Inguinal Hernia/Hydrocele

Arlet G. Kurkchubasche, MD, and Thomas F. Tracy, Jr, MD

epair of the infant hernia is one of the principal operations in pediatric surgery, requiring a meticulous and standardized technique. Although simple in concept, the repair is technically demanding as the surgeon attempts to minimize unnecessary trauma to ilio-inguinal and genitofemoral nerves and the structures of the spermatic cord, all while operating through small skin incisions and dissecting even ner structures. Expert pediatric surgeons will often perform the procedure with magnication for precision and control. While the technique of indirect hernia repair is constant across the ages, the repair in the premature infant poses particular operative challenges because of the fragile nature of the hernia sac and the short length of the inguinal canal. In the following series of diagrams, a technique is outlined in which a sequential series of interventions are performed stepwise after identication of critical anatomic landmarks. The principles of infant hernia repair are based on the knowledge that an indirect inguinal hernia develops as a consequence of persistent patency of the processus vaginalis. There is no associated defect in the fascia or musculature related to the inguinal canal, therefore, high ligation of the sac is essential and sufcient for repair. Direct inguinal hernias and femoral hernias occur only rarely in children, and when encountered, are dealt with by applying standard adult repair techniques. A primary repair for direct hernia, however, is typically accomplished without the use of mesh in children. In view of the preponderance of indirect hernia, this discussion will focus on its operative management. The operation can be approached via a 1 to 3 cm incision in an inguinal skin crease just superior to the palpated external ring. The supercial tissues that are exposed are mobile and can easily be retracted to expose the essential anatomic elements. Conceptually, the operation proceeds by a combination of blunt and sharp dissection through successive layers of fascia to reach the hernia sac and nally separate it from the remainder of the spermatic cord structures.

DIAGNOSIS AND TIMING OF REPAIR

The diagnosis of infant hernia is made on the basis of the history provided by the parent or pediatrician and physical examination. Asymmetry of the inguinal region with a reducible mass is diagnostic. In a boy, the physical examination must also document whether there is an associated hydrocele and whether both testes are descended. The presence of a noncommunicating or otherwise static hydrocele, in the absence of a hernia, does not require operative intervention until the hydrocele has demonstrated persistence through the age of 18 to 24 months. A communicating hydrocele, dened by variation in scrotal size, a palpable thickening of the cord and a subtle silk string sign representing a larger patent processus, is best closed if it persists through the rst year. Occasionally a well-dened hydrocele of the cord may mimic a hernia, presenting a diagnostic dilemma that can be solved by manually verifying that the proximal canal is empty. Incomplete descent of the testis, particularly in the premature infant, is usually associated with a hernia and careful expectant management is often advised so as to avoid the potential complications associated with an orchidopexy at this early stage. The timing of infant repair should generally occur within several weeks of diagnosis to minimize the risk of incarceration which is greater in the rst months postnatally. For the hospitalized premature infant, repair is traditionally delayed until the child approaches discharge. Even then, delay may be desirable if some of the comorbidities, particularly pulmonary compromise, are expected to substantially improve or resolve within a period of months. However, once an infant or child presents with incarceration and a reduction is accomplished, prompt operative repair is recommended. The repair of the irreducible incarcerated infant hernia is challenging, as the integrity of the sac and the identication of the vas deferens and vessels is further compromised by inammation and edema. In the infant girl, incarceration can involve the ovary rather than the intestine. This diagnosis is made on palpation of a slippery almond shaped mass in the labium majora. Despite this incarceration, these infants appear clinically well and can undergo a semielective repair, usually the following day.

