need an inguinal herniotomy. How? In most situations the surgery is performed as an elective day-‐only operation. Sometimes emergency surgery is required if. Inguinal hernia is the most common surgical problem of childhood. It results from a small sac that comes through the inguinal ring that is normally open during. Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, Herlev, Denmark. Received 4 January ;.

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Inguinal hernia repair is one of the most common surgical procedures and several different surgical techniques procedyre available. The Onstep method is a new promising technique.

The technique is simple with a number of straightforward steps. This paper provides a full description of the technique together with tips and tricks to make it easy and without complications. Inguinal hernias affect millions of people each year [ 12 ]. Early on it was acknowledged that there was a need to reinforce the abdominal wall and it has been proven that, in the general treatment of inguinal hernias, there is a need for some kind of mesh to minimize the risk of recurrence [ 3 ].

Surgeons are seeking the optimal mesh and location and method of placement. Two methods are currently dominating, one being the open anterior approach, the Lichtenstein repair, and the other being the posterior approach, the laparoscopic repair [ 4 ].

Many berniotomy methods have been tested and even robot-assisted groin hernia repair has now been reported [ 5 ]. The focus now is on debilitating chronic pain that occurs in 0.

Hernia repair

The laparoscopic and the Lichtenstein methods are dominating, probably because of reproducible results and the relative simplicity of the techniques, which allows for surgeons worldwide to learn and teach the techniques.

There are, however, still complications related to the Lichtenstein and the laparoscopic techniques and concern regarding cost and learning issues with the laparoscopic technique. For laparoscopic techniques there is a need for endoscopic equipment which increases the costs [ 7 ] and the Lichtenstein technique has an increased risk of chronic pain, which may be severe herniotlmy disabling [ 8 ].

Chronic pain after inguinal hernia repair is difficult to treat successfully [ 9 ]. There is a need for a simple technique that does not require the same equipment and training as the laparoscopic technique but still results in low risk of chronic pain.

One such method seems to be the Onstep technique [ 10 ]. The Onstep technique is simple, has a prodedure duration of surgery, and consists of a hernoitomy of standardized steps. However, in order to ensure that the procedure is conducted the right way, which will also allow for comparison of results across institutions, there is a need for a thorough presentation of the technique. Furthermore, we have found a few tips and hernuotomy that facilitate the procedure. The patient hetniotomy be positioned in a supine, flat position and under general anesthesia.

For a list of required surgical instruments, see the following. Materials for the Onstep Procedure gerniotomy as follows: Scissors mayo and metzenbaum. Nonabsorbable suture for the mesh. Absorbable suture for fascia closure. Onflex-mesh, most often size medium. The procedure is conducted as follows: Note that proper determination of the incision site will ensure that the right tissue plane will be created for optimal visualization and prosthetic placement and the superficial anterior branches of the iliohypogastric and ilioinguinal nerves are avoided and spared from injury.

Then, continue the dissection using forceps and scissors taking care not to injure the internal oblique aponeurosis.

The incision in the external oblique aponeurosis should be transversal and not follow the fibers. The dissection should be performed gently and only using the index finger.

The finger moves close to the roof of this dissected space, herjiotomy again avoiding the nerves that will be positioned on the floor of this newly developed space.

The cord is elevated up and out of the incision site Figure 5. To facilitate grabbing of the cord, the finger should go along the roof of the newly created space and bend the finger forward in order to get the cord. At this point it is easy to see if there is a berniotomy hernia and if a lateral hernia is present herniotojy is left in the herhiotomy cord until later.

This is to avoid a conflict with the iliac vessels. Be careful not to make the perforation too large procdeure this will increase the risk of mesh displacement and thereby the risk of hernia recurrence. At this point of the procedure it is important to slow down and to move very gently with the finger in the preperitoneal space. It is not a good idea to dissect herniktomy in the preperitoneal space as the space for the mesh will be dissected automatically by the gauze placement see below.


If blood is seen coming up from the preperitoneal space there is probably a lesion in the small blood vessels and it is important proceduge look carefully for this and take care of it by electrocautery under direct visual guidance.

The direction of the gauze insertion into the preperitoneal space should again be medial and not lateral. It will be easier to maneuver the gauze if it is moist with saline before placement.

This means that the spermatic cord should be dissected and a hernia sac isolated and taken care of. The Onstep technique does not decide the method of repair of a lateral hernia component so either dissect and invaginate the sac entirely or open and transect the sac according to local routines. Be careful not to cut the herniogomy or to open the pocket in the mesh with the ring. Also the lateral parts of the Onflex mesh are removed Figure 9.

When cutting the lateral part, make sure to avoid cutting in the stitched line because it will open the pocket holding the stiff ring in the mesh. Place three interrupted sutures with nonabsorbable suture material to join the prosthetic tails together Figure One suture is placed procedyre to the spermatic cord, one at the end of the lateral tails of heniotomy patch ensuring that they do not overlap, and one at the midpoint of the slit.

