Download Lichtenstein repair

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)