This script is in the process of conversion from a pdf file to a wiki file.

In the meantime you can still use the pdf version below.

HERNIA INGUINAL - ADULT

A PANTOGEN OPERATION SCRIPT

MICHAEL EDWARDS

NO INFORMATION IN THIS SCRIPT SHOULD BE USED WITHOUT THE APPROVAL OF A FULLY TRAINED PRACTISING SURGEON

THIS SCRIPT COVERS:

LAY OUT OF OPERATION SECTIONS AND STEPS

The operation is divided into SECTIONS.

The SECTIONS are displayed in sequence in the following paragraphs.

Each SECTION is divided into an unlimited number of very small STEPS.

Each STEP contains an unlimited amount of supporting information (PANTINOS)

CurrentTechniques IN OPEN REPAIR OF INGUINAL HERNIA (ADULT ) (OPERATION 001 LAST UPDATED JAN 23 1995) LICHTENSTEIN REPAIR SHOULDICE REPAIR BASSINI REPAIR SURGEON..........MICHAEL H. EDWARDS FRCS COMPUTER CONSULTANT......PATRICK J. TRIGWELL BSC MSC LIST OF CONTENTS PAGE NUMBER OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 2 4 OBJECTIVES OF CurrentTechniques 6 SCOPE OF CurrentTechniques IN OPEN INGUINAL HERNIA REPAIR 7 NOTEPAD 8 WARNING TO USERS OF CurrentTechniques 9 HOW TO USE MULTIMEDIA CurrentTechniques 16 ANATOMY REVIEW 19 PATHOPHYSIOLOGY STEP NUMBER 20 1 PRELIMINARIES 20 8 ANAESTHESIA 21 9 POSITION 21 10 STANCE 21 11 PREPARING THE SKIN 22 15 LOCAL ANAESTHESIA 24 17 INCISING THE SKIN 25 19 DISSECTION 29 33 FINDING AN INDIRECT SAC 30 38 TREATING AN INDIRECT SAC 35 60 FINDING A DIRECT SAC 36 63 TREATING A DIRECT SAC 39 79 REPAIR 40 80 LICHTENSTEIN REPAIR 50 117 SHOULDICE REPAIR (TRANSVERSALIS FASCIA PLICATION + CONJOINT TENDON REPAIR) 53 127 BASSINI REPAIR (CONJOINT TENDON REPAIR) 57 134 CLOSURE 60 151 FINAL TOUCHES 62 157 EQUIPMENT AND MATERIALS LIST (FRIARAGE HOSPITAL) PAGE STEP NUMBER NUMBER 64 158 EQUIPMENT AND MATERIALS LIST (ST JOHN OF GOD HOSPITAL) Page 2 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 3 66 ANNOTATE EQUIPMENT AND MATERIALS 67 INFORMATION FOR PATIENTS 79 TUTORIALS OBJECTIVES OF CurrentTechniques For the practising surgeon, CurrentTechniques provides: Comparison of the smallest detail of surgical method of another practising surgeon against his/her own. The creation of an ever valid record of his/her own methods. Page 3 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 4 Essential details of operations with which he/she may not be familiar. A structure upon which the practising surgeon can build developments and improvements of surgical method. An ever up to date, personalised, quality protocol for his/her operations. A structure for adjusting the surgical team to change. Accelerated training of residents. Training in computer aided education. Suggested approach Run through the program. Browse around the program. Try the questionnaires. Add annotations to steps as needed. Make notes in notebook as needed. Have your equipment and materials list loaded into the personal equipment and materials page. For the resident, CurrentTechniques provides: Essential details of operations. Details of the senior surgeon's preferred methods. A structure for making his/her own operative surgical manual. Accelerated learning in operative surgery. A helpful way to pass operative surgery examinations. Training in computer aided education Suggested approach Run through the program. Browse around the program. Try the questionnaire. Add annotations to steps as needed. Make notes in notebook as needed. Make notes of questions to ask the senoir surgeon. For the student, CurrentTechniques provides: Easy learning of anatomy, pathophysiology, and principles of operations. Details of operative steps as required. Training in computer aided education Suggested approach. Run the program but do not read the details of the steps at first. Read the details of the steps once you have grasped the major features. Page 4 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 5 For the scrub nurse, CurrentTechniques provides: Easy learning of anatomy, pathophysiology, and principles of operations. Easy learning of details of equipment and materials. Ever up to date details of equipment and materials. Easy refresher courses for scrub nurses. SCOPE OF CurrentTechniques IN OPEN INGUINAL HERNIA REPAIR REPAIR Page 5 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 6 LICHTENSTEIN SHOULDICE BASSINI PATIENT 12 YEARS PLUS For a child of 12 years or less: See Repair of Inguinal Hernia ( Child ) Filename INGHERCH. MALE FEMALE HERNIA TYPE INDIRECT DIRECT SLIDING EXPLORATION FOR SUSPECTED HERNIA RECURRENT UNILATERAL BILATERAL ANAESTHESIA LOCAL GENERAL EPIDURAL SPINAL NOTEPAD NOTEPAD Page 6 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 7 WARNING TO USERS OF CurrentTechniques CurrentTechniques is a useful tool for training and for quality control, but it has major limitations. It does not cover all the details of the procedures. It is not a comprehensive training system. It may complement, but it does not replace standard accepted surgical practices, or accepted forms of surgical teaching and training. It does not set out to establish or impose any specific standard of surgical practice. Page 7 CurrentTechniques in Open Inguinal Hernia Repair It does not set out to impose any particular way of performing an operation. Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 8 It describes some procedures which carry an inherent high risk of serious or lethal complications. It describes some procedures and operations which are changing very rapidly, but the information in CurrentTechniques is only as good as its last update. We reserve the right to alter the text, layout, presentation, and computer and other electronic features without warning. CurrentTechniques assumes certain levels of surgical skill which are reflected in the grading of the operations. eg.The steps of an oesophagectomy are far more difficult than the steps in an inguinal hernia repair. The grading of the operations does not correlate with the seniority of the surgeon, because of the wide range of technical ability among surgeons of the same seniority. Even Grade 1 operations cannot be done safely by those who do not have skills in basic surgical techniques. It is possible for a surgeon to follow CurrentTechniques steps to the letter, and still get into serious trouble for a large number of reasons, some of which are listed above. The clinical judgement of the surgeon at all times overrides the information given in CurrentTechniques. We stress that there are entirely acceptable alternatives to all the procedures, techniques, equipment , and materials mentioned in CurrentTechniques. We do not claim that any of the procedures, techniques, equipment, and materials in CurrentTechniques are in any way superior to others. While the author and publishers have made strenuous efforts to make CurrentTechniques as safe and as reliable as they possibly can, they accept no liability for: Problems occurring from the use of CurrentTechniques in its original or in any modified form, either now or in the future. Any difficulties encountered in performing any of the techniques, or using any of the equipment or materials, surgical and non-surgical, described in the text. Changes, discrepancies, or errors that may appear in the information as the result of data inputting, programming, system faults, data handling, transmission, and printing or any other computerised process. How to use MULTIMEDIA CurrentTechniques New to computers? Click on the Welcome to CurrentTechniques icon. Press any of the pale keys on the computer keyboard. This will start the program showing how to use the cursor, and how to click. Page 8 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 9 New to CurrentTechniques? Click on the Welcome to CurrentTechniques icon. Click on the Hand icon opposite the New to CurrentTechniques sentence on the window. Then follow the instructions to learn about CurrentTechniques. New to CurrentTechniques in Open Repair of Inguinal Hernia (adult)? Click on the Hand icon opposite Hotline to Inguinal Hernia Repair. Or, click on the Open the Manual icon on the top of the cover window. Choose the language of the sound track The sound track covers the text of the all the steps and how to do them. It does not cover the extra information screens. You have a choice of 2 languages on the sound track - UK English and American English. Click on the Language icon. Click on the language of your choice. Sound on/off You can switch off the sound completely (sound track, music, and sound effects). Click on the Sound icon (it looks like an ear), and the sound will switch off. The icon changes to the Sound Off icon (an ear with a cross on it). To switch the sound on again, click on the Sound Off icon. Open the manual Click on the Open the Manual icon at the top of the screen to open the MULTIMEDIA CurrentTechniques manual at the first page. This will tell you: Which types of inguinal hernia are described in the manual. Which methods of repair are covered. Which patients are suitable. Which type of anaesthesia is suitable. Which aspects are not covered. Click on any blue text with underlining to obtain more information. Start the operation Click on the Start the Operation icon at the top of the screen of the first page of the manual. This will show and tell you how to use the icons to make your way through the operation. Page 9 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 10 All the icons are listed below in order of appearance. We give details below of the features of each icon. Operation name This is not an icon. This manual describes 3 ways of repairing an inguinal hernia in an adult. Hundreds of variants in type of patient, type of hernia, and other features are covered in the manual. How difficult an operation? This is a guide to show which features of the patient will make the operation more difficult. The standard level of difficulty for the operation is 3 out of an arbitrary 12 as applied to a male patient. Click on the features in the 2 columns to see how they may influence the difficulty. How long an operation? This is a guide to show how features of the patient will influence the length of an operation. The duration is based on an arbitrary 30 minutes operating for a male patient. Click on the features in the 2 columns to see how they may influence the timing. How much Local Anaesthetic? This feature will instantly calculate a safe maximum volume of a given strength of a given local anaesthetic agent according to a patient's weight. Click on the box which records the patient's weight according to kilograms, pounds, or stones and pounds. Enter the patient's weight using the numbers on your computer keyboard. The correct volume of local anaesthetic will instantly appear on the screen. You can change the weight by typing in new numbers and removing the old ones using the delete key or backspace key on your computer. Or, you can calculate the volume as described in step 8. Step number This is not an icon. Each step of the operation has a number. The numbers are primarily there to keep the steps of the operation in order and to allow easy browsing round the manual. Page 10 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 11 There is no need to learn the numbers. It is very important, however, to learn the sequence of the steps. The manual is divided into sections for ease of understanding. Each section consists of a list of the steps covered in that section. Each section is given a step number for convenience. Go to the next step The icon here is a hand pointing to the right, with NEXT written on it. Click anywhere on the hand or NEXT to move to the next step. Go back a step The icon here is a hand pointing to the left, with BACK written on it. Click anywhere on the hand or BACK to move back one step. Select another step Click on the Select icon to take you to a complete list of all the steps of the operation. Click on the down facing arrow at the bottom right hand corner of the Select screen to move the list downwards 1 step. Keep pressing the clicker on the down arrow to scroll the list slowly downwards. Click on the column just above the down arrow to jump down the steps, a screen at a time. To move the list of steps upwards one step at a time, slowly and continuously, or a screen at a time, click on or below the upward facing arrow at the top right hand corner of the screen. To move very fast up or down the list of steps, hold the clicker on the box in the column between the up arrow and the down arrow. Drag the box up or down the column using your mouse or trackball. The list of steps will follow instantly. Release the clicker when you have found the step you want. The step will get a blue background. To bring the chosen step onto the screen, click on the written title of the step. The step will appear in red at the bottom of the window. Click on the OK icon at the bottom of the window. Or, just double click on the written title of the step. To close the window, click on the Cancel icon. Jump to another step The text may instruct you to go to a step in a different part of the operation, eg If there is no indirect