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Minter RM, Doherty GM. Minter R.M., Doherty G.M. Eds. Rebecca M. Minter, and Gerard M. Doherty. New York, NY: McGraw-Hill, 2010, http://accesssurgery.mhmedical.com/content.aspx?bookid=429&Sectionid=40112062. Download citation file: RIS (Zotero) EndNote BibTex Medlars ProCite RefWorks Reference Manager © Copyright Tools Search Book Top Return Clip Search Book Chapter 48. Pediatric Inguinal Hernia Kimberly McCrudden Erickson, MD + Indications ++ Presence of a hernia (elective).Incarceration or strangulation (emergent). + Contraindications ++ Absolute ++ Coagulopathy.Thrombocytopenia. ++ Relative ++ Extreme prematurity.Cardiopulmonary comorbidities.Immunosuppression. + Informed Consent ++ Expected Benefits ++ The most important goal is to eliminate the risk of incarceration and strangulation.Repair can also provide relief from discomfort associated with the hernia. ++ Potential Risks ++ Risks include: Bleeding.Wound infection.Injury to the vas deferens.Injury to the testicular vessels.Injury to the ilioinguinal nerve.Parents should also be informed that the procedure is performed under general anesthesia. ++ Equipment ++ A basic pediatric soft tissue tray should provide the various small retractors (Davis, U.S. Army retractors) needed for the surgery.Peritoneoscopy equipment. 2.7-mm, 70-degree angled laparoscope.Small, blunt-tipped metal 3-mm trocar.Laparoscopy equipment (light cord, camera cord, and a single video monitor). + Patient Preparation ++ No special preparation is required other than a thorough preoperative examination with attention to both inguinal regions.The side of the symptomatic hernia should be marked by the surgeon on the patient on the day of surgery with the parent or guardian present. + Patient Positioning ++ The patient should be supine on the operating table.Following induction of general anesthesia, the patient may be turned on his or her side for placement of a caudal block if appropriate. + Procedure ++ The following steps describe the procedure for a male patient. The procedure is performed under general anesthesia with or without the addition of a caudal block.The entire lower abdomen, perineum, and upper thighs are scrubbed, prepared with povidone-iodine, and draped in the standard sterile fashion.Figure 48–1: A 1–2-cm transverse skin incision is made along the lowest inguinal skin crease approximately 1 cm superior and lateral to the pubic tubercle. The subcutaneous fat is separated to expose Scarpa's fascia, which is incised with either Metzenbaum scissors or electrocautery.Figure 48–2: The opening in Scarpa's fascia is then explored using a hemostat to expose the external oblique aponeurosis below. This allows for placement of small Davis retractors into the wound. A key maneuver at this point is to dissect laterally to fully expose the groove between the abdominal wall and the lateral border of the external oblique fascia.This groove is then followed inferiorly to the external ring, where the spermatic cord and associated hernia sac exit the inguinal canal.A hemostat is placed in the external ring and a small nick is made in the ring using a knife.The hemostat is briefly removed to allow the ilioinguinal nerve to fall away and is then replaced in the external ring.The external oblique fascia is incised from along its fibers for a distance of 1–2 cm.The edges of the opened external oblique fascia are grasped with atraumatic forceps and the undersurface of each leaf is gently brushed clear of the underlying cord structures to protect the nerve and facilitate later closure.The ilioinguinal nerve should then be visualized and gently dissected free.Figure 48–3: Using atraumatic tissue forceps, the cremasteric fibers are grasped and separated to identify the underlying hernia sac. The sac lies anteromedial to the cord structures and has a glistening, whitish appearance.The sac is grasped with one forceps while the other is used to sweep the muscular fibers down toward the floor of the inguinal canal.The sac is then retracted medially with two atraumatic forceps by the assistant, while the surgeon dissects the spermatic vessels and vas deferens off the sac.Of note, the spermatic vessels are the first structures encountered on the lateral edge of the sac. If the vas is seen first, the orientation of the sac must be evaluated.The vas and vessels must never be directly grasped or held with forceps as this can cause significant damage.Figure 48–4: After the cord structures have been separated from the sac, the sac is inspected to ensure that no abdominal viscera are trapped within. Unless the sac is blind-ending, it is divided between hemostats.The proximal end of the sac is lifted vertically and the cord structures are dissected free down to the level of the internal ring, where properitoneal