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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 (?)