hernia, you need to jump forwards a long way to the step describing how to find a direct hernia. Page 11 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 12 All instructions of this type are written in RED. Click on the red text, and you will immediately jump to the new step. Route map + selecting a step The Route map displays the main steps of the operation in the form of a flow diagram. (The numbers of the less important steps are visible on the main steps.) Main steps which are instructions are shown as boxes. Main steps which are decisions are shown as diamonds. The Route map will show you where you are in the operation. It will help you to quickly find and go to any main step in the operation. It will show you how many and where major decisions are needed in the operation. Click on the Route map icon (Route + a mini-flow diagram) to open the Route map. A red dot on the Route map will show you where you are In the operation. Click on the down facing arrow at the bottom right hand corner of the Route map screen to move the list down 1 step. Keep pressing the clicker on the down arrow to scroll the Route map slowly downwards. Click on the column just above the down arrow to jump down the Route map a screen at a time. To move very fast up or down the Route map, hold the clicker on the box in the column between the up arrow and the down arrow. Drag the box up or down the column using your mouse or trackball. The Route map will follow instantly. To move the Route map upwards one step at a time, slowly and continuously, or a screen at a time, click on or below the upward facing arrow at the top right hand corner of the screen. Release the clicker when you have found the Route map you want. When you have found the step you want, click on the step. The step will appear on your screen. To close the Route map, click on Cancel. Extra text, information, references, abstracts Click on any underlined blue text to obtain a window with extra text, references, or abstracts. Click on the OK icon to close the window. Diagrams There are 2 sorts of diagrams. 1 Each step has a diagram occupying one half of the screen. Page 12 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 13 To see the diagram in more detail, click on View on the menu bar on the top of the screen. Then click on Diagram to show the diagram on higher magnification. To move around the enlarged diagram, use the scroll arrow and boxes on the scroll bars on the side and the bottom of the diagram, as you do for scrolling on the Routemap. 2 Click on the Diagram + Pencil icon to obtain an extra diagram window. Click on the Close icon to close the Diagram window. Tutorial There are 6 Tutorials covering the main parts of the operation. ie. the anatomy, dissection, management of the hernial sacs, and the techniques of the different repairs. Each Tutorial consists of 8 Questions. Each Tutorial will ask questions which are yes/no, multiple choice, or identification types. The text will make each type clear. The Tutorial will give a helpful explanation and more information, even if your answer is wrong. The Tutorial will calculate a score of as many correct answers as there are out of the number answered by the user. You will find the Tutorials on: Page Anatomy and Pathophysiology Page Dissection Page Management of hernial sacs Page Lichtenstein repair Page Shouldice repair Page Bassini repair Click on the Open Tutorial icon to open the Tutorial window. Click on the answer you think is correct. Click on the OK icon. You will get a response from the Tutorial. Click on the Exit icon to leave the Tutorial whenever you like. You will see your score. Click on the OK icon to leave the Tutorial. Video There are 10 clips of video among the steps of the operation. Their main value is to give a general impression of parts of the operation. The text plus the diagrams are more useful for training. Click on the Video icon (Video + camera) to start a video. Click on the up arrow on the upper right hand corner of the Video to enlarge the video to fill the whole screen. Page 13 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 14 Click on the black square control at the bottom of the window to stop the video. Drag the hollow square control on the bottom of the window from side to side to run the video forwards or backwards at your own pace. Click on the Cancel icon to close the Video. Annotating and bookmarking of all steps You can annotate every step of the operation. You can type in any comments you wish. There is no limit to the amount of text you can insert this way. Once an annotation has been made to a step, the window of the step will have its upper right hand corner turned down, marked with a star (a Bookmark). Clicking on the star will bring down that annotation. Click on the Annotate icon to bring down a blank annotation window. Once you have made an annotation, you can click on the relevant icon to Cancel and Quit, to Clear the annotation, or to Save the annotation and Quit. You can scroll the annotation down if it is larger than the window using the control on the right hand side of the window. Annotating the Equipment and Materials You have a whole screen at the end of the operation to allow you to list and update your own preferred equipment and materials. Notepad You can make any notes you wish in the Notepad on page Exit to beginning of CurrentTechniques Click on the Exit icon on the upper part of any step. Exit to Windows Double click on the Exit icon on the upperpart of any step. Or, click on the Exit icon on the cover window of CurrentTechniques Exit to DOS Double click on the drawer icon on the top left hand corner of the cover window of CurrentTechniques. Printouts Page 14 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 15 You can print out any of the text and diagrams on this CD-ROM. SECTION ANATOMY REVIEW You may find that running through the operation 2 or 3 times will give a very clear idea about the anatomy. The following points should clarify common anatomical blind spots. Page 15 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 16 The abdominal wall consists of 3 layers of muscle and sheets of tendon (aponeuroses). They run from the spine, round to the linea alba in the midline anteriorly. In the lower abdomen they all run in front of the vertical rectus abdominus muscle just lateral to the linea on each side. These layers are covered with fat and the skin. Inside these layers lie the extraperitoneal fat and the peritoneum. The outermost layer, the external oblique, is muscle laterally, but just consists of a strong aponeurosis medially. The inferior margin of the external oblique arises from the iliac crest of the pelvis. It is inserted medially into region of the pubic tubercle. Between the iliac crest and the pubic tubercle, the external oblique has a free lower margin. This free margin is thickened with a selvedge to form the inguinal ligament. The inguinal ligament merges with the fascia on the iliacus muscle inside the pelvis and the fascia of the thigh muscles to close off the free margin (the ilio-pubic tract). The spermatic cord, on its way to the testis, (or the round ligament on its way to the labium in the female) pushes through a gap in the external oblique aponeurosis . This gap is just lateral to the pubic tubercle, and is called the superficial external ring. The 2 inner layers arise not only from the iliac crest as the external oblique does, and but also from the lateral half of the inguinal ligament itself.Their anatomy is a little complicated here, but provides the key to understanding inguinal hernias. Unfortunately, the 2 inner layers sweep over the posterior wall of the inguinal to insert into the pubic tubercle area. The posterior wall is made up of only a weak fascia of the innermost layer (the transversalis fascia). This fascia is all that separates the extraperitoneal fat and the inferior epigastric vessels from the inguinal canal. A direct hernia will develop here.by pushing directly through the posterior wall of the inguinal canal. The 2 inner layers in this region are called the conjoint tendon. The inferior margin of the conjoint tendon as it sweeps over the posterior wall of the inguinal canal is called the transversus abdominus arch (semicircular fold of Douglas). The spermatic cord (or round ligament) pushes through a gap in the inner 2 layers. This gap is lateral to the external ring, covered by the external oblique. It is called the deep inguinal ring. Page 16 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 17 The spermatic cord, (or round ligament), therefore runs between the deep and external rings in a canal, the inguinal canal. An indirect hernia will push through the internal ring, along the inguinal canal inside the coverings of the spermatic cord, and may extend down to the testis. The path of this type of hernia is therefore "indirect", compared with the "direct" path of the direct hernia. The spermatic cord consists of: the vas - a 1mm. diameter white cordlike tube running up from the testis to the seminal vesicle near the prostate gland testicular artery pampiniform plexus of tributaries of the testicular vein artey to the vas testicular nerves connective tissue and fat ilio-inguinal nerve The cremaster muscle - brownish strands running from the internal oblique muscle layer to the testis to control the position of the testis. (other coverings on the spermatic cord, the external spermatic fascia, from the external oblique, and the internal spermatic fascia from the transversus abdominus, are rarely seen outside anatomy books.) In the female, these coverings simply add some bulk to the round ligament. The inferior epigastric artery and vein run upwards from the external iliac vessels on the medial side of the internal ring, deep to the transversus layer. The sensory and motor nerve supply to the lower part of the abdominal wall runs between the external oblique and the internal oblique layers from the first lumbar nerve root. It comes in two parts. The upper nerve, the ilio-hypogastric nerve runs above the inguinal canal. The lower nerve, the ilio-inguinal nerve runs in the inguinal canal and passes under the cremaster muscle down towards the testis. In the female it lies in an equivalent position superficial to the round ligament. These nerves will be visible when the external oblique aponeurosis is opened. Page 17 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 18 In addition the genital branch of the genito-femoral nerve runs along the back wall of the spermatic cord or round ligament to the skin of the scrotum and labium respectively. The subcutaneous layer consists of fat and a thin layer of condensed fibrous tissue called Scarpa's fascia. Scarpa's fascia can be confused with the deep fascia on the surface of the external oblique. Named blood vessels run on Scarpa's fascia. The superficial epigastric artery and vein run vertically over the centre of the inguinal canal. Branches of the superficial external pudendal vessels run vertically, medial to the external ring. The superfical circumflex iliac vessels run obliquely downwards towards the middle of the inguinal region, lateral to the external ring. SECTION PATHOPHYSIOLOGY A hernia is an abnormal bulge of tissue through a defect. In the inguinal region the defect is either directly through the weak posterior wall of the inguinal canal ( a direct hernia). Or it is bulge through a weakness in the deep inguinal ring ( an indirect hernia). Page 18 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 19 Factors which account for the development of hernias, and which are of relevance to the repair operations include: Congenital failure of closure of a peritoneal sac of peritoneum dragged into the scrotum by the descending testis. Obesity with infiltration of all layers of the inguinal region with fat. Weakness due to : ageing ilio-inguinal nerve damage from previous appendectomy previous hernia repair nearby wound such as laparotomy . The bulge may be just a localised weakness, unlike the generalised weaknesses seen in Malgaigne's bulges. Or it may consist of extraperitoneal fat (a lipoma of the cord). Or there may be a sac of peritoneum. The sac may be confined to the inguinal canal, or it may be a complete (vaginal) sac containing at its bottom the testis. The contents of the sac are usually omentum or small bowel. Rarely an undescended testis or an ovary may be present. Occasionally a hernia is the presenting feature of an ascites, malignant or benign, or of a malignant deposit from an intraabdominal malignancy. The contents of a sac may be adherent to its wall. A sliding hernia consists of a retroperitoneal viscus such as the large bowel or bladder which been drawn down as part of the wall of the hernia, rather than as one of the contents. Combinations of types are common. An increasingly common variant is a subclinical hernia causing persistent pain in the groin in professional footballers

SECTION 1.00 PRELIMINARIES

STEP 1.01 CHECK YOU HAVE THE CORRECT PATIENT

STEP 1.02 CHECK YOU HAVE THE CORRECT SIDE.

