Open repair of the pediatric inguinal hernia
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The patient should be placed on the operating table in a supine position with his or her legs slightly abducted. The lower abdomen and inguinoscrotal or inguinolabial area and upper thighs must be included in the operative field. The hernia contents must be completely reduced into the peritoneal cavity before the procedure.
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Incision is made in the skin of the inguinal crease just lateral to the pubic tubercle. The skin incision is typically small (1-2 cm). Electrocautery is used to control any bleeding that may occur.
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Next, identify and incise the Scarpa fascia. In young children, the Scarpa fascia may be confused with the aponeurosis of the external oblique. However, the Scarpa fascia is smooth, does not have any fibrous bands, and does not glisten like the aponeurosis. In addition, a layer of fat is found beneath the Scarpa fascia but not under the external oblique.
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One should not raise any skin flaps. Dissection is started through the external oblique at the lateral aspect of the incision and extended to the inguinal ligament.
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The external ring is identified by dissecting medially along the inguinal ligament. The ring is incised, taking care to avoid injury to the usually visible ilioinguinal nerve. This incision reveals the cremaster fibers of the cord.
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The hernia sac can be identified in the anteromedial aspect of the cord, and medial retraction of the sac reveals the underlying testicular vessels and vas deferens. Fine tissue forceps are used to tease these structures away from the hernia sac. An Allis clamp may be placed around the vas and the testicular vessels to keep them away from further dissection.
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The sac can then be clamped and divided. The proximal sac is mobilized to the internal ring, which is often signified by the presence of retroperitoneal fat.
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Once the sac is confirmed to be empty, it is twisted on itself and doubly suture-ligated with sutures (eg, 4-0 or silk or Vicryl sutures can be used).
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If the ring is not enlarged, the distal sac is opened to drain any residual fluid and the sac is partially excised. Then, closure is accomplished in layers with absorbable sutures.
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If the internal ring is enlarged, the cord must be elevated from its bed with a soft rubber drain. A silk suture between the transversalis fascia and the inguinal ligament can be used to tighten the ring. Alternatively, a modified Bassini type of repair can be used to reinforce the inguinal floor.
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If destruction of the canal floor is present, a reconstructive procedure, such as that of Bassini or McVay, is necessary.
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The McVay type of repair incorporates a relaxing incision in the rectus sheath that allows the conjoined tendon to be pulled down to the Cooper ligament and the femoral sheath.
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The incised aponeurosis of the external abdominal oblique muscle is closed with interrupted 4-0 or 5-0 silk sutures or a continuous 4-0 polyglycolic acid suture.
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Typically one or two interrupted absorbable sutures are used to close the Scarpa fascia. The skin can be closed with absorbable sutures
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Typical appearance of an infant with a large right indirect inguinal hernia. The right scrotal sac is enlarged and contains palpable loops of bowel and fluid.
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A premature baby boy with bilateral giant inguinoscrotal hernias. Because of the large size of the hernias, operative repair typically requires repair of the inguinal floor in addition to the high ligation of the indirect hernia sac.
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Illustration of the technique for intraoperative diagnostic laparoscopy to evaluate for the presence of an asymptomatic contralateral inguinal hernia at the time of elective repair of an indirect inguinal hernia.
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Laparoscopic view of a left indirect inguinal hernia at the time of surgery for laparoscopic needle-assisted repair.
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Laparoscopic needle-assisted repair of a left indirect inguinal hernia. Note the passage of a Prolene suture through a small 22G spinal needle; this is used for creation of the purse-string suture that closes the open inguinal ring.
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Laparoscopic view of the repaired left indirect inguinal hernia with the closed Prolene purse-string suture around the internal inguinal ring.
