1. 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

2. 3 year old male

3. Incarcerated Inguinal Hernia

4. 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

5. From Atlas of Pediatric Surgery, Ashcraft, 1994
Inguinal Hernia
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

6. Overview Review Anatomy Biostatistics Operative Description
Advanced Laparoscopic Anatomy
EBM-Core Competency

7. DEFINITION
”…..an abnormal protrusion of a viscus through its containing wall”

8. Anatomy

10. BOUNDARIES OF INGUINAL CANAL
FLOOR: Inguinal ligament
ANTERIOR WALL: External Oblique
POSTERIOR WALL: Transversalis fascia
MEDIAL-POSTERIOR WALL: Internal oblique and transversalis (when they fuse become conjoint tendon.)

11. Inguinal/Scrotal Anatomy
From Surgery of Infants and Children, Oldham, et. al., 1997

12. CONTENTS OF CANAL 3 ARTERIES: Testicular Artery Artery to Vas
Artery to cremaster
3 NERVES:
Genital branch of genitofemoral nerve
Sympathetic fibres
Ilioinguinal nerve
3 LAYERS OF FASCIA:
External spermatic fascia
Cremasteric fascia
Internal spermatic fascia.
3 OTHERS:
Vas deferens
Panpiniform plexus
Lymphatics

13. ANATOMICAL DEFINITION
INDIRECT
Lateral to IEA
Outside Hasselbach triangle.
Therefore hernia goes from DR SR scrotum.
Therefore, indirect hernias are deep ring
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.

15. 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.

16. Biostatistics All ages Both sexes % Incidence: Inguinal 80%
Incisional 10%
Femoral 7%

17. 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

18. Etiologies Increased Abdominal Pressure: Weakened Abdominal Wall:
Heavy lifting
Chronic cough
BPH
Constipation
Ascites
Weakened Abdominal Wall:
Increasing age
Malnutrion
Collagen disorders
Smoking

19. 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

21. 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

22. 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)

29. Specific Surgical Procedures
Laparoscopic hernia repair
Early attempts resulted in exceptionally high reoccurrence rates

32. 1.

35. 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, Ratliff et. al.

36. Compare 2 fixation methods
50 men unilateral inguinal repair
Reevaluation in 6 and 12 weeks.
Staple time 20 min
Suture time 29
No difference in pain scores

37. Diagnose Correctly
Perform Safe Interventions
Hernia Survivors, Jan 2008

38. Inguinal hernia in bulls