1. Most inguinal hernias are repaired.

2. Repair techniques: There are several open and laparoscopic techniques described to repair an inguinal hernia:

3. Selecting the correct approach to repair an inguinal hernia.

1. The diagnosis of groin swellings is notoriously difficult. Experienced as well as inexperienced surgeons make frequent mistakes. Do not accept the diagnosis of the referring doctor, but take a fresh history and carry out a complete examination. Is there another possible cause for the patient’s symptoms apart from the hernia? If a clear history of a reducible intermittent lump in the groin is accompanied by a negative examination, a hernia will be found on exploration; if in doubt, consider herniography.

2. Palpation is not the only or even the most important method of examination. Look with the patient standing and again with the patient supine. If you see a lump, ask yourself ‘Where is it?’ If it is reducible, where does it first reappear on coughing or straining? A cough impulse may be absent, especially over a femoral hernia in which a small sac is covered by much fatty extra-peritoneal tissue. Conversely, a cough impulse is present over Malgaigne’s (Parisian surgeon 1806–1856) bulging, or a saphena varix.

3. Always examine the scrotum and its contents in male patients. If there is a swelling, ask yourself the fundamental question ‘Can I get above it?’ Occasionally you discover undescended testes; deal with them at the same procedure.

4. Finally, examine the other hernial orifices.

1. Obtain the patient’s signed consent, warning of the possible complications of haematoma (especially for large inguinoscrotal hernias), ischaemic orchitis, persistent groin pain, hernia recurrence, wound and mesh infection, and damage to local structures, which can be more significant with a laparoscopic approach. In laparoscopic surgery obtain consent for conversion to open repair if necessary. Discuss with the patient what action you should take, if, at operation for unilateral hernia, an unexpected, asymptomatic contralateral hernia is revealed. Record the agreed consent on the form.

2. Mark the hernia side.

Local anaesthesia for inguinal hernia repair

1. Start the incision a finger’s breadth above the palpable pubic tubercle within the skin crease which is often present (as opposed to parallel to the inguinal ligament) and extend this to two-thirds of the way to the anterior superior iliac spine. Incise the fascia to expose the external oblique aponeurosis, ligating and dividing two or three large veins that cross the line of the incision. Avoid cutting into the hernial sac and spermatic cord at the medial end of the incision.

2. Expose the glistening fibres of the external oblique aponeurosis and identify the external inguinal ring, which confirms the line of the inguinal canal.

3. With a scalpel split the external oblique aponeurosis in the line of the fibres. Enlarge the split medially and laterally by pushing the half-closed blades of the scissors in the line of the fibres. At the medial end of the split you open the external inguinal ring. Ensure that you do so. Do not allow curved blades of scissors to skirt around the crura of the ring. Preserve the ilioinguinal nerve, lying under the external oblique, to minimize the risk of postoperative numbness and pain.

4. Apply artery forceps to the edges of the aponeurosis and gently elevate each side. As you evert the upper leaf, look for the arching lower border of internal oblique muscle, with the cord below it. As you evert the lower leaf, sweep loose tissue from the deep surface of the inguinal ligament.

1. Start to mobilize the cord by incising, just above and lateral to the public tubercle, the ‘mesentery’ of fascia and fibres of cremasteric muscle that extends downwards from the medial part of the conjoint tendon to envelop the cord. Deepen this small incision behind the cord, drawing the latter downwards while passing the index finger from below against the pubic tubercle, to develop a plane to encircle the cord and apply a hernia ring.

2. Now dislocate the cord laterally and downwards by incising the coverings along lines just above and below it. This exposes a direct hernia, which can be freed from the cord.

3. Carefully divide the fibres of cremaster just distal to the internal ring, ensuring haemostasis.

4. Even though a direct hernia is evident, examine the cord. Normally it is about the thickness of a pencil. It is markedly distended by an unreduced, sometimes adherent or sliding, hernia. A thickened sac results from a longstanding indirect hernia. Cord lipomata produce thickening, as does an encysted hydrocele of the cord (in females a hydrocele of the canal of Nuck). To exclude an indirect sac, open the spermatic fascia covering the cord and identify the edge of the peritoneum deep to the internal ring.

5. Identify the lower arching fibres of the internal oblique muscle, becoming tendinous at the conjoint tendon, and examine the posterior wall below this. A direct hernia may be a large bulge, a diffuse weakness of the whole posterior wall or, less often, a funicular hernia through a small localized defect (Ogilvie’s hernia).

6. If you have any concern that a femoral hernia may be present, incise the transversalis fascia to expose the upper aspect of the femoral canal. If a femoral sac is present, deal with it via a High approach repair (Lothiesen procedure, see later).

7. The cremasteric vessels pass medially from the inferior epigastric vessels adjacent to the cord. If the internal ring is enlarged it may be necessary to carefully identify, isolate, ligate and then divide the cremasteric vessels to facilitate a snug repair at the internal ring. If they are injured more medially, ligate them proximally and distally to the damage.

Indirect sac

Large indirect sac

Sliding indirect sac

Direct sac

Combined direct and indirect sac

1. The mesh should have overall dimensions of 11 cm × 6 cm. To accommodate this, separate the external oblique aponeurosis from the deeper layers superiorly and medially and from the muscular part of internal oblique laterally to create an adequate pocket to receive the mesh.

2. Prepare the polypropylene mesh as indicated in Figure 6.2A. The lower medial corner is slightly rounded, the upper medial corner rather more so. The mesh is then incised from its lateral margin, placing the cut one-third of the distance from the lower edge. The cut extends for approximately half the length of the mesh, depending upon the size of the patient; it may need to be extended when the mesh is in place. In small patients the upper edge may need to be trimmed slightly.

3. Place the mesh in its final position (Fig. 6.2B). Lift the cord and bring the narrow lower tail through under it, below the internal ring. Then tuck the lateral end under the external oblique; the lower edge of the mesh now lies along the inguinal ligament. Now insert the upper two-thirds of the mesh so that it lies under the external oblique aponeurosis superiorly and medially, ensuring that there is a good overlap on the rectus sheath medially. Tuck the wide upper tail under the external oblique laterally, with its lower edge over the lower tail. Insert your fingers under external oblique superiorly and laterally to ensure that the mesh lies quite flat in the peripheral part of the pocket, though there may be a slight bulge centrally.

4. The mesh does need to be secured in place across the posterior wall of the inguinal canal. Although most use polypropylene sutures, it is possible to use staples or glue. Start the fixation by passing a 2/0 polypropylene stitch through the mesh and the tissues overlying the pubic tubercle and tying this. Use this to form a continuous locking suture between the lower edge of the mesh and the inguinal ligament, working from medial to lateral, extending to at least 2 cm lateral to the internal ring. Take irregular bites of the inguinal ligament to avoid splitting it and do not allow the lower leaf of the external oblique to roll in and be included in the sutures; if this happens, there will be no external oblique left to close. For the medial part of this suture line it is best to retract the cord downwards. Then, as the suture approaches the internal ring, move the cord cephalad and pass the needle under it to continue laterally. When suturing immediately in front of the femoral vessels be careful to take only the ligament and not a bite of a major vessel!

5. If the slit in the mesh is too short extend it so that the cord passes directly from the internal ring to the opening in the mesh. A bulky cord may be accommodated by making a small cut in the mesh at right-angles to the slit. If you made too long a cut, all is not lost; simply shorten the slit with one or two sutures.

6. Overlap the tails of the mesh by bringing the lower edge of the upper portion in front of the lower tail and securing it to the inguinal ligament with two interrupted sutures (or by including it in the lateral part of the continuous suture). The resulting opening in the mesh should be a snug, but not a tight, fit around the cord (Fig. 6.2B).

7. Now secure the medial and upper margins of the mesh with about six interrupted sutures, avoiding the nerves (Fig. 6.2B). These are most conveniently placed 0.5 cm away from the edge, so that the mesh lies flat on the underlying aponeurosis or muscle. The medial sutures are particularly important as there is less overlapping of the mesh there, making it a potential site for recurrence.

