Shouldice Repair of Inguinal Hernia - general and visceral surgery

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date of publication: 21.09.2009

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  • Principle

    • 23-5

    Duplicating the transversalis fascia and attaching the transversus abdominis and internal oblique to the inguinal ligament.

  • Inguinal skin incision

    • 23-6

    Make the skin incision, measuring about 4 cm, in the line of the inguinal canal 2 fingers medial to it (solid line), or make a transverse incision 2 fingers superior to the pubic bone. Then divide the subcutaneous tissue down to the external oblique aponeurosis.

  • Division of the external oblique aponeurosis

    • 23-7

    Now longitudinally divide the fibers of the external oblique, including the superficial inguinal ring. After clamping the aponeurotic flaps and retracting them upward, free the aponeurosis from the internal oblique and cremaster by blunt dissection.
    Caution: The iliohypogastric nerve courses immediately below the aponeurosis!

  • Mobilization and taping of the spermatic cord

    • 23-8

    Pass a tape around the spermatic cord, gently lift it and free the cord by blunt dissection from the transversalis fascia below.
    After dividing the cremaster muscle longitudinally, excise its fibers leaving generous stumps, thereby freeing the cord. In this step of the procedure the ilioinguinal nerve and the genital branch of the genitofemoral nerve must be spared.
    Important: Postoperative neuralgia can be prevented by proceeding as follows: If you cannot spare the ilioinguinal and/or hypogastric nerves and/or the genital branch of the genitofemoral nerve, you must excise them and infiltrate their stumps with local anesthetic.

  • Identification of the hernia sac contents

  • Hernia sac management in direct hernia

  • Hernia sac management in indirect hernia

  • Checking the transversalis fascia

  • Dividing the transversalis fascia

  • Shouldice suture line I

  • Shouldice suture line II

  • Shouldice suture line III and IV

  • Closure of the external aponeurosis

  • End of procedure