Inguinal hernia repair, Rutkow Plug

The Rutkow principle of inguinal hernia repair involves the insertion of an umbrella-like mesh plug into the local defect beneath the transversalis fascia. A second flat mesh, the onlay patch (similar to the Lichtenstein principle), is placed over the plug.

A skin incision approximately 4 cm long is made obliquely 2 fingerbreadths above the inguinal ligament (solid line) or alternatively a transverse skin incision 2 fingerbreadths above the pubic bone. Subsequently, the subcutis is incised down to the external aponeurosis.

The external aponeurosis is opened parallel to the fibers, including the external inguinal ring. The fascial edges are clamped, elevated, and the fascia is bluntly separated from the internal oblique muscle and the cremaster muscle.
Attention: The iliohypogastric nerve lies on the internal oblique muscle!

The spermatic cord is, if necessary, initially prepared and looped together with an indirect hernia sac at the level of the pubic tubercle from the underlying fascia transversalis or a direct hernia sac.

The cremaster muscle fibers are split longitudinally and the spermatic cord structures are identified. Attention must be paid to the course of the nerves and the epigastric vessels.

Remarks

1. When looping the spermatic cord and preparing the hernia sac, the genital branch of the genitofemoral nerve must be preserved, which extends at the lower edge of the spermatic cord with the cremaster fibers in direct proximity to the external spermatic vein.

2. To avoid postoperative neuralgias, the following should be noted: If the genital branch of the genitofemoral nerve, the ilioinguinal nerve, or the hypogastric nerve cannot be preserved, the affected nerves should be resected and the resection ends infiltrated with a local anesthetic.

3. Extensive exposure and manipulation of the nerves should be avoided, and in case of doubt, it is better to perform a neurectomy than to leave a damaged nerve.