8. The mesh repair is now completed. It appears slightly redundant centrally but that does not matter.

9. Replace the cord in the inguinal canal.

10. Wash the inguinal canal with any remaining local anaesthetic, making sure not to remove it too quickly.

11. Close the external oblique aponeurosis with a synthetic absorbable suture, starting laterally and ending medially to reform the external ring snugly but not tightly around the emerging cord. Once again, take care to take bites at unequal distances from the edges; otherwise you will pull from the cut edges a strip of aponeurosis.

12. Appose the subcutaneous fascia with fine absorbable stitches and close the skin wound (see above).

1. Following repair of inguinal hernia under local anaesthesia, allow the patient to leave the operating theatre on foot. This is good for confidence.

2. Encourage patients to mobilize immediately after recovery from general anaesthesia.

3. Activities should be limited only by the patient’s comfort.

1. Scrotal complications: Ischaemic orchitis is an uncommon complication presenting as pain and swelling in the first few days after hernia repair. In a proportion of cases it results in testicular atrophy. Damage to the vas should be recognized and repaired at the time of hernia repair. Hydrocele formation is more common after transection of the sac and resorbs spontaneously in most cases. Genital oedema, relatively common in the first 3 days, settles spontaneously, requiring reassurance only.

2. Haematoma: Bruising can be significant, often involving the scrotum, to the alarm of the patient, developing a couple of days after surgery. Even significant haematomas can be left to resolve, although this may take months and does increase the risk of orchitis, mesh infection and possibly recurrence and groin pain.

3. Wound infections: Reddening of the wounds is not uncommon, but frank purulent discharge is. If this persists, be concerned about a mesh infection and consider removing the mesh.

4. Nerve injury: Some degree of transient numbness below and medial to the incision is very common and may persist with little disability. Of much more significance is the incidence of chronic residual pain that occurs in at least 3% of conventional hernia repairs.

5. Urinary problems: Make sure you are aware of the possibility of bladder injury and recognize it at the time of surgery. Treat it by primary repair and insert an indwelling catheter until a cystogram demonstrates healing. Postoperative urinary retention becomes more common with age, after general anaesthesia and following bilateral hernia repair and usually resolves following a 24-hour period of catheterization.

6. Impotence: This is an occasional complaint for which there does not appear to be an organic basis.

1. Consider laparoscopic repair to avoid the adherent tissues.

2. For open operations, take considerable time to define the anatomy. This is difficult as there is distortion from the previous repair and all structures tend to be encased in fibrous tissue.

3. Once the anatomy is defined, secure the posterior wall and undertake a mesh repair as described.

4. Orchidectomy need not be considered, but warn the patient of the increased risk of ischaemic orchitis.

1. Incise or excise the previous skin scar.

2. Deepen the incision at a higher or more lateral level than the previous approach, so that unscarred external oblique aponeurosis is encountered first.

3. Display the external oblique aponeurosis downwards to the inguinal ligament.

4. Re-open the inguinal canal through the scar in the external oblique aponeurosis. Avoid damaging the contents of the canal, which will be adherent.

5. Elevate the upper and lower leaves of the external oblique aponeurosis until you reach unscarred tissue.

6. Isolate the spermatic cord below the pubic tubercle and follow it up to the internal ring. It may lie in an unusual place or be adherent and the vas may have been separated from the vessels.

1. Look for an indirect recurrence. If you find a sac, isolate it, empty it, then transfix, ligate and divide it at the neck.

2. Look for a direct recurrence. If the recurrence is funicular, isolate it, empty it, then transfix, ligate and divide it at the neck. If it is a diffuse bulge, invert the sac with a running suture to maintain the invagination.

1. Almost always, the repair should be a mesh repair as outlined above.

2. Occasionally, for a small well defined direct defect, a ‘plug’ repair can be undertaken. Insert a bunched-up piece of polypropylene mesh through the small defect into the extra-peritoneal space and secure it with a few sutures across the open defect.

1. Most operations listed as strangulated hernia are carried out for painful, irreducible or obstructed hernias.

2. An open approach to the strangulated inguinal hernia repair is easiest and most common,

3. Strangulation results from venous obstruction, a rise in capillary hydrostatic pressure, transudation of fluid, exudation of protein and cells, and eventual arterial obstruction. Alternatively, the pressure of a sharp constriction ring at the neck of the sac may cause local necrosis of the bowel wall.

4. Once diagnosed, try to reduce the hernia, making emergency surgery unnecessary and allowing for an early elective operation. The effect of reassuring the patient, who is laid supine in the head-down position, encourages spontaneous reduction. Try to gently reduce the hernia, making sure not to hurt the patient. There is a slight but real risk that you may reduce the hernia en masse: that is, the hernia remains within the peritoneal sac, the neck of which remains as a constriction, so the strangulation is not relieved. Some hernias reduce spontaneously when the patient is sedated prior to operation, or when anaesthesia is induced.

1. Do not rush patients with strangulated hernias to the operating theatre. Make sure you know any reason (such as urinary outflow obstruction or a chest infection) why the patient has developed strangulation now. Identify coincidental disease that may make general anaesthesia and operation hazardous.

2. If strangulation has been present for some time, the patient requires fluid and electrolyte replacement. This takes priority over the operation. It is likely, in such cases, that bowel in the hernia will already be irreversibly ischaemic, so little is lost by the delay.

1. The approach is open and identical to that for an elective operation.

1. If the history was short, the sac will frequently be empty by the time you expose it. The relaxation produced by the anaesthetic often succeeds when other conservative methods have failed to reduce a hernia. There is then no merit in exploring the abdomen. Repair the hernia as though this were an elective operation.

2. If bowel is present in the sac, do not let it slip back into the abdomen but gently draw it down into view. The bowel is likely to have suffered the greatest damage where it was trapped at the neck of the sac.

3. Feel the margins of the neck of the sac with a fingertip.

4. In Richter’s hernia, a knuckle of the bowel wall is trapped. The bowel lumen is thus not obstructed but the knuckle may become gangrenous and perforate.

5. Maydl’s strangulation is very rare. Two loops lie in the sac but the blood supply to an intermediate loop within the abdomen may be prejudiced so that it is gangrenous.

1. If the neck of the hernia sac is constricted, first draw down healthy bowel, then place an index fingertip on each side of the contents, nails facing outwards. Gently dilate the neck of the sac (Fig. 6.3). Make sure the bowel does not slip back. Draw it out to ensure that there is no peritoneal constriction and to expose healthy bowel.

2. If the bowel is viable, return it to the abdomen.

3. If necessary, resect a gangrenous segment of bowel, performing an end-to-end anastomosis.

1. Do not shave the abdomen.

2. Ensure that the patient empties the bladder before the operation. Do not routinely pass a urinary catheter. If preliminary laparoscopic assessment reveals that the bladder is full, pass a catheter before proceeding further with the operation.

3. Place the anaesthetized patient supine on the operating table with arms by the side as they sometimes interfere with the operation if they are folded across the chest.

4. Clean the abdomen with povidone-iodine 10% alcoholic solution or other antiseptic.

5. Drape the whole abdomen to give adequate exposure for the placement of port sites.

6. As the lead surgeon, stand on the side opposite the inguinal hernia, or the hernia which is largest (Fig. 6.4). An assistant and/or ‘scrub’ nurse stands on the other side (Fig. 6.5).

7. Position television monitors at the foot of the patient. Although one screen is sufficient, a second screen helps the assistant.

8. Ensure that you can observe the carbon dioxide insufflator to monitor gas flow and intra-abdominal pressure.

9. Do not have a screen between you and the anaesthetist as this interferes with your manipulation of instruments.

1. Make a transverse incision exactly 1.5 cm from the midline immediately below the umbilicus on the side of the hernia. Make the incision to the side of the larger of the hernias when bilateral hernias are to be repaired (Fig. 6.6).

