Note: Bailey & Love's Short Practice of Surgery is not available in this library's collection. The following is based on Schwartz's Principles of Surgery, 11th Edition — which covers the same material in equivalent or greater depth.

Hernioplasty — Surgical Procedure

Preoperative Setup

• Patient position: supine
• Anaesthesia: local, spinal, or general (open approach); general anaesthesia is mandatory for laparoscopic repair
• The inguinal region is prepared and draped

Open Approach

Step 1 — Incision & Exposure

• A skin incision is made 2 cm above and parallel to the inguinal ligament, from the pubic tubercle to the anterior superior iliac spine
• Subcutaneous fat is divided; Scarpa's fascia is incised to expose the external oblique aponeurosis (EOA)
• The EOA is incised along the direction of its fibres from the external ring, taking care to avoid the underlying ilioinguinal nerve
• The spermatic cord (or round ligament in females) is mobilised by blunt dissection and looped with a Penrose drain

Step 2 — Hernia Sac Identification & Management

• Indirect hernia sac: found anteromedially within the cord; dissected free from cord structures; reduced or transfixed and excised at the level of the internal ring
• Direct hernia sac: lies medial to the inferior epigastric vessels; the sac (transversalis fascia bulge) is reduced; no need for high ligation

The Lichtenstein Tension-Free Hernioplasty (Gold Standard Open Repair)

Steps:

1. Exposure: identical initial exposure as above — inguinal canal dissected to expose the shelving edge of the inguinal ligament, pubic tubercle, and Hesselbach's triangle
2. Mesh selection & sizing: A "flat-iron" shaped polypropylene mesh with a keyhole cut for cord egress is used. It must be large enough to extend 2–3 cm superior to Hesselbach's triangle
3. Medial fixation: The medial edge is affixed to the anterior rectus sheath, overlapping the pubic tubercle by 1.5–2 cm — this refinement minimises medial recurrence
4. Inferior fixation: A permanent, synthetic, monofilament suture (e.g., Prolene) fixes the inferior margin along the shelving edge of the inguinal ligament from medial to lateral, ending at the internal ring. Care is taken not to place sutures directly into the periosteum of the pubic tubercle
5. Superior fixation: The upper border of the mesh is fixed to the internal oblique aponeurosis and medial edge to the rectus sheath using a synthetic absorbable suture
6. Keyhole/internal ring: The lateral tails of the mesh are tailored to fit snugly around the spermatic cord at the internal ring (not tightly). The tails are sutured to the inguinal ligament and tucked beneath the EOA
7. Femoral hernia extension (if present): A triangular extension of the inferior mesh is sutured to Cooper's ligament medially and the inguinal ligament laterally

Step 3 — Wound Closure

• Cord contents are returned to anatomic position
• EOA is re-approximated continuously from medial to lateral with absorbable suture; external ring reconstructed snugly around the cord
• Scarpa's fascia and skin closed in layers

Plug and Patch Technique (Gilbert–Rutkow Modification)

Caution: isolated case series have reported plug migration causing bowel obstruction and chronic pain.

Laparoscopic Approaches

1. Transabdominal Preperitoneal (TAPP)

• Pneumoperitoneum to 15 mmHg; patient in Trendelenburg
• Three ports: one umbilical (12 mm) + two lateral 5-mm ports
• Peritoneal incision made at the medial umbilical ligament, 3–4 cm superior to the defect, carried laterally to the ASIS
• Preperitoneal space developed; cord skeletonised; sac reduced
• Mesh 10 × 15 cm rolled and inserted through the 12-mm port; unrolled in the preperitoneal space
• Secured medially to Cooper's ligament with an endoscopic tacker; laterally toward the ASIS
• Peritoneum closed with a running suture or tacker

2. Totally Extraperitoneal (TEP)

• Avoids peritoneal entry entirely
• Preperitoneal space developed using a balloon dissector via infraumbilical incision
• CO₂ insufflation to 8–12 mmHg in the extraperitoneal space
• Two additional trocars inserted under direct vision
• Dissection, hernia reduction, and mesh placement identical to TAPP
• No peritoneal closure required
• Preferred for bilateral and recurrent hernias after prior open anterior repair (Grade A recommendation, IEHS guidelines)

Key Anatomical Landmarks to Protect

Comparison of Techniques

Lichtenstein Tension-Free Hernioplasty

Step-by-Step Technique

Step 1 — Incision

• A skin incision 2 cm above and parallel to the inguinal ligament, from just medial to the anterior superior iliac spine (ASIS) to the pubic tubercle
• Subcutaneous fat divided; Scarpa's fascia incised

Step 2 — Opening the Inguinal Canal

• The external oblique aponeurosis (EOA) is split along its fibres from the external ring toward the internal ring
• The ilioinguinal nerve is identified and carefully preserved just beneath the EOA
• The iliohypogastric nerve is identified running along the superior edge of the internal oblique

Step 3 — Cord Mobilisation

• The spermatic cord is mobilised from the floor of the inguinal canal using blunt and sharp dissection
• The cord is looped with a Penrose drain or finger
• The cremaster muscle fibres are divided to inspect for a hernia sac

Step 4 — Hernia Sac Handling

• Indirect sac: found anteromedially within the cord; dissected free from cord structures; reduced into the preperitoneal space or transfixed and excised at the internal ring
  • If the sac extends into the scrotum, it is divided in the canal (not fully dissected) to avoid injury to testicular blood supply
• Direct sac: the transversalis fascia bulge is simply reduced — formal sac excision is not required

Step 5 — Mesh Preparation

• A flat, "flat-iron" shaped polypropylene mesh is used — pre-shaped with a keyhole slit at the lateral end for cord egress
• The mesh must be large enough to extend 2–3 cm superior to Hesselbach's triangle to cover the entire myopectineal orifice

Step 6 — Mesh Fixation (the critical step)

Critical rule: Do NOT place sutures directly into the periosteum of the pubic tubercle — this causes severe chronic pain.

Step 7 — Femoral Hernia Modification (if present)

• A triangular extension of the inferior aspect of the mesh is created
• Sutured to Cooper's ligament medially and to the inguinal ligament laterally
• This closes the femoral ring from above

Step 8 — Wound Closure

1. Cord contents returned to anatomic position in the inguinal canal
2. EOA re-approximated continuously from medial to lateral with absorbable suture
3. The external ring is reconstructed in close apposition to the spermatic cord — not too tight (causes strangulation), not too loose (appears as recurrence on exam)
4. Scarpa's fascia closed with absorbable sutures
5. Skin closed with subcuticular sutures or staples

Key Points to Remember

Advantages of Lichtenstein over Tissue Repairs