Hernia,
Hydrocele
Stephen Confer, MD
Ben O. Donovan, MD
Brad Kropp, MD
Dominic Frimberger, MD
University of Oklahoma
Department of Urology
Section of Pediatric Urology
3 year old male
Incarcerated Inguinal Hernia
Hernia Reduction
• Unable to reduce: OR
• If extremely difficult (sedation): repair next day
• If able to reduce without sedation: repair soon
From Surgery of Infants and Children, Oldham, et. al., 1997
Inguinal Hernia
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Most can be reduced in clinic or ED
Bowel usually OK if able to reduce
17% reincarceration rate
Beware the “inguinal node’ in females
– incarcerated ovary
From Atlas of Pediatric Surgery, Ashcraft, 1994
Overview
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Review Anatomy
Biostatistics
Operative Description
Advanced
Laparoscopic
Anatomy
• EBM-Core
Competency
DEFINITION
• ”…..an abnormal
protrusion of a viscus
through its containing
wall”
Anatomy
BOUNDARIES OF INGUINAL
CANAL
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FLOOR: Inguinal ligament
ANTERIOR WALL: External Oblique
POSTERIOR WALL: Transversalis fascia
MEDIAL-POSTERIOR WALL: Internal
oblique and transversalis (when they fuse
become conjoint tendon.)
Inguinal/Scrotal Anatomy
From Surgery of Infants and Children, Oldham, et. al., 1997
CONTENTS OF CANAL
3 ARTERIES:
• Testicular Artery
• Artery to Vas
• Artery to cremaster
3 LAYERS OF FASCIA:
• External spermatic fascia
• Cremasteric fascia
• Internal spermatic fascia.
3 NERVES:
• Genital branch of
genitofemoral nerve
• Sympathetic fibres
• Ilioinguinal nerve
3 OTHERS:
• Vas deferens
• Panpiniform plexus
• Lymphatics
ANATOMICAL DEFINITION
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INDIRECT
Lateral to IEA
Outside Hasselbach
triangle.
Therefore hernia goes
from DR SR
scrotum.
Therefore, indirect
hernias are controlled @
deep ring
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DIRECT
Medial to IEA
Inside Hasselbach
triangle.
It is a bulge in fascia
transversalis.
Therefore if bulge
medial to fingers at
deep ring it is direct.
ANATOMICAL DEFINITION
• Note that scrotal swellings are usually
indirect.
• However, large directs can cross superficial
ring and enter the scrotum. This is rare.
• An indirect and direct hernia occurring
simultaneously is termed a pantaloon
hernia.
Biostatistics
• All ages
• Both sexes
• % Incidence: Inguinal 80%
Incisional 10%
Femoral 7%
Biostatistics
• Approximately 700,000 hernia repairs are
performed as an outpatient procedure each year
• Approximately 75% of all hernias occur in the
inguinal region
• Approximately 50% of hernias are indirect
inguinal hernias
• A vast majority occur in males
• Hernias more commonly occur on the right side
Etiologies
Increased Abdominal
Pressure:
• Heavy lifting
• Chronic cough
• BPH
• Constipation
• Ascites
Weakened Abdominal
Wall:
• Increasing age
• Malnutrion
• Collagen disorders
• Smoking
Diagnosis
• They may describe minor pain or vague
discomfort associated with the bulge
• Extreme pain usually represents
incarceration with intestinal vascular
compromise
• Paresthesias may be present if inguinal
nerves are compressed
Surgical Management of Inguinal
Hernias
• Inguinal hernias should be surgically repaired
following diagnosis by physical exam
• The natural history of groin hernias is one of
progressive enlargement and weakening with the
potential for incarceration and obstruction of the
intestine
• Hernias do not resolve spontaneously or improve
with time
• Wearing a truss does not cure a hernia
The Operation
• The incision is made two finger breadths above the
inguinal ligament
• Careful dissection through the subcutaneous and
external oblique fascia is made
• The spermatic cord is mobilized
• The cremasteric muscle fibers are divided and
separated from underlying cord structures
• The hernia sac is dissected from the cord structures and
opened
• The neck of the sac is suture-ligated at the level of the
internal ring (excess sac is removed)
Specific Surgical Procedures
• Laparoscopic hernia repair
– Early attempts resulted in exceptionally high
reoccurrence rates
Practice based learning and
improvement
• Prospective Randomized Controlled Trial to
compare skin staples and polypropylene for
securing the mesh in inguinal hernia repair.
• British Journal of Surgery 1998, 85,790792. Ratliff et. al.
Compare 2 fixation methods
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50 men unilateral inguinal repair
Reevaluation in 6 and 12 weeks.
Staple time 20 min
Suture time 29
No difference in pain scores
Inguinal hernia in bulls