Operative Techniques

The layers of the abdominal wall from external to internal are as follows: skin, subcutaneous fat, Scarpa's fascia, Camper's fascia, external abdominal oblique, internal abdominal oblique, transversus abdominis, transversalis fascia, preperitoneal

fat, and the peritoneum. Numerous fascial layers condense, converge and insert forming important ligaments in the inguinal region.

The inguinal ligament is formed by the posterior reflection of the external abdominal oblique fascia. The inguinal canal is formed anteriorly by the aponeurosis of the external abdominal oblique, posteriorly by the transversus abdominis apo-neurosis and the transversalis fascia, superiorly by the internal abdominal oblique and transversus abdominis muscles, and inferiorly by the inguinal and lacunar ligaments. The lacunar ligament is a triangular expansion of the inguinal ligament medially to insert on the pectin pubis.

The iliopubic tract is an aponeurotic band within the transversalis fascia. It attaches laterally to the ileopectineal arch and the anterior superior iliac spine. It travels medially to attach to the pubic tubercle and Cooper's ligament. Diagramatically, it is often confused with the inguinal ligament but is, in fact a separate stucture deep to the inguinal ligament. It is seen from within the preperitoneal space and is extremely important in preperitoneal and laparoscopic repairs.

Cooper's (pectineal) ligament is a strong fibrous band along the superior pubic ramus attaching medially to the lacunar ligament. The conjoint tendon is a convergence of aponeurosis of internal oblique and transverse abdominis muscles. It is present in less than 10% of cases.3

Table 16.1 describes the common inguinal hernia operations performed. Inguinal hernias can be repaired from an anterior, preperitoneal or intraperitoneal approach. They can be traditional or tension free repairs, laparoscopic or direct vision repairs, and they can be repaired with or without mesh. All open anterior inguinal hernia repairs share several features: exploration with exposure of necessary structures, reduction or ligation of the hernia sac, and closure of the abdominal wall defect with or without autogenous or mesh reinforcement. The type of repair performed is tailored to patient circumstances and the surgeon's preference. With the many options in hernia surgery it is important to balance the recurrence rate, the risk of complications, patient concerns, and the cost of the procedure.

0 0

Post a comment