Operative surgery

Basics of operative surgery

Hernia Surgery: Herniotomy

Bassini’s Herniorrhaphy

Bassini’s• the transversalis fascia is incised from the pubic tubercle to the

internal inguinal ring, thereby entering the preperitoneal space. • Preperitoneal fat is bluntly dissected from the upper margin of the

posterior side of the transversalis fascia to permit adequate tissue mobilization.

• A triple-layer repair is then performed to restore integrity to the floor. • The medial tissues, including the internal oblique muscle, transversus

abdominis muscle, and transversalis fascia, are fixed to the shelving edge of the inguinal ligament and pubic periosteum with interrupted sutures.

• The lateral border of the repair is the medial border of the internal inguinal ring, which subsequently is reinforced by the repair.

Shouldice’s Herniorrhaphy

• Original descriptions of the Shouldice technique involved the use of a stainless steel wire.

• With the posterior inguinal floor exposed, an incision in the transversalis fascia is performed between the pubic tubercle and internal ring.

• Care is taken to avoid injury to any preperitoneal structures, and these are bluntly dissected to mobilize the upper and lower fascial flaps.

• The first layer of repair begins at the pubic tubercle where the iliopubic tract is sutured to the lateral edge of the rectus sheath, then progressing laterally.

• The inferior flap of the transversalis fascia, which includes the iliopubic tract, is sutured continuously to the posterior aspect of the superior flap of the transversalis fascia until the internal ring is encountered. At this point, the internal ring has been reconstituted.

• The suture is not tied here, but rather is continued back upon itself in the medial direction. At the internal ring, the second layer is the reapproximation of the superior edge of the transversalis fascia to the inferior fascial margin and the shelving edge of the inguinal ligament. The suture is then tied to the tail of the original stitch.

• A third suture is started at the tightened inguinal ring, joining the internal oblique and transversus abdominis aponeuroses to external oblique aponeurotic fibers just superficial to the inguinal ligament.

• This layer is continued to the pubic tubercle where it reverses upon itself to create a fourth suture line, which is similar and superficial to the third layer.