The technique indicated for femoral hernias in cases where prosthetic material is contraindicated is:
The McVay repair addresses both inguinal and femoral ring defects. This technique is indicated for femoral hernias and in cases where the use of prosthetic material is contraindicated (Fig. below). Once the spermatic cord has been isolated, an incision in the transversalis fascia permits entry into the preperitoneal space. The upper flap is mobilized by gentle blunt dissection of underlying tissue. Cooper ligament is bluntly dissected to expose its surface. A 2- to 4-cm relaxing incision is made in the anterior rectus sheath vertically from the pubic tubercle. This incision is essential to reduce tension on the repair; however, it may result in increased postoperative pain and higher risk of ventral abdominal herniation. Using either interrupted or continuous suture, the superior transversalis flap is then fastened to Cooper ligament, and the repair is continued laterally along Cooper ligament to occlude the femoral ring. Lateral to the femoral ring, a transition stitch is placed, affixing the transversalis fascia to the inguinal ligament. The transversalis is then sutured to the inguinal ligament laterally to the internal ring.
McVay Cooper ligament repair.
General anesthesia induction resulting in reduction of an incarcerated or strangulated inguinal hernia during laparoscopic repair:
Laparoscopic inguinal hernia repairs reinforce the abdominal wall via a posterior approach. Principal laparoscopic methods include the transabdominal preperitoneal (TAPP) repair, the totally extraperitoneal (TEP) repair, and the less commonly performed intraperitoneal onlay mesh (IPOM) repair. Although laparoscopic repairs in experienced hands are relatively expedient, they necessitate the administration of general anesthesia and its inherent risks. Any patient with a contraindication to the use of general anesthesia should not undergo laparoscopic hernia repair. Occasionally, general anesthesia induction may result in reduction of an incarcerated or strangulated inguinal hernia. If the surgeon suspects this might have occurred, the abdomen should be explored for nonviable tissue either via laparoscopy or upon conversion to an open laparotomy.
The medical issue NOT associated with hernia recurrence is:
When a patient develops pain, bulging, or a mass at the site of an inguinal hernia repair, clinical entities such as seroma, persistent cord lipoma, and hernia recurrence should be considered. Common medical issues associated with recurrence include malnutrition, immunosuppression, diabetes, steroid use, and smoking. Technical causes of recurrence include improper mesh size, tissue ischemia, infection, and tension in the reconstruction. A focused physical examination should be performed. As with primary hernias, ultrasound, (CT), or magnetic resonance imaging (MRI) can elucidate ambiguous physical findings. When a recurrent hernia is discovered and warrants reoperation, an approach through a virgin plane facilitates its dissection and exposure. Extensive dissection of the scarred field and mesh may result in injury to cord structures, viscera, large blood vessels, and nerves. After an initial anterior approach, the posterior laparoscopic approach will usually be easier and more effective than another anterior dissection. Conversely, failed preperitoneal repairs should be approached using an open anterior repair.
Nociceptive pain is:
Pain after inguinal hernia repair is classified into acute or chronic manifestations of three mechanisms: nociceptive (somatic), neuropathic, and visceral pain. Nociceptive pain is the most common of the three. Because it is usually a result of ligamentous or muscular trauma and inflammation, nociceptive pain is reproduced with abdominal muscle contraction. Treatment consists of rest, nonsteroidal anti-inflammatory drugs (NSAIDs ), and reassurance, as it resolves spontaneously in most cases. Neuropathic pain occurs as a result of direct nerve damage or entrapment. It may present early or late, and it manifests as a localized, sharp, burning, or tearing sensation. It may respond to pharmacologic therapy and to local steroid or anesthetic injections when indicated. Visceral pain refers to pain conveyed through afferent autonomic pain fibers. It is usually poorly localized and may occur during ejaculation as a result of sympathetic plexus injury.
The triangle of pain is bordered by all of the following EXCEPT:
The preperitoneal anatomy seen in laparoscopic hernia repair led to characterization of important anatomic areas of interest, known as the triangle of doom, the triangle of pain, and the circle of death (Fig. below). The triangle of doom is bordered medially by the vas deferens and laterally by the vessels of the spermatic cord. The contents of the space include the external iliac vessels, deep circumflex iliac vein, femoral nerve, and genital branch of the genitofemoral nerve. The triangle of pain is a region bordered by the iliopubic tract and gonadal vessels, and it encompasses the lateral femoral cutaneous, femoral branch of the genitofemoral, and femoral nerves. The circle of death is a vascular continuation formed by the common iliac, internal iliac, obturator, inferior epigastric, and external iliac vessels.
Borders and contents of the A. triangle of doom and B. triangle of pain. a . = a rtery; Ant. = anterior; br. = branch; Lat. = lateral; n. = nerve; v. = vein.
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