2. Deepen the incision to the rectus sheath using small retractors to facilitate dissection.

3. Incise the rectus sheath for about 1 cm.

4. Identify the medial border of the rectus muscle and retract it laterally. Access has now been gained to the space within the rectus sheath.

5. In order to fashion a pre-peritoneal space, pass a 10-mm trocar and cannula with a balloon at its tip into the rectus sheath and guide it downwards until it reaches the pubic symphysis and then angle the tip to a position just behind the symphysis (Fig. 6.7).

6. Insert a 30 degree laparoscope into the cannula and maintain the tip of the cannula at a point immediately deep to the pubic bone. Gently inflate the balloon around the end of the cannula until the pubic bone is visible, thereby creating a space between the peritoneum posteriorly and the rectus muscle anteriorly. The lower edge of the posterior rectus sheath can be seen (arcuate line). Inflate the balloon under direct vision and resist the urge to pump the balloon up quickly as this will reduce the likelihood of bleeding. Ensure that the balloon inflates completely. Approximately 30 pumps are required (Fig. 6.8).

7. Deflate the balloon and withdraw the cannula. Replace the 10-mm cannula with another that has a small retaining balloon at its tip and inflate this so that the balloon sits just inside the rectus sheath (Fig. 6.9). The cannula is designed so that there is very little extension beyond the balloon, ensuring that the cannula does not get in the way of the two further cannulas that will be needed. Pass the laparoscope back into position through the umbilical cannula.

8. Attach the gas lead to the cannula and inflate with carbon dioxide up to a pressure of 8–10 mmHg. Note the partially created pocket in the pre-peritoneal space. Further dissection is now required.

9. Place a second 5-mm trocar and cannula under laparoscopic vision in the pre-peritoneal space already created using a 1-cm midline incision approximately three fingerbreadths below the umbilical cannula at the level where the posterior rectus sheath becomes deficient. This ensures that the second cannula is placed as high as possible in order to facilitate further dissection of the pre-peritoneal space, but is not placed too close to the umbilical cannula, which would cause technical difficulties.

1. Place a blunt-ended 5-mm dissector in the second (subumbilical) cannula and enlarge the pre-peritoneal space by blunt dissection.

2. Clarify the anatomy. Note the pubic bone medially. Identify the inferior epigastric vessels, which are normally visible at this stage (Fig. 6.10).

3. Strip the peritoneum downward away from the anterior abdominal wall. Do not start at the internal ring but dissect laterally and medially first.

4. Commence the dissection laterally in the region of the anterior superior iliac spine and ensure that the epigastric vessels do not come down with the dissected peritoneal sac but remain up on the anterior abdominal wall.

5. Coagulate small blood vessels and do not rush this phase of the operation.

6. Continue to strip the fat and areolar tissue and the peritoneal sac downwards and backwards in the lateral part of the dissection to reveal a portion of the psoas muscle.

7. Identify the pubic bone medially and gently strip the peritoneum down from this area. The bladder will be seen below the pubic bone near the midline and is gently stripped downwards and backwards. Look for the sac of a direct inguinal hernia, which will be seen attached to the white fold of transversalis fascia.

8. Note an indirect sac as it passes forwards into the internal ring close to the lower end of the inferior epigastric vessels.

1. Create a space for an additional 5-mm cannula by enlarging the preperitoneal pocket by blunt stripping of the peritoneum away from the muscles of the anterior abdominal wall on the side of the hernia.

2. Identify the point of insertion by placing the scope near the abdominal wall and seeing the light shine through. Then insert a needle through the abdominal wall and confirm this by seeing it in the extra-peritoneal space. Inject some local at this time. Place the 5-mm trocar and cannula under laparoscopic vision at a point 2 cm medial to the anterior superior spine on the side opposite the hernia. Use this cannula to pass the 5-mm forceps.

3. Retract and free a direct hernia sac by stripping it away from the white fold of transversalis fascia using blunt and occasional scissors dissection. Make sure the sac is completely freed from its coverings and the pre-peritoneal space can be enlarged below it.

4. Turn your attention to the region of the internal ring.

5. Using a mixture of blunt and, if necessary sharp, dissection carefully dissect the tissues in the region of the internal ring and identify any hernia sac.

6. Grasp an indirect sac with the left-hand grasper and pull it backwards, stripping tissue away from it with the right-hand instrument. As you withdraw the sac place the right-hand forceps beyond the left-hand forceps and further retract the sac with the right hand using the left-hand instrument to strip tissue away from it. Large sacs can usually be withdrawn in this way (Fig. 6.11).

7. As the indirect sac is gradually withdrawn, look for the vas deferens or round ligament (passing medially) and the gonadal vessels (passing laterally). These structures are applied to the deep surface of the peritoneum at the internal ring.

8. Using blunt and sharp dissection separate the vas deferens and gonadal vessels from the peritoneum of the sac so that the latter can be fully withdrawn (Fig. 6.12).

9. When you have withdrawn the sac fully, strip the peritoneum back further from the internal ring to enlarge the pre-peritoneal pocket. The edge of the peritoneum should be at least 3–4 cm distant from the internal ring (Fig. 6.13).

10. Avoid injury to the iliac vessels, which lie deep to the triangle between the vas deferens and the gonadal vessels. Do not tamper with the fatty tissue deep to these structures as they protect you from damaging the iliac vessels

11. Prepare a similar pocket in the pre-peritoneal space on the opposite side if you are repairing bilateral hernias.

12. For unilateral hernias prepare a 15-cm × 10-cm patch of polypropylene mesh. To orientate the mesh correctly mark the long axis of the mesh by drawing a line on it.

13. Grasp the mesh with forceps and insert it into the pre-peritoneal space using the midline subumbilical cannula.

14. Position the mesh so that it covers the inguinal region from the midline, passing laterally for 15 cm. Ensure that it covers the region of the internal ring, the region medial to the inferior epigastric vessels and the femoral canal and that it reaches the midline. Ensure that the mesh is lying flat against the anterior abdominal wall and on the psoas muscle (Fig. 6.14).

15. Staple or glue the mesh in position. Do not leave it unfixed. If you are using staples, secure the lower medial part of the mesh to Cooper’s ligament or the pubic bone first, then fix the upper border of the mesh to the abdominal wall. Do not place staples elsewhere.

16. Place a second mesh in a similar fashion if treating bilateral hernias. It is important that the right- and left-sided meshes overlap the midline.

1. Check that there is no bleeding and control it with diathermy or clips.

2. Remove any staples that have fallen loose.

3. Place a large volume of low concentration local anaesthetic into the pre-peritoneal space.

    Disconnect the insufflation and, as the pre-peritoneal space ‘collapses’, ensure that the mesh remains flat against the anterior abdominal wall. It is important that the lower edge of the mesh is not lifted up by the peritoneum as the pre-peritoneal space collapses.

4. Remove the cannulas and check that there is no bleeding.

5. Close the anterior rectus sheath as hernias can develop here. Close the skin incision with a single polypropylene 3/0 suture

1. Create a pneumoperitoneum using an open (Hasson) technique (see Chapter 5).

2. Make a vertical 1-cm incision from the centre of the umbilicus towards the symphysis pubis. Incise down to the rectus sheath. Open it to enter the peritoneal cavity under direct vision.

3. Insert a 10-mm blunt-tipped trocar and cannula into the peritoneal cavity under direct vision.

4. Attach the lead from the insufflator to the cannula and rapidly create a pneumoperitoneum up to a maximum pressure of 13–14 mmHg.

5. First ‘white-balance’ the video camera. Remove the trocar and pass a laparoscope into the cannula and into the abdomen. Prefer a 30-degree scope. Direct the laparoscope towards the groin.