4 CHECK THERE IS NO OTHER PROCEDURE TO DO 5 CHECK THERE IS A DIATHERMY PAD 6 CHECK THERE IS AN ECG MONITOR 7 CHECK THE PATIENT IS SHAVED FROM UMBILICUS TO MID THIGH 8 SECTION ANAESTHESIA LOCAL anaesthesia technique is described in this account. An acceptable upper dose of lignocaine is 3 mg. per kilogram (200 mg. for a 70 Kg person). (40 ml of 0.5% Lignocaine). A higher dose raises the risk of toxic effects if the drug reaches the circulation. NB You MUST have facilities and staff to correct any complications of local anaesthesia eg. Hypotension, Page 20 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 21 cardiac arrhythmias, respiratory arrest, coma, convulsions, and anaphylactic reactions.

• • • For GENERAL, SPINAL and EPIDURAL anaesthesia just ignore the asterisked steps.

ALL GENERAL ANAESTHESIA patients are given a Bupivacaine nerve block at the beginning of the operation. (See STEP 15) 9 SECTION POSITION SUPINE with bare skin from costal margin to mid thigh, free from all tubing, wires, electrodes, etc. 10 SECTION STANCE Stand on the side of the hernia with one assistant on the opposite side. For a double hernia, start on the less severe side. This will get your eye in for the more difficult side, and reduce the chance of an infection. 11 SECTION PREPARING THE SKIN Use two swabs on sticks with 0.5% chlorhexidene in 70% propanol, followed by one to dry off. Clean the skin from the umbilicus to the mid- thigh, and from the iliac crest to 5 cm beyond the mid-line. For a double Hernia, prepare the skin to the opposite iliac crest. Page 21 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 22 12 TOWELLING UP Place an upper towel down to the iliac crest. Place a lower towel up to the symphysis pubis. Place a lateral towel to the anterior superior iliac spine. Place a medial towel 5 cm. beyond the midline. For a double hernia, place a medial towel to the opposite anterior superior iliac spine. Cover the second side with a temporary extra towel. 13 FIX THE TOWELS Use 4 towel clips. 14 CHECK DIATHERMY IS WORKING 15 SECTION LOCAL ANAESTHESIA Use 5 mg/ml ( 0.5% ) plain Lignocaine. i.e. 40 ml. for a 70 kg. person. Make sure all needles are pushed firmly onto the syringes until they creak. Raise a 2 ml. skin bleb of Lignocaine at the anterior superior iliac spine. Use an orange 25 SWG needle on a 20 ml syringe. Page 22 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 23 Next, with a green 21 SWG needle, raise a ridge of skin using 15 ml. of Lignocaine from the anterior iliac spine to the symphysis pubis. Then infiltrate the fat and abdominal wall in the same line with another 15 ml. Block the ilio-inguinal and ilio-hypogastric nerves with 10 ml. anaesthetic just medial to the anterior superior iliac spine, 2 cm. deep to the skin. Test the skin for anaesthesia with the scalpel point. If the patient still feels pain, wait 3 minutes. If there is still pain after this, inject another 5 ml. of Lignocaine into the most superficial layer of the skin. You must have complete anaesthesia before you can continue. If the patient is still feeling discomfort, consider a giving Diazepam or Pethidine with the supervision of the anaesthetist. Very rarely a general anaesthetic is needed. FOR A PATIENT WITH A GENERAL ANAESTHETIC Inject BUPIVACAINE 0.5% (20 ml. for a 70 Kg. patient) into the ilio-inguinal nerve medial to the anterior superior iliac spine. Page 23 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 24 16 STEADY THE SKIN Press on the skin with one swab held by your assistant and another held in your left hand. 17 SECTION INCISING THE SKIN Use a scalpel with a no. 23 Swann-Morton blade. Incise the skin parallel to the inguinal skin crease and 3 cm. above it. Cut 2cm. from the anterior superior iliac spine to 1 cm. from the mid line, 1 cm. above the pubic tubercle. A less medial limit will make exposure of the medial end of the posterior inguinal wall difficult. Avoid the dorsal vein of penis.

• • • Tissue that is " oedematous " with Lignocaine will be anaesthetic.
    • Inject more Lignocaine as required to keep absolute control of pain.

But remember you may well be exceeding the recommended maximum dose of 3 mg/Kg ( 40 ml 0.5% Lignocaine for a 70 kg patient.) 18 COAGULATE VESSELS Page 24 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 25 These will be the superficial epigastric artery and vein laterally, plus some irritating veins in the medial part of the wound. Ligate any vessels which continue to bleed with 2/0 Vicryl ( Ethicon W9025). Page 25 CurrentTechniques in Open Inguinal Hernia Repair 0 EXPOSE THE OSIS Firmly sweep away the fat of the xpose the stripes of the 1 ATTACH 2 SKIN Use 2 dressing towels tucked old the towels to each edge asten the towels to the wound 2 RETRACT THE Use a Traver's self retaining lace its handle medially to 19 SECTION DISSECTION 2 EXTERNAL OBLIQUE APONEUR upper and lower flaps using a swab in each hand. E aponeurosis clearly before you continue. 2 EDGE TOWELS under the upper and lower wound edges. H with 2 Tetra clips. F ends with towel clips. 2 SKIN AND FAT retractor. P avoid obstructing your access. Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 26 Page 26 CurrentTechniques in Open Inguinal Hernia Repair ee the external ring and the ee at least 10cm. of external 3 INCISE THE OSIS Use a scalpel with a no. 23 ut the aponeurosis for 2 cm. in 4 PICK UP THE OSIS Put 1 artery clip on the upper 5 EXTEND THE Slit the fibres using partly open aterally extend 3 cm. beyond edially extend into the gap in 6 DISPLAY THE CONJOINT S spermatic cord or round ligament medially. S oblique aponeurosis laterally. 2 EXTERNAL OBLIQUE APONEUR Swann-Morton blade. C the line of the fibres leading to the external ring. 2 EXTERNAL OBLIQUE APONEUREDGES leaf for your assistant and 1 on the lower leaf for yourself. 2 EXTERNAL OBLIQUE INCISION scissors. L the spermatic cord ( or round ligament which is surprisingly large ) and the internal ring. M the external oblique aponeurosis ( the external ring ). 2 Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 27 Page 27 CurrentTechniques in Open Inguinal Hernia Repair Use artery forceps to elevate the external oblique aponeurosis ze swab to clear ompletely the conjoint tendon 27 MOBILISE THE CORD (OR Slide your finger medially between the lower surface of the n as far edially as the bony hardness ed more naesthetic medially. 28 HOOK YOUR FINGER Hook your finger round the spermatic cord (or round 9 COAGULATE AND DIVIDE THE TENDON AND CORD (OR ROUND LIGAMENT) flaps 3 cm. Use a gau c of adventitia and fat. ROUND LIGAMENT) cord (round ligament) and the inside of the lower leaf of the external oblique aponeurosis (the inguinal ligament). Do this finger dissectio m of the pubic tubercle. *** You may ne a ligament ) to identify the adventitia and vessels lying medially on the pubic tubercle. 2 MEDIAL VESSELS Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 28 Page 28 CurrentTechniques in Open Inguinal Hernia Repair This will free the spermatic cord ( or round ligament ). ed more naesthetic here. 30 FREE THE ILIOINGUINAL Use scissors to dissect the nerve from the front of the 31 RETRACT THE ILIO-INGUINAL Hold the nerve behind the artery clip on the lower leaf of the ly ith scissors as far laterally as nerve end away from ny repair stitches, to avoid 32 RETRACT THE CORD Use a cord retractor to retract the cord downwards. 3 SECTION FINDING AN AC 34 LIPOMA(S) OF THE CORD

• • • You may ne

a NERVE spermatic cord. NERVE external oblique aponeurosis. If the nerve breaks, cut it clean w you can. Keep the a postoperative neuralgia. 3 INDIRECT SLOOK FOR Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 29 Page 29 CurrentTechniques in Open Inguinal Hernia Repair These lie in the lateral part of the internal ring. gs 5 cm. or more in ngth. internal ring. Their ttachment to the internal ring is 35 EXCISE ANY LIPOMA(S) Clip with 2 artery forceps, cut with scissors, and tie off using 2/0 Vicryl ties (Ethicon W9025). 36 LOOK FOR AN INDIRECT SAC Use gauze dissection to find an indirect sac lying in the front of the spermatic cord. to do this. uous 2/0 Vicryl (Ethicon 9136). 37 IF THERE IS NO INDIRECT SAC O TO STEP 60 (FINDING A DIRECT SAC) divide the remaster, so that the cord Unlike hernias, they consist only of fat. They are soft, lobulated, yellow swellin le They arise from the lateral part of the a rather friable. You may need to open the front coverings of the cord Use gauze dissection to achieve this. If you tear the sac, repair it with contin W G Before deciding that there is no indirect sac, c Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 30 Page 30 CurrentTechniques in Open Inguinal Hernia Repair REDUCE IT TEP 61 R A DIRECT SAC). 38 SECTION TREATING AN INDIRECT SAC 39 THE SAC Press on the sac with your fingers to reduce omentum, bowel and other contents back ions. GO TO STEP 50 OR there may be a SLIDING hernia READ ON 41 IS IT A SLIDING INDIRECT HERNIA? This has thick walls consisting of colon or bladder. ush a SLIDING HERNIA back consists only of vas, testicular artery, and pampiniform plexus. FOR AN INDIRECT BULGE, GO TO S (LOOK FO IF THERE IS ANINDIRECT SAC 40 REDUCE ANY CONTENTS OF into the abdomen. If the contents will not reduce, there may be adhes (OPEN THE SAC) - It bleeds on dissection. P inside the internal ring. Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 31 Page 31 CurrentTechniques in Open Inguinal Hernia Repair GO TO STEP 61 C) If you are whether it is a sliding hernia or ot, treat it as a SLIDING DIRECT SAC) 42 IF THE INDIRECT SAC IS NOT SLIDING An empty non-sliding sac is bluish-white. ere on the surface f the cord (or round ligament) 43 IF THE LOWER MARGIN OF THE INDIRECT SAC IS GO TO STEP 49 (DISSECT OUT THE SAC) 44 IF THERE IS A COMPLETE SAC (VAGINAL SAC) This runs down into the scrotum. You need to make a rather more f the sac in the accessible part of the cord. (LOOK FOR A DIRECT SA in doubt about n HERNIA GO TO STEP 61 (LOOK FOR A Its rounded lower margin will be present anywh o unless it extends as far down as the testis (Complete sac). Dissect patiently with a gauze to display it. VISIBLE fiddly dissection round the back o Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 32 Page 32 CurrentTechniques in Open Inguinal Hernia Repair mage to the vas. 45 CLEAR A 2 CM. LENGTH OF COMPLETE SAC Use an artery forcep. 47 Use scissors to cut the sac 1 forcep. This allows the distal end of sac ng ssues. 48 HOLD THE PROXIMAL END OF THE SAC Use the artery forcep. 49 from the spermatic cord right up to the internal ring and INTO the internal ring. Take special care when dissecting the sac off the cord, to prevent da If the sac tears, take even more care. 46 CLIP THE FREEDLENGTH OF COMPLETE SAC CUT THE SAC cm. beyond the artery to remain open and drain its contents into the surroundi ti DISSECT OUT THE SAC Use gauze dissection

• • • You may need to inject more anaesthetic into the neck of the sac.

