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Lichtenstein Repair of Inguinal Hernia - Carter Patient Preparation: Examine patient in preop to confirm hernia side and mark with pen before patient is given anxiolytic, make sure H&P and consent are concordant. Complete interval H&P. Key Equipment and Instruments: Ethicon polypropylene softmesh sheet, 3 x 6 inches Bacitracin soak Small and medium Richardson retractors Wheatlaner ¼ inch penrose drain #15 blade 2-0 prolene suture 2-0 polysorb suture 3-0 polysorb suture 3-0 polysorb ties 4-0 biosyn suture 1% lidocaine (30cc) + 0.5% marcaine + epi (30cc) mixed in 1:1 ratio Indermil Sterristrip Setup Supine, LMA/ETT + local (anesthesia choice), both arms out on armboard, kefzol 1-2g IV, no Foley, clip hair, drape testicle out of field. Bovie only, no suction (use raytecs) Incision: PROCEDURE Incision: Mark out pubic tubercle, ASIS. Draw line connecting the two. This is the course of the inguinal ligament Go 1.5cm superior and 1cm lateral to the tubercle, then draw 6cm curvilinear line towards ASIS. Inject 10ml local to planned incision, 10ml regional block (at blue circle). Incise skin with #15 blade Dissection: 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) nick aponeurosis with #15 blade dissect underneath with metzembaum scissors bluntly, then extend incision into external ring. avoid ilioinguinal nerve which lies underneath. The nerve stays with the cord structures throughout the dissection. Inject local anesthetic into the nerve when it is identified. Straight kelly to edges of aponeurosis, then 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 Use finger to lift cord structures off tubercle, control with ¼ inch penrose. look at floor to see if direct hernia present. Divide adherent cremasterics. Cord dissection: dissect longitudinally along cord, find sac, dissect to internal ring. Perform high ligation with 2-0 suture ligation. minimal cremasteric dissection. Identify and preserve ilioinguinal nerve. Sometimes need to Bovie divide attaching cremasterics and loose attachments at base of sac. Prior to ligation, insert finger through defect to feel for femoral hernia If direct sac, invert it with 2-0 polysorb pursestring, no ligation. If giant scrotal hernia, divide sac early. Leave scrotal component in scrotum. High ligaiton. Remove any cord lipomas, ligating base with 2-0 polysorb Repair: Soak 3x6in soft polypropylene mesh in bacitracin Round out one side to fit anatomy Retract cord structures superiorly 2-0 prolene anchor suture from nose of mesh to rectus sheath, 2cm medial to tubercle (this ensures at least 2cm of tubercle overlap) Run suture to reflected inguinal ligament (4-5 throws) and tie to itself lateral to internal ring Slit mesh. Lower tail is 1/3 (1in) wide, upper tail is 2/3 (2in) wide Pass upper tail under cord structures and retract cord inferiorly Single 2-0 prolene to rectus sheath 1cm superior to first suture Single 2-0 prolene to internal oblique superiorly, leaving slight wrinkle in mesh over floor of canal. If iliohypogastric nerve in the way, slit the mesh to accommodate nerve Cross tails. Suture bottom edge of top tail to bottom edge of bottom tail to reflected inguinal ligament with 2-0 prolene Tuck tails under the aponeurosis of the external oblique Assess internal ring. Place additional suture if needed. Irrigate with bacitracin irrigant. Closure: close aponeurosis with 3-0 polysorb running. Irrigate. close Scarpa's with 3-0 polysorb running. Irrigate. close skin with 4-0 biosyn running indermil, then single sterri-strip lenghways tug on testicle to return it to scrotal sac Postoperative Care: home same day on: vicodin 5/500 #35 1 refill dulcolax prn ibuprofen 600mg po TID x5d (unless history of GIB or renal insufficiency)