Plate 207

Any indirect inguinal hernia should be repaired electively unless contraindicated by the large size of the hernia or by the age or poor physical condition of the patient. The appearance of indirect inguinal hernia in middle-aged or elderly patients requires thorough medical investigation. Before repair is advised, it is wise to rule out any other source of pathology as a cause for the patient's complaint rather than ascribe it to the presence of an indirect inguinal hernia. Patients who have straining from symptomatic gastrointestinal tract obstruction, chronic pulmonary disease, or prostatism need appropriate diagnostic studies.

Repair of an inguinal hernia in an infant or child is indicated as soon as practical after the diagnosis is made. In the presence of an undescended testicle, the repair, which includes an orchiopexy, should be delayed until 3 to 5 years of age to permit maximum spontaneous descent. The orchiopexy is indicated at any age if there is strong indication for repairing the hernia due to incarceration.

Obese persons should be refused repair until their weight has been substantially reduced to a point within the range of their calculated ideal weight in order to ensure a low recurrence rate. Repair should also be delayed in patients with acute upper respiratory infections or a chronic cough until these conditions have been remedied. Smoking is curtailed or stopped and frequent intermittent positive-pressure breathing, with appropriate drugs added, should be instituted several days before surgery.

In the presence of strangulation, the operation is delayed only long enough for fluid and electrolyte balance to be established by the intravenous administration of Ringer's lactate solution. Systemic antibiotic therapy is instituted. Colloid solutions or blood products may be needed, especially if gangrenous bowel is suspected. A small nasogastric tube is passed, and constant gastric suction is maintained before, during, and for several days after operation. Sufficient time must be taken to ensure a satisfactory urine output of at least 30 to 50 mL per hour, a pulse under 100 per minute, and an appropriate blood pressure with a normal central venous pressure. Repeated electrolyte values should be approaching normal. Adequate preparation may require from several hours to a much longer period for the administration of several liters of fluids and electrolytes, especially potassium and blood, in the patient who has had intestinal obstruction for several days. Operative intervention before stabilization may have disastrous results.

A child 2 years or older should be prepared psychologically in advance for the hospital experience. Booklets that describe in simple narrative style the various details of hospitalization and operation can be read to the child before operation. Such preparation undoubtedly serves to diminish the incidence of emotional trauma as a complication of elective surgery.

Uncomplicated inguinal hernias in patients of any age may be repaired as ambulatory surgical procedures using local, regional, or general anesthesia.

Local infiltration anesthesia should be considered, since it allows approximation of the tissues at a more normal tension and also makes it possible for the patient to increase the intra-abdominal pressure by coughing, which will aid in identifying the sac and in testing the adequacy of the repair. Note the position of the nerves for local anesthesia (Figure 1). If obstruction is present, general anesthesia with an endotracheal tube and cuff is recommended to avoid the ever-present threat of tracheal aspiration.

Inhalation anesthesia is the method of choice in children and anxious adults.

The patient is placed in a supine position with a pillow beneath the knees so that slight relaxation at the groin is achieved. The table is tilted with the head down slightly to aid in reducing the contents of the hernia sac and in retracting a thick abdominal wall by gravity.

The skin preparation is routine.

Incision and Exposure

A skin incision, extending from just below and medial to the anterosuperior iliac spine to the pubic spine, is made 2 to 3 cm above and parallel to Poupart's ligament (Figure 1, A). A more comfortable and cosmetic incision results if the major crease in the lines of skin cleavage is followed (Figure 1, B). This may be defined by gentle downward traction on the abdominal wall, which demarcates the natural crease in the skin beneath the plastic drape. Either incision is carried down to the external oblique fascia. Several blood vessels, especially the superficial epigastric vein and the external pudendal vein, are usually encountered in the subcutaneous tissue in the lower portion of the incision. These must be clamped and tied (Figure 2).

Details of Procedure

The external oblique is carefully cleaned of all fat by sharp dissection throughout the length of the wound, and the external ring is visualized (Figure 2). After the margins of the wound have been covered with gauze moistened in isotonic saline, a small incision is made in the direction of the fibers of the external oblique, which extend into the medial side of the external inguinal ring (Figure 2). The edges of the external oblique are held away from the internal oblique muscle to avoid injury to the underlying nerves as the incision is continued through the medial side of the external ring (Figure 3). The nerves are most commonly injured at the external ring. The lower side of the external oblique is freed by blunt dissection down to include Poupart's ligament. The upper margin is similarly freed for some distance. As the ilioinguinal nerve is dissected free from the adjacent structures, a bleeding point is commonly encountered as it passes over the internal oblique (Figure 4). This bleeding vessel, if encountered, must be tied carefully; otherwise a hematoma may develop in the wound. When the ilioinguinal nerve has been carefully dissected free, it is pulled to one side over a hemostat placed at the edge of the incision (Figure 5). The cremasteric fibers are grasped with toothed forceps and divided in order to approach the sac (Figure 6). The sac itself is seen as a definite white membrane that lies in front and toward the inner side of the cord; it is usually easily differentiated from surrounding tissues. If the hernia is small, the sac lies high in the canal. The vas deferens can be recognized by palpation because it is firmer than the other structures of the cord. The wall of the sac is lifted up gently and opened with care to avoid possible injury to its contents (Figure 7). While the margins of the opened sac are grasped with hemostats, the contents are replaced within the peritoneal cavity. With the index finger of the left hand introduced into the sac to give counter-resistance, the surgeon frees the sac with the right hand by either blunt or sharp dissection (Figure 8). If the dissection is kept close to the sac, an avascular cleavage plane will be found. Sharp dissection is advisable to separate the vas deferens and adjacent vessels from the sac (Figure 9). If this is done carefully, fewer bleeding points will be encountered than if an effort is made to sweep these structures away from the sac by means of blunt dissection with gauze. The dissection is then continued until the properitoneal fat is displaced and the peritoneum beyond the narrow neck of the sac is visualized.

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