Avoid the vas which lies very close to the sac. Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 33 Page 33 CurrentTechniques in Open Inguinal Hernia Repair void the inferior epigastric vein the peritoneal avity. 50 OPEN THE SAC n 3 artery forceps. Cut into the apex of the sac with 51 IF YOU FIND A SLIDING HERNIA owel forming the inside wall of the sac. Repair the opening in the sac educe the hernia. (LOOK FOR A DIRECT 52 IF YOU FIND ADHESIONS BETWEEN THE SAC AND L Make quite sure that it is not really a sliding hernia. If it is sliding hernia, FOR A DIRECT SAC)) A and artery which lie medially and are very delicate. If the sac tears, clip the edge of the tear to prevent the tear extending up into c Hold the apex of the sac betwee scissors if it is not the complete type of sac.. i.e. Large b with 2/0 Vicryl (Ethicon W9136) R GO TO STEP 61 SAC) OMENTUM ORSMALL BOWE GO TO STEP 61 (LOOK Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 34 Page 34 CurrentTechniques in Open Inguinal Hernia Repair Divide genuine adhesions so that the cont back into the abdominal cavity. 53 CHECK THERE IS NO INTERSTITIAL HERNIA An interstitial hernia runs between the layers of the abdominal muscles. 54 TWIST THE SAC ny contents entering from the peritoneal cavity. 55 TRANSFIX THE SAC the twisted sac at its nction with the peritoneal cavity. 56 CUT THE SAC . 7 RELAX YOUR STITCH there is no bleeding from the cut surface of the sac. 58 STITCH ents can be reduced READ ON If there is an interstitial hernia, reduce it. READ ON Rotate the 3 artery forceps on its apex to push back a Transfix ju Use a No. 1 Vicryl stitch ( Ethicon W 9251). Use scissors to cut the sac 1 cm. from the stitch 5 HOLD ON THE This will check that CUT THE Use scissors to cut the Vicryl 1 cm. from the knot. Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 35 Page 35 CurrentTechniques in Open Inguinal Hernia Repair STUMP OF THE SAC Push the stump inside the internal ring. 60 SECTION FINDING A DIRECT SAC A A direct sac lies medial to the inferior epigastric vessels. 62 O DIRECT SAC an 5 cm. in diameter, (and most direct hernias come into this category), GO TO STEP 79 TO STEP 79 (REPAIR) 63 SECTION TREATING A DIRECT SAC A CM. DIAMETER 65 Press on the sac with your fingers to reduce the contents back into the abdomen. 59 PUSH THE 61 LOOK FOR DIRECT SAC IF THERE IS N Or only a BULGE less th (REPAIR) NB FOR NO INDIRECT SAC + NO DIRECT SAC GO 64 IF THERE ISDIRECT SAC MORE THAN 5 REDUCE ANYCONTENTS OF THE SAC Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 36 Page 36 CurrentTechniques in Open Inguinal Hernia Repair (OPEN THE SAC) IDING hernia - REA 66 IS IT A SLIDING DIRECT HERNIA? This has thick walls consisting of colon or bladder. It bleeds on dissection. HERNIA back side the extraperitoneal fat. O TO STEP 79 you are in doubt about iding hernia or not, treat it as a SLIDING ERNIA TEP 79 (REPAIR) 67 IF THE DIRECT SAC IS NOT SLIDING Use a gauze swab.

• • • You may need more

naesthetic injected into the If the contents will not reduce, there may be adhesions. GO TO STEP 69 OR there may be a SL D ON Push a SLIDING in G (REPAIR) If whether it is a sl H ie Reduce it. GO TO S 68 DISSECT THE SAC a neck of the sac. Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 37 Page 37 CurrentTechniques in Open Inguinal Hernia Repair irect hernia or ulge, and hold it reduced with a 69 OPEN THE SAC of the sac etween 3 artery forceps. Cut into the apex of the sac with 70 IF YOU FIND A SLIDING HERNIA bowel forming the inside wall of the sac. Repair the opening in the sac educe the hernia. 71 IF YOU FIND ADHESIONS BETWEEN THE SAC AND L Make quite sure that it is not really a SLIDING hernia. (If it is a SLIDING HERNIA, (REPAIR) Avoid the inferior epigastric vein and artery which lie laterally and are very delicate. (If you are planning a Lichtenstein repair, you need only reduce the d b continuous stitch of 2/0 Prolene (Ethicon W8522)) Hold the apex b scissors. ie Large with 2/0 Vicryl (Ethicon W9136) R GO TO STEP 79 (REPAIR) OMENTUM ORSMALL BOWE reduce it. GO TO STEP 79 Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 38 Page 38 CurrentTechniques in Open Inguinal Hernia Repair nuine adhesions so that the contents can be reduce back into the abdominal cavity. 72 CHECK THERE IS NO INTERSTITIAL HERNIA This runs between the layers of the abdominal muscles. If there is an interstitial hernia, EAD ON 73 TWIST THE SAC otate the 3 artery forceps on its h back any contents entering from the peritoneal cavity. 4 TRANSFIX THE SAC Transfix the twisted sac at its junction with the peritoneal cavity. 75 CUT THE SAC . HOLD ON THE STITCH Divide ge READ ON reduce the sac. R R apex to pus 7 Use a No. 1 Vicryl stitch ( Ethicon W 9251). Use scissors to cut the sac 1 cm. from the stitch 76 RELAX YOUR Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 39 Page 39 CurrentTechniques in Open Inguinal Hernia Repair This will check that there is no bleeding from the cut surface of the sac. 77 CUT THE STITCH sors to cut the Vicryl 1 cm. from the knot. 78 PUSH THE STUMP OF THE SAC Push the stump into the posterior wall of the inguinal canal. 79 SECTION REPAIR t tendon repairs are adequate for female hernias and may be indicated for poor risk by doing the Conjoint ndon part of the inguinal or all types of inguinal ernia, especially recurrent n Use scis Conjoin males needing a quick operation. NB Beginners should gain experience te hernia repair 5 times before progressing to the Transversalis Fascia plication + Conjoint Tendon repair (Shouldice repair proper ). Lichtenstein mesh repairs are suitable f h ones. There is probably less postoperative pain, and a quicker return to preoperative levels of activity. The long term results in terms of recurrence are not as clearly established as for the Shouldice repair which has the best long term results. Some recurrent hernias consist of only a 1 or 2cm. defect in a Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 40 Page 40 CurrentTechniques in Open Inguinal Hernia Repair therwise strong repair. Closure 80 SECTION LICHTENSTEIN REP SUBSECTIONS paring a space for the 1 81 SUBSECTION PREPARING A E 2 THE SPERMATIC Check the cord is mobilised from the deep ring to the upper part of display the s operations fibrosing the tum, o or these defects with 2 layers of continuous No 1 nylon (Ethicon W749) is sufficient. AIR 81 Pre mesh 90 Preparing the mesh 97 Suturing the mesh 02 Cutting the tails SPACE FOR TH MESH CHECK 8 CORD IS FREE the scrotum. Ideally the cord should pull down asily to clearly e inguinal ligament from the pubic tubercle to the deep inguinal ring. If it will not mobilise due to reviou p cord to the inside of the scrothe suturing of the mesh will be a little more difficult. Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 41 Page 41 CurrentTechniques in Open Inguinal Hernia Repair heck the round ligament is 3 OPEN UP THE F Use blunt dissection to free the

• • You will need more local

f 4 OPEN THE This will allow the mesh to extend to IOR Y E THE OSIS For 8 cm. above the inguinal 86 IDENTIFY AGAIN TRIC 7 FOR A FIRST Aim to lay the mesh below the al C excised in a female. 8 MEDIAL END OTHE SPACE tissue to 2 cms beyond the mid line.

