Hello, I am Dr. T. K. Swamy, surgical gastroenterologist. In this video, I will show you our technique of doing open hernia repair for an inguinal hernia, Lichtenstein repair. Every general surgeon must be well-versed with the open surgery.
Because you'll be forced to do the surgery when the hernia is very big or when there is obstruction or strangulation when there is recurrence after tip or tap or when there are a lot of scars in the lower abdomen You will be forced to do the surgery. So you must be well-versed with the open surgery It is not enough if you just know how to do it. You must do the surgery without complications You must do the surgery without recurrence your recurrence rate and the post-operative Neurology has to be less than 0.5 percent.
This is very very important. This video will definitely help you to achieve this to certain extent. Few words about Lichtenstein.
Lichtenstein did 3125 cases from the year 1984 to 1992. He followed up most of the cases. 87% of the time he followed all the cases. He had four recurrences. Three in front of the pubic tubercle and one under the inguinal ligament. He came out with a lot of modifications.
I will be doing this surgery with those modifications only. Lichtenstein died at the age of 80 in 2000. He was not operating for 18 years before his death because he had Parkinson's. Most of the surgeries were done by his assistant, Professor Parviz Ahmed. Professor Ahmed's surgery is available in the internet. It's a real pleasure to watch the original author doing the surgery.
You also can have a look. Coming to this patient, this patient is a 70 year old male. with a direct inguinal hernia on the left side.
This patient wanted open surgery. He was against laparoscopic surgery. Some of the family members had some problem with the laparoscopic surgery, so he wanted only open surgery, so we are doing open surgery.
But routinely, we do tip only. Very rarely, we do tap and open surgery. Without much ado, let us get into the video and see.
The patient is under spinal anesthesia. I am standing on the left side of the patient. The assistant surgeon is standing opposite to me, that's on the right side of the patient.
The staff nurse is to my left. I'm using the inguinal incision. You can use either the inguinal incision or a transverse incision.
The transverse incision is usually away from the inguinal canal so we don't prefer. Moreover the transverse incision incision is away from the internal and external ring you need to use more retraction the neuropraxia is more common with the transverse incision but the cosmetically transverse incision is better we routinely use the inguinal incision you have to divide the both layers of the superficial fascia that vein is the superficial inferior pigastric you can either use artery forceps or you can divide with the diathema you can either ligate or cut with the diathema The superficial fascia has got two layers, fatty layer and that's the membranous layer, deeper layer and there will be a thin layer over the external oblique muscle, that one, that one you have to keep it. there. You should not wipe it with your finger or with the gauze piece.
That only will hold the muscle fibers of the external oblique. If you remove that, when you hold it to the straight artery forceps, the external oblique muscle fibers will come off. Make a small opening in the external oblique because the ilio-inguinal nerve will be directly down. So you need to be careful, make a small incision, hold it to the straight artery forceps on both the sides. Then take the scissor, push all the tissues down because the ilio-inguinal nerve might be there under the muscle.
So push everything down. Then don't cut with the scissor, just push the scissor. You should not use a shearing moment. just push it so that you split the muscle you don't cut the muscle if the nerve is underneath that will be pushed to one side now hold it closer migrate this forceps also then lift it then again with a scissor you move all the tissues down go up to the internal ring keep pushing this might go up or down because the fibers will crisscross at the lateral border you might wonder why i am coagulating this bleeder this is the biggest bleeder of the whole surgery you will understand at the end End of the surgery. We don't allow the blade to trickle down.
Push it again. Almost we are at the lateral border of the internal ring. There the tissues are very thin.
Hold it closer. Move all the tissues. There is little bit of ring left there.
Cut it with the diatom carefully. Now you have two flaps, upper one and lower one. It is very important you dissect two to three centimeters above the upper flap.
