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360 Inguinal and Femoral Hernias and Hydroceles Inguinal and Femoral Hernias and Hydroceles
361 Inguinal and Femoral Hernias and Hydroceles 361
the inguinal canal before looking for the hernia sac. Here, too, one may
decide to open the external oblique aponeurosis to include the external
inguinal ring or not to include it in the incision.
2. The sac is normally found on the anteromedial aspect of the
elements of the spermatic cord after bluntly spreading the fibres of the
cremasteric muscle; it is picked up with haemostats (Figure 58.5C) and
dissected free of the cord, using both blunt and sharp dissection.
3. Once the sac is dissected up to the internal inguinal ring, it is opened
(Figure 58.5D), and its content(s) replaced into the peritoneal cavity to (A) (B)
make sure it is empty. Figure 58.5E shows the vas deferens.
Where the sac is big and extends into the scrotum, no attempt should
be made to dissect it completely into the scrotum. This will lead to
unnecessary bleeding and haematoma formation postoperatively. Using
sharp dissection and several haemostats (a minimum of 6), a large
hernia sac can be circumferentially dissected, clamped, and amputated
distally without having to follow it into the scrotum.
4. The dissection is then continued proximally towards the internal
inguinal ring until the peritoneum (a white structure; see Figure 58.5F)
or preperitoneal fat is visualised.
(C) (D)
5. The sac is then twisted several times (Figure 58.5F) on itself to
make sure the reduced content(s) stay in the peritoneal cavity out of
harm’s way, and the neck is then transfixed and ligated high up in the
internal inguinal ring with Vicryl 3/0 or 2/0, and excess sac excised.
High ligation of the hernia sac is all that is required. Sometimes,
an enlarged internal inguinal ring is narrowed at the medial margin by
placing one or two sutures through the transversalis fascia.
6.Haemostasis is secured and, where the aponeurosis was opened, it is
re-approximated with Vicryl and the skin closed with a suitable suture
material. Usually, one Vicryl 2/0 or 3/0 suture of 90 cm in length is
adequate enough to suture-ligate the sac, and close the aponeurosis (E) (F)
and the skin, especially if one uses the subcuticular method of closure
(Figure 58.5G).
For postoperative pain control, a local anaesthetic such as
bupivacaine is injected into the wound during closure. The child can
®
then be given either paracetamol, Tylenol syrup, or a suppository for
use in the house, as herniotomy is considered an outpatient procedure.
A controversial topic concerns the routine exploration of the
contralateral side for an inguinal hernia. It is known that more than 50%
of children younger than 2 years of age have a PPV, but only about 10%
will eventually develop a clinical hernia; most PPV will spontaneously
close and not develop into hernias. Many reports in the literature (G)
(including those from Africa) show that fewer than 7% of children Figure 58.5A–G: The various steps of herniotomy of an inguinal hernia in a child.
who had a herniotomy done on one side will eventually develop a
hernia on the contralateral side. This is a low incidence rate and does The child with an irreducible (incarcerated) IH that is tender, making
not, therefore, suggest or justify the need for routinely exploring the the child irritable, should be admitted to hospital and an attempt made to
contralateral groin for a metachronous hernia. reduce the mass manually. Even in our subregion, where late presentation
Despite the above-stated argument, some paediatric surgeons will is the order of the day, an attempt should first be made to reduce all
still routinely explore the opposite groin in children younger than 2 incarcerated hernias provided there are no signs and symptoms of
years of age, in older boys with a clinical hernia on the left, and in girls peritonitis and toxicity. When this fails, surgery can then be performed.
younger than 10 years of age because hernias on both sides for these Most incarcerated hernias in children have not yet strangulated and
groups are more common. Our experience, though, does not support can be manually reduced; this will prevent the need for an emergency
this fact. Due to the high negative rate in exploration of the contralateral surgery, with its attendant significantly increased risk to the constituents
side and possible injury to the vas deferens and testicular vessels, it is of the spermatic cord as a result of oedema of the tissues.
strongly recommended to perform a unilateral repair of inguinal hernia When manual reduction of a hernia is attempted on a child with an
if it is on only one side. incarcerated hernia, the child should be given an analgesic (pethidine
Herniotomy should be performed on premature babies before they or tramadol at a dose of 2 mg/kg intramuscularly) and sedated with
are discharged home from hospital due to the frequent incarceration of diazepam (2 mg intramuscularly or intravenously or even rectally),
IH in such children. and the foot of the bed should be elevated slightly to allow the
Findings in a hernia sac may include intestines, ovary with the intraabdominal organs to fall back and to keep the intraabdominal
fallopian tube, uterus (rare), ovotestis, omentum (in older children), pressure from being exerted on the inguinal area.
appendix (Amyand’s hernia; see Figure 58.6), Meckel’s diverticulum Manual reduction is then attempted as follows:
(Littre’s hernia), or Richter’s hernia (entrapment of a portion of the
antimesenteric wall of the bowel in the hernia sac). 1. If the incarcerated hernia is on the right side, the thumb and index