What are preprocedural consideration for an open inguinal hernia repair?

Updated: Apr 16, 2020
  • Author: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS; Chief Editor: Kurt E Roberts, MD  more...
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Answer

For better hemostasis, sharp dissection is preferred to blunt dissection. This is one operation in which, as the saying goes, every red blood cell must be caught.

If a lipoma is present in the spermatic cord, as is often the case, it should be excised to reduce the bulk of the cord; cord structures, however, must be protected. Some surgeons excise the cremaster muscle fibers in the cord; others prefer not to.

With a direct hernia, the sac is not dissected and opened, as is done with an indirect inguinal hernia. Rather, it is inverted (pushed back) into the extraperitoneal space, sometimes with plication of the transversalis fascia.

Bilateral hernias can be repaired in a single procedure, especially with a Lichtenstein tension-free mesh hernioplasty. Some surgeons, however, prefer to repair only one hernia at a time, deferring repair of the other for about 4-6 weeks; this avoids the risk of bilateral infection and the higher risk of penile and scrotal edema after bilateral inguinal hernia repair.

If the hernia is irreducible or obstructed, the sac should be opened first at its fundus, before it is dissected up to its neck, to allow evacuation of toxic fluid and inspection of the bowel for ischemia. If the conventional technique, in which the sac is first completely dissected up to its neck, is followed, the ischemic bowel may slip back into the peritoneal cavity before the sac is opened at its fundus and may then be difficult to retrieve for inspection.

Ischemic bowel is blue-black and thick-walled, lacks luster, feels firm to the touch, and has no peristalsis. The bowel must be wrapped in moist warm packs, and 100% oxygen should be delivered for a few minutes. The bowel is then reassessed for viability. Any nonviable bowel will have to be resected.


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