From the Department of Surgery, Division of Pediatric Surgery, Brown Medical School, Providence, RI. Address reprint requests to Thomas F. Tracy, Jr, MD, Department of Surgery, Division of Pediatric Surgery, 593 Eddy Street, HCH 147, Providence, RI 02903. 2005 Elsevier Inc. All rights reserved. 1524-153X/04/0604-0004$30.00/0 doi:10.1053/j.optechgensurg.2004.10.004

EVALUATION OF THE CONTRALATERAL CANAL

Ten percent of childhood hernias are bilateral at presentation. This number may vary with age with the highest

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reports of bilaterality observed in preterm infants. Surgeons have speculated that a routine exploration of the contralateral canal should yield a predictable incidence of patent processus and undiagnosed hernias. With the advent of laparoscopy, the technique for exploration became a topic for controversy.1 Ultimately, a more practical perspective returned to focus on the true incidence of metachronous hernia rather than asymptomatic patency of the processus. For all but premature infants, this number has now been demonstrated to be 10% to 12% and provides a basis for justifying whether operative and anesthetic risks are such that contralateral exploration, open or laparoscopic, is even warranted.2

Kurkchubasche and Tracy

ANESTHETIC AND PAIN MANAGEMENT

Hernia repair in children is performed as an outpatient operation under general anesthesia. The airway may be controlled by bag mask ventilation, laryngeal mask air-

way, or endotracheal intubation depending on the age, size and comorbidities of the patient. Spinal anesthesia in some institutions is reserved for those premature infants in whom pulmonary morbidity is such that intubation would be associated with prolonged postoperative dependency on mechanical ventilation. Techniques for optimizing perioperative analgesia include inltration of lidocaine or bupivacaine to block the ilioinguinal nerve and caudal blocks in children under one year of age. Acetaminophen or ibuprofen, with or without codeine, is provided for postoperative analgesia in the outpatient setting. Criteria for prolonged or overnight observation are based on the risk for apnea and/or bradycardia related to prematurity. The former premature infant under 50 weeks corrected gestational age is generally admitted for cardiac and respiratory monitoring. Term infants have minimal risk for post anesthetic apnea beyond the 90 minutes of immediate postoperative monitoring.

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SURGICAL TECHNIQUE
It is advisable to perform the operation wearing operating loupes to provide adequate magnication to visualize the critical elements in this operation.

(A) After induction of anesthesia, antiseptic skin preparation is completed encompassing the abdomen and genitalia. Draping should allow for access to the scrotum and to the abdomen for other approaches in cases of incarceration. The affected inguinal canal is palpated and the transverse incision is situated in the lowest skin fold immediately over the canal and superior to the external ring. The length of the incision can vary from 1 to 3 cm depending on the patients size.

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(B) The subcutaneous tissues are separated bluntly using the Metzenbaum scissors, exposing Scarpass fascia which is grasped with atraumatic forceps and incised. Placement and spreading of the scissors in this opening then allows the insertion of retractors to expose the external oblique fascia.

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This exposure is now maintained with the insertion of two pyloric, Senn, or similar retractors. The operating surgeon holds the lateral retractor, while the assistant exerts gentle countertraction medially. Dissection over the anterolateral aspect of the external oblique exposes ne areolar tissue that is bluntly swept laterally with the Metzenbaum scissors, revealing the true lateral border (groove) of the external oblique. By following the groove formed by the fascia distally, a point is reached at the external ring where tissue exiting from the external ring creates an acute angle toward the thigh. This landmark can be veried by pushing closed Metzenbaum scissors or a blunt instrument against the anterior bers of the external oblique. Once this landmark has been dened, only then is an incision made in the external oblique bers. Occasionally, a skin incision made too medially or failure to determine the lateral groove will result in dissection of the distal rectus bers rather than the external oblique. This places the bladder and the transversalis at risk in a lost dissection via a small incision.

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After the external oblique incision is created with a #15 scalpel blade, the Metzenbaum scissors are again used to dene the canal by passing the tightly closed blunt tip subjacent to the external oblique fascia into the scrotum or labia. This action also results in separating the ilioinguinal nerve from the undersurface of the fascia. The incision is extended distally with the Metzenbaum scissors through the external ring, and then proximally to the level of the internal ring.

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Grasping the incised edges of the external oblique, the cremasteric bers, hernia sac, and contents of the cord are exposed. The ilioinguinal nerve is visualized and dissected free.

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Using two atraumatic forceps, the surgeon now holds some cremasteric bers while with the other forceps separates the bers to reach deeper to elevate the hernia sac, vas and spermatic vessels. The sac is suspended by one or preferably two forceps, held by an assistant, while another forceps sweeps the muscular bers downwards allowing more sac to become visible.