anaesthesia here because oinnervation from the opposite side. 8 SPACE SUPERL strong tissue superiorly. 85 FRE EXTERNAL OBLIQUE APONEURFROM THE CONJOINT TENDON ligament. THE ILIO-HYPOGASNERVE 8 TIME HERNIA: site of penetration of the extern Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 42 oblique aponeurosis by the ilio-hypogastric nerve. 88 FOR A RECURRENT HERNIA, WITH A DIFFUSE WEAKNESS: Extend the space beyond the nerve penetration point. Cut the nerve, if necessary, to avoid any nerve entrapment. 89 CHECK THE SPACE LATERALLY Free the external oblique aponeurosis from the internal oblique for 6 cms beyond the lateral aspect of the internal ring. Enlarge the opening in the external oblique laterally to get access here if needed. 90 SUBSECTION PREPARING THE MESH 91 TRIM THE MESH Use an 8 x 16 cm. piece of Marlex mesh. This should give a 2 cm. margin around most hernias. For a larger hernia or diffuse weakness of the muscle, use a larger piece of mesh to give the same 2 cm. clearance. Page 42 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 43 92 HOLD THE MESH OUT FLAT USE A NO-TOUCH TECHNIQUE Use artery forceps on three corners. 93 TRIM THE INFERIOR MARGIN Use scissors. Cut the inferior margin to match the curve of the inguinal ligament. Remove the selvedge from the mesh. 94 TRIM THE MEDIAL EDGE Cut the medial edge in a curve to match the medial space. 95 REMOVE THE UPPER SELVEDGE Trim the edge to fit the space under the external oblique. 96 CHECK THE MESH SIZE Test fit the mesh into the medial half of the space. Trim the mesh with scissors as needed to fit. Page 43 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 44 97 SUBSECTION SUTURING THE MESH 98 SUTURE THE MESH INFERIORLY Use 2/0 Prolene on a 25mm. cutting needle (Ethicon W8522). Start at the lower margin of the mesh medially. Place the first stitch through the aponeurotic tissue overlying the pubic tubercle. Avoid the periosteum of the pubic tubercle. Tie the stitch with four throws. Cut the loose end 10 mm. long Run a continuous stitch through the innermost part of the inguinal ligament from the pubic tubercle to the medial border of the internal ring. Take 5 mm. bites of inguinal ligament 7 mm. apart. Take 5 mm. bites of the lower border of the mesh. Do not damage the inferior epigastric vessels laterally. Page 44 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 45 Tie the stitch with five throws. Cut the end 10 mm. long. 99 TUCK THE MESH IN MEDIALLY Check the mesh lies without folds. Enlarge the space medially as needed to let the mesh lie without folds. When placing the mesh for the second side of a double hernia repair, overlap the second piece of mesh over the first. 100 TUCK THE MESH IN SUPERIORLY Tuck the mesh under the ilio-hypogastric nerve. 101 STITCH THE MESH MEDIALLY Use interrupted stitches of 2/0 Proline (W8522) 7mm. apart. Open the space to allow the mesh to lie neatly without folds. Go up as far as the ilio-hypogastric nerve for a normal hernia repair. Divide the nerve and go to 2 cms above the limit of a larger hernia. Page 45 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 46 Be prepared for variations in the anatomy of the ilio-hypogastric and ilio-inguinal nerves. 102 STITCH THE SUPERIOR EDGE OF THE MESH Use interrupted stitches of 2/0 Prolene (Ethicon W8522). Place the stitches 1 cm. apart. Take bites 3 mm. from the edge of the margin. Stitch into the internal oblique aponeurosis and rectus sheath as far as the medial edge of the internal ring. Check the mesh is lying without tension and without folds on the conjoint tendon. Reposition the stitches as necessary. 103 SUBSECTION CUTTING THE TAILS The horizontal slit in the mesh will accommodate the cord at the deep inguinal ring. The resultant tails are overlapped lateral to the deep Page 46 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 47 ring to reinforce the internal oblique and transversus abdominus layers. 104 HOLD THE MESH Use two artery forceps on the lateral corners of the mesh. 105 CUT THE SLIT Use dissecting scissors. Cut the mesh from the lateral end to the medial limit of the internal ring. Make a horizontal cut to produce two tails. The lower tail is one-third, the upper tail two-thirds of the height of the mesh. 106 REPOSITION THE ILIO- INGUINAL NERVE 107 FIT THE TAILS Hold the lower tail below the spermatic cord. Feed the upper tail behind the spermatic cord using an artery forcep. 108 OVERLAP THE TAILS LATERALLY Extend the slit medially to release any pressure by the Page 47 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 48 mesh on the medial edge of the internal ring. 109 STITCH THE TAILS Use one 2/0 Prolene stitch (Ethicon W8522). Place the stitch through the tails where they overlap at the lateral limit of the internal ring. Run this stitch through the internal oblique muscle to hold the mesh in place. 110 TRIM THE TAILS Hold the two tails of the mesh out laterally. Cut the tails across, 6 cm. lateral to the internal ring. 111 TUCK IN THE TAILS Tuck the tails in the space between the internal oblique muscle and the external oblique aponeurosis lateral to the deep inguinal ring. Make sure the tails lie flat. Check they are not curled up or wrinkled. Page 48 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 49 112 CHECK THE MESH LIES PROPERLY The patch of mesh with its overlapping tails laterally should be lying without tension on the tissue. Release folds and tension lines by enlarging the anatomical space or by repositioning the sutures. If this is not effective, or if the patch is too small, start again with a new piece of mesh. GO BACK TO STEP 90 (SUBSECTION PREPARING THE MESH) 113 CHECK HAEMOSTASIS 114 CHECK CEFUROXIME AND METRONIDAZOLE HAVE BEEN GIVEN 1.5g. Cefuroxime and 1.0g. Metronidazole intravenous bolus. 115 GO TO STEP 134 ( CLOSURE) 116 IF YOU ARE PLANNING TO DO ONLY A Page 49 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 50 CONJOINT TENDON REPAIR (BASSINI) GO TO STEP 127 (BASSINI REPAIR) 117 SECTION IF YOU ARE PLANNING A SHOULDICE REPAIR (i.e. a TRANSVERSALIS FASCIA PLICATION + CONJOINT TENDON REPAIR ) READ ON 118 TRANSVERSALIS FASCIA PLICATION 119 FIND THE TRANSVERSALIS FASCIA This runs between the inferior epigastric vessels and the pubic tubercle, running from the conjoint tendon down behind the inguinal ligament. It is a thin sheet of bluish white tissue. It covers the gap between the inside of the external oblique aponeurosis and the lower border of the conjoint tendon. It may be covered with fat and vessels which need to be cleared off with a gauze. It may look insignificant, but even the thinnest layer plicates to make a strong start to the repair. Page 50 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 51 It often consists of a direct inguinal hernial sac less than 5 cm. in diameter or a smaller bulge. Any transfixed direct hernia sac will form part of the transversalis fascia here.

• • • You may need more anaesthetic injected here.