fat is identified.To facilitate this dissection, the assistant should place gentle downward traction on the spermatic cord structures.At this point, peritoneoscopy may be performed if the clinical situation warrants and the sac appears sturdy. To perform peritoneoscopy, the sac is opened and secured with hemostats.A 3-mm blunt metal trocar is inserted directly into the sac and secured with a heavy silk tie.The abdomen is insufflated with CO2 (8–12 mm Hg), and a 2.7-mm, 70-degree scope is inserted with the lens facing the opposite inguinal region.The vas deferens and spermatic vessels on the opposite side are identified and the region is inspected for a patent processus vaginalis on the contralateral side.The scope and trocar are removed, and desufflation is ensured by placing a tissue forceps into the sac and observing for release of air and abdominal decompression.Figure 48–5: High ligation of the proximal sac is then performed by twisting the sac and placing two 3-0 or 4-0 Vicryl suture ligatures at the base. Care must be taken to avoid incorporating the cord structures in these sutures as twisting the sac may alter the anatomy at the internal ring.Following ligation, the excess sac is removed with scissors.The distal end of the sac heading toward the scrotum may be opened widely along its anterior surface.If a noncommunicating hydrocele also exists, it should be opened widely and a portion of this sac excised.If the testicle is visualized, any associated appendix testes should be excised or cauterized. The testicle must be placed back in the scrotum prior to closure.Figure 48–6: Once hemostasis is ensured, the external oblique fascia is closed using interrupted Vicryl sutures, taking care to identify and protect the ilioinguinal nerve. If a preoperative caudal block was not used, an ilioinguinal nerve block can be placed under direct visualization at this juncture.Scarpa's fascia is then reapproximated using buried, interrupted Vicryl sutures.The skin is closed with a running 5-0 Monocryl suture. The wound may be dressed using an adhesive (Collodion, Dermabond, Indermil) in children who are still in diapers, or Steri-Strips with Benzoin in older children. ++Figure 48–1Graphic Jump Location+View Full Size | Favorite Figure | Download Slide (.ppt) ++Figure 48–2Graphic Jump Location+View Full Size | Favorite Figure | Download Slide (.ppt) ++Figure 48–3Graphic Jump Location+View Full Size | Favorite Figure | Download Slide (.ppt) ++Figure 48–4Graphic Jump Location+View Full Size | Favorite Figure | Download Slide (.ppt) ++Figure 48–5Graphic Jump Location+View Full Size | Favorite Figure | Download Slide (.ppt) ++Figure 48–6Graphic Jump Location+View Full Size | Favorite Figure | Download Slide (.ppt) + Postoperative Care ++ Analgesia using acetaminophen, ibuprofen, and narcotics as needed.Heavy lifting and high-contact sports in older children and adolescents should be limited for 4–6 weeks postoperatively. + Potential Complications ++ Acute ++ Bleeding.Wound infection.Injury to spermatic vessels.Injury to vas deferens.Postoperative hydrocele.Damage or entrapment of ilioinguinal nerve. ++ Chronic ++ Testicular atrophy.Recurrence.Iatrogenic undescended testicle. + Pearls and Tips ++ To avoid getting lost in a pediatric hernia and thereby risking injury to the bladder or the floor of the inguinal canal, always clearly identify and dissect out the groove along the lateral edge of the external oblique fascia early in the operation.In the newborn, the internal ring lies almost directly below the external ring so it may not be necessary to incise the external oblique aponeurosis to obtain adequate exposure and perform a high ligation of the sac.The initial surgical approach to the inguinal canal in girls is the same as in boys. However, in girls the round ligament may be divided. The hernia sac should be opened and inspected in all cases, as many inguinal hernias in girls contain a sliding component.The ovary, fallopian tube, and mesosalpinx can be present either in the hernia sac or within the wall of the sac. Care must be taken to avoid injury to these structures.If the fallopian tube lies within the wall of the sac, a purse-string closure of the sac may be performed followed by inversion of the sac and separate closure of the internal ring. + References ++Ein SH, Njere I, Ein A. Six thousand three hundred sixty-one pediatric inguinal hernias: a 35-year review. J Pediatr Surg. 2006;41:980–986. [PubMed: 16677897] ++Fonkalsrud EW, Stolar CJ. Disorders of the Inguinal Canal. In: O'Neill JA, Grosfeld JL, Fonkalsrud EW, et al, eds. Principles of Pediatric Surgery, 2nd ed. St Louis, MO: Mosby; 2004:437–442. ++Manoharan S, Samarakkody U, Kulkarni M, et al. Evidence-based change of practice in the management of unilateral inguinal hernia. J Pediatr Surg. 2006;40:1163–1166.