Open Right Inguinal Hernia Repair

David R. Farley, MD
Student Author:
Matthew Zeller

Background Information:

Inguinal hernias occur when abdominal contents herniate through the inguinal canal (indirect) or Hesselbach’s triangle (direct). Inguinal hernias are repaired using open or minimally invasive (laparoscopic or robotic) techniques.

Indications:

Symptomatic direct or indirect inguinal hernia. Within ten years, up to 70% of asymptomatic inguinal hernias will become symptomatic.

Procedure Description:

An open inguinal hernia is a procedure performed through an incision in the groin overlying the inguinal canal. There are many techniques of open inguinal hernia repair, the most common being the Lichtenstein repair. This technique uses a mesh to reinforce inguinal structures after reducing the hernia sack.

Key Anatomy:

Subcutaneous tissue

  • Camper’s fascia
  • Scarpa’s fascia

Abdominal wall:

  • External oblique aponeurosis
  • Internal oblique muscle
  • Hesselbach’s triangle (direct hernia space)
  • Lateral border: inferior epigastric vessels
  • Inferior border: inguinal ligament
  • Medial border: lateral border of rectus abdominous muscle

Inguinal anatomy

  • Deep (internal) inguinal ring
  • Superficial (external) inguinal ring
  • Spermatic cord
  • Cremaster muscle
  • Panpiniform venous plexus
  • Testicular artery
  • Vas deferens
  • Artery of the vas deferens
  • Inguinal ligament (Poupart’s ligament)
  • Shelving edge of the inguinal ligament
  • Cooper’s ligament
  • Lacunar ligament

Nerves

  • Ilioinguinal nerve
  • Genital branch of the genitofemoral nerve
  • Iliohypogastric nerve

Misc

  • Anterior superior iliac spine (ASIS)
  • Pubic tubercle
  • Iliac vessels

Risks:

General surgical risks:

  • Bleeding
  • Infection

Risks with open hernia repair with mesh (incidence following an open hernia repair with mesh)

  • Post herniorrhaphy neuralgia/inguinodynia (13% at three months follow up) (Nienhuijs, et al. 2007)
  • Seroma (1.6%) or hematoma formation (6.1%) (Fitzgibbons, et al. 2006)
  • Deep surgical site infection (0.45%) (Orelio, et al. 2020)
  • Often requiring mesh removal
  • Orchitis (0.7%) (Hawn, et al. 2006)
  • Sexual dysfunction and pain with sexual activity (13% and 3.7% respectively) (Ssentongo, et al. 2020)
  • Injury to hernia contents

Additional resources:

ACS/ASC Core Curriculum

Online MedEd:

Mayo Clinic

Text:

  • Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice by Courtney M. Townsend Jr. JR. MD
  • Zollinger’s Atlas of Surgical Operations, Tenth Edition 10th Edition

           by Robert Zollinger, E. Ellison

  • Atlas of General Surgical Techniques: Townsend, Evers
  • Essentials of General Surgery 5th Edition, by Peter F. Lawrence MD, Richard M. Bell MD, Merril T. Dayton MD, James C. Hebert MD FACS

Key Literature:

References:

  1. Fitzgibbons RJ Jr, Giobbie-Hurder A, Gibbs JO, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial [published correction appears in JAMA. 2006 Jun 21;295(23):2726]. JAMA. 2006;295(3):285-292. doi:10.1001/jama.295.3.285
  2. Orelio CC, van Hessen C, Sanchez-Manuel FJ, Aufenacker TJ, Scholten RJ. Antibiotic prophylaxis for prevention of postoperative wound infection in adults undergoing open elective inguinal or femoral hernia repair. Cochrane Database Syst Rev. 2020;4(4):CD003769. Published 2020 Apr 21. doi:10.1002/14651858.CD003769.pub5
  3. Nienhuijs S, Staal E, Strobbe L, Rosman C, Groenewoud H, Bleichrodt R. Chronic pain after mesh repair of inguinal hernia: a systematic review. Am J Surg. 2007;194(3):394-400. doi:10.1016/j.amjsurg.2007.02.012
  4. Hawn MT, Itani KM, Giobbie-Hurder A, McCarthy M Jr, Jonasson O, Neumayer LA. Patient-reported outcomes after inguinal herniorrhaphy. Surgery. 2006;140(2):198-205. doi:10.1016/j.surg.2006.02.003
  5. Ssentongo AE, Kwon EG, Zhou S, Ssentongo P, Soybel DI. Pain and Dysfunction with Sexual Activity after Inguinal Hernia Repair: Systematic Review and Meta-Analysis. J Am Coll Surg. 2020;230(2):237-250.e7. doi:10.1016/j.jamcollsurg.2019.10.010