Don't use the finger blindly. there you have to be careful about the iliohypogastric nerve. To my surprise, we have not seen these two nerves, iliohypogastric and ilioinguinal in this patient. I will demonstrate both the nerves in some other case and it is very rare in some patients it will not be seen 15% of the individuals will not be able to see now catch hold of the lower flap this lower flap has to be dissected until you see the inguinal ligament clearly from the pubic tubercle laterally then laterally we have to go 2 centimeter above the pubic tubercle that's very very important point you have to remember is the whole iguana ligament you can see clearly now you have to dissect the cremaster fascia i'm cutting only the cremaster fascia nothing else not the muscle from lateral to medial you have to cut only the fascia you see the testicular vein there if there is bleeding it's very difficult to see the tissues now we have to dissect in between the sac and the cord structures for that you have to find out the cleavage see i am looking for the cleavage there that's the cleavage there will always be a cleavage even in long-standing cases so first you have to find out then you must start dissecting in that direction that is the cremation muscle first find out the cleavage between the muscle and the sac sac on the cord keep developing there still the cremastic fascia is there you have to go up to the medial border of the direct sac little bit there divide carefully now catch hold of the sac with the alice forceps or Babcock alice is better for me I don't like the Babcock's because it's more traumatizing now I am dissecting the cremaster muscle there you have to look for the iliangula now the nerve is not there but decide carefully every time you have to see whether the nerve is there or not if the nerve is there you have to maintain the fascia around the nerve don't handle the nerve unnecessarily don't strip the nerve I will demonstrate in some other case cut close to the sac Don't strip the cremaster muscle. In our student days we used to remove the cremaster muscle.
We used to divide the muscle from lateral to medial. We used to excise the whole of the cremaster muscle. Some used to do archidectomy also. We were so cruel.
The modern hernia surgery tells you don't do that. One small advice to the beginner surgeon. The beginner surgeons must try to become a meticulous surgeon right from the beginning.
You must learn the deliberate dissection technique on the tissue handling properly. Just observe how I am using the non-tooth forceps, the diathermy pencil, how I move the tissues before dividing, when and where I am using the diathermy. All this you observe keenly. then you will do a better job than this.
You have to observe keenly. I am going very close to the sac. The non toothed forceps is holding the cremaster bundle. If you see carefully, the cremaster bundle has got the deep cremaster fascia. That fascia should not be disturbed.
If you disturb the deep cremaster fascia, the genital branch of genital femoral will be exposed. The vas will be exposed. Now you have to maintain that fascia and then decide, you go on the sac side. Hold the sac closer to the area of dissection. That's what we learnt in laparoscopic surgery.
You have to hold the tissues closer to the area of dissection. Then only you can dissect properly. Go in small increments. If there is little bit of bleeding, arrest immediately. Then proceed with the surgery.
Now I am dissecting medially. In long-standing cases there will be little bit of fibrosis but even then you will be able to dissect well. Now almost the chromastic bundle is out of danger now. This part of the surgery is very very important.
You should not use the finger to dissect. In our student days, we used to insert our index finger down and pull the card up. We should not do that.
Finger dissection must be avoided. There you have to define the medial border of the defect because we want to close the defect. Now you can see the defect clearly.
That's the defect. Now I am coming laterally towards the internal ring. There you must see whether the patient has got any indirect sac or not. and then dissect if the indirect sac is there that has to be divided. Now this chord structure should not be pulled up with the finger.
You see the window is clearly seen. Don't use the finger to hook it up. You can see the window there with the diatomy carefully dissect.
By doing this, you'll be maintaining the fascia around the wires and the nerve. So keep a right angle on the artery forceps and put a tape or some tube so that you can retract the cord structures out of the way. Hold it with an artery forceps.
Now the sac is free all around, it can be invaginated. You have to invaginate, you can invaginate both the direct and indirect sac, but if the indirect sac is very big, we have to divide it. But most of the time in laparoscopic surgery we don't divide, we just pull it out, pull it in.
So if the sac is bigger in open surgery we definitely excise but if in the direct hernia you should not do that because most of the time the bladder will be there so don't open the direct sac only the indirect sac you can open see whether the bowel is there or not and then divide. Now I am closing the defect I am using polypropylene. You can use either absorbable or non-absorbable but I use non-absorbable because I had bad experience even with the delayed absorbables dissolving in few days I have seen so I'm using non-absorbable.
