Operations for abdominal

hernias

Department of Fundamental
medicine,
Immanuel Kant Baltic Federal
University,
Kaliningrad
Irina A. Stepanyan
The topical tasks of surgical operations for hernias of the
anterior abdominal wall are to repair a hernial
protrusion and to reinforce a weakness of the abdominal
cavity by means of plasty to prevent its relapse.

The abdominal wall is supported by autogenous tissues:

aponeuroses (the aponeurotic plasty), muscles and
aponeuroses (the musculoaponeurotic plasty) or
muscles and fasciae (the musculofascial plasty) — or
by synthetic tissues.
 A surgical operation includes
the following stages:
1. layer-by-layer dissection of tissues above a hernial
protrusion considering the topographoanatomic
relations in the given region;
2. dissection of the hernial porta;
3. exposing the separated hernial sac;
4. opening the sac and examining its contents;
5. ligation and cutting the sac off at its neck;
6. plastic closing of the hernial porta.
Depending on the type of hernia, tissue condition, and
hernial protrusion size, different means are applied to
open the hernial sac, to treat its contents, and to make
plasty to the hernial porta.

The principal cause for both indirect and

direct inguinal hernias is the inconsistence of
the posterior wall of the inguinal canal, and
all the types of plasty should be targeted to
reinforce it.
The general technique in operations for the indirect
inguinal hernias

A patient is in a supine position (lying on their back). A skin

incision of 10—12 cm long is done parallel and 2 cm upwards
of the inguinal ligament from the limit of its lateral and middle
third up to the pubic tubercle. The subcutaneous cellular tissue
and the deep lamina of the superficial fascia are dissected;
a. et v. epigastricae superficiales are cut between the forceps;
and the external oblique aponeurosis with the dilated
superficial inguinal ring are opened rather wide.
A grooved probe is entered into the inguinal canal through
the superficial inguinal ring or through an opening made
after the aponeurotic fold has been dissected;
upon the probe, the external oblique aponeurosis is cut
lengthways the fibers.
The edges of the cut aponeurosis are taken on the forceps
and drawn apart: the inferior free borders of the internal
oblique and transverse abdominal muscle, the spermatic
cord thickened by the hernial sac lying between the muscles
and the inguinal ligament, as well as n. ilioinguinalis on the
surface of the cord are opened.

The groove of the inguinal ligament is cleansed of cellular

tissue by a swab up to the place of its attachment to the
pubic bone — the inferior flap of the external oblique
aponeurosis is pulled off downwards while performing the
cleansing.
Separating the hernial sac.
The common tunica vaginalis of
the spermatic cord with the
muscular fibers of m. cremaster
over it are cut longitudinally and
the wall of the hernial sac is found
among the elements of the cord by
its whitish colour.
The found area of the wall is
clipped with forceps, and bluntly
(however sharply at some parts)
the whole hernial sac is gradually
separated. It is done first in distal
direction until its fundus is found
and then proximally up to the
neck in the region of the deep
inguinal ring.
Separated on its entire length, the
hernial sac is opened by two clamp-
forceps closer to its fundus; further
the incision is prolonged under visual
control.

If there are no hernial contents, one

has to make sure a hernial sac is
connected with the peritoneal cavity,
for only this can prove it has been
really a hernial sac separated.

The contents of the sac are pulled up,

smoothed, examined and, if they are
undamaged, returned into the
peritoneal cavity. Adhesions with the
hernial sac are dissected.
Adhesions are fibrous bands that form between tissues
and organs, often as a result of injury during surgery. They
may be thought of as internal scar tissue that connects
tissues not normally connected.

Abdominal adhesions (or intra-abdominal adhesions) are

most commonly caused by abdominal surgical procedures.
The adhesions start to form within hours of surgery and
may cause internal organs to attach to the surgical site or to
other organs in the abdominal cavity. Adhesion-related
twisting and pulling of internal organs may result in
complications such as abdominal pain or intestinal
obstruction.
The empty sac is a little stretched, sutured through with
catgut at the neck, ligated from either sides and cut off.

After it has been proven the hernial sac stump is not bleeding,
free ends of the ligatures are cut off.

The spermatic cord is put in its place, and the plasty of the
inguinal canal is performed.
 Inguinal canal plasty
in indirect and direct hernias

As it was already mentioned, in any hernia — both

indirect and direct — after treating of the hernial sac it is
necessary to reinforce the posterior, weakest
wall of the inguinal canal.

The basic approach for most ways of the canal plasty is

that of E. Bassini, a surgeon from Padua, Italy, who
was the first to perform such an operation in December
24, 1884. Its essence lies in putting a row of deep sutures
to narrow the dilated deep inguinal ring to a normal size
and reinforcing the weakened posterior wall of the canal.
The spermatic cord is driven apart with a holder
from the inguinal space.

