Defining the position of deep inguinal ring in patients with indirect inguinal hernias

Individual mesh size for open anterior inguinal hernia repair: an anthropometric study in Turkish male patients

PURPOSE

To conduct a study to determine the measurements of the inguinal region in male patients with inguinal hernias to reveal the proper mesh size for each patient.

METHODS

In this prospective study, the anthropometric measurements were obtained from 100 consecutive adult male patients with unilateral primary inguinal hernias. First, the distance between the pubic tubercle and the medial border of the deep inguinal ring was measured (x). Second, the distance between the inner edge of the inguinal ligament and the uppermost level of the internal oblique aponeurosis at the midpoint of the inguinal ligament corresponding to the Hesselbach triangle was measured (y). Individual mesh sizes were calculated according to the original recommendations for mesh overlap.

RESULTS

The mean x value was 41.6 mm (22-55 mm), the mean y value was 45.2 mm (30-68 mm). The mean dimensions of the mesh were 126.6 mm × 65.2 mm. The largest mesh was 140 mm × 88 mm, and the smallest one was 107 mm × 62 mm. The mean mesh area was 8320 mm². It was larger than the index mesh area recommended by the Lichtenstein Hernia Institute in 45 patients and smaller in 55 patients.

CONCLUSIONS

The intraoperative measurements for ideal mesh size in Lichtenstein repair of inguinal hernias may present somewhat different mesh dimensions in many patients. Individualization of mesh size may be of importance in surgical outcomes.

Anatomical differentiation of direct and indirect inguinal hernias: Is it worthwhile in the modern era?

The study aimed to assess the clinical accuracy of differentiating direct and indirect inguinal hernias preoperatively by different grades of surgeons. A retrospective audit was conducted over a 9-year period and comprised all adult inguinal hernia patients operated by one consultant surgeon. The hernias were differentiated into direct and indirect hernias based on the direction of cough impulse and the deep ring occlusion test. The preoperative diagnosis was compared with intraoperative findings. During the study period, 503 patients were examined. Of these, 272 patients were diagnosed as having indirect hernias and 56 patients as having direct hernias. In 175 patients, no attempt was made to differentiate indirect and direct hernias. When compared with intraoperative findings, the diagnosis was correct in 77% of the indirect hernias and 55% of direct hernias. Of the patients in whom no differentiation was attempted, 115 patients had indirect hernias, 56 had direct hernias, and four had both. For indirect hernias, the diagnostic accuracy was 82, 63, and 30% for consultant, registrars, and senior house officers. For direct hernias, the diagnostic accuracy was 66, 50, and 44%, respectively. This study demonstrates relatively poor accuracy in diagnosing direct inguinal hernias regardless of seniority.

A new accurate method of physical examination for differentiation of inguinal hernia types

BACKGROUND

It is generally stated that preoperative differentiation between indirect and direct inguinal hernias by physical examination is inaccurate and irrelevant. With the expansion of the laparoscopic technique, new relevance has emerged. Laparoscopic correction of an indirect hernia is more challenging and time consuming than laparoscopic correction of a direct hernia. Preoperative knowledge concerning the type of hernia informs the laparoscopic surgeon about the required expertise and the expected operative time, and this knowledge is useful for training programs and management. The authors therefore developed a new accurate and easy method of physical examination to differentiate types of inguinal hernia. A prospective study was conducted to determine the accuracy of this new method that combines physical examination with a hand-held Doppler device (not ultrasound) to differentiate types of inguinal hernia.

METHODS

This prospective diagnostics study consisted of two consecutive parts. Each part included 100 consecutive patients presenting with an inguinal hernia. The inguinal occlusion test was used to differentiate the types of inguinal hernia during physical examination in the first part of the study. A hand-held Doppler device was used for adequate localization of the epigastric vessels in addition to the occlusion test in the second part of the study. Preoperative remarks were compared with findings during laparoscopic inguinal hernia repair. The McNemar symmetry χ (2) test was used for statistical evaluation

RESULTS

The first part of the study showed a preoperative accuracy of 35 % for direct inguinal hernias and 86 % for indirect inguinal hernias (p < 0.001). The second part of the study showed a preoperative accuracy of 79 % for direct inguinal hernias and 93 % for indirect inguinal hernias (p < 0.001) CONCLUSION: The inguinal occlusion test combined with the use of a handheld Doppler device is accurate in distinguishing direct and indirect inguinal hernias and provides useful management information in laparoscopic inguinal hernia repair.

Defining the position of the deep inguinal ring using findings at laparoscopic inguinal hernia repair

PURPOSE

We aim to establish the surface marking of the deep inguinal ring by laparoscopy and investigate if the patient's build influences it.

METHODS

Sixty consecutive patients undergoing laparoscopic hernia repairs were studied. The bony landmarks, anterior-superior iliac spine (ASIS) and pubic tubercle (PT), and the two traditional landmarks, the mid-inguinal point (MIP) and midpoint of inguinal ligament (MPIL), were marked on the anaesthetized patient before the surgery. The deep ring was located by indenting the surface until laparoscopy shows the deep ring being occluded.

RESULTS

The true surface marking of the deep ring was found to lie at a mean distance of 9.6 mm medial to the MPIL landmark and 4.5 mm lateral to the MIP, approximately one-third of the distance from the MIP to the MPIL. Multivariate analysis confirmed that age, gender, race, BMI or pelvic habitus did not vary it.

CONCLUSIONS

The deep ring is located under a point just lateral to the MIP, which is the midpoint of a line drawn joining the ASIS and pubic symphysis. This should be taught to future generations of medical students as the point to apply occluding pressure to differentiate clinically between direct and indirect inguinal hernias.

An old technique for surgery of 'high' undescended testis revisited

INTRODUCTION

Most undescended testes resolve spontaneously in the first year of life. If the testis remains undescended by the second year, the most probable means of scrotal placement is orchiopexy. After the first successful operation for orchiopexy, many surgical modifications were described. This study presents our limited experience with Prentiss' maneuver in six boys with high undescended testes.

PATIENTS AND METHODS

Two left, two right and two bilateral testes, in six patients, were operated. Five patients were admitted with the complaint of unilaterally or bilaterally 'empty scrotum'. The sixth patient previously had a right high undescended testis which had been placed in a high scrotal position. Following the standard steps of inguinal orchiopexy Prentiss' maneuver were performed and yielded adequate distance to place the testes mid scrotum.

RESULTS

On follow-up, Doppler ultrasound examination revealed normal sized testes with normal blood flow in all patients with dimensions correlated with age.

CONCLUSION

Although perhaps only useful in orchiopexy for high undescended testis, incision of the transversalis fascia preserves testicular blood flow by relieving tension on the testicular vessels.