The technical de surgical treatment of inguinal hernias are many et Varied. The choice of a process is difficult because of the large number of techniques proposed. In this article, we invite you to discover the essentials to know about the operating techniques during a inguinal hernia.
Brief reminder about inguinal hernia
La inguinal hernia corresponds to the passage of an intra-abdominal element (viscera) through the abdominal wall.
It results in the appearance of a arch in the groin area, which can be reducible (by simple pressure or when lying down) or irreducible (we then speak of a strangulated hernia).
This protrusion can be done:
- either by the deep inguinal orifice which has become too loose;
- or by an orifice appearing accidentally by rupture of the wall of the abdomen following numerous repeated efforts, for example.
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The different surgical techniques for an inguinal hernia
Herniorraphy (direct surgical repair of an inguinal hernia)
1. Positioning the patient
The operation can be performed under local, locoregional or general anesthesia. The patient is installed in the supine position (lying on the back).
A 2 cm incision is made on the lower abdominal skin fold opposite the superﬁcial inguinal orifice. It is located 1 cm outside the pubic spine.
3. Dissection of the hernial sac
The dissection of the underlying adipose tissue is carried out with an electric scalpel up to the fascia superficialis (membrane located under the skin which envelops our entire body). The latter is opened with fine scissors.
The practitioner then uses Faraboeuf retractors (instruments to spread and keep the two parts of an incision in place) to highlight the superﬁcial inguinal orifice from which the hernia sac emerges.
Exposure of the sac can be facilitated by opening the superficial inguinal orifice in the direction of the muscle fibers of the external oblique muscle, taking care not to injure the genital branch of the genito-femoral nerve.
The dissection of the bag is done using Christophe forceps along the internal face of the crural arch under the superficial inguinal orifice for its lower edge and under the joint tendon for its upper edge. It is performed slightly below the plane of the superficial inguinal orifice, which allows in the event of perforation of the bag to resume the dissection higher up.
4. Identification of the spermatic cord
After dissection of the hernial sac, the elements of the spermatic cord are identified. The cord is separated from the bag and stretched over an atraumatic clamp.
5. Dissection of cord and sac elements
The dissection of the hernial sac is continued by freeing it from the spermatic cord. This dissection must be meticulous, the bag must be freed without damaging the elements of the cord and without being opened. The cremasteric fibers which surround the sac can be separated in their axis at the upper surface of the cord.
This allows the sac to be better exposed, which is then caught using dissecting forceps. The external side of the bag is in slight tension and the elements are lowered using another dissecting forceps.
6. Closure of the peritoneal-vaginal canal
Care should be taken during this stage to always control the distance from the spermatic cord. The isolated hernia sac will be closed using Christophe forceps after having checked its emptiness (absence of digestive contents). The peritoneal sac is cut with scissors.
A stitch with an absorbable thread (sterile thread mounted on a needle) is made at the base of the sac as close as possible to the superﬁcial inguinal orifice, in order to prevent a recurrence (hernia in the sac).
And for the parietal closure, we use a single strand thread with slow resorption.
7. Parietal closure
The surgeon closes the superficial inguinal orifice lengthwise with an absorbable suture, avoiding taking the genital branch of the genito-femoral nerve and the spermatic cord.
The fascia superficialis is closed with separate stitches of the same thread.
Finally, skin closure can be achieved by an intradermal overlock with resorbable thread. A waterproof dry dressing is then applied. Finally, the position of the testicle in the homolateral purse is checked.
8. Prosthetic plasties
These techniques consist of implement a prosthesis of non-absorbable tissue covering the orifice of weakness in the hernial region.
There are 2 types of approaches first.
- Classic approach (inguinal incision).
- Laparoscopic route.
These prostheses cover the areas of dehiscence or traction on the muscular or aponeurotic structures.
Hernia repair by laparoscopy
It's about a surgical technique thanks to which the surgeon operates "with a closed stomach". He uses instruments and a camera which are introduced through small skin incisions in the abdomen. The intervention consists of placing a prosthesis. It requires general anesthesia with an approach by camera in the preperitoneal space.
It can be done in 2 ways.
This is done by direct access to the preperitoneal space. We do not go into the abdominal cavity. The operation takes place in the space between the muscles and the peritoneum.
2. By trans-abdominal preperitoneal route
In this case, the (peritoneal) incision begins outside the anterosuperior iliac spine and extends medially to the homolateral umbilical ligament, remaining close to the deep inguinal orifice.
The posterior peritoneal flap is dissected first with the peritoneal sac. Then, the (peritoneal) sac is completely freed from the inguinal canal, cord elements and iliac vessels. A prosthesis is placed, which covers the transversalis fascia, the transverse arch and the inguinal orifice. The prosthesis may not be fixed. But if it is, it is fixed with staples to the Cooper's ligament, to the rectus, just inside the internal orifice. Once the prosthesis is correctly in place, the posterior peritoneal flap is closed.
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