Chapter 48

• Presence of a hernia (elective).
• Incarceration or strangulation (emergent).

### Absolute

• Coagulopathy.
• Thrombocytopenia.

### Relative

• Extreme prematurity.
• Cardiopulmonary comorbidities.
• Immunosuppression.

### 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).

• 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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