Lichtenstein hernioplasty

This video demonstrates the steps and technique in performing a Lichtenstein's tension-free open repair.The patient had a small indirect hernia sac, which was mobilized and reduced, and the mesh was secured over the posterior inguinal canal to control the hernia defect.

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Lichtenstein   hernioplasty

Authors
PK Amid
Abstract
This video demonstrates the steps and technique in performing a Lichtenstein's tension-free open repair.The patient had a small indirect hernia sac, which was mobilized and reduced, and the mesh was secured over the posterior inguinal canal to control the hernia defect.
Catégorie
basic techniques
Mots-clés
Lichtenstein hernia repair,herniorrhaphy
Type de vidéo
Durée
15'00''
Publication
2005-05
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, May 2005;5(05).
URL: http://www.websurg.com/doi-vd01en1167e.htm

Lichtenstein   hernioplasty

1. Case presentation 00'14''
The incision will start from the pubic tubercle and go laterally within the skin line for 5cm. We are going to start the local anesthesia, it is a very simple 5 step injection. The most important step of local anesthesia: the external oblique is exposed and you inject 10cc of local anesthesia directly under the external oblique aponeurosis. The whole cord is really elevated and I don’t have to do much more work. There is a little bit of attachments. I will stay very close to the hernia sac to save all these small vessels to decrease the possibility of orchitis and as you see the dissection is very easy because the injection of local anesthesia here has already helped, has developed a good tissue plane for me. This is the end of the sac; when the sac is very large, don’t dissect it completely, just transect and leave the distal portion. I put my finger inside the internal ring, right here, and the sac goes in, that is all that is done to the sac. During the operation, this sac may keep popping out, but it will no longer do that as soon as I put the mesh in, so there is really no reason to put a plug here in order to keep the sac, and I will demonstrate this to you in a second. This is the inguinal canal from the shelving margin up to there, starting from here it’s about 4 to 5cm. The mesh is 7.5cm, 3 inches wide, as I showed you the floor of the canal was this big, this is what we need for the overlap. It is a mistake to use a mesh less than at least 7cm. I am going to trim about 1cm here because it appears to be a little large. Then I curve the corner of the mesh to fit the anatomy of the patient. This is going to be the upper side, this is going to be the inguinal ligament side, here you need less trimming. Now this mesh is ready to go in, this side of the mesh is going to be sutured to the shelving margin, pubic tubercle is going to be here and about 2cm of the mesh is going to be above the pubic tubercle, this is where the mesh is going to go. Very good demonstration here of the pubic tubercle but that is not where the mesh is going to start. My suture is going to be on the rectus sheath right here. This is just an estimation of the distance from where I put my suture to the shelving margin; if I put my needle there, it should be correct. This is a monofilamented non-absorbable suture that just happens to be Novofol, I like Novofol because the needle is very smooth and the memory on the suture is less than Prolene. Now I am going to suture the mesh to the shelving margin, here it is very easy to make a mistake, and catch the periosteum of the pubic tubercle. It is very wrong to do that, it is the most common cause of postoperative pain. I am not going deep, it is very superficial on the shelving margin of inguinal ligament. This is the shelving margin, sutured to the lower edge of the mesh. I am right over the femoral vessel here. This is the internal ring where my finger is, the last suture is going to be at the level of the lateral border of the internal ring. This is going to be the last suture on the shelving margin and to the mesh. Let me show you the suture line here now. The suture line starts from the rectus sheath and goes along the shelving margin to the internal ring. As you see, you do not have to make this close together. Now I have to make a cut on the mesh, the cut is going to end at the medial border of the internal ring. This is the internal ring, lateral border is where the last suture was, right here, the medial border is right here. I am going to cut this mesh right to where the medial border is. Now we have 2 tails, this is the lower tail, this is the upper tail. I am going to pass the upper tail under the cord, and now the spermatic cord is in between the two tails, the upper tail crosses over the lower one. All I have to do is fix the upper edge of the mesh to the rectus sheath and internal oblique aponeurosis with the only true entrusted absorbable suture. My assistant will elevate the external oblique. This is the rectus sheath; as we go lateral, this would be the aponeurosis of the internal oblique. This is the muscle, internal oblique muscle, aponeurosis of the internal oblique, ilio-hypogastric nerve here that we are going to watch carefully to make sure it is not damaged. This is again internal oblique, this is the nerve. I want you to pay attention to 2 things: because the nerve is right in my vision, there is no way my suture will injure it unless I do it intentionally. Another thing is I can make this mesh look very tight, if I make it look tight like that, this patient is on the surgical table sometimes they have some sedation so they are very relaxed. If the mesh is tight when the patient is relaxed, then it becomes tighter when the patient stands up. So when I am suturing the upper edge, I am going to make a little wrinkle here, I am going to make this mesh loose. I am talking about this wrinkle that you see here, I don’t want this to be flat. I am just next to the nerve, this is my suture and this is the nerve. We have the upper tail of the mesh that goes over the lower tail and then, I will take a bite from the shelving margin, then from the lower edge of the lower tail, then from the lower edge of the upper tail and I will make an internal ring, which has a sling configuration. But before we do that, I am going to show you something. Can we ask the patient to cough hard? The hernia sac comes up when the patient coughs. I put it back in and I am going to put this suture and then I will ask you to cough. As I said, one bite from the inguinal ligament, one bite from the lower edge of the lower tail, one bite from the upper edge. Here is how tight the ring is going to be. If I go in this direction, put my suture there, the ring is going to be too tight. If I put it here, the ring is going to be too dilated, so it has to be just enough. Of course, we are going to test that, there is no problem if the ring is just too tight or just too large; if it is too tight, you cut the mesh just a little more; if it is too large, you put a stitch on it. I put this suture too low, so I am going to put one higher up, it is going to be the third one. I should have put that a little higher up so I don’t have to do this again. Again, aponeurosis of the internal oblique here. This is not really necessary but I just want to make it a little more comfortable to your eyes. If this is too tight, you can cut a bit of the mesh here. If it is too loose, you can put a suture here to make it tighter and again the important thing is this wrinkle, I am going to ask the patient to cough and you will see that this wrinkle will straighten. You see it gets filled up. Now I am going to close the external ring, this part is just routine like any other operation. When I close this, I only put the edges together, I don’t take big bites because if you do you, you will create tension on the external oblique aponeurosis, which is a source of pain. This is the internal ring that we made, here’s the cord, the mesh is covering the whole floor, from beyond the pubic tubercle to beyond the internal ring. This is the wrinkle that we did intentionally. Now this is closed. Again this is edge to edge. I think this is the last stitch, there is not too much left there. It does not matter how big the external ring is, it is not a part of the external repair.