Open Right Inguinal Hernia Repair

Background Information:

Inguinal hernias occur when abdominal contents herniate through the inguinal canal (indirect) or Hesselbach's triangle (direct) or both (pantaloon hernia). Direct inguinal hernias occur secondary to increased intraabdominal pressure and indirect hernias resulting from patent processus vaginalis in males or canal of Nuck in females (an extension of the peritoneum that closes during normal development). Inguinal hernias may contain various contents but commonly contain intraperitoneal fat, small bowel, or cord lipoma. An inguinal hernia containing the appendix is termed an Amyand’s hernia. A sliding hernia occurs when a retroperitoneal organ makes up part of the hernia sac. Inguinal hernias are repaired using open or minimally invasive (laparoscopic or robotic) techniques. Asymptomatic inguinal hernias often become symptomatic over time. 

Indications:

Symptomatic direct or indirect inguinal hernias should be electively repaired. Incarcerated hernias should be repaired emergently.

Procedure Description:

An open inguinal hernia is a procedure performed through an incision in the groin overlying the inguinal canal. There are many techniques of open inguinal hernia repair, the most common being the Lichtenstein repair. This technique uses a mesh to reinforce inguinal structures after reducing the hernia sack and isolating the spermatic cord contents. The Lichtenstein repair is a tension-free mesh repair.

Key Anatomy:

Subcutaneous tissue 

• Camper's fascia
• Scarpa's fascia

Abdominal wall:

• External oblique aponeurosis
• Internal oblique muscle
• Hesselbach's triangle (direct hernia space)

• ~Lateral border: inferior epigastric vessels
• ~Inferior border: inguinal ligament
• ~Medial border: lateral border of rectus abdominis muscle

Inguinal anatomy

• Deep (internal) inguinal ring
• Superficial (external) inguinal ring
• Spermatic cord

• ~Cremaster muscle (fibers from internal oblique muscle)
• ~Pampiniform venous plexus
• ~Testicular artery
• ~Vas deferens

• ~~Artery of the vas deferens

• Inguinal ligament (Poupart's ligament)

• ~Shelving edge of the inguinal ligament

• Cooper's ligament
• Lacunar ligament

Nerves

• Ilioinguinal nerve
• Genital branch of the genitofemoral nerve
• Iliohypogastric nerve

Misc

• Anterior superior iliac spine (ASIS)
• Pubic tubercle 
• Iliac vessels

Risks:

General surgical risks:

• Bleeding
• Infection

Risks with open hernia repair with mesh (incidence following an open hernia repair with mesh)

• Post herniorrhaphy neuralgia/inguinodynia (13% at three months follow upⁱ) 
• Seroma (1.6%²) or hematoma formation (6.1%²)
• Deep surgical site infection (0.45%³)

• ~Often requiring mesh removal

• Orchitis (0.7%4⁴)
• Sexual dysfunction and pain with sexual activity (13% and 3.7% respectively⁵)
• Injury to hernia contents