120 INCISE THE TRANSVERSALIS FASCIA Use scissors to open the middle of the fascia in the line of the inguinal ligament. 121 CLIP THE UPPER AND LOWER LEAVES OF THE OPENING IN THE TRANSVERSALIS FASCIA Use 2 artery forceps. 122 EXTEND THE TRANSVERSALIS FASCIA INCISION Use scissors to cut the fascia medially to the margin of the rectus sheath, and laterally to the inferior epigastric vessels. The fascia may fade out laterally. 123 PUSH EXTRAPERITONEAL FAT DEEPLY Use a finger. Page 51 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 52 This will separate it from the transversalis fascia. There will be a vessel to coagulate medially. Keep your finger on the extraperitoneal fat. 124 INSERT A TRANSVERSALIS FASCIA PLICATION STITCH Place a No. 1 monofilament nylon ( Ethicon W749) in the medial end of the opening in the transversalis fascia. Tie the stitch with three half hitches. Hold the end with an artery clip. 125 STITCH THE INNER PLICATION SUTURE LINE Continue the stitching with the nylon using 1 cm. bites. Run from the medial end of the transversalis incision to its lateral limit at the internal ring. Use the edge of the lower leaf and the inside of the upper leaf. Use the conjoint tendon if the transversalis fascia fades out laterally. Avoid the inferior epigastric vessels. If there is bleeding from the inferior epigastric vessels, Page 52 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 53 tightening the stitch usually controls it. If not, formal clipping, ligation and tying will be needed. 126 STITCH THE OUTER PLICATION LINE Just run the inner plication suture back to the medial end of the transversalis fascia incision. Use the edges of the lower and upper leaves. Tie the suture to the held end with 5 half hitches and cut the ends 10 mm. long. The transversalis fascia should now feel very strong with this plication. 127 SECTION BASSINI REPAIR (THE CONJOINT TENDON REPAIR) 128 IN THE FEMALE Clip, cut and tie off the round ligament using a 2/0 Vicryl tie ( Ethicon W9025). 129 IN BOTH SEXES DISSECT THE UPPER LEAF OF THE EXTERNAL OBLIQUE APONEUROSIS Use a swab to display the conjoint tendon. Clear the conjoint tendon from the midline to the lateral side of the internal ring and to 5 cm. above the transversalis fascia. Page 53 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 54 Preserve the ilio-hypogastric nerve seen running medially on the conjoint tendon at the top of this dissection. The pubic tubercle should also be clearly visible and palpable. This is important to allow precise insertion of the next layer of stitches and to prevent the needle catching the upper leaf of the external oblique aponeurosis. 130 RETRACT THE EXTERNAL OBLIQUE APONEUROSIS UPWARDS Use a Langenbeck retractor to expose the pubic tubercle and the medial part of the conjoint tendon. 131 INSERT THE FIRST STITCH OF THE CONJOINT TENDON REPAIR Use a 1 cm. bite of a new length of No. 1 nylon (Ethicon W749). Insert the stitch into the periosteum of the pubic tubercle. Insert it also into the conjoint tendon 2 cm. above the pubic tubercle. This is an important anchor stitch which prevents a medial recurrence. The stitch should be able to easily withstand a vertical pull of Page 54 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 55 1000 gm. if it bites properly into the pubic tubercle. The tissues will always come together There is no need to make relaxing incisions into the rectus sheath. Tie the stitch with three half hitches. Hold the end with an artery clip. 132 CONTINUE THE INNER LAYER OF THE CONJOINT TENDON REPAIR Continue laterally to the internal ring. Use 1 cm. bites between the conjoint tendon and the INNERMOST part of the inguinal ligament. This is deeper than the obvious fold in lower leaf of the external oblique aponeurosis. Unless you do this, you will not have enough aponeurosis for closing the front of the inguinal canal. Avoid damaging the femoral vein below the inguinal ligament with the needle. If you do, apply pressure and call a more experienced surgeon You can stitch into the muscle if there is no tendon (aponeurosis). Page 55 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 56 If the conjoint tendon feels tight, take 3-4 stitches before snugging them all down together. Avoid the inferior epigastric vessels. If there is bleeding from the inferior epigastric vessels, tightening the stitch usually controls it. If not, formal clipping, ligation and tying will be needed. IN A MALE Leave a 1 cm. gap in the internal ring medial to the cord to prevent compression of the testicular vessels. There is no need to place stitches lateral to the internal ring. IN A FEMALE Close off the internal ring completely. 133 CONTINUE THE STITCHING AS THE OUTER LAYER OF THE CONJOINT TENDON REPAIR Continue the stitching from the internal ring back to the pubic tubercle. Take 1 cm. bites of the conjoint tendon and the visible parts of the inside of the external oblique aponeurosis. Page 56 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 57 Again leave as much external oblique aponeurosis as possible to allow easy closure of the front wall of the inguinal canal later. Tie the stitch to the held nylon with 5 half- hitches. Cut the ends 10 mm. long. The posterior inguinal wall should feel very strong now. 134 SECTION CLOSURE 135 REMOVE THE EXTERNAL OBLIQUE FORCEPS 136 REPLACE THE ILIO-INGUINAL NERVE Lie the nerve back in the inguinal canal. 137 RETRACT THE SUBCUTANEOUS TISSUES LATERALLY Use a Langenbeck retractor to display the lateral end of the incision in the external oblique. 138 CLOSE THE LATERAL END OF THE EXTERNAL OBLIQUE INCISION Use a remaining length of No. 1 monofilament nylon ( Ethicon W749 ) to place an inverted Page 57 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 58 stitch into the end of the opening. Use 5 half-hitches and hold the loose end IN THE INGUINAL CANAL with an artery forcep. 139 CHECK THE SWAB, NEEDLE AND INSTRUMENT COUNT 140 CLOSE THE EXTERNAL OBLIQUE APONEUROSIS Run the nylon stitch medially using continuous stitches 1 cm. apart. Cover the loose end of nylon with the closure. Cut the loose end. Continue stitching medially to the external ring, or the pubic tubercle, whichever is more lateral. This is where you will appreciate the earlier conservation of the external oblique aponeurosis. Tie the knot with 5 half-hitches. Cut the ends of the knot 10 mm. long. 141 REMOVE THE WEST' RETRACTOR Page 58 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 59 142 REMOVE THE SKIN EDGE TOWELS 143 CHECK HAEMOSTASIS 144 CLOSE THE FAT Use continuous No. 1 Vicryl ( Ethicon W9251 ). 145 CLOSE THE SKIN Use continuous subcuticular 3/0 Vicryl (Ethicon W 9890). Put 5 throws on the end of the stitch. 146 RECHECK THE SWAB, NEEDLE AND INSTRUMENT COUNTS 147 SPRAY THE WOUND Use an acrylic spray (Nobecutaine ). 148 TO REPAIR THE SECOND SIDE OF A DOUBLE HERNIA Change gloves Take the temporary towel off the second side. Put the diathermy pedal on the second side. Clean the skin of the second side again with Chlorhexidine in propanol Page 59 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 60 GO BACK TO STEP 16 (STEADY THE SKIN) 149 CHECK THERE IS NO OTHER PROCEDURE TO DO 150 DRESS THE SKIN Use a Primapore dressing. 151 SECTION FINAL TOUCHES 152 PULL ON EACH TESTIS This will make sure the testes are in satisfactory positions in the bottom of the scrotum. 153 WRITE LEGIBLE OPERATION DETAILS 154 FILL IN THE SURGICAL AUDIT FORM 155 PRESCRIBE HEPARIN 5000 UNITS SUBCUTANEOUSLY BD Until the patient leaves hospital if he/she is over 40 years. 156 DICTATE AN OPERATION LETTER TO THE GENERAL Page 60 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 61 PRACTITIONER + TO THE REFERRING PHYSICIAN Page 61 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 62 157 EQUIPMENT AND MATERIALS LIST (FRIARAGE HOSPITAL) BASIC PACK GENERAL MINOR INSTRUMENTS 10 CURVED JOLLS - NOT STRAIGHT 2 WEST SELF RETAINING RETRACTORS 2 LARGE LANGENBECKS 2 BABCOCKS 1 NO 5 KNIFE HANDLE PREPARATION HIBITANE 2 X WET, 1 X DRY. SUTURES NO MATERIAL TIES 1 X W9025 2/0 VICRYL TRANSFIXION 2 X W9251 2/0 VICRYL REPAIR 2 X W749 1 NYLON FAT 2 X W9251 1 VICRYL SKIN 1 X W9890 3/0 VICRYL OTHER BLADES 2 X C DIATHERMY MONOPOLAR, FLEX, HOLDER, MEDIUM FORCEPS DRAINS PATIENT'S POSITION SUPINE TABLE FITTINGS ANAESTHETIC SCREEN WOUND INFILTRATION WITH A GENERAL ANAESTHETIC (NOT SPINAL, NOT EPIDURAL) INJECTED AFTER TOWELLING UP 20 ML. 0.5% BUPIVACAINE (MARCAINE) 1 X 20 ML. SYRINGE Page 62 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 63 1 X 21 SWG GREEN NEEDLE IF LOCAL ANAESTHETIC ONLY 80 ML. 0.5% LIGNOCAINE SPRAYS NOBECUTAINE DRESSINGS PRIMAPORE ADDITIONAL ITEMS 158 EQUIPMENT AND MATERIALS Page 63 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 64 LIST (ST JOHN OF GOD HOSPITAL) GLOVES 7 BIOGEL BASIC TRAY 5 SPONGE HOLDERS 5 TOWEL CLIPS 1 SCALPEL HANDLE 1 WESTS SELF RETAINING RETRACTOR 2 LANGENBECK RETRACTORS 20 ARTERY FORCEPS 5 LITTLEWOODS FORCEPS 2 HEAVY NONTOOTHED DISSECTING FORCEPS 1 PAIR CURVED DISSECTING SCISSORS 2 PAIRS MAYO 7" STRAIGHT SCISSORS 2 NEEDLE HOLDERS DIATHERMY SUTURES TIES W9025 PERITONEUM W9251 FASCIA/REPAIR 2 X W749 SKIN W9890 OTHERS FAT W9251 BLADES NO 22 X 2 DIATHERMY + DISSECTING FORCEP ADDITIONAL INFORMATION 4 LARGE TETRA TOWEL CLIPS 2 SMALL TOWEL CLIPS STERIPAD DRESSING INJECTIONS MARCAINE 0.5% PLAIN 20 ML. AFTER TOWELLING UP 20 ML. SYRINGE 1 GREEN NEEDLE ADDITIONAL INSTRUMENTS DRAIN POSITION SUPINE Page 64 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 65 TABLE FITMENTS SPRAYS NOBECUTAINE CATHETERS EQUIPMENT AND MATERIALS Page 65 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 66 Hernia (Inguinal) - Adult Day Case Page 66 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 67 Your Inguinal Hernia Operation - Some Information These notes give a guide to your operation. They tell you about getting ready at home, getting to hospital, and what it will be like in hospital. They will tell you what it will be like afterwards and how to look after yourself. They do not cover everything. If you have any queries please ask. We hope you will find these notes useful and that they will help to make your stay in hospital easier. What is a Hernia? A hernia is a bulge or weakness in the muscles which form the front of the body wall. In your case the hernia is in the groin. Sometimes they are on both sides. They can be caused by the body wall being weak from birth. Sometimes the body wall weakens with the passing of time. Sometimes the body is overstrained by coughing, heavy work or sport etc. Hernias are very common and are easily treated. If left untreated they get bigger, cause pain and can cause a blockage in the bowel. What does the operation consist of? A cut is made into the skin overlying the hernia. The bulge is pushed back or is cut off. The weak part is mended and strengthened, usually with nylon stitches. The cut in the skin is then closed up. We can do your operation as a day case. This means that you come into hospital on the day of the operation and go home the same day. We can do this because of new ways of doing the operation, better anaesthetics and new ways of pain relief. It will save you 2 nights or so in hospital. Are there any alternatives? Simply waiting and seeing if you have more trouble is not a good idea. The hernia will always get worse. A truss will usually hold the hernia back in place. It is useful as a stop-gap until you have the operation. It is a good idea if you do not like the idea of an operation, or if you are not fit enough for one. Keyhole operations for hernia repair are experimental. It will be 5-10 years before we will know if this is a good way. What to do before coming to hospital Page 67 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 68 Check you have a relative or friend who can come with you to hospital, take you home, and look after you for the first 3 days after the operation. You only need normal home care, not hospital care. Check your friend can drive or take you home in a taxi. Check you have a telephone at home. Have nothing to eat or drink from midnight before the operation. This means not even a sip of water. Your stomach needs to be empty for a safe anaesthetic. However, you can take your normal tablets and medicines. Getting to hospital Come with your relative or friend so that they will know the way when coming to collect you after the operation. Also the ward staff can go over the pick-up time and any other details. What happens before the operation? Welcome to the ward You will be welcomed to the ward by the nurses or the receptionist. You will have your details checked. You will be shown to your bed and will be asked to change into a cotton gown. You will have some basic tests done, such as pulse, temperature, and blood pressure. You will be asked to hand in any medicines or drugs you may be taking, so that your drug treatment in hospital will be correct. Please tell the nurses of any allergies to drugs or dressings. Visits by the surgical team You will be seen first by the House Surgeon, who will interview and examine you. He, or she, will check that all your special tests such as blood samples are in order. The operation will be explained to you. You will be asked to sign your consent for the operation. If you are not clear about any part of the operation, ask for more details from the doctors or from the nurses. They are never too busy to do this. You will have the operation site marked on you with a skin pencil. Page 68 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 69 You will be seen by the surgeon who will be doing the operation. He will check that all the necessary preparations have been made. Visits by the anaesthetic team One or more anaesthetists who will be giving your anaesthetic will interview and examine you. They will be especially interested in chest troubles, dental treatment and any previous anaesthetics you have had, plus any anaesthetic problems in the family. Usually we give a general anaesthetic so that you will be asleep. Sometimes it is better just to freeze the skin with injections. The anaesthetist will talk to you about this. The Periods The periods do not affect the operation. Shaving You will be shaved to remove excess hair. Timing of the operation The timing of your operation is usually arranged the day before. The nurses will tell you when to expect to go to the operating theatre. Do not be surprised, however, if there are changes to the exact timing. Premedication You may be given a sedative injection or tablets about 1 hour before the operation. Transfer to theatre You will be taken on a trolley to the operating suite by a ward nurse and a theatre porter. You will be wearing a cotton gown. Wedding rings will be fastened with tape. Removable dentures will be left on the ward. There will be several checks on your details on the way to the anaesthetic room where your anaesthetic will begin. If you are having a local anaesthetic This means you will be awake during the operation. There will be a nurse to talk to all the time. You will be lying on the