6. Adjust the operating table so that the patient is positioned head-down and allow the intestines and omentum to fall away from the groin area to facilitate your view of the hernia orifice.

7. Under direct vision, create two new ports. Insert a 5-mm trocar and cannula at the level of the umbilicus lateral to the lateral border of the left and right rectus muscle (Fig. 6.15).

1. If adhesions obscure your view of the inguinal region, divide them carefully using scissors and diathermy. If they are very dense, consider conversion to open hernia repair.

2. Now establish the anatomy as it relates to the hernia (Fig. 6.16). Starting at the midline, identify the bladder and the median umbilical ligament (obliterated urachus) on the inner aspect of the lower abdominal wall. Check that the bladder is not full and catheterize the patient if it is.

3. Moving away from the midline, identify the medial umbilical ligament (obliterated umbilical artery). Immediately lateral to this is the area through which a direct inguinal hernia may pass. Lateral to this, note another ridge, the inferior epigastric vessels that form the lateral umbilical ligament. Lateral to this again is the internal ring through which an indirect inguinal hernia may pass.

4. Moving yet further laterally, compress the abdominal wall at the anterior superior iliac spine and note the lateral extent of the dissection for the TAPP repair.

5. Locate the region of the internal ring by looking for two divergent structures which emerge from it. Passing medially, particularly in thin patients, identify the vas deferens (round ligament of the uterus in females) beneath the peritoneum. Passing laterally from the internal ring is a less distinct ridge caused by the gonadal vessels. Between the diverging vas and the gonadal vessels is the ‘triangle of doom’ containing the external iliac vessels.

6. Identify whether the hernia is direct (medial to the inferior epigastric vessels) or indirect (lateral to the inferior epigastric vessels).

7. The steps involved in the repair of direct and indirect hernias are essentially the same. However, whereas a direct hernia sac is normally easy to retract, a large indirect hernia sac may be difficult to retract from the scrotum and may need to be divided at or distal to the internal ring. Check that there is not an unexpected hernia on the other side. Now decide whether your repair will be unilateral or bilateral.

8. Do not be alarmed if you find a sliding hernia, as you should not separate the colon from the peritoneal sac. The colon will be retracted with the sac when you are dissecting a pre-peritoneal pocket in which to place the mesh.

1. Ensure that any contents of the hernia sacs are reduced. Omentum adherent to the inside of the sac can be separated with scissors and diathermy. If the contents cannot be reduced laparoscopically, convert to an open repair.

2. Prepare a pre-peritoneal pocket between the peritoneum and the abdominal muscles in which to place the artificial mesh. The pocket should extend from the midline medially to approximately the level of the anterior superior iliac spine laterally. For bilateral hernias, pockets need to be fashioned on both sides and become continuous across the midline. A single large mesh or two individual meshes can be used for bilateral hernias.

3. Pick up the peritoneum 1–2 cm above the hernial orifice and make a short incision through the peritoneum using scissors with diathermy attached for haemostasis (Fig. 6.17). Gas may now enter the pre-peritoneal space and help to lift the peritoneum away from the underlying fascia and muscles.

4. Extend the incision laterally to a level below the anterior superior iliac spine, carefully avoiding the inferior epigastric vessels, and medially into the peritoneal fold of the medial umbilical ligament. It is seldom necessary to fully divide this ligament, which sometimes bleeds.

5. By blunt and sharp scissors dissection (with diathermy), separate the peritoneum below the initial incision away from the underlying fascia and muscle.

6. Deepen the pre-peritoneal pocket medially and laterally before separating the peritoneum from the internal ring where the peritoneum will be at its most adherent and there will be a risk of injury to the gonadal vessels and the vas deferens.

7. Strip the peritoneum medially downwards and inwards. In the case of a direct hernial sac it usually retracts out of the hernia orifice with traction and with a little blunt and sharp dissection so that the whole sac is freed from the transversalis fascia. The latter appears as a white fold attached to the sac. Identify the shining white appearance of the superior ramus of the pubic bone and gently strip the tissues downwards away from the pubic ramus, extending the dissection 1–2 cm beyond the midline. The bladder is seen below and behind the area of dissection.

8. Fashion the lateral part of the peritoneal pocket by stripping the peritoneum downwards and away from the abdominal wall. Below the level of the inguinal ligament, branches of the genitofemoral nerve may be seen lying on the psoas muscle and should be carefully preserved.

9. Now separate the peritoneum, or an indirect sac if present, from the structures at the internal ring (Fig. 6.18). If there is no indirect sac, separate the peritoneum, using a mixture of blunt and sharp dissection, from the vas deferens or round ligament passing medially and from the gonadal vessels passing laterally from the internal ring. The round ligament is often very adherent to the peritoneum and may be divided.

10. Retract an indirect sac or transect it if it is large. The sac lies anterior to the vas deferens and the gonadal vessels. Retract it progressively from the inguinal canal using a grasper held in the left hand. Control scissors in the right hand for blunt and sharp dissection, to strip away the coverings of the sac. As the dissection proceeds, look for the gonadal vessels laterally and the vas deferens medially. Dissect the peritoneum away from these structures.

11. A large sac is difficult to reduce, so transect it. Withdraw the sac partially into the abdomen and divide around its circumference, taking care posteriorly where the vas deferens and the gonadal vessels are closely applied. The distal sac retracts back into the inguinal canal. Dissect the transected proximal sac away from the gonadal vessels and vas deferens. Control bleeding with diathermy.

12. Transection of the indirect sac results in a hole in the mobilized peritoneum that requires closure when the mesh has been placed.

13. Now check that the depth of the pre-peritoneal pocket is sufficient to accommodate a 10-cm deep mesh extending for 15 cm from the midline laterally towards the anterior superior iliac spine. Divide any strands of tissue that would get in the way and prevent the mesh from lying flat (Fig. 6.19).

14. If you are repairing bilateral hernias, repeat the dissection of the pre-peritoneal pocket on the other side. The resultant pocket extends from one anterior superior iliac spine to the other. It is not usually necessary to divide the peritoneum above the bladder, nor is it necessary to divide either of the medial umbilical ligaments unless access is difficult.

15. Cut the synthetic mesh to the required dimension. For a unilateral hernia this is normally 15 cm × 10 cm. Bilateral hernias can be repaired using two separate 15-cm × 10-cm patches or by one large 28-cm × 10-cm mesh; this is stronger but more difficult to place. The latter is more difficult to orientate within the abdomen but is aided by cutting off the corners along one of the long sides of the mesh or by drawing a line on the mesh to indicate the long transverse axis.

16. Take hold of one corner of the mesh with a strong grasper and pass it through the 12-mm port under vision into the region of the pocket you have created.

17. Orientate the mesh so that it covers the groin from the midline to the anterior superior iliac spine within the pocket in front of the peritoneal flap, using graspers in each hand. Ensure that the mesh is lying flat and covers the hernial orifice.

18. If you are repairing bilateral hernias with a 28-cm × 10-cm mesh, pass it behind the midline peritoneum, which has been left undivided, and position it to lie flat and cover the relevant areas on both sides. Alternatively, place two 15-cm × 10-cm meshes meeting in the midline.

19. Most surgeons staple or glue the mesh in position. Take great care where you put staples. Place three to five staples spaced across the upper border of the mesh, attaching it to the abdominal muscles. Two or three staples may be used to fix the mesh to Cooper’s ligament on the superior aspect of the pubic bone medially. No other staples are required (Fig. 6.20).

20. Cover the mesh with the peritoneum forming the pocket. Pick up the upper border of the peritoneum with a grasper in the left hand and staple the flap of peritoneum to the abdominal wall, covering the mesh completely. Alternatively, place a running suture between the peritoneum above the mesh and the free peritoneal flap. Ensure complete coverage of the mesh in order to avoid small-bowel adhesion and possible small-bowel obstruction (Fig. 6.21).

