CHAPTER 30 Inguinal Hernias and Hydroceles
Inguinal Hernias
Step 1: Surgical Anatomy
♦ Inguinal hernia repair is the most common procedure performed by pediatric surgeons. In controlled population studies, the incidence of inguinal hernias in children ranges from 1% to 5% (Cox, 1985). Hernias are more common in males, premature infants, those with medical conditions resulting in increased abdominal pressure, and children with connective tissue disorders.
Step 2: Preoperative Considerations
♦ With regard to premature infants with inguinal hernias, the timing of repair remains controversial. If the hernia does not incarcerate or cause an obstruction, most surgeons choose to repair premature infant hernias electively when the children are older and better able to tolerate general anesthesia.
♦ Recently some surgeons have been advocating a laparoscopic approach to pediatric inguinal hernia repair, particularly for synchronous hernias, recurrent hernias, and female hernias. However, there is a higher reported recurrence rate that ranges from 2% to 5% (Schier, 2006; Ozgediz et al., 2007). A brief description of laparoscopic inguinal hernia repair is included herein.
♦ At the time of repair and after the induction of general anesthesia, many pediatric anesthesiologists provide regional pain relief by administering a caudal block in children up to 2 years of age. The combination of a long-acting local anesthetic and narcotic is administered in the caudal epidural space and can augment operative and postoperative pain control.
Step 3: Operative Steps
Inguinal Hernia Repair Technique
Male Patients
♦ Just above the pubic bone, along a transverse skin fold, mark the midline. The incision should be overlying the cord structures, with the medial end just superior and lateral to the pubic tubercle.
♦ Create a transverse incision by scoring the skin, exposing the white dermis. In the center of the scored dermis, use the scalpel to cut into the yellow subcutaneous tissue. Perpendicular to the incision, bluntly insert Metzenbaum scissors into the subcutaneous space and spread the dermis open to the full length of the incision (Fig. 30-1).
♦ Perpendicular to the incision, bluntly spread the subcutaneous tissue with the Metzenbaum scissors to expose the white Scarpa fascia. Using Adson forceps with teeth, grasp and lift the Scarpa fascia. Generously cut the fascia perpendicular to the wound, and then use the Metzenbaum scissors to spread bluntly between the cut edges of the Scarpa fascia to expose the external oblique fascia.
♦ Use Ragnell retractors and Metzenbaum scissors to expose and bluntly dissect the external oblique fascia and clearly identify the inferior border of the inguinal ligament (Fig. 30-2). With the border of the inguinal ligament identified, use a no. 15 blade to create a nick in the external oblique fascia in the direction of its fibers.
♦ Gently spread the nick perpendicular to the fibers with a hemostat clamp. Then place two hemostat clamps on both cut edges of the fascia, and then hold both clamps up with one hand, lifting the fascia upward (Fig. 30-3). With Metzenbaum scissors pointing upward, insert the closed blades into the opening of the fascia and push in the direction of the inguinal ligament through the external ring. Remove the scissors and then insert one blade of the Metzenbaum scissors into the opening and push in the direction of its fibers until the fascia is cut through the external ring. Take care to preserve the ilioinguinal and iliohypogastric nerves.
♦ Bluntly dissect the adhesions to the cord structures and hernia sac off of the inferior cut edge of the fascia and the superior cut edge of the fascia. With Ragnell retractors, retract medially and inferiorly, holding the shelving border of the Poupart ligament out of the way.
♦ On the distal portion of the cord structures, bluntly spread the cremasteric muscle fibers perpendicular to the direction of the cord to expose cord structures and the hernia sac. With the same clamp, gently reach in and grasp the hernia sac and cord structures without clamping down and elevate the cord structures and hernia sac (Fig. 30-4). With the other hand, use smooth forceps to sweep away cremasteric muscle fibers on the inferior and superior aspects of the cord structures. Once the cord structures are isolated from the muscle fibers, pass the forceps underneath the cord structures and hernia sac and lift and elevate (Fig. 30-5).
♦ Place the left index finger underneath the cord structures and identify the hernia sac. Secure the hernia sac by pinching it between the left index finger and thumb. With the right hand, use smooth forceps to sweep gently and bluntly the cord vascular structures and the vas deferens inferiorly away from the hernia sac (Figs. 30-6 and 30-7). As more hernia sac is exposed, continue to grasp more of the sac superiorly between the left index finger and thumb, and sweep away the cord structures until they are completely free from attachments to the hernia sac (Fig. 30-8)
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