operating table. We put several cuffs and pads on your chest, arms, fingers and leg. This helps check such things as your pulse and blood pressure during the operation. We clean the skin round your groin with an antiseptic which is rather cold. Then we cover your trunk and legs with sterile green sheets. We then inject Page 69 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 70 local anaesthetic liquid into the skin of your groin to make it numb. This stings a bit, but soon passes off. Then we do the operation. If you feel anything, we can give you more anaesthetic. The operation takes about 40 minutes. You can talk to us during this time, but you will not be able to see any of the operation. If you are having a general anaesthetic You will have an injection into an arm or hand vein, and will go off to sleep. What happens after the operation? After the operation, you go on a trolley to the recovery ward for a few minutes. Then you go by trolley back to the main ward. Coming round after a general anaesthetic Although you will be conscious a minute or two after the operation ends, you are unlikely to remember anything until you are back in your bed on the ward. Some patients feel a bit sick for up to 24 hours after operation, but this passes off. You will be given some treatment for sickness if necessary. You may be given oxygen from a face mask for a few hours if you have had chest problems in the past. Warning after a General Anaesthetic The drugs we give for a general anaesthetic will make you clumsy, slow and forgetful for about 24 hours. This happens even if you feel quite alright. For 24 hours after your general anaesthetic: Do not make any important decisions. Do not drive. Do not use machinery at work or at home. (e.g. even take extra care boiling a kettle). Will it hurt? Every patient has local anaesthetic injected into the wound, even if you have a general anaesthetic for the operation. Usually the wound is pain-free. There may be some discomfort on moving. Tablets of CoCodamol should easily control this discomfort. If not, we can give painkilling injections. Page 70 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 71 Ask for more if the pain is still unpleasant. Leaving the ward After an hour or two on the ward, you should feel fit enough to go home. Before you go, we do the following: Check the wound is comfortable Check the wound is not bleeding Check there is no swelling Change the dressing Give you 2 spare dressings Give you 20 CoCodamol tablets to take home. You can take 2 at a time every 6 hours as needed Give you a Follow Up Appointment for 1 month Give you a note to be given to your General Practitioner Give you a work certificate, sick note, etc. Check you have the ward telephone number For Northallerton 0609 779911 extension 3077 or 4701 after 8 p.m. or weekends For Darlington 0325 74 3312 or 74 3515 at weekends For Scorton 0748 811 535 NB. If you do not feel like going home , we can easily arrange for you to stay in hospital. Getting home Make sure you are going home by car with your relative or friend. WARNING The local anaesthetic in your wound may make your leg give way for 12 hours or so. Be especially careful when getting in or out of a car, when climbing stairs, or when getting in or out of bed. What about informing my relatives and contacts? With your permission, the nurses and doctors will keep your relatives and contacts up to date with your progress. At home Page 71 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 72 Go to bed Take 2 CoCodamol tablets every 6 hours to control any pain. Next morning You should be able to get out of bed quite easily despite some discomfort. You will not do the wound any harm. The exercise is good for you. Phone us up in the Day Ward during the morning to let us know how you are getting on. The second day after the operation, you should be able to spend most of your time out of bed in reasonable comfort. You should be able to walk 50 yards slowly. By the end of a week the wound should be nearly pain-free. Drinking and eating You will be able to drink within an hour or two of the operation provided you are not feeling sick. The next day you should be able to manage small helpings of normal food. Opening bowels It is quite normal for the bowels not to open for a day or so after operation. If you have not opened your bowels after two days and you feel uncomfortable, take a laxative such as senna. Passing urine It is important that you pass urine and empty your bladder within 6-12 hours of the operation. If you have difficulty, take 2 CoCodamol tablets and have a warm bath. If you are still in trouble, phone our ward. Sleeping Take CoCodamol rather than sleeping pills to help you to sleep. If you normally take sleeping pills, you can take them as well as the CoCodamol. The wound and stitches The wound has a dressing which may show some staining with old blood after 24 hours. Take this dressing off. Put a clean one in its place. Page 72 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 73 You can leave the wound without dressings after 5 days or so, when it is comfortable. There are no stitches in the skin. The wound is held together underneath the skin and does not need further attention. There may be some purple bruising around the wound which spreads downward by gravity and fades to a yellow colour after 2 to 3 days. It is not important. There may be some swelling of the surrounding skin which also improves in 2 to 3 days. After 7 to 10 days, slight crusts on the wound will fall off. The cellulose varnish will peel off and can be assisted with nail varnish remover. Occasionally minor match-head sized blebs form on the wound line. These settle down after discharging a blob of yellow fluid for a day or so. Washing You can wash the wound area as soon as the dressing has been removed. Soap and warm tap water are entirely adequate. Salted water is not necessary. You can shower or take a bath as often as you want. General recovery You are likely to feel very tired and need rests 2 to 3 times a day for a week or more. You will gradually improve. By the time a month has passed you will be able to return completely to your usual level of activity. Lifting At first discomfort in the wound will prevent you from harming yourself by too heavy lifting. After one month you can lift whatever you like. There is no value in trying to speed the recovery of the wound by special exercises before the month is out. Driving You can drive as soon as you can make an emergency stop without discomfort in the wound, i.e. after about 10 days. What about sex? You can restart sexual relations within a week or two, when the wound is comfortable enough. Remember that the hernia operation is not a sterilisation procedure. Work Page 73 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 74 You should be able to return to a light job after about 2 weeks, and any heavy job within 4 weeks. What if anything goes wrong? Complications are rare and seldom serious. If you think that all is not well, please phone the ward. We can advise and help 24 hours a day. Bruising and swelling may be troublesome, particularly if the hernia was large. The swelling may take 4 to 6 weeks to settle down. Infection is a rare problem and settles down with antibiotics in a week or two. Aches and twinges may be felt in the wound for up to 6 months. Occasionally there are numb patches in the skin around the wound which get better after 2 to 3 months. The risk of a recurrence of the hernia is about 1 in 100. Things to look out for in the first 24 hours Bleeding from the wound is the most important thing to look out for. A little blood staining of the dressing is normal. If bleeding continues after changing the dressing twice, phone the ward. If you cannot get through to the ward, come straight away to the Casualty Department of the hospital. The bleeding is not life-threatening, but is a nuisance if allowed to continue. Bleeding can also show up as a painful swelling under the skin. Phone us up about this. Things to look out for in the first week If the wound gets painful, reddened, and swollen, there may be some infection. Phone the ward. If you are not happy about your progress, phone the ward. General advice Page 74 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 75 The operation should not be underestimated, but practically all patients are back to their normal duties within one month. Page 75 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 76 Any Questions? If you have any questions, jot them down here and ask the doctors or nurses for answers. Any complaints? If you have any complaints, please contact the doctors or nurses straight away. If this does not solve the problem, please write to me at Ward 3, The Friarage Hospital, Northallerton. Michael H Edwards Consultant Surgeon Acknowledgement We gratefully acknowledge the generous support for the development and launching of SCALPEL Information Systems for patients, from: Northallerton Red Cross Society The crew of the Royal Fleet Auxiliary 'ARGUS' If you would like to help towards other ventures to benefit patients, please send donations to: The Chairman British Red Cross 62 Thirsk Road Northallerton DL6 1PN (Please make cheques payable to "British Red Cross") Page 76 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 77 Have you any comments? We welcome your comments and suggestions covering your illness, your treatment in hospital, and your recovery. Please write below any points you would like to make. If you prefer, you need not give your name. Full name: Hospital: Ward: Date of stay in hospital: Operation: Out patients department: Your admission arrangements: Your welcome on the ward: Nursing staff: General ward atmosphere: Medical staff: Ward orderlies: Portering staff: X-ray staff: ECG staff: Did you know who was who?: Bedding: Food and drink: Privacy: Locker space: Toilets: Bathrooms: Other patients: Noise: Information: Telephone/TV/radio/newspapers: Timing of operation: Preparations for your operation: Going into the theatre: In the operating theatre: In the recovery room: Coming back from theatre: Page 77 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 78 Intensive Care ward: Recovery on the ward: Pain control: Sleeping: Wound dressings: Stitches, clips: Progress reports: Visiting hours: Rest room: Tablets, medicines, injections: Going-home arrangements: Out-patient follow up: Anything else? Continue comments overleaf if you wish. Please send this questionnaire to Mr M Edwards, Ward 3, Friarage Hospital, Northallerton, North Yorkshire DL6 1JG. TUTORIALS 1 ANATOMY AND PATHOPHYSIOLOGY (at end of pathophysiology) 2 PREPARATIONS (step 22) Page 78 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 79 3 DISSECTION (step 78) 4 LICHTENSTEIN REPAIR ( step 112) 5 SHOULDICE REPAIR (step 126) 6 BASSINI REPAIR ( step 152) 1 ANATOMY AND PATHO-PHYSIOLOGY 1 The Inguinal canal runs: a Between the external oblique and the internal oblique layers. You are correct. b Between the internal oblique and the transversus layers. You are wrong. The inguinal canal runs more superficially. Think of the internal oblique and transversus layers as essentially inseparable at this level. c Between the transversus abdominus and the peritoneum. You are wrong. Reread the Anatomy Section. 2 The superior margin of the posterior wall of the inguinal canal is: a The ilio- inguinal nerve. You are wrong. The margin is the transverse arch of the internal oblique and transversus layers. b The transverse arch of the internal oblique and transversus layers. You are correct. c The inferior epigastric vessels. You are wrong. The margin is the transverse arch of the internal oblique and transversus layers. Re read the Anatomy Section. 3 The internal ring lies: a Medial to the inferior epigastric vessels. You are wrong. The internal ring lies lateral to the inferior epigastric vessels. b Below the inguinal ligament. You are wrong. The internal ring lies above the inguinal ligament. c Lateral to the posterior wall of the inguinal canal. You are correct. 4 An indirect inguinal hernia runs: a Anterior to the cremaster muscle. You are wrong. The indirect hernia is an out pouching of peritoneum which runs inside the sleeve of cremaster muscle in the spermatic cord. b Anterior to the ilio-inguinal nerve. You are wrong. The indirect hernia in an out pouching of peritoneum which runs deep to the ilio-inguinal nerve in the spermatic cord. c Anterior to the inferior epigastric vessels. Page 79 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 80 You are correct. 5 A sliding hernia typically : a Contains large bowel in the sac. You are wrong. The large bowel actually forms part of the wall of the sac. It is not a content of the sac. b Has large bowel forming part of its wall. You are correct. c Has small bowel sliding in and out. You have missed the point. A sliding inguinal hernia has a viscus such as large bowel forming part of the wall of its sac. The sac may contain small bowel, just as any other type of hernia. 6 On the diagram, click on: a The vas. b The pubic tubercle. c The transversus abdominal arch. 7 The vas: a Runs around the inferior epigastric vessels. You are correct. b Penetrates the posterior wall of the inguinal canal. You are wrong. The vas enters the inguinal canal from the lateral side through the deep inguinal ring. c Runs lateral to the deep inguinal ring. You are wrong. The vas runs laterally along the inguinal canal, round the inferior epigastric vessels, and then medially and deeply towards the prostate. 8 A direct hernia passes directly: a Into the scrotum. You have missed the point. Rarely, direct hernias extend as far as the scrotum. The important point is that they pass directly through the posterior inguinal canal. b Into the subcutaneous tissues. You have missed the point. Large direct hernias may extend as far as the subcutaneous tissues. The important point is that they pass directly through the posterior inguinal canal. c Directly through the posterior wall of the inguinal canal. You are correct. 2 PREPARATIONS 1 Is the surgeon entirely responsible for operating on the correct patient? a Yes. You are correct. The surgeon (ie the person who makes the incision) is entirely responsible, no matter how many checks other staff have made. Page 80 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 81 b No. You are wrong. The surgeon (ie the person who makes the incision) is entirely responsible, no matter how many checks other staff have made. 2 Is the surgeon entirely responsible for operating on the correct side? a Yes. You are correct. The surgeon is entirely responsible. Checks by other staff are not excuses for any error. b No. You are wrong. The surgeon is entirely responsible. Checks by other staff are not excuses for any error. 3 What is an acceptable upper dose of Lignocaine in mg/Kg? a 1mg/Kg. You are wrong. 3mg/Kg is an acceptable upper dose. A lower dose is perfectly acceptable if it gives the required amount of anaesthesia. A higher dose requires very dose supervision and can be most dangerous. b 3mg/Kg. You are correct. 