If the finger is not long enough, then a blunt instrument can be used in the pocket instead of your finger. If wrinkles or buckles are observed or felt this is an indication that the dissected space was insufficient for the size of the patch and further gentle dissection is required. This is typically done by pushing the fatty tissue with the index finger away from the area below the mesh so that the mesh will be placed in close contact with the bone. There are certain technical tips available for the Onstep procedure in order to make it easier to perform.

When performing training sessions with the Onstep procedure herinotomy usually get questions regarding the placement of the skin incision Figure 1. People may wonder why the incision is placed more cranially than they are used to when performing the Lichtenstein ptocedure. The main reason for the more cranial placement of the incision is that the entry into the space between the external and internal oblique aponeurosis is easier because the two aponeuroses at this level are divided into distinct different layers.

This makes it easier to get into the correct space. Furthermore, and perhaps most importantly, the entry into the space between the two aponeuroses is cranial to the natural course of the ilioinguinal as well as the iliohypogastric nerves which are running prcoedure caudal to the incision site.

When the incision in the external aponeurosis is performed, then the dissection after this is done by blunt finger dissection without any instruments. This will hopefully minimize the risk of nerve damage. In the next part of the procedure the cord has to be mobilized Figure 5. This can sometimes be a little difficult and the easiest approach may be to use your index finger as a hook and try to take the cord from the caudal part and then lift it up cranially and out of the pfocedure incision.

This is probably part of the reason why use of local anesthesia infiltration as the sole anesthetic agent may be inadequate to obtain full pain relief during the operation.

During the next step where a perforation has to be made in the floor of the inguinal canal Figure prcoedure it is very important to stretch out the tissue with the index finger.

Hernia repair – Wikipedia

Especially when a medial hernia is present the tissue may be quite floppy and if this is the case then it is more difficult to stretch the back wall of the inguinal canal with the index finger. Here it may be necessary sometimes to use a gauze on the index finger in order to apply more force during the stretching procedure.

The place to make the perforation should be chosen as close as possible to the lateral edge of the rectus muscle and as close as possible to the pubic bone. It is important to make the perforation in the back wall of the inguinal canal not too big.


This means in detail that as soon as your index finger has gone through the tissue here then the speed of the operation has to be lowered significantly. It is important to move the index jerniotomy in the preperitoneal space with extreme caution and very slowly. Push the fatty tissue in the preperitoneal space in the cranial direction as gently as possible thus moving it away from the pubic bone.

Herniotomy, hernia surgery – Hirslanden Private Hospital Group

Be aware procdeure that there are small vessels in this area, which may be destroyed even by gentle movement of the finger. So, in order to avoid bleeding, be really careful and do not procedur the finger around too much. If there is bleeding, put in a proper sized speculum and then under direct visualization take care of the problem with electrocautery. Another important problem with the perforation is not to make it too big.

If the perforation is too big, then the mesh will be able to slide up and down and then it will be possible for the mesh to shift its position resulting in a recurrence. On the other hand the perforation berniotomy not be too small because then the mesh will fold when passing through the perforation.

So, a good advice is to do the perforation with the index finger and be very gentle with the finger movement, and then the end result of the size of the perforation is probably around 1. During the next step where a gauze is placed in the preperitoneal space Figure 7it will make the procedure easier if the gauze is moist with isotonic saline. In rare cases, where, for example, radiation therapy has been used in this area for prostatic cancer, there may be extensive fibrosis, so that dissection in the preperitoneal space will be proceduer.

Often after radical prostatectomy with radiation therapy it is possible to do an Onstep procedure without any problems at all.

However, in rare cases the fibrosis may be extensive so that it may be difficult and therefore dangerous to make the preperitoneal dissection in order for the mesh to be placed properly. In these cases simply back up at this point of the operation and do a Lichtenstein procedure instead. The next part of the operation pdocedure placement of the mesh in the preperitoneal space.

For this there is a pocket in the mesh, which is intended for the index finger to push the mesh down into the preperitoneal space. However, with short fingers like ours, it may not be possible in the average patient to hedniotomy all the way down to the bottom of the mesh placement with the index finger.

In procedrue cases it can be easy to use, for example, the handle of the Langenbeck retractor as an extension of the index finger to push the mesh down to its proper place. As always when moving in the preperitoneal space it has to be slow and careful movement. After mesh placement the position is checked by the index finger hetniotomy the cranial procedur of the mesh, so that the mesh placement is felt hernitoomy on the pubic bone without interpositioned fatty tissue.

If there is any fatty tissue between the mesh and the bone take care of that so the mesh is positioned directly in the bone.

Open inguinal herniotomy: Analysis of variations

When the slit in the mesh is closed by sutures it is important to use nonabsorbable sutures instead of absorbable sutures. We procedyre had recurrences because of breakage of the absorbable sutures.

Closing of the skin is the last part of the procedure, but the only thing the patient will see. The use of clips can cause discomfort for the patient in the first days, since the incision is placed right under the belt. Therefore we advise using sutures or if using clips we then advice to keep the bandage on for 3—5 days. The technique does not leave the preperitoneal or the inguinal canal untouched, so concern has been raised of how to manage recurrences.

In clinical practice this is however not a problem.