Several millimeters higher the inguinal ligament,

the transversalis fascia is dissected by a scalpel
from the medial border of the deep inguinal ring to
the pubic tubercle.

Behind the fascia, the peritoneal sac coated with

adipose tissue becomes visible. It should be kept in
mind that the inferior epigastric vessels are
situated at the internal border of the deep inguinal
ring.
After the peritoneum has been separated from
the upper half of the dissected transversalis
fascia, musculofascial layer is separated bluntly;
it consists of the inferior free borders of the
internal oblique and transverse abdominal
muscle and the transversalis fascia. This very
layer is to be attached to the inguinal ligament
for reinforcing the posterior wall of the canal.
The ductus deferens is replaced laterally. The
musculofascial layer from its medial side is
sutured through by a much curved needle with a
firm ligature; further with the same needle and
thread the periosteum of the pubic tubercle is
sutured through in the place of the inguinal
ligament attachment to it.
The ends of the ligatures are not tied, but
grabbed with a tool. Stepping off 1 — 1.5 cm
from the previous suture, the upper layer and
the inguinal ligament are sutured through once
more. Next (commonly 6-8) sutures are put in
the same way up to the medial border of the
internal inguinal ring.
Suturing the inguinal ligament through needs special accuracy.
The ligament consists of large fibers tracing parallel to its free
deep edge (the iliopubic cord). If the same fibers are caught in
with every further suture, there is danger of the fibers’
disarrangement; so, the needle should be punctured out of the
inguinal ligament either closer or a little further of the
ligament’s edge. The medial part of the inguinal ligament is to
be sutured through with utmost care, for femoral vessels run
right under the ligament here.
The n. ilioinguinalis
should be kept away
from getting into the
suture.
Then, all the sutures are tied
in turn. After the last suture
is tied, the deep inguinal ring
through which the elements
of the spermatic cord trace
should not cause their
squeezing. To make the
optimal size of the opening,
it is advisable to enter a little
finger into the deep ring
before tying the last suture.
If the inguinal space is high and the muscular layer
thinned, it may be difficult to pull the muscles up to
the inguinal ligament because much strain causes
sutures to lacerate.

To avoid it, in the medial part of the would-be

posterior wall of the inguinal canal, the external
border of the rectus sheath is attached to the inguinal
ligament; due to this procedure, borders of the
internal oblique and transverse muscle are quite easily
pulled down to the inguinal ligament.
After deep sutures have been put in, the spermatic cord is
returned to its place and the borders of the cut external oblique
aponeurosis are sutured together over the cord focusing not to
narrow the superficial inguinal ring.

Among lots of other approaches for autoplastic reinforcing the

posterior wall of inguinal canal, the approach of Shouldice
since the end of XX century is to be emphasized.

At the present time, Bassini’s and Shouldice’s approaches lead

the list in autoplasty. The techniques described are known as the
best among those with the minimal percent of relapses.
The most effective and almost
free-of-relapse device is the
posterior wall plasty with a
polypropylene mesh which is
sutured to the superior and
inferior walls of the inguinal
canal.

These days such operations

known as Lichtenstein repair
have been performed with
increasing frequency and
success.
Such an operation can be done both with the open
approach and with the laparoscopic technique.

For a long time it has been believed (especially in

Russia) that indirect hernias require reinforcing
the anterior wall of the inguinal canal. It is true
that at large hernias the external oblique aponeurosis, i.e.
the anterior wall of the inguinal canal, is thinned.
There were many methods of its reinforcing suggested
(those of Girard, Girard - Spasokoukotsky, Kimbarovsky, et
al.) But the main ground for inguinal hernias — weakness
of the posterior wall — is not prevented by them.
At present time these methods are of just historical interest;
they might be applied only to very young people with sound
tissues in the inguinal region.

Girard method Spasokoukotsky method

 1

2 3

Girard method
Spasokoukotsky method
 Operations for congenital inguinal hernia

The hernial sac in a congenital inguinal hernia is a

non-obliterated vaginal process of the
peritoneum.

The spermatic cord is tightly fixed externally to the wall

of the hernial sac while the testis, coated with the
peritoneum mesoperitoneally, is in the sac along with
the hernial contents. In such cases the surgery target is
to eliminate the connection of the hernial sac with the
peritoneal cavity.
The hernial sac is dissected longitudinally. Its borders are
drawn apart by taking them upon the clip-forceps.

