c l i n i c a l f o l i o s : n a r r a t i v e





A D V E R T I S E M E N T

 

Hernia Technique Master Class: 4

A D V E R T I S E M E N T

   
 

Orientation for placing a hernia incision is based on the bony landmarks of anterior superior spine and pubic tubercle. The latter is always at the root of the scrotum. The superficial inguinal ring is just lateral to the pubic tubercle, and the deep inguinal ring is midway between the two bony landmarks. Ends of the incision can be located 3cm above the deep and superficial rings to create a line parallel to the inguinal ligament for optimal access to the inguinal canal. The incision should not extend too far medial because of increased subcutaneous vascularity toward the midline. If the incision is made transversely in the lower abdominal skin crease for “cosmesis”, the distance to the superficial ring is greater and entails more dissection and tissue trauma.    

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Hernia Technique Master Class: 5

A D V E R T I S E M E N T

   
 

The superficial epigastric vessels from the first part of the femorals parallel the inferior epigastrics and lie in the subcutaneous tissue just superficial to Scarpa’s fascia. Dissection of the sub-Q should proceed cautiously by layers with good traction to identify the vessels before they are cut. Artery and vein may lie close together or be separated, and there may be more than one branch of each. Control of these vessels is important to prevent post-op hematoma.     

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Hernia Technique Master Class: 6

A D V E R T I S E M E N T

   

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External oblique aponeurosis is next exposed down to the inguinal ligament without stripping the superficial plexus of fine vessels on its surface which constitute its blood supply. A Wheatlaner retractor can be placed to retract the subcutaneous tissue at this point. The medial and lateral crura and bridging intracrural fibers of the superficial ring are identified near the pubic tubercle.    

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This page was last modified on 2/10/2009.