21. Repair any hole in the peritoneal covering of the mesh either with staples or by suturing. Such a hole might permit small bowel to pass into the pre-peritoneal space you have created and give rise to small-bowel obstruction.

1. Check that there is no bleeding. Control bleeding from damaged inferior epigastric and gonadal vessels using haemostatic clips. Gonadal injury is unlikely unless previous surgery has been performed, compromising alternative blood supply.

2. Remove any staples that have fallen loose.

3. Check that there are no defects in the peritoneal covering of the mesh. If the peritoneum is thin and tending to tear, staple the margins of the defect in the peritoneum to the mesh, thereby reducing the likelihood of small-bowel herniation.

4. If you have repaired a sliding hernia, carefully check that the colon has not been injured in any way.

5. Disconnect the insufflation and allow the abdomen to deflate.

6. Remove the 5-mm cannulas under direct vision and check that there is no bleeding. Control any bleeding and, in the case of unexpected brisk bleeding from the deep part of the port site, pass a Foley catheter into the abdomen through the port site and blow up the balloon. Exert traction on the catheter, thus compressing the port site. The balloon can be left in position and removed later on the ward if necessary.

7. Do not remove the 10-mm cannula until the pneumoperitoneum has been evacuated lest a knuckle of small bowel be forced into the port site.

8. Close the rectus sheath in the 10-mm port sites using 2/0 multifilament synthetic absorbable sutures. Close the skin incisions with polypropylene 3/0 sutures.

1. Repair all femoral hernias because of the high risk of strangulation.

2. One of the reasons for offering surgical repair freely is that an open operation can be accomplished easily using local anaesthesia.

3. Laparoscopic femoral hernia repair is not advocated as an alternative to open femoral hernia repair. A co-existing femoral hernia may be repaired at the same time as an inguinal hernia using the laparoscopic route.

4. Be aware of the prevascular femoral hernia; its neck extends laterally in front of the vessels.

5. Be skilled in each of the three current open approaches for femoral hernia repair (Fig. 6.22). They all have merits and they are all safe, provided the operation is skilfully performed. In general, the low approach is used for elective operations and McEvedy’s for strangulated hernias.

1. Make an incision 4–5 cm long in the crease of the groin, below the medial half of the inguinal ligament.

2. Cut the superficial tissues over the hernia in the line of the skin incision. Look out for the small veins running into the long saphenous vein; ligate and divide them as necessary.

Hernial sac

1. The inguinal and pectineal ligaments meet medially through the arched lacunar ligament. The object of the repair is to unite the ligaments for about 1 cm laterally, without producing constriction of the femoral vein (Fig. 6.23).

2. Use 2/0 monofilament nylon or polypropylene, on a small needle. Many use a J-shaped needle.

3. Place a small curved retractor over the femoral vein to protect it and draw it laterally. Insert a stitch deeply into the inguinal ligament and use this to draw the ligament upwards, while the needle is insinuated behind it, to take a good bite of the pectineal ligament. Avoid taking too deep a bite or the needle point will break as it strikes the pubic crest. One, two or three stitches may be used but, for ease of access, insert all the stitches before tying any. As the stitches are tightened, ensure that the femoral vein is not constricted.

4. Alternatively, the femoral canal may be occluded with a ‘plug’ of rolled mesh, secured with three sutures. This technique is simpler to perform, less likely to result in compression of the femoral vein and less prone to recurrence.

1. The advantage of this approach is that it can be used for repairing co-existing inguinal and femoral hernias.

2. For femoral hernia alone it has the disadvantage that it damages the inguinal canal and could lead to a subsequent inguinal hernia.

1. Expose the inguinal canal and dislocate the cord, as for operation for inguinal hernia.

2. Incise the transversalis fascia.

Hernial sac

1. With the index finger, feel the margins of the femoral canal. In front is the inguinal ligament, medially the lacunar ligament, posteriorly the pectineal ligament and laterally the femoral vein.

2. Narrow the triangular gap by inserting non-absorbable sutures of 2/0 monofilament nylon or polypropylene between the pectineal ligament and the inguinal ligament.

3. If the upper approach was selected because there is also an inguinal hernia, deal with an indirect sac now.

4. Either close the incision in the posterior wall transversalis fascia with a non-absorbable suture or carry out a mesh Lichtenstein repair.

1. Use this approach for strangulated hernias as it provides excellent access for assessment of bowel and if necessary for resection.

2. The skin incision, as originally described, left an ugly scar, but this can be avoided by placing it more horizontally.

3. A urinary catheter inserted preoperatively, reduces the risk of damage to the bladder.

1. Make an incision from 3 cm above the pubic tubercle running obliquely upwards and laterally for 7–8 cm, crossing the lateral border of the rectus muscle, which lies more vertically. Reflect the skin flaps so as to display the lateral part of the rectus sheath.

2. Incise the lower rectus sheath about 1–2 cm from, and parallel to, its lateral border. The lateral edge may tend to separate into its two anatomical layers.

3. Lift the lateral edge of the sheath and incise the thin transversalis fascia from about 2.5 cm above the pubic tubercle to mobilize the lower lateral edge of the rectus medially. Ligate and divide the inferior epigastric vessels which cross this line low down. The neck of the hernia is now in view as it enters the femoral canal.

1. Retract the lower skin flap and isolate the sac.

2. Reduce the sac, manipulating it from above and below. Open and empty it, then transfix, ligate and divide the neck of the sac.

3. For a strangulated hernia (which is the reason for using this approach) the peritoneum may be opened above the neck to facilitate assessment of the bowel and any necessary resection.

4. Repair the canal from above.

5. Close the incision in the rectus sheath with 0 nylon or polypropylene.

6. Appose the subcutaneous layers and close the skin.

1. Most hernias in adults are para-umbilical, protruding adjacent to the cicatrix. The contents are most frequently omentum, which is often adherent to the interior of the sac.

2. Some adults, especially of African origin, have true umbilical hernias that have been present throughout life.

3. Repair umbilical hernia by early operation for fear of strangulation. In particular operate on strangulated, painful (reducible or not) hernias, especially those with small, hard margins. However:

4. An open or laparoscopic approach can be used. With an open approach a mesh is placed either extra-peritoneally, deep to the abdominal wall, or as an onlay mesh anterior to it, often in association with a traditional double breasted ‘Mayo’s repair’. With a laparoscopic approach the mesh is secured intra-peritoneally against the defect with staples or sutures. For small primary umbilical hernias an open approach is recommended. For recurrent or periumbilical incisional hernias a laparoscopic approach may be considered.

5. In large hernias which distort the entire umbilicus, the possibility of excising and refashioning the umbilicus should be discussed preoperatively.

1. Make a curved incision in the groove above or below the hernia. If necessary extend the cut transversely outwards on each side, for 2–4 cm.

2. Deepen the incision, identify the aponeurosis and expose it around the adjacent half of the circumference of the hernia.

3. If the hernia is small, preserve the umbilical skin by dissecting it off the hernia as a flap. If the hernia is large, make a spindle-shaped incision to include the umbilicus, excising the stretched skin.

4. Expose 2 cm of aponeurosis around the remainder of the margin of the hernia.

1. Cut through the thinned-out edge of aponeurosis to expose the peritoneum and gradually work round to display the whole circumference of the neck of the sac.

2. Clear the sac of fatty tissue and cut it right round, at least 2 cm distal to the neck if possible. The contents of the sac are less likely to be adherent here than in the fundus, but free them if necessary. Mark the peritoneal edges with artery forceps.

3. If the contents of the sac are free, reduce them. If they are adherent to the fundus of the sac, free them and return them to the peritoneal cavity. If there is a mass of fibrous omentum, excise it with the fundus of the sac but take care to ligate all the bleeding omental vessels and avoid damaging the transverse colon.

4. Separate the peritoneum from the under-surface of the rectus sheath all round, without tearing it.

5. Close the peritoneal neck of the sac with a continuous 2/0 synthetic absorbable suture, producing a transverse linear suture line.