You can either use interrupted or a continuous suture. I'm using the interrupted switcher as the assistant to hold the sack inside. Put two or three stitches so that the sack is not sprouting outside.
now i have come to the last stitch i have already put four stitches this here you have to be careful about the inferior pegastic vessel the most important is the inferior pegastic vane the outer will be very thick and it's very difficult to take bite in the artery but can be injured but the commonly injured is the vein there are two veins on either side of the artery so if you go by the side of the artery also you might injure so it is always better to go little medially to take the bite you should not make the internal gang very tight here so now the there's a little bit of Cremast muscle fiber has come off. Don't leave the loose tissues. You must excise the loose tissues there. They will become the nidus of infection later. and then you make all the strands flat the posterior wall has to be flat otherwise these small strands will lift the mesh up so cut out there be careful you don't injure any now Now I want to dissect little bit more on the upper flap because I want to keep a bigger mesh.
Here you have to be careful about the iliohypogastric now. If the now is there, you go away from the now. Apply diathermy in two or three places, not continuously.
Then you push it, it will go because they are not densely adherent. If you push, they will go. Don't use the finger.
If you use the finger, they will start bleeding. Use a diathemy. If there is bleeding, arrest immediately. Now I am measuring the breadth of the mesh. This has to be measured exactly so that we get the right size mesh.
It comes to around 6 cm, the breadth. You have to take at least one to one and a half centimeter more. You have to keep the mesh loose.
You must always use a larger mesh. There is nothing like seven centimeter or eight centimeter. It all depends on the size of the patient.
some patients even the 6 centimeter will be too big the idea is you have to cover the whole of the huddle backs triangle and you have to go 3 to 4 centimeter away from the triangle that is the idea now take the mesh I'm taking lightweight polypropylene mesh the size is 15 into 15 so that you can design whatever way you want you This patient needs a 6 centimeter so I will take 7.5 centimeter. If you fold the mist then it becomes 7.5 centimeter into 15 centimeter. Divide it in the middle and then keep the half of the mesh inside the glove pack.
and then keep it safely don't throw it sometimes this mesh will fly away or it will fall down then you'll be able to use the other half so it's very important to keep it around the corners and then you have to take the bite first in the mesh when you are taking on the left side you have to take the bite first in the mesh then in the tubercle you have to go two centimeter beyond the tubercle this is very very important you should not take the bite at the tubercle, the pubic tubercle you must go at least 1.5 centimeter to 2 centimeter medial to the pubic tubercle you can take either your u stitch or you can take direct stitch if you are taking u stitch you have to take the bite on both sides first on the mesh if you don't take u stage you take the bite first in the mesh on the left side if you are doing it on the right side you have to take the bite on the pubic tubercle side and then on the mesh you can use either a continuous or interrupted continuous is better it's more stable there will not be any gap for the hernia to sneak peek inside don't take the bite from the periosteum that's another important point now still I have not come to the pubic tubercle side now we are closer to the pubic tubercle so we are two stitch away This is very very important going medial to the pubic tubercle. The medial recurrence is more common in a direct hernia. Take thick bites while taking on the inguinal ligament you have to be careful you should not go deeper you might injure the femoral artery or the femoral vein keep suturing up to the medial border of the internal ring and stop there. Then you lift the cord structures and take the thread down through the window. Now you have to Cut the mesh to accommodate the card structures.
That you have to go up to the medial border of the internal ring. For this the recommended is you have to divide the mesh two-third above and one-third below. You should not make the lower third like a strip, small strip.
Two-third above and one-third below. If you Cut too much then you can put a stitch there no problem but you have to cut it adequately just to the medial border of the internal ring. Then take the lower tail down and You have to suture again the lower part. You hold it with the artery forceps. With the weight of the artery forceps, it will lie down.
You need not hold it. The assistant need not hold it. You can leave it.
Because by the weight of the artery forceps, that strip will stay there. Ask the assistant to hold the thread. Otherwise you will knot the thread.
Take a thicker bite. You can take a little wider bite not deeper bite. Now see whether the tension is adequate or not. If it is too tight, you loosen it.
If it is loose, you can just pull it and then tighten the thread. That's the advantage of continuous suture. Now that is the last stitch, that is at the latter border of the internal ring.
