

Hemostasis

The size of the bleeding point along the spermatic cord

There are many surgical methods for repairing inguinal hernia, which should be selected according to the specific circumstances of the patient's age, the size of the hernia sac, the duration of the disease, and the presence or absence of recurrence.

1. Adult abdominal hernia repair, except for those who have incarcerated or strangulated should be emergency surgery, elective surgery.

2. Adults with increased intra-abdominal pressure (such as ascites, urinary retention, severe chronic cough, etc.) or other systemic serious diseases (such as pulmonary heart disease, heart failure, etc.), and early and late pregnancy, are not suitable Surgical treatment.

3. Many inguinal hernias in children can heal with age. About 40% of infants and young children with oblique hernia due to congenital peritoneal herniation are self-healing in about 6 months after birth, and about 60% to 2 years old. Therefore, smaller hernia sacs less than 2 cm in diameter are suitable for surgery after 1 to 2 years of age.

4. When an incarcerated oblique hernia also suffers from a local skin disease, surgery should be performed after the skin disease is cured.

1. Clear diagnosis of oblique hernia or straight hernia, or coexistence of both, whether it is slippery hernia, incarcerated or strangulated, etc.

2. Learn in detail the severity of intestinal obstruction, dehydration, shock, etc., and which serious diseases are complicated by the whole body, and actively take corresponding preventive measures.

3. Empty the bladder before surgery.

Epidural anesthesia for adults; ketamine or sacral anesthesia for children.

(I) Repair of inguinal hernia with spermatic cord in situ (Ferguson)

1. Posture, incision supine position. An oblique incision parallel to the inguinal ligament is made from 3cm above the midpoint of the inguinal ligament to the pubic tubercle and is about 6cm long.

2. After exposing the hernia sac to open the skin, the first thing encountered is the superficial fascia (ie, subcutaneous fat). When cutting this layer, two superficial abdominal wall arteries can be seen in the operative field (ie, the superficial abdominal wall arteries in the outer section of the incision and the superficial external vulva arteries in the inner section of the incision). They should be ligated and cut one by one to prevent unnecessary bleeding , And then cut the deep layer of superficial fascia along the incision direction.

Use gauze-wrapped fingers to bluntly separate the connective tissue below the deep layer of the superficial fascia to expose the oblique tendon of the external abdomen. Make a small cut in the external oblique tendon, use the scissors to sneak under the aponeurosis, then use the scissors to lift the aponeurosis, and cut up and down in the direction of the fiber, so as not to damage the diaphragm that is close to the aponeurosis. Inferior and sacral inguinal nerves. When cutting downwards towards the outer ring, you can use forceps to insert the outer ring and stretch it out to avoid sacral inguinal nerves passing through the outer ring.

Use small hemostats to clamp and lift the two edges of the external oblique tendon, and use gauze-wrapped fingers to separate the sides of the aponeurotic incision. The inferior lateral border needs to be separated from the inguinal ligament, and the superior medial side must be separated from the intraabdominal oblique, transverse free abdominal margin and joint tendon. During the separation, care should be taken not to damage the inferior diaphragmatic nerve and diaphragmatic inguinal nerve on the deep side of the external oblique tendon.

Pull the internal oblique and transverse abdominal muscles upward with a right-angled hook to reveal the spermatic cord and the cremaster muscle overlying it. Cut the cremaster muscle in front and gently clamp the incision margin with small hemostats and pull it to the sides to see the spermatic cord.

Carefully separate the spermatic cord, paying attention to the surrounding tissue, and look for the hernia sac above and below the spermatic cord. In case of difficulty, the patient can be instructed to cough or contract the abdominal muscles so that the hernia sacs protrude. After the hernia sac is identified, it can be lifted and cut.

3. High Ligation Hernia Sac For high ligation of the hernia sac, the hernia sac must first be separated upward to the inner ring. When separating the hernia sac, you can use a hemostat to lift the incision of the hernia sac, and use your left finger to extend into the hernia sac as a support, and then use your right finger to wrap the gauze carefully and bluntly to separate the hernia sac and spermatic cord. If the adhesion is heavy, sharp separation can also be used.

