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Minimally Invasive Open Preperitoneal Inguinal Hernia Repair

Michael Reinhorn, MD, MBA, FACS
Tufts University School of Medicine

Type of Anesthesia

  1. Sedation is given at the beginning of the case while the patient is in the operating room
  2. 0.5% Marcaine + 1% lidocaine with epinephrine infiltrated into skin and subcutaneous tissues at beginning of case
  3. Ilioinguinal block given at beginning of case with same local anesthetic
  4. Local anesthetic also infiltrated before each tissue plane opened
  5. 10 cc of the local mix is is placed into the preperitoneal space at the initiation of the preperitoneal dissection in order to minimize the sedation used

Patient Positioning

  1. Patient is placed in supine position
  2. Ensure that all bony prominences are padded

Exposure and Surgical Approach

  1. Transverse incision marked 1 cm above the halfway point on the line drawn between ipsilateral pubic tubercle and anterior superior iliac spine. The incision is 1/3rd lateral and 2/3rds medial (3.0 - 4.5 cm)
  2. Incision made in the skin and subcutaneous tissues
  3. Local infiltrated under external oblique
  4. External oblique opened along axis of muscle fibers
  5. Local anesthetic infiltrated into junction of internal oblique and rectus sheath
  6. Internal oblique opened in muscle-splitting fashion to expose transversalis fascia
  7. Transversalis fascia opened to expose preperitoneal space, taking care not to injure inferior epigastric vessels

Identify Hernia Sac in the Preperitoneal Space

Encirclement of Hernia Sac

Development of Preperitoneal Space

  1. Peritoneum separated from anterior abdominal wall via blunt dissection. Typically the dissection is performed from lateral to medial
  2. Hernia sac dissected free of attachments from internal ring, past bifurcation of spermatic cord where vas deferens deflects medially
  3. Peritoneum slowly teased away from the transversalis fascia along Hasselbach’s triangle to address direct hernia component
  4. Development of preperitoneal space below Cooper’s ligament

Placement of Ventrio ST Mesh

  1. Placement of Ventrio ST mesh within preperitoneal space to address indirect, direct and femoral spaces, with no suture anchors placed

Closure

  1. 3-0 Vicryl used to re-approximate external oblique fascia
  2. 3-0 Vicryl used to close Scarpa’s fascia
  3. 4-0 Vicryl as running suture used to close skin

Postoperative Care

  1. Oral acetaminophen  and ibuprofen for pain control
  2. Toradol 30mg IV usually given in the OR
  3. Patients are provided a prescription for vicodin if needed - Typically less than 50% usage
  4. Foll Activity restriction for 2 weeks. Treadmill and exercise bike use as tolerated