Successful surgical repair of a hernia depends on a tension-free closure of the hernia defect to attain the lowest possible recurrence rate. Previous efforts to simply identify the defect and suture it closed resulted in unacceptably high recurrence rates of up to 15%. Modern techniques have improved upon this recurrence rate by placement of mesh over the hernia defect, or in the case of laparoscopic repair, behind the hernia defect. One exception to this rule is the classic Shouldice repair, which uses meticulous dissection and closure without mesh placement to obtain a consistently low recurrence rate. Another benefit of the tension-free closure is that it has been shown to cause the patient significantly less pain and discomfort in the short-term postoperative period.

All of the open anterior herniorraphy techniques begin with a transversely-oriented slightly curvilinear skin incision of approximately 6–8 cm positioned one to two fingerbreadths above the inguinal ligament. Dissection is carried down through the subcutaneous and Scarpa's layers. The external oblique aponeurosis is identified and cleaned so that the external ring is identified inferomedially. Being careful to avoid injury to the iliohypogastric and ilioinguinal nerves, the aponeurosis is incised sharply and opened along its length through the external ring with fine scissors. The nerves underlying the external oblique fascia are then identified and isolated for protection. The soft tissue is cleared off the posterior surface of the external oblique aponeurosis on both sides and the spermatic cord is mobilized. Using a combination of blunt and sharp dissection, the cremaster muscle fibers enveloping the cord are separated from the cord structures and the cord itself is isolated. At this point, it is possible to accurately define the anatomy of the hernia. An indirect hernia will present with a sac attached to the cord in an anteromedial position extending superiorly through the internal ring. A direct inguinal hernia will present as a weakness in the floor of the canal posterior to the cord. A pantaloon defect will present as both a direct and indirect defect in the same inguinal canal.

One of the most widely applied repair techniques is the Lichtenstein repair.  This repair was the first pure prosthetic, tension-free repair to achieve consistently low recurrence rates in long-term outcomes analysis. This operation begins with the incision of the external oblique aponeurosis, and the isolation of the cord structures. Any indirect hernia sac is mobilized off the cord to the level of the internal ring. At this point, a large mesh tailored to fit along the inguinal canal floor is placed so that the curved end lies directly on top of the pubic tubercle. The mesh patch extends underneath the cord until the spermatic cord and the tails of the mesh patch meet laterally. Here, an incision is made in the mesh, and the cord is inserted between the tails of the mesh, thereby creating a new, tighter, and more medial internal ring. The tails are sutured together with one nonabsorbable stitch just proximal to the attachment of the cord. The mesh is then sutured in a continuous or interrupted fashion to the pubic tubercle inferiorly, the conjoined tendon medially, and the inguinal ligament laterally.

Figure legend: A rectangular piece of polypropylene mesh approximately 2 ½ to 3 cm by 8 to 10 cm in size is cut with a lateral slit for the cord and a medial blunt oval for the pubis. The mesh is positioned on the floor of the canal with the tails overlapping lateral to the internal ring and cord. A nonabsorbable 00 suture anchors the mesh to the pubic tubercle. This continuous suture secures the inferior edge of the mesh to the inguinal ligament while interrupted absorbable sutures anchor the superior edge to the internal oblique muscle. Care is taken in the placement of the superior suture so as to avoid any nerve branches.

Board Review Questions

1. A four-layer, suture repair of an inguinal hernia is a

A. Pott’s repair

B. Shouldice repair 

C. McVay repair

D. Lichtenstein repair

2. In the setting of an equivocal examination, which of the following has the greatest sensitivity in diagnosing an inguinal hernia?

A. Repeat examination by a second surgeon

B. Ultrasound

C. CT scan

D. MRI 

3. Contraindications for a transperitoneal laparoscopic inguinal hernia repair include

A. Inability to tolerate general anesthesia 

B. Previous gastric surgery

C. Morbid obesity

D. Diabetes

Answers

1. The correct answer is B. Shouldice repair 

2. The correct answer is D. MRI 

3. The correct answer is A. Inability to tolerate general anesthesia