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). Protect the cord structures within an Allis clamp, ensuring the presence of the vas deferens within the clamp (Fig. 30-9). Then divide the hernia sac between hemostat clamps.
♦ Take the proximal clamp, hold the hernia sac upright to the ceiling, and retract the Allis clamp with the cord structures toward the pubis. Gently and bluntly dissect the cord structures away from the hernia sac to the level of the internal ring (Fig. 30-10). With the cord structures retracted away from the hernia sac, twist the proximal hernia sac. If there is a question of intraperitoneal contents within the hernia sac, open the sac and inspect it before ligating the hernia sac. Then suture ligate the base of the hernia sac at the level of the internal ring with a 4-0 Vicryl suture twice (Fig. 30-11). Excise the excess proximal hernia sac.
♦ Open the distal hemostat and drain any residual fluid. It is unnecessary and potentially harmful to excise and remove the distal hernia sac. Release the cord structures from the Allis clamp. With the exposed scrotum, pull on the ipsilateral testicle to pull the cord structures back into the inguinal canal. Lift the two straight hemostat clamps that were placed on the edges of the external oblique fascia, and place two simple interrupted 4-0 Vicryl sutures for closure (Fig. 30-12).
Female Patients
♦ The equivalent of the processus vaginalis in females is the canal of Nuck. The distal round ligament is identified, isolated, and then divided. The hernia sac is then identified. Inspect the proximal hernia sac for contents such as ovary or fallopian tube.
♦ If the hernia sac is empty, it may be twisted and ligated in a similar fashion to males. If there is a fallopian tube identified within the wall of the sac, it should not be dissected off of the sac because this may lead to bleeding and injury to the tube. A purse-string suture may be placed distal to the fallopian tube to close the peritoneum.
Laparoscopic Inguinal Hernia Repair (Fig. 30-13)
♦ Along the superior border of the umbilicus, a small incision is created, and Veress needle insufflation is performed to a pressure of 12 mm Hg.
♦ On each side of the umbilicus, a 2-mm or 3-mm working port versus stab incision working ports are placed for infants and toddlers. Larger children should have 5-mm ports placed to either side of the umbilicus.
♦ With the laparoscope, both internal rings are inspected for the presence of a hernia. If abdominal contents are within the hernias, they are reduced with a combination of internal traction and external manual reduction. All hernias larger than 2 mm are closed.
♦ A 4-0 nonabsorbable, monofilament suture, cut to 7 cm, is inserted into the peritoneum, through the abdominal wall, near the inguinal ring. The needle is then grasped intracorporeally with a needle driver.
♦ The internal ring is closed by grasping the peritoneum and placing sutures in either a circumferential nature or an N-shaped fashion to close the internal ring. Great care is taken not to injure the vas deferens or cord vessels when placing the sutures. The suture should create a loose fold of peritoneum around the cord structures so that there is no pressure on the structures.
Step 4: Postoperative Care
♦ Most patients may be discharged home the same day. Infants who were born prematurely and are less than 52 weeks’ conceptual age are admitted for overnight apnea and bradycardia monitoring.
♦ Patients are given age-appropriate pain medication. Patients may bathe in 2 days, and Steri-strips are allowed to fall off on their own in 7 to 10 days. In infants and toddlers, there are no special precautions, and patients may resume activities as tolerated. In older children, we recommend no physical education or heavy exertion for 2 weeks.
Step 5: Pearls and Pitfalls
♦ During the hernia repair, it is important to be cognizant and aware of intraperitoneal sliding components within the hernia sac. To that end, if the proximal sac is unusually thickened, we do not hesitate to open the sac and inspect. In females, the fallopian tube may be attached to the peritoneum, and great care should be exercised to ligate the hernia sac distal to these structures. After ligating the hernia sac, if the internal ring is patulous and attenuated, one can perform a Bassini-like closure of the internal ring, approximating the conjoined tendon to the shelving border of the Poupart ligament with one or two absorbable stitches.
