Muscle and Nerves
The cremasteric muscle starts at the internal inguinal ring and runs down to the testicle. When the testicle is exposed to cold and during intercourse the muscle pulls the testicle up. But the cremasteric muscle can add a significant amount of bulk to the spermatic cord.
Some surgeons routinely advise removing the cremasteric muscle to make the spermatic cord smaller in diameter. This allows for a tighter hernia repair. On the other hand, if the cremasteric muscle is removed, then the testicle may no longer rise when exposed to cold. Also, some of the blood supply and innervation to the testicle travel within the cremasteric muscle and thus could be damaged when the cremasteric muscle is cut.
If there is a significant bulk to the cremasteric muscle, then Dr. Brown excises some of the cremasteric muscle to allow the internal right to be made tighter, but if the muscle is thin and does not compromise repair and he leaves it undisturbed. If there is concern about the blood supply to the testicle, then the cremasteric muscle should be left intact.
There are three major nerves in the inguinal area. The iliohypogastric nerve, the ilioinguinal nerve, and the genital nerve. The iliohypogastric nerve provides sensation to the pubic hair area and the upper part of the scrotum or Mons. The ilioinguinal nerve provides sensation along the inguinal ligament, on the inside of the upper thigh, and on the outside of the scrotum or Mons. The genital nerve provides innervation to the cremasteric muscles and sensation to the testicle or labia majora.
Damage to any of these nerves can cause chronic pain after the surgery. Some surgeons advise routine transection of these nerves to avoid postoperative pain. But cutting the nerves causes the skin to be numb. And if the nerve tries to grow back and a neroma forms, then that can be a source of cause chronic pain. Dr. Brown feels it is best to carefully identify the nerves during the operation. And then take care not to damage the nerves while the hernia is being repaired.
The iliohypogastric nerve can usually be identified running parallel to the inguinal ligament about a centimeter above the level of internal ring and deep to the external oblique aponeurosis. It will emerge through a hole in the external oblique aponeurosis just above the external inguinal ring and continue its journey to the skin.
The ilioinguinal nerve joins the spermatic cord (or round ligament in women) at the internal inguinal ring and then runs along the anterior superior aspect the spermatic cord (or round ligament).
The genital nerve usually joins the spermatic cord (or round ligament) at the internal inguinal ring and then runs along the posterior aspect of the spermatic cord (or the round ligament). Of the three nerves, the course of genital nerve is the most variable. Instead of traveling with the spermatic cord (or round ligament), it can be found near the inguinal ligament or running along the floor of the inguinal canal.
Learn more about Dr. Brown’s approach to hernia repair without mesh. Contact Dr. Brown today.