The hernial contents are placed into the peritoneal cavity and
the internal surface of the sac is inspected. Connection with
the peritoneal cavity is blocked either by putting in a purse-
string suture on the neck of the sac or by its common ligation.

For the second approach, the peritoneum of the hernial sac

on the posterior wall of its neck is cut transversally and taken
upon clip-forceps. Pulling the spermatic cord a little and
applying the tissue infiltration with the Novocain solution,
the neck of the sac is bluntly and carefully separated by a
gauze swab from the spermatic cord lying externally. After
the neck of the sac has been separated, it is sutured through
and ligated.
This approach is not always effective to isolate the neck of
the hernial sac, because the elements of the spermatic cord
are adhered with the thin peritoneal sac that is easily broken
at its separating. It is possible to put in a purse-string
suture to the neck of the hernial sac from inside so that the
spermatic cord is not taken into the suture but as if step it
over it by grabbing the peritoneum from either side and
leaving the cord outside of the suture.

Stepping 1,5—2 cm distal of the put-in purse-string suture,

the wall of the hernial sac is carefully cut transversally. The
distal edge of the cut is a little mobilized down and then the
purse-string suture is tied and knotted. Thus the connection
with the peritoneal cavity is eliminated.
To avoid a postoperational edema of the testis’ tunicas, the
hernial sac is either excised along the spermatic cord with
leaving a strap of peritoneum of 1.5-2.0 cm around the
testis, or the sac is turned out and sutured posterior of the
cord and testis by catgut separate stitches (Winkelmann’s
operation). The testis is carefully returned to the fundus of
the scrotum.

The inguinal canal plasty is made according to any

approach that helps to reinforce its posterior wall.
 Umbilical hernias

The skin is cut longitudinally along the midline several

centimeters up of the umbilicus, leaving it to the right
and continued for 3-4 cm down of it.
In obese patients, the cut is commonly semilunar or
oval bordering the hernial protrusion from below. The
skin and subcutaneous cellular tissue are dissected up
to the aponeurosis of the linea alba.
When preparing a skin flap from left to right, the skin
along with the subcutaneous tissue is separated from
the hernial sac. The sac is extracted until the hernial
porta formed by the aponeurotic border of the
umbilical ring are clearly seen.

A grooved probe is entered between the hernial neck

and umbilical ring and the ring is dissected upon it
transversally or across the linea alba up and down. The
hernial sac is cleared completely, opened, its contents
returned in their place, the peritoneum is excised and
sutured with continuous catgut suture.
Mayo plasty is performed when the umbilical ring is dissected transversally.
U- shaped sutures are put in. The upper flap of the aponeurosis is sutured
through with silk first from outside to inside (entoectad) stepping from the
border 1.5 cm; further, with the same ligature a stitch is made on the inferior
border of the aponeurosis from outside to inside and then vice versa stepping off
from the border just 0.5 cm with suturing finished on the superior border at the
same level. There are commonly 3 of such stitches — 1 in the centre and 2 from
either side. At tying, the inferior border of the aponeurosis is replaced under the
superior one and is fixed as duplication. The free edge of the superior flap of the
aponeurosis is apposed with the surface of the inferior flap by separate
interrupted stitches (the second row of the suture).
Sapezhko plasty is performed when the umbilical ring is dissected
longitudinally. An assistant pulls off the left edge of aponeurosis upon
Kocher’s forceps and flexes it so that its internal surface is maximally
turned out. A surgeon pulls the right edge of the aponeurosis up to it trying
to place it as far as possible and apposes them by separate interrupted or
U-shaped silk stitches. The free left edge of the aponeurosis is laid upon
the right one and sewed up with separate stitches. Thus the abdominal
wall is aponeurotically duplicated.
Lexer’s plasty is commonly done in children for
small umbilical hernias by reducing the umbilical
aponeurotic ring with a purse-string suture
upon which separate interrupted sutures
are put in.
Lexer’s plasty of the abdominal wall at the umbilical hernia:
1 — the purse-string suture around the umbilical ring;

2 — interrupted stitches put in to the anterior wall of the rectus

abdominis sheaths
 Linea alba hernias
The cut of the skin with further hernial
sac and porta treatment is carried out as
for umbilical hernias. The borders of the
cleared hernial porta are dissected at
either side in both directions. The edges
of the aponeurosis are apposed and
sutured edge to edge transversally, or
Sapezhko - Dyakonov plasty is
performed: a duplication is created
of the aponeurotic flaps of linea
alba vertically by putting in several U-
shaped stitches with the further sewing
of the free flap of the aponeurosis to the
anterior wall of the rectus sheath by
interrupted sutures.
Like in all other types of external
abdominal hernias, at the present
time the optimal repair is a plasty
with synthetic mesh.