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As the sac and cord structures are elevated, an inverted V-shaped aperture becomes evident under the canal contents. Forceps or a hemostat can then be passed through this aperture to elevate all of the cord and keep the relevant structures at the skin wound level for the retractors to be removed. Care must be taken to avoid injury to the oor of the inguinal canal, as the forceps are passed under the cord structures and hernia sac.

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The assistant continues to grasp the sac with two atraumatic forceps and suspends it on an incline toward the midline. By gently pulling or scratching the tissue on the surface of the suspended sac with open atraumatic forceps, the surgeon searches for a small pad of fat that acts as a reliable landmark for the spermatic fascial plane separating the sac from the cord structures. The assistant continues to maintain the sac on some traction in the medial position. Once identied, this fatty tissue is elevated laterally, opening the fascial plane, which allows the surgeon to lift the cord structures off the surface of the sac. The spermatic vessels are the rst structures identied on the lateral aspect of the sac and are often quite separate from the vas deferens that enters the canal from the posteromedial aspect at the internal ring. The assistant surgeon helps by regrasping more of the exposed hernia sac as it is dissected, thereby rolling it medially. Here the spermatic cord is simply draped over the surgeons nger for the purpose of demonstrating the dissection plane.

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These spermatic cord elements are bluntly separated from the sac without ever grasping them with an instrument. Once the forceps have successfully passed between the sac and spermatic cord structures, a vessel loop, Allis clamp or other suitable retracting device encompasses the cord structures to deect them inferiorly and laterally toward the ipsilateral knee. The distal end of the sac may now be evident and can be grasped with forceps or a hemostat. If the sac extends into the scrotum it is reasonable to divide the sac between clamps at this point, provided there is sufcient proximal and distal separation from the vessels and vas deferens. The spermatic cord and proximal portion of the sac are suspended vertically, allowing for the best visualization of the investing spermatic fascia. The spermatic fascia has greater tensile strength than the sac at this level and is best divided with ne-tipped scissors rather than by blunt dissection. The edge of the hernia sac and spermatic cord structures must be clearly visualized during this sharp dissection.

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The proximal end of the sac is reected toward the superior aspect of the wound, separating it from the cord structures that continue to be retracted laterally and toward the ipsilateral knee. This exposes the residual spermatic fascial investments of the spermatic cord and hernia. Note the diaphanous nature of the sac on its posterior aspect approaching the internal ring. Here it is the most vulnerable to disruption, which must be recognized promptly and controlled such that the nal ligature is beyond or proximal to a tear, to avoid a recurrence of the hernia. Division of this layer of tissue allows the sac to be completely separated from the vas and vessels at the level of the internal ring, recognized by the presence of preperitoneal fat.

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Proximal dissection of the sac to the internal ring may reveal either a very narrow neck or a wide base that must be carefully considered as the dissection is completed.

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The sac is held perpendicular to the wound and is then doubly ligated with a simple tie proximally and suture ligature distally using suture material of the surgeons choice, typically silk or vicryl (polyglactin 910). Although some surgeons opt to twist the sac before placing the ligature, this maneuver can inadvertently pull the vas deferens into the ligature. The excess sac is then transected well above the ligature and the sutures are cut resulting in complete retraction of the hernia stump to the level of the peritoneum adjacent to the internal ring. This provides further conrmation that a high ligation was achieved. Closure of the internal ring is not necessary unless there is a large aperture in a premature infant with a very short inguinal canal. In the repair of a hernia in female infants, it is important to realize that the extension of the suspensory ligaments into the sac can bring the fallopian tube close to the internal ring, placing it at risk with blind high ligation of the sac. A Potts-Goldstein ap type repair using a prolene pursestring suture is often advisable and the internal ring is then tightened or closed completely. The distal portion of the sac is now separated to the extent possible from the distal structures taking care to avoid the pitfall of a serpentine vas deferens. If incompletely resected, the edges of the sac are grasped and examined for any bleeding points requiring minimal cautery. The vessel loop retracting the cord structures is released and the cord structures are returned into the canal by placing traction either directly on the testes or indirectly via the gubernaculum from the scrotal skin. It is important to assure that the testis is correctly situated within the scrotum beyond the pouch of Dennis Browne to avoid postoperative cryptorchidism.

