McFan's Indirect Inguinal Hernia Repair

Familiarity with the anatomy of the inguinal region is essential for the inguinal hernia repair. The inguinal canal originates from the inguinal inner ring (abdominal ring) and ends in the inguinal outer ring (subcutaneous ring). The inner ring is an oval crease on the transverse fascia, and its position is equivalent to about 1.5 cm above the midpoint of the anterior superior iliac spine and the pubic symphysis. The inguinal outer ring is formed by the aponeurotic fibers of the external oblique muscle. The triangular fissure is on the outside of the pubic tuberosity. The groin area is located at the ankle, triangular, with one on each side. The upper boundary is on the horizontal line of the anterior superior iliac spine to the outer edge of the rectus abdominis, the inner boundary is the outer edge of the rectus abdominis, and the lower boundary is the inguinal ligament. The abdominal wall of the inguinal region can be divided into 9 layers from shallow to deep, namely skin, subcutaneous tissue, superficial fascia (Scarpa fascia), external oblique muscle and aponeurosis, intra-abdominal oblique muscle, transverse abdominis muscle, transverse transverse fascia, Extraperitoneal fat and parietal peritoneum. Although its level is the same as that of other parts of the abdominal wall, it is far weaker. The part of the external oblique aponeurosis between the anterior superior iliac spine and the pubic symphysis is turned upside down and thickened to become the inguinal ligament. A small portion of the fiber inside the ligament continues to fold back, down, and outward into a ligament, attached to the pubic comb, and its curved free edge constitutes the inner boundary of the femoral ring. This ligament continues to extend outward, and the aponeurosis attached to the pubic comb line is called the pubic ligament. Part of the fibers of the inferior oblique muscle and the lower edge of the transverse abdominis muscles circumscribe the posterior to the spermatic cord, stop at the pubic tuberosity, and fuse into a joint sputum. Some of the fibers on the lower edge of the above two muscles migrate down the inner and outer edges of the spermatic cord to form a thinner testicular muscle. The inferior epigastric nerve passes through the intra-abdominal oblique muscle about 2.5 cm in front of the anterior superior iliac spine, runs inward and downward on the deep side of the external oblique muscle, and then passes through the external oblique muscle aponeurosis about 2.5 cm above the outer ring. Leave the inguinal canal. The inguinal nerve is thinner than the inferior epigastric nerve. It is almost parallel to the inferior genus, and is accompanied by spermatic cord in the groin, and then exits the outer ring and is distributed in the scrotum or labia majora. The genital tract of the reproductive femoral nucleus penetrates along the posterior aspect of the spermatic cord and is distributed in the inner lining of the testicular and scrotal. In the inguinal region, the inferior epigastric artery is obliquely moved from the outside to the upper side, through the medial edge of the inguinal region, up to the deep rectus abdominis, intersecting the lateral edge of the rectus abdominis. The inferior epigastric artery is on the outer side, the outer rectus abdominis is on the inner side, and the inguinal ligament is on the lower side. A triangular area is formed between the three, called the groin triangle. There is no rectus abdominis in this triangle, and the transverse fascia is weaker than other parts. It is the weakest part of the inguinal region, and the groin is directly protruding to the body surface. Treatment of diseases: inguinal hernia, inguinal hernia Indication McVeigh's inguinal hernia repair is suitable for adults, the elderly and recurrent inguinal hernias with weak abdominal muscles. It is characterized by suturing the combined tendon on the pubic ligament to achieve the purpose of strengthening and repairing the posterior wall of the inguinal canal. Contraindications 1. Patients with acute diseases, lesions in the skin of the sputum, or severe cough, etc., increase the intra-abdominal pressure. 2. Elderly paralyzed patients with long-term survival and no serious symptoms are expected. Preoperative preparation 1. Repeat the detailed physical examination and necessary laboratory tests before surgery, paying special attention to the throat, heart, lung, blood and surgical site. 2. Complete the skin preparation in the operating area one day before the operation. 3. If there is an upper respiratory tract infection, chronic cough, chronic constipation or other conditions that increase the intra-abdominal pressure, it should be controlled before surgery. Surgical procedure 1. Incision, dissection of the hernia sac, hernia sac resection and high ligation and other steps with the Brazilian fascia inguinal hernia repair. 2. Lift the spermatic cord and touch the femoral artery in the middle of the middle part of the inguinal ligament. The inner side is the femoral vein. The finger is placed close to this as a marker, and the fascia transverse fascia is bluntly stripped inward and downward along the inner edge of the pubic symphysis. Pushing the loose connective tissue on the superficial surface reveals the pubic ligament. 3. From the inside and the bottom of the incision, suture the joint iliac crest on the pubic ligament with a thick non-absorbent suture, and sew 2 or 3 needles together. The first suture should pass through the ligament of the sac and then tighten the suture. When sewing the last needle, the left hand finger can be used to block the femoral vein to avoid damage. The free edges of the remaining intra-abdominal oblique muscles and the transverse abdominis muscles are then sewn on the superior inguinal ligament. 