Extra-peritoneal mesh repair

Mayo’s repair (Fig. 6.24)

Onlay mesh repair

1. If the skin over the fundus was preserved, pick up the under-surface of the navel with a synthetic absorbable stitch and sew it to the rectus sheath to produce a dimple. Suture the skin as a curved line above or below the newly fashioned umbilicus.

2. If the umbilicus was excised, close the subcutaneous fat and the skin as a transverse suture line.

1. Place the anaesthetized patient supine on the operating table with their arms by their side.

2. Clean the abdomen with povidone-iodine 10% alcoholic solution or other antiseptic.

3. Drape the whole abdomen to give adequate exposure for the placement of port sites.

4. Stand on the same side as the assistant and/or ‘scrub’ nurse. Position television monitors on the opposite side of the patient. Sometimes with mesh placement it is easier to move around the patient and so it is therefore useful to have a monitor on both sides.

1. Obtain access in an area away from any previous incision and away from the hernia, both of which are usually in the midline. Previous incisions may have adhesions or bowel adherent to them, presenting an inherent risk of damage, so gain access to the abdominal cavity as far back laterally as is safe on the insufflated abdomen. Use either an open (Hasson) technique or a closed technique using a Veress needle. The left subcostal area is often suitable for initial insufflation with a Veress needle.

2. Insert a 10-mm trocar and cannula through the initial incision as described, far back laterally on the abdomen. Use a ‘Visi’ port if possible, as entry can be watched.

3. Remove the trocar and introduce a laparoscope through the cannula into the abdomen.

4. Assess the abdomen and select a suitable position to insert a 5-mm trocar and cannula to the left of the laparoscope and another 5-mm trocar and cannula further left of the laparoscope, both under direct vision (Fig. 6.25).

5. Place ports to access midline hernias either on the right and/or the left of the abdomen, depending on your preference. Add an extra-port if access is difficult.

1. Define the margins of the hernia defect and ensure that any adhesions are cleared for at least 5 cm from the edge of the hernial defect.

2. Reduce the contents of the hernia sac using graspers and diathermy scissors. If this is not possible, convert to an open repair.

3. Leave the peritoneal sac in situ. It is very difficult to dissect a sufficiently large pre-peritoneal pocket into which a mesh can be placed in such a way that it is extra-peritoneal.

4. Assess the size of mesh required to give a minimum of a 4-cm overlap of the hernial defect on all sides. Cut the mesh in a circle shape to give an equal overlap on all sides. Mark the centre of the mesh with a marker pen to aid orientation inside the abdomen and ensure you position it centrally over the hernia defect.

5. Insert the mesh through the 12-mm cannula. Unfold it, using two graspers, and orientate it centrally over the hernial defect, ensuring equal coverage on all sides. This is sometimes helped by passing a suture from the centre of the mesh through the umbilicus. Remove this later.

6. Make sure that the mesh lies flat over the abdominal wall. Staple it into position along all sides. Try and use absorbable tacks. Although they are more expensive and more difficult to handle, they reduce the risk of adhesions. If you are inserting a large mesh, be willing to apply a second inner row of staples around the defect to fix it securely to the abdominal wall.

1. Is the hernial defect well covered with mesh overlapping at least 4 cm all round?

2. Check any residual bleeding, using laparoscopic clips if necessary.

3. Remove any staples that have fallen loose.

4. Disconnect the insufflation equipment, allow the abdomen to deflate and remove the cannulas under direct vision.

5. Close the 12-mm port site using a 2/0 multifilament synthetic absorbable suture. Close the skin incisions with polypropylene 3/0 sutures.

1. Repair infantile umbilical hernia via an open approach.

2. Most infantile umbilical hernias protrude through the incompletely closed cicatrix. They occur more frequently in infants of African origin. Most of them close spontaneously without surgical repair, especially if the neck is less than 2 cm in diameter, so wait for 1–2 years. Repair them only if they increase in size.

3. Infants infrequently develop a supra-umbilical hernia. It will not close spontaneously, so repair it locally through a transverse incision sited directly over the defect.

1. Approach the hernia through a transverse incision curved beneath the everted umbilicus.

2. Preserve the umbilical skin by turning it upwards as a flap.

1. Expose the aponeurosis and the neck of the sac, which is within the cicatrix. The separation is much easier than in acquired hernias.

2. Open the sac, empty it, then close it by suture or transfixion ligature.

1. Edge-to-edge repair of the aponeurosis is effective.

2. Make sure the peritoneum is separated sufficiently to allow good bites of sheath to be taken, without piercing the peritoneum.

3. Create a transverse suture line using polypropylene or nylon, inverting the knots.

1. Suture the deep surface of the umbilical skin to the aponeurosis with fine absorbable synthetic material.

2. Close the skin to leave a curved transverse wound, using an absorbable subcuticular stitch.

1. Neglected or imperfectly treated umbilical sepsis in infants can progress to septicaemia, distant pyogenic infections, pylephlebitis, liver suppuration and fatal jaundice.

2. An enteroteratoma is the remnant of the vitellointestinal duct forming a raspberry tumour. Cauterize it to destroy the mucosa.

3. Persistent discharge from the umbilicus in infants, children and young adults is likely to result from a congenital abnormality. An MRI (magnetic resonance imaging) scan may show the connecting track:

4. In adults, infection is often the result of aggregated keratin forming an ‘omphalolith’ (Greek: lithos = stone), which can be lifted out of a deep umbilicus without anaesthesia. Persistent omphalitis stimulates granulation tissue, treated by cautery. Recurrent infections may require a minor plastic procedure to reduce the depth of the umbilicus.

5. The umbilicus is a rare site for pilonidal sinus, treated by excision.

6. Endometrioma at the umbilicus classically bleeds at the time of the menses.

7. Squamous epithelioma may develop at the umbilicus and subsequently can involve the inguinal lymph nodes. Excise the umbilicus and, if indicated, carry out bilateral block dissection of the inguinal nodes (vide infra).

8. Secondary carcinoma from the liver or porta hepatis may reach the umbilicus along the ligamentum teres. This presents as Sister Joseph’s nodule (first noticed by an observant nun and immortalized by the famous surgeon and author Hamilton Bailey 1894–1961).

9. A port-site metastasis may occur after laparoscopic surgery for malignancy.

1. In an epigastric hernia a small knuckle of extra-peritoneal fat insinuates itself through a vascular opening in the linea alba. It rarely has a peritoneal sac or contains bowel.

2. Port-site hernias occur after laparoscopic surgery. Repair is similar to that for epigastric hernia.

3. Laparoscopic repair is an alternative to the open operation, but for small hernias has no advantages.

1. Make a transverse incision through the skin and deepen it down to the herniated fat.

2. Define the margins of the defect and reduce the hernia. If there is a peritoneal sac, simply invaginate it into the peritoneal cavity.

3. Suture a small (less than 1 cm) defect with a good rim using non-absorbable stitches, inverting the knots. Otherwise place a piece of polypropylene mesh 2 cm larger than the defect in each direction in the extra-peritoneal plane and secure it, as described for the underlay repair of a well-defined inguinal defect.

4. Close the skin, using a synthetic, absorbable subcuticular suture.

1. Incisional hernia is a deep disruption of the abdominal wound while the superficial layers remain intact (if the superficial layers also separate then a burst abdomen results).

2. Herniation may occur early, while the patient is still in hospital. More usually it develops during the following months or years.

3. Incisional hernias are associated with careless suturing, the use of rapidly absorbable instead of non-absorbable material, haematomas and infection, the insertion of drains through the main incision and damage to abdominal nerves. Jaundice, malnutrition, obesity, postoperative distension and re-exploration through the same incision after a short interval are other contributory factors, as are steroids and immunosuppression. Incisional hernia may follow delayed healing of a laparostomy.

