Surgical approach and sac isolation
Surgical intervention is performed with the patient in the supine position. First, the surgeon incises the skin and subcutaneous tissue with the superficial fascia. At this stage, the superficial epigastric vessels (a. et v. epigastricae superficiales) must be transected and ligated.
After exposing the aponeurosis of the external oblique abdominal muscle, it is incised along the fibers to open the inguinal canal. Inside, the spermatic cord is found, which is thickened in case of a hernia. The ilioinguinal nerve (n. ilioinguinalis) runs on its surface and requires careful handling.
Steps for working with the hernial sac:
- Identification: among the fibers of the cremaster muscle (m. cremaster), the whitish wall of the sac is found.
- Isolation: the sac is grasped and separated from the surrounding tissues by blunt and sharp dissection — first toward the fundus, then toward the neck (in the area of the deep inguinal ring).
- Opening and revision: the sac is opened under visual control. The organs are inspected, adhesions (if any) are dissected, and viable contents are reduced back into the abdominal cavity.
- Transection: the neck is transfixed with catgut and ligated, after which the distal part of the sac is excised, strictly monitoring the hemostasis of the stump.
Plastic repair of the posterior wall of the inguinal canal
Strengthening the posterior wall is a fundamental treatment principle, as it is the weakest spot of the inguinal region.
- Bassini method: a classical technique that involves narrowing the stretched internal ring and fixing a single musculo-fascial block (internal oblique and transversus abdominis muscles together with the transversalis fascia) to the inguinal ligament. Sutures are placed posterior to the spermatic cord.
- Postempski method: a radical autoplasty variant in which the inguinal canal is completely obliterated. The deep ring is displaced laterally, and the muscles, transversalis fascia, and medial flap of the aponeurosis are sutured to the inguinal ligament. The spermatic cord is brought out into the subcutaneous tissue.
- Kukudzhanov method: used for direct hernias. To strengthen the medial section, the posterior wall of the rectus sheath is sutured to the pectineal ligament, while the lateral section muscles are fixed to the inguinal ligament.
Anterior wall repair (historical methods)
In the past, anterior wall reinforcement methods (above the spermatic cord) were actively used to treat indirect hernias. Today they are primarily of historical interest, as they do not solve the problem of posterior wall weakness and often lead to recurrences due to tissue tension.
- Girard–Spasokukotsky method: the internal oblique, transversus abdominis muscles, and the upper aponeurotic flap are simultaneously sutured to the inguinal ligament superficial to the cord.
- Kimbarovsky suture: a technical modification aimed at joining homogeneous tissues. The edge of the muscle is wrapped with the aponeurotic flap (the needle passes through the edge of the aponeurosis, captures the muscle, and exits back through the aponeurosis), after which this "roll" is fixed to the inguinal ligament. This reduces the risk of suture cutout.
Modern methods: alloplasty and laparoscopy
For a long time, prosthetics was limited due to the high reactogenicity of materials. Today the situation has changed thanks to inert polymers.
Lichtenstein operation is recognized as the modern "gold standard." This is a tension-free technique in which the inguinal triangle is covered with a special polypropylene mesh. The absence of tension on the patient's own tissues drastically reduces pain and the likelihood of recurrence.
Laparoscopic hernioplasty allows the placement of a polypropylene mesh from the inside (via intraperitoneal or preperitoneal approach). Advantages: minimal tissue trauma, discharge on days 2–3, and rapid return to work. Disadvantages: requires expensive equipment and has a number of specific contraindications.
Briefly: answers to topical questions
Which nerves run in the inguinal canal and are at risk during hernial sac isolation and tissue suturing?
During inguinal hernia surgery, the following neural structures must be considered in the inguinal canal:
- Ilioinguinal nerve (n. ilioinguinalis) — located on the surface of the spermatic cord; when suturing tissues, care must be taken to avoid catching it in the suture.
- Neural elements running within the spermatic cord include: genital branch of the genitofemoral nerve (r. genitalis n. genitofemoralis), sympathetic plexus of the ductus deferens (plexus sympathicus deferentialis), and testicular sympathetic plexus (plexus sympathicus testicularis).
What are the anatomical boundaries of the inguinal triangle (Hesselbach's triangle), within which direct inguinal hernias develop?
The anatomical boundaries of the inguinal (Hesselbach's) triangle form a space on the posterior surface of the anterior abdominal wall through which direct inguinal hernias emerge.
- Lateral boundary — inferior epigastric vessels (a. et v. epigastricae inferiores), which form the lateral umbilical fold (plica umbilicalis lateralis).
- Medial boundary — lateral edge of the rectus abdominis muscle.
- Inferior boundary — inguinal ligament.
The floor of this triangle is formed by the thinned transversalis fascia (fascia transversalis), unsupported by muscles.
What anatomical elements are part of the spermatic cord?
The spermatic cord consists of a complex of anatomical structures covered by fascial layers.
- Ductus deferens (ductus deferens).
- Arteries: testicular artery (a. testicularis), artery of the ductus deferens (a. ductus deferentis / a. deferentialis), cremasteric artery (a. cremasterica).
- Veins: pampiniform venous plexus (plexus pampiniformis / plexus venosus pampiniformis), testicular veins, veins of the ductus deferens.
- Nerves: genital branch of the genitofemoral nerve (r. genitalis n. genitofemoralis), sympathetic plexus of the ductus deferens (plexus sympathicus deferentialis), testicular sympathetic plexus (plexus sympathicus testicularis).
- Lymphatic vessels.
- Remnant of the processus vaginalis of the peritoneum.
- Loose connective tissue.
To easily understand the essence of the Kimbarovsky suture, imagine that the "aponeurosis hugs the muscle." The muscle edge is tucked under the aponeurosis so that connective tissue lies against the inguinal ligament, ensuring strong fusion without cutout.
Class and exam questions
Why are anterior wall reinforcement methods (Girard, Spasokukotsky) rarely used nowadays?
They do not eliminate the main cause of the hernia — weakness of the posterior wall of the inguinal canal. In addition, tightening the muscles creates severe tissue tension, leading to ischemia and a high risk of recurrence.
How to avoid dangerous narrowing of the deep ring during its suture?
Surgeons use a simple technical trick: before tying the final stitch, the little finger is inserted into the newly formed deep inguinal ring. This protects the elements of the spermatic cord from compression.
What is the anatomical complexity of working with the inguinal ligament?
Its fibers run parallel to the deep margin. If the needle is inserted strictly along a single line, the ligament may split. Also, major femoral vessels run immediately medial and inferior to it, requiring extreme caution.
What else to study on this topic
- Layered topography of the anterior abdominal wall
- Anatomical differences between indirect and direct inguinal hernias
- Formation and elements of the spermatic cord
- Lichtenstein tension-free repair technique
- Topography of femoral vessels and nerves in the inguinal region
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