Questions concerning open surgery fro Direct inguinal hernia
01/31/2023 at 7:11 pm #33681
All open surgeries seem to start about the same. It’s not until the external oblique is opened up that the different choices basically begin. (I’m a layman, by the way, and writing this to try to understand it better, so anything I say here is correctable.)
1) At the point that the external oblique aponeurosis is opened and the spermatic cord is lifted from the surrounding tissues, the first question for a Direct hernia, for my mind, is whether or not it is usually obvious enough to skip a dissection of the cord and whether this is a good practice if there doesnt seem to be an indirect hernia present?
2)When the transversalis fascia is brought into sight after the cord is lifted,is the transversalis fascia actually usually torn such that it’s just intestines covered by the peritoneum, or is the transversalis fascia just stretched?
3)in a Lichtenstein, is there any effort to close the transversalis fascia or tighten it before the mesh is placed? (I watched one video where this wasn’t done. In a video presentation by Dr Towfigh, i understood that she recommended this.)
4)What tissues will the mesh have contact with. Is it just mostly touching at the bottom and edge on the transversalis fascia, or will it also be touching and adhering to the rectus muscle or other tissues?
5)On the medial connection of the mesh to the body, how many stitches are placed and what are they stitched to?
6) It is suggested to leave a little wrinkle in the mesh because it will shrink. If that looseness isn’t there,how is it adjusted?
7l Before the external oblique aponeurosis is closed the spermatic cord will be resting on the mesh. What will prevent it from adhering to the mesh and causing it to loose mobility?
8)In a direct hernia in which the spermatic cord and cremasteric muscle are not dissected, is there much danger in damaging the genitofemoral nerve?
02/01/2023 at 12:53 am #33687
Dr Towfigh thank you very much for taking the time to help with our understanding.
Let me follow up on the question about “dissecting out” the spermatic cord. I put that in quotations because I’m not sure whether my lack of understanding is due to semantics, whether I’m misreading other sources, or whether there are differing opinions. Here’s a quotation from Dr Brown from earlier in the forum in which he says that the cremasteric muscle does not have to be excised (for direct hernia):
“A few patients have a bulky cremasteric muscle that can make the repair of the inguinal floor difficult, in those patient I sometimes remove the cremastic muscle. If the cremasteric muscle is excise the testicle does not retract in response to cold and during intercourse.
If there is a lipoma of the spermatic cord or an indirect hernia, the cremasteric muscle can be split to get access to those structures. The cremasteric does not have to be excised.
I do not routinely cut the nerves. Once cut there is no way to be sure that it will grow back.
Bill Brown MD”
And here is interesting video (for anyone curious about the Desarda technique- by Desarda himself, I think), in which at about the 2 minute mark Desarda lifts the cord outward. He skips the part where he cleans it away from the tissues below. I’m not able to say whether more was done to this or whether the cremasteric muscle is still there.
02/01/2023 at 12:54 am #33688
The link to the Desarda video…
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