- Presence of a hernia (elective).
- Incarceration or strangulation (emergent).
- Extreme prematurity.
- Cardiopulmonary comorbidities.
- The most important goal is to eliminate the risk of incarceration and strangulation.
- Repair can also provide relief from discomfort associated with the hernia.
- Risks include:
- 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.
- 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).
- 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.
- 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.
- 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 ...
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