You complete it there. so you have to be careful here about the femoral nerve the femoral nerve is exactly at the midpoint of the inguinal ligament and if you stop shot at the lateral border of the internal ring you need not worry if you come beyond that likely to, you will injure the femoral nerve. So these are the two nerves which you need to remember is the femoral nerve and the LFCN, lateral femoral cutaneous nerve of thigh, which are outside your wound. Inside the wound, you have the iliohypogastric, ilioinguinal and the genital branch.
So, femoral nerve and the LFCN are outside. So, you have to be careful about them also. Now, before designing the internal rim, you have to suture the medial and the superior border. Otherwise, the mesh will move down and the idea of dissection will be lost.
So, you have to cover the whole area of dissection, that is the idea. We want to put a bigger mesh, so you must fill those areas first before you define the internal ring. There you can use observable or non-observable.
We are using non-observable, but the recommended is observable. Now I am suturing the superior border. Whenever you come to the superior border, you must be conscious that the iliohypogastric nerve is there. You must be nerve conscious. It is called nerve mindfulness.
it's very very important to avoid post-operative neurology the nerve is there protect it don't handle it don't pull it maintain the fascia over the nerve i'm switching the superior border so that it will not get rolled down Some people use the self retaining retractor. We don't use because self retaining is more damaging. From the beginning to the end of the surgery it will be there and the neuropraxia is more common with the self retaining. And this retractor we will be releasing then and there. So the ischemia will not be there.
Next we have to create the prosthetic internal ring. You should not suture the mesh together like this. You have to create the prosthetic internal ring. This is very important in the case of indirect hernia.
You have to criss-cross both the tails and then you have to take the bite from the lower border of both the flaps, upper flap and the lower flap. That's the lower border of the upper flap. lower border of the lower flap and then take the bite in the inguinal ligament. So these three points are important.
Lower border of the upper flap, lower border of the lower flap and the inguinal ligament. These three together. Otherwise it will not form a good ring.
By doing this you see there is a ripple created in the mesh. So that ripple is very very important. The mesh should not lie flat on the posterior abdominal wall.
There must be must be some amount of laxity there. Then only when the patient gets up, it will get flattened. This is excess mesh on just trimming laterally for a centimeter or 1.5 centimeter, it is too long and then you push the tail inside. we did not put any stitch there and I'm switching only the upper border now that's the last stitch three or four stitches are enough you should not put too much of stitches there a line is seen there that's not the area hypogastric now that is a fold in the mesh now you can see the laxity the mesh has to lie down freely like this it should not be too lax and it's not be too tight now remove the tube and then place the card properly you need not pull the testis down to make the card straight you can just push the card that is enough now we have to switch off the external oblique Some people take it lightly to switch out the external oblique. This is very very important muscle.
Though it is not giving strength to the posterior abdominal wall, this is an important muscle. When the intra-abdominal pressure increases, this muscle will contract and keep the mesh in position. This muscle will work in our favor. Otherwise if you don't suture this properly, if this gives way, the mesh will get protruded outside. So this is an important muscle which has to be closed properly.
Use observable. But I prefer 3-0 polypropylene or 3-0 monofilament nylon ethylene. That's the perfect material but the recommended is only the absorbable. This is a 2-0 vial. 1 to 2 millimeter only don't take too wide a bite retract properly lift the muscle and then take bite only from the muscle not from the cart I'm using continuous you can use either continuous or interrupted the continuous has to be stopped at the lateral border of the external ring otherwise if you continue then the continuous suture will get loosened.
So it has to be stopped where the muscle ends. Lift properly, retract properly. You must direct the assistance properly then only you can do comfortably you know we are very comfortable now we have come closer to the Here I am external ring, so you have to complete the continuous stitch there.
So the retraction is very very important. See how it is seen because of one retractor. You should not be in a hurry to close it.
and we will complete the continuous stitch there. If you are putting interrupt it doesn't matter. It's better.
Interrupt is better. Now complete there and put one or two stitches over the external ring. Don't think that the external ring is not that important and you can leave the external ring wide open. You have to leave the tissues as you have entered to the maximum possible. So if it is possible to suture the thin layer over the external ring, you have to do it.
So I'll let thin face here, you just cover it. The healing will be better. In that bargain you should not strangulate the cord, it's also important. Just approximate the tissues without tension.