4. Incisional hernias rarely strangulate; therefore do not rush to re-operate. Repairs have a high recurrence rate, reduced by the use of mesh, but this increases the risk of persistent infection or intestinal fistula.

5. If the patient is overweight, advise reduction before surgery. Ensure that infection has completely resolved before proceeding.

6. If mesh is to be used, give perioperative antibiotic cover.

7. Laparoscopic mesh repair is an alternative.

1. Large defects are best repaired using a composite mesh to reduce the risk of bowel adhesions (see laparoscopic umbilical hernia repair, above). Infected defects can be repaired using biological meshes such as Permacol or Strattice (Lifecell Corporation) but these are very expensive.

1. Excise the old scar.

2. If the skin and peritoneum are fused, excise an ellipse of skin wide enough to expose subcutaneous tissue.

3. Dissect back the skin on each side until unscarred subcutaneous tissue is reached beyond the margins of the defect.

1. Deepen the incision until you reach aponeurosis or muscle, then work towards the margins of the defect.

2. Dissect the edges cleanly and separate the peritoneum from the deep surface all around unless you intend placing mesh intra-peritoneally.

3. If possible, invaginate the sac with a continuous suture. However, adherent contents and a narrow neck may require that the sac be opened to achieve reduction; if practicable close it.

4. Multiple defects in the abdominal wall (‘buttonhole tears’) are most conveniently managed by uniting them and repairing the resulting larger defect.

5. The cavity from which the sac has been stripped out often oozes, so meticulously apply haemostasis to minimize the risk of haematoma or seroma formation.

1. There is no advantage in attempting to define the layers of the abdominal wall.

2. Suture small defects, less than 4 cm, using non-absorbable material (0 or 1 G), but this does introduce tension adjacent to the repair so it is suitable only if the edge is strong.

3. Large defects, or poor tissue, are best repaired with a synthetic patch, to avoid a recurrence rate of 40–50%. The mesh may be applied at three levels in the abdominal wall, as described below (Fig. 6.26). Wherever it is placed it must extend at least 2 cm beyond the margin of the defect.

4. There are also methods that attach a piece of mesh to each side of the defect and then suture the two together or sandwich the abdominal wall between two layers of mesh.

Onlay patch repair

Extra-peritoneal mesh repair

Intra-peritoneal mesh repair

1. Leave the drains until the daily loss is less than 30 ml.

2. Any subsequent collection should be aspirated, with sterile precautions.

3. In the event of a wound infection, do not rush to remove the mesh, almost inevitably resulting in re-herniation; it may survive.

1. Described by Adriaan van der Spieghel (Spigelius) of Padua (1578–1625), herniation is at the lateral margin of the lower rectus sheath and often expands beneath the external oblique aponeurosis.

2. Repair may be by open operation or laparoscopically. The latter facilitates accurate diagnosis.

1. At open operation, make a skin crease incision over the lump and open the external oblique aponeurosis in the line of its fibres, extending the incision medially to open the anterior rectus sheath.

2. Once dissected, invert the sac and develop the pre-peritoneal space, allowing a check along the lateral edge of the rectus for other defects. Then place a mesh extra-peritoneally. The layers of the abdominal wall can usually be closed without tension using a 0 Prolene suture.

1. Stomas leave weak areas in the abdominal wall. The whole area around the stoma may bulge diffusely or a segment of bowel may herniate. In addition, the stoma itself may prolapse.

2. Some parastomal hernias can be accepted, in particular diffuse hernias that are not troublesome, since they are unlikely to produce obstruction.

3. Re-siting the stoma, usually on the opposite side of the abdomen, is an effective treatment but involves a laparotomy and has a high rate of re-herniation.

4. The best method is to repair the hernia with polypropylene (or Vypro) mesh, either at laparotomy or by a local approach through a curved skin incision lateral to the stoma.

5. The mesh may be placed either extra-peritoneally or on the outside of the abdominal wall. Cut a hole in the mesh for the bowel, with a slit to enable it to be inserted without detaching the stoma from the skin. The slit is then sutured. The risk is wound infection, minimized by antibiotic prophylaxis and by sealing the stoma with plastic film.

1. Neonatal diaphragmatic hernia must be repaired immediately because the lungs cannot expand since the chest cavity is filled with abdominal viscera. It is generally diagnosed on ultrasound scan before delivery so that specialist paediatric care can be arranged. There is no hernial sac because the defect is the persistent pleuroperitoneal canal – the hernia of Bochdalek (Vincent Bochdalek 1801–1883, Prague anatomist).

2. Adults occasionally present with acute obstruction within a persistent pleuroperitoneal canal, almost always on the left side. It may also follow thoracoabdominal surgery.

3. Reduction from below is easy, unless the abdominal viscera are adherent within the chest.

1. By whatever approach is favoured, reduce the abdominal viscera.

2. Trace out the margins of the defect and close it using non-absorbable sutures. The margins usually come together more easily than anticipated.

Hernia of the foramen of Morgagni

Eventration of the diaphragm (Latin: e = out + venter = belly; protrusion of the belly)

Traumatic hernia

1. This may emerge spontaneously through the triangle of Petit (Jean Louis Petit 1674–1741, Parisian surgeon), bounded by the iliac crest, the posterior edge of the external oblique and the anterior edge of the latissimus dorsi muscles.

2. Lumbar hernia complicates renal incisions in the loin, drainage of lumbar abscess, trauma or paralysis of the muscles in the lumbar region.

3. Operative repair is rarely required.

1. This is rare. Most occur in females aged over 50 years, and on the right side.

2. Most are admitted with small-bowel obstruction, which, at operation, is discovered to be from an obturator hernia, sometimes of Richter’s type. A possible clinical clue is radiation of pain down the inner thigh to the knee. CT is diagnostic.

3. If diagnosed preoperatively it can be repaired laparoscopically by extending the pre-peritoneal TAPP (transabdominal pre-peritoneal hernia) or TEP (totally extra-peritoneal hernia) dissection inferiorly to include the obturator canal.

1. Assuming the operation is being performed for intestinal obstruction and the small bowel is found to be tethered in the region of the obturator canal, improve the access by carrying the incision down to the pubis. A catheter should already be draining the bladder.

2. Identify the canal with the nerve entering it from the anteromedial aspect; the artery is posterolateral.

3. Gently free the bowel and inspect it to determine if it is viable.

4. Either make no attempt to repair the defect or suture peritoneum over a mesh patch.

1. Gluteal hernia emerges above or below the pyriformis muscle through the greater sciatic notch.

2. Sciatic hernia emerges through the lesser sciatic notch.

3. These hernias are usually discovered at exploratory laparotomy for intestinal obstruction and rarely produce a palpable swelling in the buttock.

1. Internal hernias present as intestinal obstruction. Most follow abdominal or abdominothoracic operations, the most common mechanism being a band adhesion. Intestine may herniate behind an anterior gastroenterostomy, through a transverse mesocolic defect following posterior gastroenterostomy or beside an abdominal stoma if the lateral space is not closed.

2. Internal hernias also occur at anatomical openings, such as the foramen of Winslow (Jacob Winslow 1669–1760, Danish anatomist) or the paraduodenal fossae, and through defects in the falciform ligament, the mesentery or the broad ligament. Think before dividing the ‘band’, as it may contain an important structure such as the portal triad! After dealing with the bowel the defect must be closed.

1. A sudden strain may rupture one of the inferior epigastric vessels entering the lower rectus abdominis muscle, producing pain. It is more common in patients who are anticoagulated.

2. On the right side, the localized pain and tenderness may be misdiagnosed as appendicitis. However, the patient does not have systemic or gastrointestinal symptoms, pyrexia or leucocytosis. Furthermore, the local tenderness in the right iliac fossa is greater when the patient puts the muscles under tension.

