How is the hernia sac identified and managed in the Lichtenstein tension-free mesh repair?

Updated: Jan 17, 2018
  • Author: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS; Chief Editor: Kurt E Roberts, MD  more...
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Answer

The cord structures and all of the nerves of the inguinal canal having been visualized, the next step is to identify and isolate the hernia sac. The patient is asked to cough, and the groin region is examined for the presence of an indirect hernia, a direct hernia, a femoral hernia, a combined hernia, or a spigelian hernia.

A hernia sac can be managed by means of inversion, division, resection, or ligation. Resection and ligation of a small hernia sac should not be performed unnecessarily, because postoperative pain commonly results. However, the hernia sac must be well separated from the internal ring before it is invaginated. The risk of recurrence is not increased when a small or medium-sized indirect hernia sac is not ligated. [54] Excision of an indirect inguinal hernia sac is associated with a lower risk of hernia recurrence than is division or invagination. [55]

When the hernia sac is excised or divided, the proximal sac should never be left open; doing so may lead to recurrence. The proximal sac is dissected free of cord structures well above the internal ring, and a high ligation of the neck of the sac should be performed.

The indirect hernia sac lies anterolateral to the cord structures and is visualized by dividing the cremaster muscle longitudinally (see the image below). The cremaster muscle should not be divided transversely or excised, because doing so may result in low-lying testes and dysejaculation.

Open inguinal hernia repair. Cremaster muscle pick Open inguinal hernia repair. Cremaster muscle picked up to be incised longitudinally between hemostats.

The peritoneal sac is identified and separated from the spermatic vessels and the vas deferens up to its neck (see the images below). A small or medium-sized hernia sac may be isolated and inverted into the preperitoneal space without suture ligation. For a voluminous scrotal hernia sac, no attempt should be made to dissect it completely and excise it; such an attempt can result in ischemic orchitis. [5]

Open inguinal hernia repair. Hernia sac separated Open inguinal hernia repair. Hernia sac separated from cord structures.
Open inguinal hernia repair. Indirect hernia sac d Open inguinal hernia repair. Indirect hernia sac dissected and being separated from lipoma of cord and cord structures.
Open inguinal hernia repair. Lipoma of cord dissec Open inguinal hernia repair. Lipoma of cord dissected free and excised.
Open inguinal hernia repair. Indirect hernia sac s Open inguinal hernia repair. Indirect hernia sac separated from cord structures in midinguinal region toward neck of sac.
Open inguinal hernia repair. Voluminous indirect h Open inguinal hernia repair. Voluminous indirect hernia sac separated from cord structures in midinguinal region up to neck of sac.

The neck of a large hernia sac is transected at the midpoint of the inguinal canal (see the first image below), and the proximal part is suture-ligated. A high ligation of the proximal sac is recommended, and the stump is reduced deep underneath the internal ring (see the second image below). The distal sac is left in place; however, the anterior wall of the distal sac is incised to prevent postoperative hydrocele formation (see the third image below).

Open inguinal hernia repair. Hernia sac being divi Open inguinal hernia repair. Hernia sac being divided near neck.
Open inguinal hernia repair. Contents of hernia sa Open inguinal hernia repair. Contents of hernia sac reduced and proximal end to be sutured closed.
Open inguinal hernia repair. Anterior wall of dist Open inguinal hernia repair. Anterior wall of distal sac incised to prevent hydrocele formation.

A direct inguinal hernia lies posteromedial to the cord structures. The direct hernia sac is isolated and dissected free. Its contents are reduced, and the peritoneal sac is inverted and maintained in position with a purse-string suture.

If a femoral hernia is suspected, the femoral ring should be evaluated by incising the medial part of the iliopubic tract. If a sac is seen entering the femoral ring, it is reduced and dealt with by inverting or ligating the neck of the sac. A spigelian hernia is managed in a similar manner. A sliding hernia is simply dissected free and inverted in the preperitoneal space.


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