4. Put back the sperm. Rinse the wound. The aponeurosis, subcutaneous tissue and skin of the external oblique muscle were sutured intermittently in front of the spermatic cord. complication Bleeding during surgery Some have a large amount of bleeding, and bleeding can be caused by damage to the following blood vessels: 1 The pubic branch of the obturator artery (so-called corona mortis) refers to the branch of the obturator artery surrounding the hernia sac. 2 abdominal artery. 3 strands of motion, veins. It is cumbersome to infuse the bleeding caused by the two blood vessels in the front, but as long as the incision is extended and the exposure is improved, these blood vessels can be ligated or sewn without causing a big problem. The problem caused by femoral injury is more serious. When the inguinal ligament is sutured, the suture is too deep, which may damage the femoral blood vessels and cause massive bleeding. It is best to withdraw the needle before ligating the damaged blood vessel, and locally stop the bleeding. If the pressure can not stop bleeding immediately, it is necessary to enlarge the incision, fully expose the injured femoral blood vessels, and then local compression to stop bleeding, or use fine needle suture to repair the blood vessel breach. 2. Cut off the vas deferens After accidentally injuring the vas deferens, it should be repaired immediately. The ends of the ends can be anastomosed with a very fine non-absorbent line. It is also possible to use a thin plastic tube for internal support, and then suture the anastomosis with a thin line to break the plastic tube. If there is an operating microscope on site, you can also use 6-0 thin wire to do the opposite end, in this case you do not need to use the inner support tube. 3. Damage to the lower abdomen nerve The important nerves encountered during hernia repair include the inferior epigastric nerve and the inguinal hernia, in addition to the sensory branch of the radial nerve and the reproductive branch of the reproductive femoral nerve. Because the inguinal inguinal nerve is located under the aponeurosis of the external oblique muscle near the outer ring, it is easy to damage the nerve when the diaphragm is cut. In the Cooper method, the inferior epigastric nerve is easily damaged when the incision is made in the anterior rectus sheath of the rectus abdominis. Once nerve damage occurs, repair has no real value. The nerve ends can be clamped with silver clips after trimming to avoid neuromas. Due to the overlap and cross-linkage of the segmental distribution of the nerve, the affected part may feel numb gradually after the injury. Inadvertent suture of the suture may cause long-term symptoms. The reproductive branch of the reproductive femoral nerve may be damaged when the testicular muscle near the inner ring is severed. The patient may have a testicular testicular sag before the operation. In the process of repairing and suturing the tendon, if the inguinal ligament is sewed too deeply, the femoral nerve may be sewed sometimes, and the femoral nerve may be incomplete after surgery, and the patient may fall easily when walking. It can be recovered after removing the suture that sewn the nerve. 4. Injury to the testicular arterial blood supply In the process of free hernia sac, the vascular bundle that damages the spermatic cord should be prevented. These blood vessels are thin and difficult to repair. The internal spermatic artery begins in the abdominal aorta, and the distal testicular artery is the main arterial supply of the testes. The internal spermatic artery is connected to the spermatic cord in the inner ring plane. The external spermatic artery is a branch of the inferior epigastric artery. After the spermatic cord tissue is added, the vas deferens is passed through the inguinal canal to provide blood supply to the testicular muscle. It has an anastomosis between the inner and the inner spermatic artery. Due to the presence of the above-mentioned collateral circulation, slight accidental damage to the spermatic vessels does not cause serious consequences. However, in the case of recurrent hernia repair, occasionally the spermatic blood vessels can be transected, which may affect the testicular blood supply. This situation should be avoided as much as possible, otherwise it may cause testicular atrophy. 5. Damage to the abdominal organs In the repair surgery, each stitch should be very careful. Sliding sputum can damage the cecum or sigmoid colon. Due to the lack of knowledge of the sputum, until the sliding sputum is recognized, the intestinal wall may have been cut or the mesenteric vessels have been severed. The hernia sac is located on the anterior medial side of the spermatic cord, so the separation and incision of all hernia sacs should proceed from the front. Mesenteric blood supply enters from behind the sacral sputum, and separation in the latter often causes bleeding or intestinal necrosis due to blood supply disorders. This complication can be avoided by incision in the anterior medial side of the sacral hernia. In case of damage to the colon wall, the colon wall should be repaired as usual. The inside of the iliac crest often has a bladder wall. When the sac is cut open, the bladder can be cut due to carelessness. Seeing a blood-rich lemon-colored adipose tissue to be vigilant, it may be a pre-bladder lipoma, do not cut easily. Once the bladder wall is damaged, the bladder wall should be sutured in two layers with a fine chrome gut or absorbable suture and silk thread, while the catheter is indwelled through the urethra for several days. can be patched as usual.