The sac is opened within 2 to 3 cm of its neck, and exploration is carried out with the index finger to rule out the presence of a “pantaloon” or secondary direct or femoral hernia (Figure 10). To ensure obliteration of the sac, a purse-string suture is placed at the inner side of the neck (Figure 11), or several transfixing sutures may be used if preferred. The lumen of the neck of the sac must be visualized as sutures are placed or tied to avoid possible injury to omentum or intestine. This suture should include the transversalis fascia with the peritoneum. The neck of the sac can sometimes be identified as a slightly thickened white ring. The sac should be ligated proximal to this ring. After the purse-string suture is tied, the excess sac is amputated with scissors (Figure 12).
If desired, the ligated sac may be anchored to the overlying muscle. In this instance the long ends of the suture used to close the neck of the sac are rethreaded. The needle is inserted beneath the transversalis fascia and brought up in the edge of the internal oblique muscle, the two ends being brought through separately and tied (Figure 13). Care should be taken to avoid injuring the inferior deep epigastric vessels.
Although the classic inguinal hernia operations utilize high ligation with division of the hernia sac, two alternate methods have gained popularity with mesh repair. In small to medium-sized indirect hernias, the sac is left intact as it is dissected from the posterior cord structures. Electrocautery is used along the edge of the sac while gentle traction is applied. This minimizes bleeding and ecchymosis after surgery. Any entry into the sac is used for finger exploration and guidance of further dissection well up into the internal ring. Any opening in the sac is closed using 00 absorbable suture, and the entire sac, along with any lipoma of the cord, is returned to the preperitoneal space behind the abdominal muscular wall.
In very large inguinoscrotal hernias, the indirect sac is transected and suture-ligated near the internal ring. Only the proximal sac is dissected free into the internal ring. The distal very large sac is left untouched, as the extensive dissection from the cord vessels and the mobilization of the testicle up and out of the scrotum may result in venous thrombosis or possible ischemic orchiditis. A residual hydrocele rarely occurs.
There are various methods of repair after the sac has been removed. Large or recurrent hernias in older persons or hernias in patients doing very heavy work may be corrected by a method that either partially or completely transplants the cord and narrows the internal ring.
The cremasteric fibers, which may or may not be well developed, are approximated with interrupted 00 silk sutures (Figure 14). This covers the raw surface remaining after removal of the sac and restores the structures to a normal appearance. The cremaster muscle is pulled beneath the conjoined tendon to relieve strain on the next layer of sutures and to increase the efficiency of the repair (Figure 15). Sutures are then placed to approximate the conjoined tendon and the internal oblique muscle to Poupart's ligament, the sutures being tied anterior to the cord (Figure 16). The sutures in Poupart's ligament are placed from below upward, unequal portions of the ligament being taken to avoid fraying. The first suture should be tied loosely enough so that the cord is not constricted and there is sufficient space about the cord to permit an instrument tip to pass; moreover, care should be taken to avoid injury to or inclusion of the ilioinguinal nerve by the sutures. The external oblique fascia is approximated with interrupted sutures (Figure 17). Here again, the external ring should not constrict the cord (Figure 18). The subcutaneous tissue is carefully approximated with interrupted 0000 absorbable sutures to (Figure 19). A continuous subcutaneous closure with absorbable suture may be used, followed by adhesive skin strips and a dry sterile dressing.
A short (3-cm) skin incision is made in the suprapubic crease above the inguinal ligament and centered over the internal inguinal ring.
After the incision has been made through the skin, a small curved mosquito hemostat is placed in the subcutaneous tissue on either side of the midportion of the incision for traction. Scarpa's fascia is exposed and divided. The underlying aponeurosis of the external oblique is cleared down to the external inguinal ring. The aponeurosis of the external oblique is then opened upward from the external inguinal ring. If there is no associated scrotal hydrocele, the incision through the external oblique aponeurosis may be placed just above rather than through the external ring. Superior and inferior flaps of the aponeurosis of the external oblique are developed with the scalpel handle, and a small right-angle retractor is placed under the superior flap to expose the inguinal canal. The cremasteric muscle fibers are separated by blunt dissection. The hernia sac is identified on the anteromedial aspect of the cord structures, lifted up, and gently separated in the midportion of the inguinal canal from the vas and the vessels. The cord structures themselves should not be mobilized from the inguinal canal. The sac is divided between two straight mosquito hemostats in the mid-portion of the inguinal canal, and the proximal portion is freed well above the level of the internal ring. The neck of the sac then is closed with a suture ligature of fine silk and the sac amputated. Ordinarily, it is not necessary to open the sac during this process. However, if omentum or a loop of intestine is within the sac, the sac is opened, and these structures are returned to the peritoneal cavity before the neck of the hernia sac is closed. The distal portion of the sac is freed below the level of the external ring and excised.
The testis and cord structures are repositioned into their normal anatomic bed if they have been disturbed, and an anatomic closure is performed. The aponeurosis of the external oblique and Scarpa's fascia are closed with interrupted sutures of fine silk. A subcuticular closure with fine absorbable suture is used in children. Because of the high incidence of a patent processus vaginalis on the opposite side in instances of a clinical inguinal hernia in infants, it is common practice to perform an inguinal exploration on the opposite side in infants but not older children.
In female children, the incision and initial stages of the procedure are as described above. However, in a high proportion of cases a congenital indirect hernia in a female is a sliding type of hernia, with the fallopian tube and its mesenteric attachments making up a portion of the hernia sac. In such instances the hernia sac and round ligament are closed with a suture ligature of fine silk distal to the attachment of the mesosalpinx. The remainder of the procedure is identical with that done in the male.
The round ligament is usually closely attached to the sac, making sharp dissection necessary for separation. After the neck of the sac is freed and ligated, the repair proceeds as in the operation on the male, except that the round ligament may be included in the sutures that bring the conjoined tendon to Poupart's ligament. If the round ligament is divided, it must be ligated, since it contains a small artery, and the proximal end must be anchored in order to give support to the uterus.
The patient is placed flat in bed with the thighs somewhat flexed either by a pillow beneath the knees or, if in an adjustable bed, with the lower part of the bed somewhat elevated in order to prevent undue tension upon the sutures in the wound. Support to the scrotum may be furnished by suspensory. An ice pack may be applied to the scrotum. Coughing must be controlled by sedation. Laxatives are given in sufficient dosage to avoid undue straining at stool. Patients should ambulate and void as soon as possible. Normal activities are resumed as tolerated. However, several weeks should elapse before the patient is permitted to perform heavy physical work. Special abdominal supports usually are not necessary.
The infant or child is fed 4 to 6 hours after operation and, by the evening of operation, should be taking a normal diet.