That's the last stitch. That's it. We want to put the subcuticular stage so this subcutaneous layer has to be sutured.
You can either suture the membranous and the fatty layer separately or together. If you suture the fatty layer, the membranous layer will come together mostly. The same 2-0 Vicryl is used for this.
You need not take another suture. take nice wider bites and then invert the stitches so that the knot will go inside you have to bring the wound together for the subcuticular otherwise too much stress will be there over the subcuticular stitches so it is always better to bring the wound together to the maximum now almost it's done put one more last stitch now we are going to put the critical There are many ways of starting and ending the subcuticular. You have to take the bite well inside the wound.
That's the trick here. Go well inside and take the bite. This I have learned long, long ago from the plastic surgeons. I don't know what they are doing now.
Tighten it. If you don't take the bite well inside, what happens? You'll get a dog here and there.
I'm using absorb 30 vial you need not remove the switches so patient you know come for the review within few days we asked her to come only on the fifth day and then they will take the dressing out and then they will take bath The subcuticular is not a subcuticular actually this is a misnomer. It's an intradermal stitch actually. Subcuticular means below the skin level that means subcutaneous.
So this is not subcutaneous actually this is a intradermal. See while taking bite you just ask the assistant to hold the thread little under tension so that the wound opens you can take the bite easily. You have to take the horizontal bite to the subdomain level. You have to take the bite at the same level. If you take the bite little deeper, then that side will overwrite.
So you have to take the bite at the same level, the depth I mean. Every time you mop it. you have to hold the thread on this side and that side alternatively then it will be easier pull it if you take two or three bites together sometimes it will get knotted so you have to be careful if it gets knotted you have to divide the thread you can stop there and then start doing you should not pull the knot see while taking bite you should not take the bite exactly at the exit point opposite side You have to take the bite closer to the exit point of the previous stage. See, you should not take bite exactly opposite to the exit point. You have to go to the previous exit point and then take the bite there.
That is the important technical point. See here, I am not taking the bite exactly opposite of the exit point. I am going closer to the previous exit point and then take the bite. That is the technical point you must learn. See, I am going there, closer to that point and then take bite.
Somehow the anesthetist are not in favor of this subcuticular. If you are a junior they will tell you that the patient is a cardiac patient or the next case is waiting. They will ask you whether this old man is going to act in movies and all this they will tell but if the patient is really a cardiac patient you should not do a subcuticular because the life is more important than the line of scar so otherwise if the patient is under spinal or under local this is going to act for another number so definitely you can do As far as possible, we must leave the tissues as we have entered to the maximum possible. that's very very important every time you take the pad and then press and see otherwise you can't do this at the end so in between you have to adjust the tension This I have learnt long back. I don't know what the plastic surgeons are doing now.
They might be doing better than this. You can learn this technique from them better than from me. This patient was actually, he was very comfortable than the laparoscopy patients.
He went home the next day. at least the laparoscopy patients they will complain of shoulder pain or nausea vomiting this patient didn't complain anything he just walked home happily that's the last stitch I'm going to complete it with the cobbler stitch take two or three loops then take the needle through the loop pull the thread and this knot has to go inside otherwise it will be jetting outside take the needle and then come through the wound and come out a little away little away and then pull it that knot will go inside. Now take the pad and then see whether it has gone inside or not just press it it will go inside.
Now you can cut the thread. See the wound is very clean and it will not be seen after a month. So cut the thread half a millimeter away from the skin half a millimeter not one millimeter When the patient gets up, this half a millimeter will go inside. Put a strip of pervadenide in the ironment.
Don't put the whole tube there. Just a little bit, just for lubrication only. When you take the gauze piece, if you don't put this, the wound might get opened. Because it will get stuck to the gauze piece.
So just keep a little bit of ironment and then put the gauze piece. Then you can put the dressing. To conclude, what have you learned so far?
Number one, use a larger lax mesh. Cover the pubic tubercle. Preserve the cremaster.
Don't use finger for dissection. Invaginate the sac. Create proper prosthetic internal ring.
And be mindful of the nerves. Thank you very much for watching this video. Your comments are welcome. Thank you.