Download Patient Preparation

Inguinal Hernia - Pearl
Patient Preparation:
Examine patient in preop to confirm hernia side.
Initial the site and complete the interval H&P form.
Key Equipment and Instruments:
Ethicon Prolene hernia system (PHS) (small, medium, large). Looks like hourglass with
preperitonal planar component, central ring, Lichtenstein planar component.
Wheatlaner
#15 blade
3-0 maxon on GS22
3-0 polysorb
4-0 biosyn
1% polocaine (30cc) + 0.5% marcaine + epi (30cc) mixed in 1:1 ratio
Setup
Supine, LMA/ETT + local , both arms out on armboard or tuck non affected side, kefzol 1-2g IV,
no Foley, clip hair, drape testicle out of field.
Incision:
Procedure:
Landmarks: pubic tubercle, ASIS.
Marking pen: line starting just superior and lateral to pubic tubercle, directed 15degrees superior
from inguinal ligament.
Inject 10ml local to planned incision, 10ml regional block (at blue circle).
no suction. Dry the field with Raytec
dissect thru scarpa's fascia with Bovie.
tie off superficial inferior epigastric vein with 3-0 polysorb (if vein present)
insert wheatlaner
minimally clean off aponeurosis of external oblique with finger (feel for ridge of inguinal ligament)
inject 10cc local again towards the internal ring through the external oblique.
nick aponeurosis with #15 blade
dissect underneath with metz bluntly, then extend incision into external ring. avoid ilioinguinal
nerve which lies underneath. Inject local into the nerve when it is identified.
Handheld retractor to edges of aponeurosis, then finger (no peanut) to bluntly dissect cord
structures off aponeurosis to Poupart's ligament, conjoined tendon, muscle of internal oblique.
medially, expose tubercle.
wheatlaner to retract edges of aponeurosis
finger to lift up cord structures off tubercle, control with ¼ inch penrose.
look at floor to see if direct hernia present
if direct hernia present: incise transversalis circumferentially to allow inlay mesh component.
cord dissection: dissect longitudinally along cord, find sac, dissect to internal ring. No high
ligation. minimal cremasteric dissection. Identify and preserve ilioinguinal nerve. Bovie
circumferentially along base of sac to divide attaching cremasterics and loose attachments in
order to invert sac.
Insert finger through defect to feel for femoral hernia
Stuff raytec into inverted sac to bluntly dissect out the preperitoneal space..
Take mesh system. Round portion goes into preperitoneal space. Hold lichtenstein (upper)
portion of mesh folded longitudinally then up together and grasped with ring forceps, pull out
raytec, dunk mesh into hernia, spread out circular portion with deBakey forceps. On the
Lichtenstein side, either short end or long end can go medially depending on patient anatomy.
Spread out Lichtenstein side.
3-0 maxon simple interrupted sutures to pubic tubercle, conjoined tendon/int. oblique, and
Pouparts (3 total). Avoid iliohypogastric nerve.
Cut mesh laterally to surround internal ring
3-0 maxon to reclose slit and recreate internal ring snugly (room for Kelly clamp tips).
3-0 maxon along ringed portion of mesh to internal oblique fibers
3-0 maxon inferiorly through ringed portion of mesh to Pouparts
close aponeurosis with 3-0 polysorb running
close Scarpa's with 3-0 polysorb running
close skin with 4-0 biosyn running, knot at beginning cut slightly long and allow first throw to lasso
the cut end of suture above the knot and dunk it down. Last subcuticular goes in the reverse
direction, then back across and come out thorough skin. Tag without tying.
apply benzoin widely to include tegaderm. ¼” sterri-strips and 4x4s. Cover with the postcard
sized tegaderm.
tug on testicle to return it to scrotal sac
Postoperative Care:
home same day on:
vicodin 5/500 #35 1 refill
dulcolax prn
valium 5mg po BID x10d
ibuprofen 600mg po TID x5d
Intraop questions/pearls:
What is the most important structure to protect in the cord?
Artery-> ischemia.But this is
wrong. Ischemic orchitis caused from thrombosis of pampiniform plexus following injury, not an
injury to the artery.
Is this a direct or indirect hernia?
Doesn’t matter. It’s a hole that needs to be plugged.
Another name for DeBakey’s?
Magics (Stanford term)
Nerve is usually found under a vein.
Benzoin smells better than Mastisol.
Which testicle usually hangs lower?
Left.
Why?
Because it descends first embryologically (?)