Open Inguinal Hernia Repair
Terminology
In referring to inguinal hernias, a major defining point is location of the defect—direct versus indirect. This distinction is strictly anatomic because the operative repair is the same for both types. Approximately two thirds of inguinal hernias are indirect. Men are 25 times more likely to have an inguinal hernia than women, and indirect hernias are more common regardless of gender. A direct inguinal hernia is defined as a weakness in the transversalis fascia within the area bordered by the inguinal ligament inferiorly, the lateral border of the rectus sheath medially, and the epigastric vessels laterally (Fig. 28-1). This area is referred to as Hesselbach’s triangle.
Located lateral to the inferior epigastric vessels, an indirect inguinal hernia is characterized by the protrusion of the hernia sac through the internal inguinal ring toward the external inguinal ring and, at times, into the scrotum. Indirect inguinal hernias result from a failure of the processus vaginalis to close completely (Fig. 28-2). An inguinal hernia that has direct and indirect components is referred to as a pantaloon hernia.
A hernia is defined as reducible if its contents can be placed back into the peritoneal cavity, alleviating their displacement through the musculature. In contrast, a hernia with contents that cannot be reduced is termed incarcerated (Fig. 28-3). If the blood supply to the contents of the hernia is compromised, the hernia is defined as strangulated. Strangulation is a potentially fatal complication of a hernia and should always be considered a surgical emergency. Less common inguinal hernias include Amyand’s hernia, with the appendix (normal or acutely inflamed) contained in the hernia sac, and Littre’s hernia, which contains a Meckel’s diverticulum.
Surgical Approach
To understand the anterior approach, the surgeon must appreciate the layers of the abdominal wall and their relation to the inguinal canal. The layers and the location of their neurovascular structures include skin, subcutaneous fat (e.g., Camper’s and Scarpa’s fasciae), muscles (external and internal oblique, transversus abdominis), transversalis fascia, preperitoneal fat, and peritoneum (Fig. 28-4, A).