Inguinal and Umbilical Hernias

Chapter 86 Inguinal and Umbilical Hernias



Earl Hodin, MD



Inguinal Hernia



INTRODUCTION


Inguinal herniorrhaphy is one of the most common operations performed by the pediatric surgeon. Inguinal hernias in children are indirect, a result of a patent processus vaginalis.



INDICATION



• Presence of inguinal hernia in child

An inguinal hernia in a child warrants repair to avoid the risk of incarceration. Unlike umbilical hernias in children, inguinal hernias do not close spontaneously.



OPERATIVE STEPS



Step 1 Inguinal crease incision

Step 2 Division of Scarpa’s fascia

Step 3 Opening of external oblique aponeurosis

Step 4 Isolation of spermatic cord

Step 5 Separation of hernia from cord contents to internal ring

Step 6 Division of sac

Step 7 Contralateral laparoscopic exploration, if warranted (favored in some institutions)

Step 8 High ligation of sac

Step 9 Closure of external oblique aponeurosis and Scarpa’s fascia


External Oblique Aponeurosis Division



Ilioinguinal and Iliohypogastric Nerve Injury



• Consequence


Although division of these nerves may lead to a small area of anesthesia, entrapment by a suture can lead to significant paresthesias, which can be considerably more troublesome.

Grade 4 complication


• Repair


Once severed, these nerves cannot be repaired in children; if entrapped, reoperation with release or division may be necessary.


• Prevention


Lifting up of the aponeurosis during the division and careful identification during dissection.


Separation of the Hernia Sac



Damage to the Vas Deferens



• Consequence


Infertility is unlikely if only one vas has been damaged.

Grade 4 complication


• Repair


Primary repair should be attempted but, in smaller children, can be challenging. Successful repairs and fertility have been reported after puberty and in adulthood.1–4


• Prevention


When dissecting the hernia sac, the vas must be carefully identified and protected. A clamp should not be applied to the sac before the vas is identified. The vas and vessels should be gently teased away from the sac and never grasped with a forceps. Merely picking up the vas with forceps has been shown to lead to fibrotic luminal occlusion in rats.5,6


Damage to the Spermatic Vessels



• Consequence


Ischemic orchitis and atrophy of the affected testicle.7

Grade 4 complication


• Repair


The spermatic vessels in children are too small to repair.


• Prevention


Careful, atraumatic dissection of the cord; the use of magnifying lenses can be helpful.


High Ligation of the Sac



Tear in the Sac



• Consequence


Hernia recurrence.7

Grade 3 complication


• Repair


The sac should be repaired with a fine suture if a tear is discovered.

Related posts:

  1. Isolated Limb Perfusions and Extremity Amputations
  2. Lateral Pancreaticojejunostomy (Puestow) Procedure
  3. Left Colectomy: Open and Laparoscopic
  4. Bronchial and Vascular Sleeve Lobectomy

Stay updated, free articles. Join our Telegram channel
Tags:
Jun 21, 2017 | Posted by in GENERAL SURGERY | Comments Off on Inguinal and Umbilical Hernias

Full access? Get Clinical Tree
Get Clinical Tree app for offline access