1. TISSUE REPAIRS FOR GROIN HERNIA
• INDICATED IN FOLLOWING SITUATIONS
1. STRANGULATED INGUINAL HERNIA
2. ALLERGY TO MESH MATERIAL
3. PATIENT DOES NOT GIVE CONSENT FOR
FOREIGN MATERIAL
4. There are reports that in young males in in the
reproductive age with bilateral groin hernia ,
mesh repair on both sides may produce
oligospermiaor subfertility because of
entrapment of vas in mesh. (ATLAS OF GENERAL
SURGERY, page 40)

2. POPULAR TISSUE REPAIRS
1. BASSINI’S REPAIR
2. MARCY REPAIR
3. ILLIOPUBIC TRACT REPAIR
4. Mc VAY REPAIR
5. SHOULDICE REPAIR

3. ANAESTHESIA
• MAJORITY OF OPEN GROIN
HERNIA REPAIRS CAN BE
PERFORMED UNDER LOCAL
ANAESTHESIA UNLESS THE
HERNIA IS VERY BIG OR IF IT IS
SLIDING HERNIA OR REACHING
UPTO THE SCROTUM

4. COMMON STEPS IN OPEN NON
PROSTHETIC TISSUE REPAIR
• 1. INCISION--- AN OBLIQUE OR HORIZONTAL
INCISION IS PLACED 2 CM ABOVE AND
PARALLEL TO THE INGUINAL LIGAMENT OVER
ITS MEDIAL 2/3rd
• 2. THE INCISION IS DEEPENED THROUGH THE
CAMPER’S AND SCARPA’S FASCIA TILL
EXTERNAL OBLIQUE APONEUROSIS IS
EXPOSED

5. INCISION

6. MOBILISATION OF CORD STRUCTURES

7. HERNIOTOMY

9. LIGATION OF SAC

10. DIFFERENT REPAIRS
• BASINI’S REPAIR
• GOLD STANDAED
• INCISION IN EXTERNAL
OBLIQUE SUPERIOR TO
SKIN INCISION.
• FLAP OF FASCIA
TRANSVERSALIS,
TRANSVERSUS
ABDOMINIS AND
INTERNAL OBLIQUE

11. • FIRST STITCH CONSISTS
OF FLAP OF TRIPPLE
LAYER SUPERIORLY
AND THE PERIOSTEUM
INFERIOLY

12. MARCY’S REPAIR
• THIS REPAIR IS INDICATED
FOR GILBERT’S TYPE 2
HERNIAS IN CHILDREN AND
YOUNG ADULTS.
• THIS BASICALLY COMPRISES
OF HIGH LIGATION OF SAC
AND NARROWING OF THE
INTERNAL RING BY TAKING
INTERRUPTED SUTURES
THROUGH FASCIA
TRANSVERSALIS AND
TRANSVERSE ABDOMINUS
MUSCLE

13. ILIOPUBIC TRACT REPAIR
• IT WAS DESCRIBED BY
CONDON IN 1989.THIS
REPAIR APPROXIMATES
TRANSEVERSE
ABDOMINIS
APONEUROTIC ARCHTO
THE ILIOPUBIC TRACT
BY INVERTED SUTURES

14. McVAY REPAIR
• This repair is known as
COOPER’S ligament
repair . Interrupted non
absorbable sutures are
used to approximate
The transversus
abdominis aponeurosis
to cooper’s ligament
• RARELY PERFORMED
THESE DAYS

15. SHOULDICE REPAIR
• DOUBLE BREASTING THE
INGUINAL CANAL
• REINFORCING THE FLOOR
OF THE INGUINAL CANAL
BY A FOUR LAYERED
REPAIR
• TRANSVERSALIS FASCIA IS
SPLIT IN ITS MIDDLE
FROM DEEP ING. RING TO
PUBIS –TWO FLAPS ARE
MADE—SUP AND INF

16. • FIRST LAYER—LOWER FLAP
OF T. FASCIA –LATERAL
BORDER OF RECTUS
MEDIALLY AND UNDER
SURFACE OF UPPER FLAP
OF T. FASCIA
• A FREE EDGE OF UPPER
FLAP IS LEFT

17. • AFTER REACHING THE
DEEP RING LATERAL TO
MEDIAL
• PICKING UP THE FREE
EDGE OF THE UPPER
FLAP OF T. FASCIA AND
APPROPXIMATING IT TO
THE INGUINAL
LIGAMENT UP TO
PUBIC TUBERCLE

18. • THIRD LAYER
APPROXIMATING THE
INTERNAL OBLIQUE
AND TRANSEVERSE
ABDOMINIS
SUPERIORLY TO THE
INNER ASPECT OF THE
INGUINAL LIGAMENT