Separation of the hernia sac when you see extraperitoneal fat, it has been divided above the neck of the hernia sac. The inner structure should be identified at the inner ring. Inside the hernia sac, an arcuate ventral fascial defect margin is often seen. Put your finger through the neck of the hernia sac into the abdominal cavity, and touch the inferior abdominal wall artery to pulsate under the inner ring. The spermatic cord is outside and below the hernia sac, and the vas deferens are usually close to the wall of the hernia sac. Avoid injury during separation. Then push the contents of the hernia into the abdominal cavity with your fingers.

If the hernia sac is small, it can be sutured and cut in the neck; if the hernia sac is large, the free edge of the hernia sac can be lifted and the neck of the hernia sac can be pulled out as far as possible. Use a No. 4 silk thread for purse suture at the neck high. After the purse sutures are tightened, suture reinforcement is performed to make the peritoneum no longer have bag-shaped protrusions. The hernia sac was then removed 1 cm distal to the suture. Care must be taken to avoid spermatic cord and blood vessels under the abdominal wall when suturing, and also to avoid tying up abdominal organs. If the hernia sac is large, the lower half of the hernia sac can not be separated, and the upper half is excised only after the middle is cut off, and the lower half is retained to reduce tissue damage and bleeding. Finally push the stump of the hernia sac back into the extraperitoneal space.

4. Repair the abdominal wall without spermatic cord displacement.

First, gently pull the upper spermatic cord outward and downward, and use a No. 4 silk suture to intermittently suture the arc-shaped defect of the transverse transverse fascia. Generally, 3 to 5 stitches are required. Pass the tip of a hemostat. When suturing, care must be taken to avoid damage to the inferior abdominal wall artery and the deep spermatic cord and pubic vasculature from the deep side of the abdominal transverse fascia.

Secondly, after cutting the margin of the cremaster muscle for intermittent suture, use 4 or 7 silk threads to start the joint tendon intermittently on the inguinal ligament, with a needle pitch of about 1cm. After all the stitches are stitched, tie the threads in order from top to bottom. The pinholes on the inguinal ligament should be shallow and wide to prevent damage to the femoral arteries and veins. Do not sew several pinholes between the same fiber bundles to prevent tearing after tensioning and affect the strength after repair. Also pay attention to avoid excessive tension when stitching, which affects healing.

Then, the two layers of the external oblique tendon were overlapped and sutured intermittently with a No. 4 silk thread. When sewing to the outer ring, care should be taken to keep a gap that can accommodate a small fingertip, so as to prevent the newly formed outer ring from being too small, affecting blood flow in the spermatic cord, scrotal sacs, and even testicular atrophy. In the same fashion, we should pay attention not to sew the iliac crest, groin nerve and bladder.

5. Suture carefully to stop bleeding, if necessary, apply warm saline gauze to pressure the wound surface, the small bleeding points should be ligated one by one; then rinse the wound, and suture the superficial fascia layer and the skin intermittently with a thin silk thread. No drainage is required under normal circumstances.

(B) Repair of inguinal hernia with spermatic cord subdendronal displacement (Bassini)

The initial procedure is the same as that of inguinal hernia repair in situ. Only when repairing the abdominal wall, the spermatic cord is moved between the internal oblique and external oblique tendons, and the joint tendon is sutured to the inguinal ligament to strengthen the posterior wall of the inguinal canal. When repairing, the spermatic cord is pulled apart with a rubber sheet, and the defect on the abdominal transverse fascia is sutured intermittently. Then use 4-0 or 7-0 silk suture to suture the tendon and inguinal ligament intermittently, and sew about 4 to 5 stitches from top to bottom. Don't ligate first, wait for all the stitches, and then fasten from top to bottom. Place the spermatic cord outside the oblique muscle in the abdomen, suture the cremaster muscle intermittently, and then suture the abdomen oblique tendon in an overlapping manner. The outer ring needs to hold a small fingertip. Finally, the subcutaneous tissue and skin are sutured.

(3) Modified spermatic cord indirect inguinal hernia repair under the tendonpubic ligament repair (McVay)

The pubic ligament is the ligament that folds the inguinal ligament backwards into a pit ligament and then continues outward to the pubic comb line. McVay's autopsy shows that the joint of the tendon and the transverse abdominal fascia is not in the inguinal ligament, but in the pubic ligament. Therefore, the joint tendon should be sewn on the pubic ligament during repair. As a result, the recurrence rate of hernia can be reduced, and the chance of femoral hernia after repair is less. However, the pubic ligament is close to the femoral vein, which makes the operation difficult.

