Minimally Invasive Open Preperitoneal Inguinal Hernia Repair

Type of Anesthesia

1. Sedation is given at the beginning of the case while the patient is in the operating room
2. 0.5% Marcaine + 1% lidocaine with epinephrine infiltrated into skin and subcutaneous tissues at beginning of case
3. Ilioinguinal block given at beginning of case with same local anesthetic
4. Local anesthetic also infiltrated before each tissue plane opened
5. 10 cc of the local mix is is placed into the preperitoneal space at the initiation of the preperitoneal dissection in order to minimize the sedation used

Patient Positioning

6. Patient is placed in supine position
7. Ensure that all bony prominences are padded

Exposure and Surgical Approach

8. Transverse incision marked 1 cm above the halfway point on the line drawn between ipsilateral pubic tubercle and anterior superior iliac spine. The incision is 1/3rd lateral and 2/3rds medial (3.0 - 4.5 cm)
9. Incision made in the skin and subcutaneous tissues
10. Local infiltrated under external oblique
11. External oblique opened along axis of muscle fibers
12. Local anesthetic infiltrated into junction of internal oblique and rectus sheath
13. Internal oblique opened in muscle-splitting fashion to expose transversalis fascia
14. Transversalis fascia opened to expose preperitoneal space, taking care not to injure inferior epigastric vessels

Identify Hernia Sac in the Preperitoneal Space

Encirclement of Hernia Sac

Development of Preperitoneal Space

15. Peritoneum separated from anterior abdominal wall via blunt dissection. Typically the dissection is performed from lateral to medial
16. Hernia sac dissected free of attachments from internal ring, past bifurcation of spermatic cord where vas deferens deflects medially
17. Peritoneum slowly teased away from the transversalis fascia along Hasselbach’s triangle to address direct hernia component
18. Development of preperitoneal space below Cooper’s ligament

Placement of Ventrio ST Mesh

19. Placement of Ventrio ST mesh within preperitoneal space to address indirect, direct and femoral spaces, with no suture anchors placed

Closure

20. 3-0 Vicryl used to re-approximate external oblique fascia
21. 3-0 Vicryl used to close Scarpa’s fascia
22. 4-0 Vicryl as running suture used to close skin

Postoperative Care

23. Oral acetaminophen  and ibuprofen for pain control
24. Toradol 30mg IV usually given in the OR
25. Patients are provided a prescription for vicodin if needed - Typically less than 50% usage
26. Foll Activity restriction for 2 weeks. Treadmill and exercise bike use as tolerated