19. • FOURTH LAYER IS AGAIN APPROXIMATING
THE INTERNAL OBLIQUE AND TRANSVERSUS
ABDOMINIS SUPERIORLY TO THE INNER
ASPECT OF EXTERNAL OBLIQUE
APONEUROSIS IN A MORE SUPERFICIAL
THIS IS FOUR LAYER REPAIR
AFTER THAT EXTERNAL OBLIQUE FLAPS ARE
CLOSED TO CLOSE INGUINAL CANAL

21. FEMORAL HERNIA REPAIR
• In human anatomy of the leg, the femoral
sheath has three compartments. The lateral
compartment contains the femoral artery, the
intermediate compartment contains thefemoral
vein, and the medial and smallest compartment is
called the femoral canal. The femoral canal contains
efferent lymphatic vessels and a lymph
node embedded in a small amount
of areolar tissue. It is conical in shape and is about 2
cm long.

23. • FOR A FEMORAL HERNIA SURGERY IS ADVISED FOR
TWO REASONS:
THE INCIDENCE OF STRANGULATION IN THESE
HERNIAS IS HIGH. IN ELDERLY CONSIDERABLE
MORBIDITY
• FEMORAL SHEATH
• ANTERIORLY ---INGUINAL LIGAMENT
• POSTERIORLY---PECTINEAL LIGAMENT
• MEDIALLY ---- SHARP LATERAL MARGIN OF
LACUNAR LIGAMENT
• LATERAALY----ILIOPSOAS MUSCLE

24. TYPES OF OPERATION
• THREE APPROACHES ARE DESCRIBED
• NO SINGLE OPERATION IS IDEAL
1. THE ABDOMINAL, SUPRAPUBIC OR
EXTRAPERITONEAL OPERATION DEVELOPED
BY HENRY( Mc Evedy APPROACH)
2. THE INGUINAL OR HIGH OPERATION
3. THE CRURAL OR LOW OPERATION

25. THE LOW OPERATION
• PT SHOULD BE CATHETERISED
PREOPERATIVELY
• RYLES TUBE IF OBSTRUCTION
• GENERAL ANAESTHESIA IS PREFERED
• SUPINE POSITION
• GROIN AND LOWER ABDOMEN ARE PREPARED

26. INCISION
• A 6.0 cm long and and
oblique incision is made
directly over the hernia
and 2.0 cm below and
parallel to the inguinal
ligament
• Secure haemostasis
should be attained
before the sac is
mobilised

27. MOBILISATION OF THE SAC
• THE SAC HAVING
EMERGED FROM THE
FEMORAL CANAL , CARIES
BEFORE IT THE
TRANSVERSALIS FASCIA
AND FAT IN FRONT OF
WHICH IS THE
ATTENUATED CRIBRIFORM
FASCIA AND FEMORAL
VESSEL FASCIAL LAYER

28. • BECAUSE OF THESE FASCIAL LAYERS THE SAC
USUALLY MAKES A FORWARD AND UPWARD
TURN IN THE PATH AND ITS FUNDUS CAN BE
FOUND LYING OVER THE INGUINAL LIGAMENT
• IT IS IMPORTANT TO APPRECIATE THIS BEFORE
MOBILISATION IS ATTEMPTED . ONCE THE SAC
IS IDENTIFIED THE FASCIAL LAYERS ARE ARE
SEPARATED FROM IT BY BLUNT DISSECTION .

29. INSPECTION OF CONTENTS OF SAC
• THE LATERAL SIDE OF THE
FUNDUS SHOULD BE
OPENED . THE MEDIAL
SIDE SHOULD BE
AVOIDED AS IT MAY BE
PARIALLY FORMED BY
BLADDER. ADHERENT
EXTRAPERITONEAL FAT
ON THE FUNDUS
CONTAINS MANY
DISTENDED VEINS.
HAEMOSTASIS IS
REQUIRED. SAC IS FREED
AND CONTENTS REDUCED
TO PEROTONEAL CAVITY

30. • IF STRANGULATION THEN
AN ALTERNATIVE
APPROACH MAY BE
REQUIRED
• CLOSURE AND EXCISION OF
SAC IS DONE
• IT MAY RECEDE THROUGH
FEMORAL CANAL

31. REPAIR OF THE CANAL

32. RAISING FLAP OF PECTINEAL FASCIA

33. TENSION FREE MESH HERNIOPLASTY
FOR GROIN HERNIA—LICHTENSTEIN
,1989
• THIS OPERATION
BASICALLY COMPRISES
OF HERNIOTOMY AND
STRENGTHENING OF
POSTERIOR WALL OF
INGUINAL CANAL BY
THE MESH(
HERNIOPLASTY)

34. EXTERNAL OBLIQUE