The initial procedure is the same as that of inguinal hernia repair in situ. During the repair, the spermatic cord was opened first and the abdominal transverse fascia defect at the inner ring was sutured intermittently. Then cut the anterior sheath of rectus abdominis longitudinally to reduce the tension of suture. Use your left hand to touch the femoral vein for protection, and then use 3 or 4 stitches of sutures combined with tendon and pubic ligament. The spermatic cord was placed outside the internal oblique muscle, and after the external oblique tendon was sutured, the subcutaneous tissue and the skin were sutured in order.

(D) repair of inferior inguinal hernia by subcutaneous displacement of spermatic cord (Halsted)

The characteristic of this method is that the spermatic cord is moved to the skin, and the layers of the abdominal muscles can be used to strengthen the posterior wall of the inguinal canal and reduce the recurrence of hernia. It is suitable for patients with old age, large hernia sac and weak abdominal wall.

During the repair, the spermatic cord was opened, and the defect of the abdominal transverse fascia at the inner ring was sutured intermittently with a thin silk thread, and then the joint tendon was sutured on the inguinal ligament with a 4-0 or 7-0 silk thread. The top stitch should not be sewn too much. Tighten, so as not to oppress the spermatic cord. Then the spermatic cord was placed outside the external oblique tendon and the external oblique tendon was sutured. Sometimes, at the exit of the spermatic cord from the inner ring, a small horizontal cut is required at the upper end of the incision of the external oblique tendon, and some fibers are cut so that the spermatic cord is not compressed. Finally, the spermatic cord is placed in the subcutaneous layer, and the subcutaneous tissue and skin are sutured intermittently.

(5) Abdominal Transfascial Repair (Shouldice)

The most essential part of the Shouldice operation is to repair the inner abdominal orifice and the transverse fascia at the bottom of the inguinal canal. This method is mainly applicable to huge oblique hernias, straight hernias, and breeches hernias that coexist with straight and oblique hernias.

The steps before hernia sac removal are the same as before. When separating the neck of the capsule, you must reach the mouth of the inner ring. Separate the edge of the ventral transverse fascia from the periphery of the inner ring, purse the neck or pierce the ligature, remove the distal end of the hernia sac, and allow the stump of the hernia to retract into the inner ring Extraperitoneal space. At this time, use anatomical forceps or hemostatic forceps to lift the abdominal transverse fascia on the inner edge of the inner ring mouth, see and push back the inferior abdominal wall artery and other extraperitoneal fat tissue, and cut the abdominal transverse tendon in the posterior wall of the groin tube toward the pubic tubercle. membrane.

First lift the upper lateral flap of the abdominal transverse fascia, separate the fatty layer below it, and then lift the lower flap. Note that the branch from the inferior abdominal wall artery penetrates the fascia flap to the cremaster muscle and spermatic cord, that is, the external spermatic artery, in the branch. The base was cut and ligated. The inferior fascial flap must be detached until it fuses deep into the inguinal ligament. After adequate hemostasis, transabdominal fascia repair and inner ring reconstruction were performed. Double counter suture technique is adopted, and 4-0 or 7-0 silk thread is used to start and cross continuous suture starting from the lower end. The inferior lateral fascial flap overlaps and sutures to the deep side of the superior medial flap, and continues to the outer edge of the inner ring, leaving the spermatic cord exit.

Then, cover the free edge of the upper medial fascia flap over the lateral flap, and then continue to sew from the top of the free edge of the upper and lower flaps to the deep inguinal ligament to the pubic tubercle, starting with the first stitch. Stitches are knotted, and the stitch pitch is 2mm to 4mm. At different depths, they are stitched into uneven jagged shapes to increase strength. Complete the repair of the posterior wall of the inguinal canal and the reconstruction of the inner ring mouth.

Finally, the combined tendon and transverse abdominal aponeurosis (arch) are sutured to the inguinal ligament to strengthen the posterior wall of the inguinal canal. The spermatic cord is placed under the external oblique fascia and the fascia is sutured.

1. Massive bleeding during hernia repair can cause serious consequences. The three blood vessels most commonly bleeding are the abnormal origin branch of the obturator artery, the deep branch of the subventricular vessel, and the extrasacral or femoral arteries and veins.

