Aira Hospital

The vast majority of surgeons use an anterior (classical) approach for all types of inguinal and femoral hernias. The preperitoneal approach is however far more advantageous, in particular when dealing with femoral, recurrent and incarcerated hernias. I find the approach so easy, fast and bloodless that I use it for all hernias in that region as a routine. As you are able to deal with all types of hernias through this approach an exact preoperative diagnosis is not crucial.

Repairing a femoral hernia through the preperitoneal approach is so easy that when you have done it once you will never use the anterior approach again. The access to the hernia is direct and the reduction is very easy, as is the repair.

When dealing with recurrent hernias you avoid all the scarred tissue and distorted anatomy from previous surgery(ies). The approach is through virgin (previously untouched) area.

With incarcerated hernias you will often have to deal with gangrenous intestines needing resection and anastomosis. That can be very tight and difficult with the anterior approach – sometimes a real nuisance. With the preperitoneal approach the access to the intra abdominal content is very easy, and the resection can be done without struggling.

The strict transverse incision is placed 2-3 fingers above the pubis. The fascia is opened in the same transverse direction, splitting the oblique and transverse muscles. The rectus muscle is retracted medially. It is often necessary to cut its insertion in the pubic bone partially to get good access. Finger dissection opens up the preperitoneal space.

 

Most often I don’t open the hernia sack at all after having reduced it, but concentrates solely on closing the hernia defect anatomically. Only if the neck is narrow I do ligate and cut the sack in the traditional way.

When the peritoneum has been opened –purposely or accidentally – I usually leave it without closing, just as when doing an appendectomy (I presume that you don’t close the peritoneum when doing appendectomy either!)

Closure is straight forward – continuous nylon in the fascia followed by skin closure according to your preference. Mine is interrupted nylon.