3mg/Kg is an acceptable upper dose. A lower dose is perfectly acceptable if it gives the required amount of anaesthesia. A higher dose requires very dose supervision and can be most dangerous. c 10mg/Kg. You are wrong. 3mg/Kg is an acceptable upper dose. A lower dose is perfectly acceptable if it gives the required amount of anaesthesia. A higher dose requires very dose supervision and can be most dangerous. 4 How much Lignocaine 1% without adrenaline can you safely give a 70 Kg Person? a 10 ml. You can give up to 20 ml. of 1% lignocaine. This is 2.9 mg./Kg. for a 70Kg. person. b 20 ml. Correct. This is 2.9 mg./Kg. for a 70Kg. person ie at the upper limit of acceptability. c 50 ml. You are wrong. You can only give up to 20 ml. of 1% lignocaine which is 2.9 mg./Kg. for a 70Kg. person. 5 Can infiltration of the inguinal region seriously weaken the lower limb for an hour or more? a Yes. You are correct. The local anaesthetic can easily spread to block the motor fibres of the femoral nerve. The quadriceps Page 81 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 82 can give way when the patient tries to get out of bed or get into a car. The effect can last an hour or two with Lignocaine, and 12 hours or more with Bupivacaine. b No You are wrong.The local anaesthetic can easily spread to to block the motor fibres of the femoral nerve. The quadriceps can give way when the patient tries to get out of bed or get into a car. The effect can last an hour or two with Lignocaine, and 12 hours or more with Bupivacaine. 6 Can a medial recurrence of an inguinal hernia be caused by difficult access from too lateral a skin incision? a Yes. You are correct. If the incision is too lateral, or if it is too high, access to the medial end of the posterior wall of the inguinal canal is restricted. This will prevent a satisfactory view of repair stitches here, leading to a risk of the common medial recurrence. b No. You are wrong. If the incision is too lateral, or if it is too high, access to the medial end of the posterior wall of the inguinal canal is restricted. This will prevent a satisfactory view of repair stitches here, leading to a risk of the common medial recurrence. 7 Can the superficial fascia (Scarpa's fascia) be confused with the external oblique aponeurosis? a Yes. You are correct. Make sure you sweep the fascia firmly away. Find the stripes of the aponeurosis. b No. You are wrong. Make sure you sweep the fascia firmly away. Find the stripes of the aponeurosis. 8 Can the spermatic cord be found just under the skin after a previous repair? a Yes. You are correct. A recurrence after a previous repair is often due to an unorthodox or an old repair technique. The old Halsted repair placed the cord directly under the skin and fat. Be prepared for vital structures to be in unusual positions. b No. You are wrong. A recurrence after a previous repair is often due to an unorthodox or an old repair technique. The old Halsted repair placed the cord directly under the skin and fat. Be prepared for vital structures to be in unusual positions. Page 82 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 83 3 DISSECTION 1 How much external oblique aponeurosis exposure is optimal? a 10cm. lateral to the external ring. You are correct. b To the anterior superior iliac spine. This is excessive. You are in danger of damaging the lateral cutaneous nerve of thigh. c To the lateral margin of the external ring. This is not enough. You will find the whole of the rest of the operation unnecessarily difficult due to lack of access. 2 Mobilisation of the spermatic cord from the inguinal canal will include: a Any direct sac. You are wrong. A direct sac will lie behind a mobilised spermatic cord. b The inferior epigastric vessels. You are wrong. Thes vessels lie behind the cord. You need to avoid them when mobilising the cord. c Any indirect sac. You are correct. 3 Which order of dissection is recommended? a Lipoma of cord, indirect sac, direct sac. You are correct. This is a logical sequence running from lateral to medial. You should not overlook any pathology this way. b Ilio-inguinal nerve, direct sac, lipoma of cord. This is a jumbled approach. You may overlook pathology. c Whichever type of hernia appears first. This approach may lead you to missing multiple pathology. Stick to a logical complete system 4 Mobilise an indirect sac: a To the inferior epigastric vessels. This is not really far enough to avoid a residual sac and damage to the vas and vessels when transfixing the sac. b Into the internal ring. You are correct. c Down to the testis. You are wrong. If the sac extends this far, you do not need such an extensive dissection, because you can divide the sac in the inguinal canal. 5 The distal end of a complete (vaginal) indirect sac should be: a Left open. You are correct. Control any bleeding from the cut end of the sac with diathermy. b Tied off. Page 83 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 84 This may lead to the development of a hydrocele due to accumulation of fluid from the serosa on the testis. c Stitched to the cremaster. You are wrong. This would not be a helpful manoeuvre. 6 The dissection of a recurrent hernia is difficult because of: a Loss of tissue planes. All the listed features lead to difficulty. b Unpredictable anatomy following the previous repair. All the listed features lead to difficulty. c Scarring due to past infection. All the listed features lead to difficulty. d All the above. You are correct. 7 If you cannot find an indirect sac or a direct sac: a Look for a femoral hernia. You are correct. b Close the wound. You are wrong. You may be missing a femoral hernia. A repair of the posterior inguinal wall may be needed in the absence of a definite hernia. c Perform an inguinal hernia repair. No, you may be overlooking a femoral hernia. 8 Dissect out the round ligament: a To the external ring. You are wrong. You need to open the inguinal canal to perform a satisfactory operation in a female as well as a male patient. b Inside the internal ring. You are correct. c To the ovary. You are wrong, unless the ovary presents in the inguinal canal - an exceedingly rare occurence. 4 LICHTENSTEIN REPAIR 1 The Lichtenstein repair is designed to: a Strengthen the posterior inguinal wall. You are correct. Virtually all repairs concentrate on this principle. b Support the spermatic cord. No. The spermatic cord does not need support. Virtually all repairs concentrate on reinforcing the posterior wall of the inguinal canal. c Push the hernia back into place. Page 84 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 85 No.The hernia should be excised or be held reduced independently of the mesh. The mesh is designed to prevent recurrence by strengthening the posterior wall of the inguinal canal. 2 How big is the standard Marlex inguinal hernia mesh? a 25 x 12 cm. You are wrong, it is 16 x 8 cm. b 16 x 8 cm. Correct. c 12 x 6 cm. You are wrong, it is 16 x 8 cm, 3 How far medially should you open the space for the mesh? a To the midline. No, this will not be far enough to prevent a medial recurrence. b To 2cm. beyond the midline. Correct. c To 10cm. beyond the midline. No, this is unnecessarily far. 4 Which edge of the mesh should you stitch in place first? a Inferior. Correct. b Superior. No, the inferior edge is best stitched in first. c Medial. No, the inferior edge is best stitched in first. 5 What do you do if the mesh does not lie smoothly? a Stitch the creases down. No, it is better to adjust the stitches or trim the mesh. b Resuture the mesh. Yes, after checking the space for the mesh is big enough. c Ignore the creases. No, it is better to adjust the stitches or trim the mesh. 6 How do you cut the tails? a 2/3 above and 1/3 below. Correct. b 1/3 above and 2/3 below. You are wrong. It should be 2/3 above and 1/3 below. c 1/2 above and 1/2 below. You are wrong. It should be 2/3 above and 1/3 below. 7 How far laterally do you cut the tails? a 2cm.lateral to the internal ring. Page 85 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 86 No, this is not far enough. b 4cm. lateral to the internal ring. No, this is not far enough. c 6cm. lateral to the internal ring. Correct. 8 For a bilateral hernia, do you overlap the meshes? a Yes. Correct. b No. You are wrong. The meshes must overlap. c Sometimes. No, they should always be overlapped. 5 SHOULDICE REPAIR 1 What is a Shouldice repair? a Transversalis fascia strengthening. No, it is more than that, including a closure of the conjoint tendon. b 2 layers of stitching to the posterior inguinal wall. No, it involves 4 layers of stitching to the posterior inguinal wall. c 4 layers of stitching to the posterior wall of the inguinal canal. Correct. 2 Where is the transversalis fascia? a Between the inguinal ligament and the transversus abdominus arch. Correct. b Between the spermatic cord and the inferior epigastric vessels. No, it is more medial, between the inguinal ligament and the transversus abdominus arch. c On the surface of the transversus muscle. No, this is not what is meant by the term. It is the fascia lying between the inguinal ligament and the transversus abdominus arch. 3 What is the lateral limit when you are cutting into the transversalis fascia? a The inferior epigastric vessels. No, the limit is where the fascia peters out a little medial to the vessels. b The spermatic cord. No, this is too far laterally. You are in danger of damaging the inferior epigastric vessels. c Where the fascia peters out laterally. Correct. Page 86 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 87 4 What is the medial limit when you are cutting into the transversalis fascia? a The rectus sheath. Correct. b 5cm. from the midline. No, this is not a useful endpoint. The rectus sheath is a better endpoint. c The site of closure of any direct inguinal hernia. No, the rectus sheath is the correct endpoint. 5 What is the value of having a finger depressing the extraperitoneal fat when plicating the transversalis fascia? a It will display the edges of the transversalis fascia clearly. Correct. b It will push the intraabdominal part of the vas out of the way. No, this part of the vas lies much more deeply and is not in danger. c It will control bleeding from vessels on the extraperitoneal fat. No. It will display the edges of the transversalis fascia clearly. Control any bleeders with diathermy. 6 How many layers of stitching should go into the transversalis fascia? a 1. No, 2 is correct. An outer and an inner layer. b 2. Correct. c 4. No, 2 is correct. An outer and and an inner layer. 7 What do you do if the transversalis fascia leaf is so thin that it tears on suture? a Ignore the tearing. No, you should use nearby inguinal ligament or transversus abdominus arch. b Remove the suture. No, you should use nearby inguinal ligament or transversus abdominus arch. c Use nearby inguinal ligament or transversus abdominus arch. 8 Is the closure of the conjoint tendon onto the inguinal ligament the same for a Shouldice repair as a Bassini repair? a Yes. Correct. b Only for indirect hernias. No, it applies for all inguinal hernias. c No. You are wrong. These steps are identical. Page 87 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 88 6 BASSINI REPAIR 1 What is the aim of a Bassini repair? a To reduce a direct hernia. No, the aim is to strengthen the posterior wall of the inguinal canal. b To strengthen the posterior wall of the inguinal canal. Correct. c To tension the posterior wall of the inguinal canal. No, excessive tension is probably detremental to rapid recovery. The aim is primarily to strengthen the posterior wall of the inguinal canal. 2 Where does the first stitch of the Bassini repair go? a Into the inguinal ligament. No, the first stitch should go into the periosteum of the pubic tubercle. b Into the transversalis fascia. No, the first stitch should go into the periosteum of the pubic tubercle. c Into the periosteum of the pubic tubercle. Correct. Fears or causing osteitis pubis appear unfounded. 3 How far laterally should you stitch the conjoint tendon to the inguinal ligament? a To within 1cm. of the spermatic cord. Correct. b Far enough laterally to cause the spermatic cord to be kinked. No, this is too tight. It may lead to atrophy of the testis. c To beyond the spermatic cord. No, this will definitely damage the testis. A separate stitch lateral to the cord is probably unnecessary. 4 Why should you take bites of inguinal ligament from its deepest aspect? a To increase the strength of the repair. No, the repair is no stronger this way. It will leave sufficient external oblique to close over the cord. b To leave sufficient external oblique to close over the cord. Correct. c To alter the dynamics of the inguinal canal. No. It will leave sufficient external oblique to close over the cord. 5 Will the Bassini part of the Shouldice repair cover the transversalis fascia plication? a Always. Correct. b Sometimes. No, it will always cover the plication. Page 88 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994 OPEN REPAIR OF INGUINAL HERNIA (ADULT)Page 89 c Never. No, it will always cover the plication. 6 Where should the external oblique be repaired in relation to the spermatic cord? a In front of the cord. Correct. b Behind the cord. No, this was once a recognised method popularised by Halsted, but it has been superceded by an anatomical repair. c Lateral to the cord. No, this is not an adequate technique. It should be repaired in front of the cord. 7 How far medial should you close the external oblique? a To the position of the original external ring. Correct. b To the pubic tubercle. Close the external oblique this far only in a female. c To the internal ring. This is inadequate. Close the external oblique to the external ring unless the cord is becoming compressed. 8 Why do you need to pull the testis down into the scrotum at the end of the operation? a To straighten the cord. No, the reason is to prevent the testis becoming adherent high in the groin following the manoeuvres of the operation. b To untwist the testis. No, you should check the cord has not twisted before you close the external oblique. The reason is to prevent the testis becoming adherent high in the groin following the manoeuvres of the operation. c To prevent the testis becoming adherent high in the groin following the manoeuvres of the operation. Correct. Page 89 CurrentTechniques in Open Inguinal Hernia Repair Copyright Scalpel Information Systems 1994

CLICK HERE FOR A PDF VERSION OF THE SCRIPT

(You will need Abobe Acrobat Reader which can be downloaded from here)

WE WELCOME YOUR COMMENTS

Click on the Discussion tab at the top of the Wikisurgery screen.

Type in your comment.

Remember to sign your name and institution on the comment.

You can sign your name by clicking on the second icon on the right at the top of this

editing screen or just type in 4 tildes. (A tilde looks like this ~)

Michael Edwards

Email michaeledwardsOK@aol.com