The main cause of major bleeding is when the inguinal ligament is sutured, the stitches are too deep, and the blood vessels are punctured to cause bleeding. Therefore, when performing suture, on the one hand, the sutured ligament should be lifted as far as possible to leave the blood vessel, and on the other hand, the left hand finger can be used to push the femoral artery and vein outward. In case of bleeding, small blood vessel damage can be suppressed with compression. If the compression is not effective, the exposed area can be expanded and ligated (inherent communication branch, no tissue blood flow disorder will occur). However, in case of large blood vessel damage, it is necessary to enlarge the incision in time, temporarily compress the bleeding upper and lower blood vessels, and then repair the blood vessel breach with 3-0 silk thread. Ligation is considered a last resort. In addition, due to scrotal tissue looseness, even small bleeding points are not easy to stop bleeding by themselves, resulting in the formation of hematomas. Therefore, no matter the size of the bleeding point should be carefully ligated during operation.

2. Inferior abdominal wall nerve injury The lower abdominal wall nerves are densely distributed. Avoid injury when cutting the layers of the abdominal wall. Once cut off, the stump should be ligated to prevent blood vessels from oozing.

3. Vasectomy Injuries to young men may be considered during the operation.

4. Testicular blood transport injury Testicular supply blood vessels are more, the main branch is the internal spermatic artery (ie, testicular artery) from the abdominal aorta. In addition, there are external spermatic cord arteries, vas deferens arteries, inferior bladder arteries, prostate arteries, and genital arteries8. These arteries are connected by communication branches, so testicular ischemia and necrosis are generally not prone to occur. Even so, during hernia repair, if the spermatic cord is tightly attached to the hernia sac, the small blood vessels of the spermatic cord should be avoided during the separation process. In addition, care should be taken when sewing the inner and outer rings through which the spermatic cord passes.

5. Abdominal organ damage during the repair operation of the hernia, the most vulnerable abdominal organ is the intestine. The bowel can be cut when the hernia sac is cut, or the bowel can be ligated when the hernia sac is ligated, so check carefully before taking these two steps, and take precautions to avoid injury. The bladder is also vulnerable, especially in children where the bladder is located higher, the hernia sac is closer to the bladder, and the hernia sac is more susceptible to injury when it is separated or sutured, and must be avoided. If you cannot determine the hernia sac or bladder, you can try a puncture first; if you are not sure, you should use the abdominal approach to identify. Once visceral damage occurs during the operation, it should be repaired in time.

6. Double transverse suture of abdominal fascia should be performed on the plane and depth of irregular crossing, and finally a jagged suture is formed to increase strength and avoid tearing.

1. Protect wounds from wet urine stains. The local gauze bag is 12 to 24 hours, and the scrotum is supported to prevent hematoma.

2. Prevent the factors that cause increased intra-abdominal pressure. Such as controlling cough and preventing constipation.

3. Get out of bed 2 to 3 days after surgery, remove the stitches after 1 week, do general labor after half a month, and do heavy physical labor after 3 months.

Systemic complications

Common systemic complications after hernia repair include pneumonia, atelectasis, lower extremity thrombophlebitis, and urinary system infections. All of them should be prevented after surgery.

Incision subcutaneous (or scrotal) hematoma

Mostly due to incomplete hemostasis during surgery. Small hematomas can be extracted by puncture; if the hematoma is gradually increased, the suture should be disassembled again under aseptic operation in the operating room, and the hemostasis should be carefully stopped. Otherwise, often due to loose scrotal tissue, hematomas continue to increase, resulting in infection of the incision and affecting healing.

Incision infection

If you feel incision jump pain and fever all over the body, you should check in time. If an incision infection is found, in addition to using antibiotics throughout the body, local drainage and drainage should be considered as appropriate.

Testicular effusion

It often occurs in patients who have not removed the lower half of the hernia sac. During the operation, the lower half of the hernia sac can be opened to reduce the chance of effusion. If this occurs, be careful with puncture and aspiration.

relapse

Most of the recurrences of hernias are caused by the hernia sac neck not being truly high ligated and the internal ring mouth abdominal transverse fascia defect not repaired, and partly due to inadequate suture of the posterior wall of the groin. These should be handled during the first operation to avoid recurrence. In addition, older patients, poor general conditions, and postoperative complications are all factors that cause recurrence.