♦ When repairing hernias of premature infants, it is important to exercise the utmost care in dissecting the cord structures off of the hernia sac. Because of its fragile nature, it is not uncommon for these hernia sacs to tear proximally like “wet tissue paper,” creating a challenging and often aggravating repair.
Hydrocele of the Tunica Vaginalis
Step 1: Surgical Anatomy
♦ A communicating hydrocele has a free flow of fluid, but no abdominal viscera via a patent processus vaginalis into the scrotum. The amount of fluid will change with a change in intra-abdominal pressure in the patient.
♦ A noncommunicating hydrocele has a stable collection of fluid that does not communicate with the peritoneal cavity. On examination, the hydrocele is typically a nontender swelling of the scrotum that transilluminates with light. In a newborn infant, a noncommunicating hydrocele will often resolve by 1 year of age. If there is no resolution of the congenital hydrocele by 1 year of age, then the suspicion of a communicating hydrocele via a patent processus should be entertained and treated as a hernia.
Step 3: Operative Steps
♦ The approach to a hydrocele repair is similar to that of an inguinal hernia. A transverse incision in a skin fold in the groin is carried out as described.
♦ Many patients with hydroceles have an inguinal hernia or small patent processus vaginalis. With gentle tension on the cord structures proximally, begin to isolate the cord structures by bluntly dissecting adherent tissue off of the cord structures distally with smooth forceps. This should allow visualization of the superior aspect of the hydrocele sac. If not, then the dissection may be aided by transscrotally pushing the hydrocele up into the inguinal wound.
♦ Continue to dissect bluntly the upper part of the hydrocele sac from the overlying tissue. It is not necessary to expose more than a quarter to a third of the entire sac (Figs. 30-15 and 30-16).
♦ Open the exposed hydrocele sac sharply, releasing the hydrocele fluid. This will expose the upper portion of the testicle. Being careful to avoid injuring adherent tissue and spermatic cord structures, remove a generous portion of the upper hydrocele sac sharply. Avoid the temptation to dissect out and remove the entire hydrocele sac, which could lead to collateral injury to cord structures. It is also unnecessary to tack down the edges of the cut hydrocele sac. Leaving a generous opening in the upper hydrocele sac should prevent the recurrence of a hydrocele, and the body will reabsorb any residual fluid.
♦ Often an indirect hernia exists in continuity with the hydrocele proximally along the cord. Inspect the proximal cord structures and repair the hernia as described previously.
Step 5: Pearls and Pitfalls
♦ The primary goal of hydrocele surgery is to open and drain the hydrocele and create a generous window to prevent recurrence. One must avoid aggressive dissection and complete excision of the hydrocele sac because this would add little benefit and increase the risk of injury to collateral structures. During the procedure, if the distal scrotal hydrocele is tense and difficult to expose through the groin incision, trans-scrotal needle decompression of the hydrocele may facilitate the dissection above. It is important also to be aware of a proximal indirect hernia, which may not communicate with the distal hydrocele.
Cox JA. Inguinal hernia of childhood. Surg Clin North Am. 1985;65:1331-1342.
Harper RG, Garcia A, Sia C. Inguinal hernia: a common problem of premature infants weighing 1000 grams or less at birth. Pediatrics. 1975;56:112-115.
Ozgediz D, Roayaie K, Lee H, et al. Subcutaneous endoscopically assisted ligation (SEAL) of the internal ring for repair of inguinal hernias in children: report of a new technique and early results. Surg Endosc. 2007;21:1327-1331.
Schier F. Laparoscopic inguinal hernia repair—a prospective personal series of 542 children. J Pediatr Surg. 2006;41(6):1081-1084.
Tackett LD, Breuer CK, Luks FI, et al. Incidence of contralateral inguinal hernia: a prospective analysis. J Pediatr Surg. 1999;34:684-687.