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The pyloric retractors are re-inserted and the previously prepared edges of the external oblique fascia are reapproximated with interrupted absorbable suture material. If a preoperative ilioinguinal nerve block was not performed, the block can be administered under direct vision either at the time of opening the external oblique or on closure. Scarpass fascia is reapproximated with a single buried suture and skin is closed with a subcuticular stitch. Mastisol or benzoin is applied before covering the incision with steristrips. Alternatively the wound is sealed with collodion or other dressing.

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VARIATIONS AND PITFALLS IN OPERATIVE TECHNIQUE

Female infant hernia repair. Once the sac is
grasped between the internal oblique bers, it is elevated and will expose an artery on its posterior surface. This vessel should be carefully separated from the sac to avoid hemorrhage on transection of the sac. If the sac is empty, then the distal end can be clamped and transected with electrocautery, releasing it from its ligamentous attachments to the labia. Alternatively the sac can be divided between clamps. The proximal extent of the sac is dissected to the level of the internal ring. Care should be taken to avoid overzealous traction on the proximal sac as this can bring the adnexal structures, particularly the fallopian tube, close to the level of ligation. It is advisable to visually inspect the interior of the sac at the level of ligation. If the round ligament is very prominent at this level no attempt should be made at separation of this from the sac. If the fallopian tube is found to be present, then it must be dissected along its borders from the posterior sac. This ap is then turned in allowing for a Potts-Goldstein repair performed using a ne prolene pursestring suture to the remainder of the sac. The internal ring should be tightened or closed to prevent hernia recurrence in this instance. Another pitfall in the repair in girls is that bilateral hernias may be encountered with the androgen insensitivity syndrome (Testicular Feminization Syndrome). This diagnosis can be excluded by either visualizing the ovary or fallopian tube at the time of hernia repair or more simply by verifying the presence of a palpable cervix via a rectal examination under anesthesia. Incarcerated hernia repair. If reduction of the incarcerated intestine does not occur spontaneously with induction of anesthesia, then the intestine should not be reduced manually so as to allow for visual inspection of necrosis or signicant ischemia of the bowel. The overlying soft tissues are typically edematous and friable. Since circumferential control of the sac is often impossible, the edges of the opened sac are grasped with ne hemostats as

it is opened on its medial aspect to inspect the incarcerated intestine. Once reduced, the sac is then dissected from the cord structures and controlled more proximally for a standard high ligation. It is very important to examine and document the viability of the testis in the scenario of incarceration, as it may have undergone ischemic necrosis from venous congestion. If the intestine reduces into the abdomen before complete inspection, one may encounter chylous or bloody uid from the abdomen. This nding in isolation does not mandate laparotomy, however, close observation of the patient for obstruction or peritonitis is advisable. Surgeons should be comfortable with the need for other abdominal incisions in the midline or right lower quadrant (Laroque maneuver) to aid in manual reduction of incarcerated intestine.

CONCLUSION
Repair of infant and childhood hernia can be accomplished with little morbidity and mortality. Complications such as bleeding and infection are expected to occur with less than 1% incidence. Recurrence rates are quoted in the context of the age at repair. In the preterm neonate this may approach 5% when additional comorbidities such as bronchopulmonary dysplasia are present. In the healthy infant or child, it is expected to occur less than 1% of the time. It is standard procedure in many institutions to send the sac for pathologic examination, this serves as a method for screening for injury to the vas deferens. However, injury is recognized by the experienced surgeon at the time of operation and allows for expert consultation for the potential for microanastomosis. Occasionally a child without a vas deferens is identied. This should prompt a medical evaluation for cystic brosis.

REFERENCES
1. Miltenburg DM, Nuchtern JG, Jaksic T, et al: Laparoscopic evaluation of the pediatric inguinal hernia: a meta-analysis. J Pediatr Surg 33:874-879, 1998 2. Tackett LD, Breuer CK, Luks FI, et al: Incidence of contralateral inguinal hernia: A prospective analysis. J Pediatr Surg 34:684-687; discussion 687-688, 1999