3. Ultrasound or CT (computed tomography) confirms the diagnosis and management is then conservative.

4. If you operate thinking the patient has appendicitis and discover a haematoma lying behind the lower rectus muscle, evacuate it. If there is a suspicion of continuing bleeding, isolate and ligate the inferior epigastric vessels in continuity.

1. Wound contamination and haematoma are the major factors leading to wound infection. Following abdominal surgery a variety of organisms may be responsible. Multifilament stitches may perpetuate a wound infection, so prefer monofilament materials for non-absorbable sutures.

2. Prophylaxis for potentially contaminated wounds comprises perioperative antibiotics, scrupulous haemostasis in the abdominal wall and covering the wound edges with Betadine (povidone-iodine)-soaked swabs or plastic wound protectors.

3. The infection may be a localized wound abscess or an abscess occupying the whole wound, with or without surrounding cellulitis, or there may be cellulitis without an abscess (yet). The wound is hot, red and swollen and the patient is pyrexial and may be toxic.

1. This is usually named after Meleney, the New York surgeon who described it in 1933. When it affects the scrotum it is called Fournier’s gangrene (Jean Fournier 1832–1914, Parisian dermatologist). It may result from the synergistic effects of a number of micro-organisms, or from a single organism.

2. The nature of an operation or injury, and the patient’s general condition, may predispose to the condition. Exclude diabetes, immunosuppression, uraemia and hepatic disease.

3. It develops as a slowly extending area affecting the whole thickness of the skin. The advancing edge is typically serpiginous and leaves dead, sloughing skin that separates to expose unhealthy granulation tissue.

1. Start the patient immediately on broad-spectrum antibiotics, such as a cephalosporin and metronidazole, pending the result of bacteriology.

2. The essential action in controlling the infection is to excise all the necrotic tissue, exposing healthy, clean tissue. Leave the wound open and dress it frequently, repeating the excision of any developing necrotic tissue.

3. When the infection has been completely controlled, plan to resurface the denuded area with partial thickness skin grafts.

1. This spreading gangrene primarily affects the abdominal fascia. It may follow surgical operations or injury. It is predisposed to by general disease, particularly diabetes. Subsequently the overlying skin is also affected, but the skin involvement may not indicate the extent of the fascial infection. The mortality rate is 30%.

2. Management is with broad-spectrum antibiotics and immediate radical excision of all the necrotic tissue to leave healthy living tissue (in the limbs this may involve amputation).

1. Clostridial infection of abdominal wounds is remarkably rare, considering that the organisms can be recovered from normal faeces.

2. The patient rapidly develops pyrexia, toxicity and hypotension.

3. The discoloured wound edges are crepitant and may discharge thin pus, described as smelling ‘mousy’.

1. Administer 1 million units of benzylpenicillin and continue high doses thereafter.

2. As far as possible, and as rapidly as possible, correct the patient’s general condition.

3. Under general anaesthesia radically excise the whole area, back to clean, living tissue. Thoroughly wash the raw area with hydrogen peroxide (20 vols).

4. Hyperbaric oxygen at 3 atmospheres has been recommended.

1. Desmoid tumours are non-encapsulated tumours that develop in the muscle intersections. They are classified as fibromatoses. Hyperplastic connective tissue infiltrates locally, but does not metastasize. Most occur in women, especially those who have borne children. Remove abdominal wall desmoids completely or they recur.

2. Patients with familial adenomatous polyposis may also develop desmoids within the abdomen. These generally surround the mesenteric vessels and so are irremovable.

3. Carcinoma of intra-abdominal structures may directly invade the abdominal wall. If the tumour is otherwise resectable do not hesitate to excise a portion of the abdominal wall en bloc with the primary neoplasm.

1. Concentrate on excising the tumour with adequate clear margins and depth. In the case of a desmoid tumour do not fail to cut through healthy muscle and connective tissue all the way round.

2. If the abdominal wall is invaded from its deep surface, excise the peritoneum and the deep part of the muscle wall, but leave intact the superficial muscle layer. Do not attempt to repair the defect, which will peritonealize.

3. Close a small full-thickness defect layer by layer.

4. A large defect can often be closed by creating a flap of anterior rectus sheath based on its medial edge to swing to the opposite side, or a layer of lateral muscle may be swung over.

5. If you cannot close the defect with muscle or aponeurosis, the best alternative is to use a myocutaneous flap from the chest or thigh. Unless you are skilled in preparing such flaps, obtain the help of a plastic surgery colleague.

6. If you are completely unable to close the defect, consider inserting a polypropylene mesh or other plastic sheet until you can obtain help and advice.

7. When you cannot close the skin defect by any other means, create a large skin flap based laterally that you can slide over to cover the defect, applying split skin grafts to the donor site.

1. Radical groin dissection is carried out for resection of proven or suspected malignant lymph nodes.

2. In general surgery, the operation is employed most frequently to excise metastatic melanoma deposits from primary sites in the leg, perineum and gluteal regions.

3. The inguinal nodes may be involved by epidermoid carcinoma of the external male or female genitalia, or of the anal skin. In these cases the nodal dissection is usually accomplished in continuity with excision of the primary lesion.

1. Make a linear incision, 2.5 cm below and parallel to the inguinal ligament.

2. Alternatively, make a spindle-shaped incision, so that skin overlying involved glands can be excised en bloc.

1. Raise the upper skin flap so that the superficial and deep fascia can be incised 2–3 cm above and parallel to the inguinal ligament to display the lower fibres of the external oblique aponeurosis. Sweep the connective tissues downwards, leaving the lower portion of external oblique stripped clean.

2. Dissect the lower flap to reach the fascia lata over the lateral edge of the sartorius muscle and incise it here, preparing to sweep it medially with the superficial fascia. Look for, and preserve if possible, the lateral and intermediate cutaneous nerves of the thigh.

3. At the medial border of the sartorius muscle, the dissection extends into the femoral triangle as you display in turn the femoral nerve, femoral artery and femoral vein. In the groin, identify, doubly ligate and divide the superficial circumflex iliac, superficial epigastric and superficial external pudendal vessels, to avoid tearing their junctions with the main vessels.

4. Ligate and divide the saphenous vein at the lower extremity of the clearance and again as it joins the femoral vein, so that you remove the segment within the femoral triangle with the specimen.

5. Sweep the superficial tissues and lymph nodes medially as far as possible then incise the fascia lata vertically over the adductor magnus muscle.

6. The specimen is still attached by the fat and lymphatic tissue entering the femoral canal. Gently draw down the lymph node lying within the canal and remove it with the specimen.

1. Insert one or two suction drains.

2. Close the skin.

1. For a combined approach, make a vertical incision, starting superiorly at the midpoint of a line joining the umbilicus and anterior superior iliac spine and finishing inferiorly at the apex of the femoral triangle. The incision follows a gentle ‘S’, lest a future contracture restrict hip movements.

2. Alternatively, perform a laparoscopic iliac node dissection.

1. Enter the iliac region through the inguinal ligament, by dividing the ligament over the femoral canal or detaching it from the pubic tubercle.

2. Incise the external oblique, internal oblique and transversus abdominis muscles 1–2 cm above and parallel to the inguinal ligament, so that the inguinal ligament can be swung laterally.

3. Doubly ligate and divide the inferior epigastric vessels.

4. Sweep up the intact peritoneum from the iliac vessels, making sure that the ureter remains attached to the peritoneum and is thus preserved from damage. Divide the obliterated umbilical artery.

5. Starting in the hollow of the sacrum, sweep out the connective tissue and lymph nodes from the iliac vessels and their branches, including the obturator vessels and nerve. Remove glands along the obturator vessels and nerve and at the obturator foramen.

6. Strip out the loose tissue and lymph nodes from the femoral canal.

1. Re-attach or repair the inguinal ligament and abdominal muscles. Insert one or more suction drains.

2. Close the skin.

1. Minimize oedema of the leg by elevation then mobilize in a supporting stocking.

2. Remove the suction drains when the loss is less than 30 ml/day.