PROCEDURE: Open repair of incarcerated right inguinal hernia with mesh (3 x 6 inch polypropylene onlay) incidental appendectomy.
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SPECIMENS: 1. Incidental appendectomy 2. Hernia sac
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A right inguinal incision was performed in a standard fashion and carried down to the superior aspect of the scrotum. Subcutaneous tissue was incised through Scarpa’s layer to the external oblique fascia. A large sac was identified communicating with the cantaloupe sized scrotal hernia. The external oblique fascia was incised from the external to the internal ring. Attenuated internal oblique musculature overlying the sac was divided with the electrocautery. The sac was then incised. This allowed for manipulation of the sac contents away from the edges of the sac so that it could be dissected free from the spermatic cord. The spermatic cord structures were identified and protected throughout the case as were the sensory nerves of the inguinal canal. 1/4 inch Penrose drain was placed about the spermatic cord. The enlarged sac was dissected back to the dilated internal ring. At this point the patient was placed in Trendelenburg position and sac contents were reduced. Prior to reduction of the cecum, an elongated normal-appearing appendix was removed by first ligating the mesoappendix and tying off the vessels with interrupted 2-0 silk. The base of this appendix was clamped and the appendix was excised. The base of the appendix was tied off with 0 silk suture and the tip of the base was electrocauterized. Following reduction of the sac contents, it was identified that there was a large internal ring that required support.
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A 3 x 6 inch polypropylene mesh was then placed within the inguinal canal. It was sutured in place with interrupted 2-0 Vicryl, to the Cooper’s ligament medially and along the reflected edge of the inguinal ligament inferiorly. The mesh was split laterally allowing the cord to lie anterior to the mesh. The mesh was sutured superior medially to the conjoined tendon. The tails were brought together laterally, recreating an internal ring. The tails were tucked under the external oblique fascia.
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The dead space within the scrotum was inspected. The edges of the peritoneal sac were cauterized. 1/2 inch Penrose drain was placed in the dead space and brought out through the inferior aspect of the scrotum via a stab incision and sutured in place with 3-0 nylon. The drain was left within the scrotum and the soft tissue surrounding the drain, superiorly was closed off from the inguinal canal using a pursestring suture of 2-0 chromic, to prevent communication of the drain with the mesh. Prior to this, the wound and the scrotum were irrigated thoroughly with warm saline and hemostasis was obtained. The closure was with a running 2-0 Polysorb and the external oblique fascia. Scarpa’s layer was closed with interrupted 2-0 chromic. The skin was closed with staples. A sterile gauze dressing was applied and secured with Medipore tape. The wound was infiltrated with 0.25% Marcaine with epinephrine, 30 mL. A scrotal support was placed with gauze. The patient tolerated the procedure well and was taken to the recovery room stable.
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