Page 18 - herina surgery and possible lawsuits

in 5% cases the genital branch pierced the border between the inguinal
ligament and the external oblique aponeurosis to be distribute the inguinal

region. Therefore, the courses of the genital branches vary considerably.
[41]
These nerves are considered to be one of the culprit for post hemioplasty

chronic pain, in particular ilioinguinal and/ or genitofemoral nerve. [42]
Identification and preservation of these nerves during open inguinal hernia
surgery reduce chronic pain [43], and it is easily feasible and not time

consuming if there is knowledge of anatomy. [3 8]
Smeds et al suggested that the nerve injury is mainly due to inadequate
dissection, failure to visualise and protect the nerves, and failure to
recognise the aberrant location and anatomic variations of the nerves. Any

partial or complete transaction of the nerve leads to neuroma formation and
consequent pain along the distribution of that nerve. The nerves can also be

damaged by nerve entrapment from post-operative fibrosis, mesh-related
fibrosis or sutures used to fix the mesh. They further suggested that
resection of nerve ‘at risk’ gives better outeome.[44]
In cases of post hemioplasty pain, cryoanalgesic ablation [45] and triple

neurectomy can be considered for pain relief. [46]
3) Mesh can be put either over the fascia (ONLAY) or deep to it (INLAY).
4) In laparoscopic method the mesh is always put pre peritoneal either total

extra pentoneal or transabdominal after incismg the peritoneum. Intra
peritoneal onlay mesh has been abandoned for inguinal hemioplasty.
5) When mesh put preperitoneal, one can obliterate the potential site of
femoral henna also.

6) Large mesh in preperitoneal space does not need fixation as it maintains its
place by Ultra abdominal pressure and by tissue hydrostatic pressure as per

Pascals’ Law. This is the basis of Stoppas’ prosthetic reinforcement of the
visceral sac.

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