Herniotomy Step By step

  

-indicated in children with inguinal hernia & before herniorrhaphy in adults

-Procedure:

1-ligate & divide the 3 superficial veins
2-divide the external oblique aponeurosis in the direction of its fibers
3-reflect the external oblique aponeurosis &identify the ilioinguinal nerve & reflect it over the aponeurosis
4-separate the cord from posterior wall of the canal
5-divide the creamasteric muscle & internal spermatic fascia
6-dissect the hernial sac up to its neck
7-open the fundus of the sac
8-reduce the contents
9-transfix the sac at the deep ring
10-excise the redundant sac


There are different approaches to surgical repairs to hernia which may include the following:

Hernioplasty when herniotomy is combined with a reinforced repair of the posterior inguinal canal with autogenous (patient’s own tissue) or heterogenous material such as prolene mesh.

Herniorraphy is somewhat like hernioplasty only that no autogenous or heterogenous material is used for reinforcement.

Herniotomy is a surgical operation where the hernia sac is removed without any repair of the inguinal canal.

Read more: Discussion on Hernia Repair, Herniorraphy | Res Ipsa Loquitur - OR Nurse 

*updated

Herniorrhaphy procedure: Bassini's 

Definition: It means herniotomy and approximation of conjoined tendon to inguinal ligament to strengthen the posterior wall of the inguinal canal.

Indication: Indirect  or direct hernia with good muscle tone.

Procedure

Incision: 6-8cm incision is made parallel to the inguinal ligament at the level of deep ring in the medial two thirds of the inguinal ligament. 

Layers opened: 

• Skin
• Two layers of superficial fascia
• External oblique is incised in the line of direction fibres till external ring is open.
• Thin cremasteric box is opened.
• Identification of the sac

1. - glistening white colour,
2. Isolate the cord from the sac by blunt and sharp dissection.The cord is held separately by using cord holding forceps.
3. The sac is mobilise upto the deep ring. Mobilisation is complete when inferior epigastric artery pulsations and extraperitoneal pad of fat are seen.
4. The sac is opened and contents are examined.
5. The contents are reduced.
6. Twist the sac to avoid injury to the contents.
7. Transfixation ligature is applied as high as possible at the neck of sac and it is tightened.
8.  Excision of the sac: After excision , see the excised sac and see whether omentum or intestine have been injured.Up to this stage , it is called as HERNIOTOMY.

Repair

• Conjoined tendon above is approximated to the inguinal ligament below by using nonabsorbable suture such as Nylon, Silk  or Sutupack.
• Nonabsorbable suture is used so that its strength remaines for a long time. This repair is called BASSINI'S HERNIORRHAPHY.

Closure

• External oblique is sutured with chromic catgut or silk.
• Subcutaneous fat absorbable catgut suture.
• Skin with silk.

Post -op

• NPO fro 6-8 hours, oral fluids and soft diet later.
• Analgesics
• Antibiotics
• Scrotal support if the dissection is more(complete hernia)
• Suture removal after 7-10days.

Post-op complications

• Haematoma
• Wound infection
• Severe peritonitis pubis
• nerve entrapment causing pain. 

Source: Shenoy Nileshwar Manipal Manual surgery.