INGUINAL HERNIOTOMY

Picture of a little boy with an inguinal hernia. It is fully reducible. The ideal age for repair is over a weight of 10 kilograms and after sufficient time has been given for the canal to close by itself.
HERNIOTOMY AT THE SUPERFICIAL INGUINAL RING
(Based on a description by Mitchell Banks, 1882)
The following textbooks have been used as reference sources for this webpage:
Spitz L, Sugarman ID. Paediatric Surgery. In: Kirk RM, Ed. General Surgical Operations. 4th ed. Churchill Livingstone: London; 2000.
Ellis H, Dussek JE. Surface Anatomy. In: Bannister LH, Berry MM, Collins P, Dyson M, Dussek JE, Ferguson MWJ, eds. Grays Anatomy, 38th edn. Churchill Livingstone: New York; 1995.

Skin incision. 2 cm long, sited over the superficial inguinal ring. The 'ring' is a slit in the aponeurosis of the external oblique as it attaches to the pubic bone. The surface anatomy of the superficial inguinal ring describes its location as immediately above and lateral to the pubic crest.

Deepen the incision through the following layers sequentially:
Subcutaneous fat
Camper's fascia - fatty superficial layer of the superficial fascia
Scarpas' layer - membranous deep layer of the superficial fascia

You should now be in the plane where the spermatic cord emerges from the superficial ring. Distal to the ring, the cord is covered by external spermatic fascia and cremasteric fascia. These must be split. Rotate the cord. Split the internal spermatic fascia along the posterior aspect of the cord. This allows separation of vas deferens and vessels, from the hernia sac.

Pull as much as possible of the sac, gently, out of the inguinal canal through the superficial ring.

Ensure the cord is empty. Ligate it. Then transfix just distal to the ligature. Use a 4-0 absorbable suture.

Close the layers appropriately.

Potential hazards with this operation:
Staying too superficial: the superficial fascia is thicker in the infant than in the adult.
Straying inferiorly: Inability to find the spermatic cord can lead to the surgeon chancing upon the femoral vein
Straying medially: Inability to find the cord can lead the surgeon to incise the conjoint tendon and mistake the corner of the bladder for the hernia sac.
Displacement of testis: If the testis come up into the wound, it may be very difficult to reposition this into the scrotum. An orchidopexy may be required at this stage.
HERNIOTOMY THROUGH THE INGUINAL CANAL

The following textbooks have been used as reference sources for this webpage:
Spitz L, Sugarman ID. Paediatric Surgery. In: Kirk RM, Ed. General Surgical Operations. 4th ed. Churchill Livingstone: London; 2000.
Ellis H, Dussek JE. Surface Anatomy. In: Bannister LH, Berry MM, Collins P, Dyson M, Dussek JE, Ferguson MWJ, eds. Grays Anatomy, 38th edn. Churchill Livingstone: New York; 1995.

Skin incision: Midway between the deep ring and the pubic tubercle. The deep ring is located 1 cm lateral to the midinguinal point, or at the midpoint of the inguinal ligament. Make the incision in the skin crease, about 2 cm in length.

Deepen the incision through the following layers sequentially:
Subcutaneous fat
Camper's fascia - fatty superficial layer of the superficial fascia
Scarpas' layer - membranous deep layer of the superficial fascia

Expose a 2 sq. cm area of external oblque aponeurosis. This should be at least 1 cm above its inferior margin (i.e., the inguinal ligament). Incise through this tissue and retract the edges. Avoid opening the superficial inguinal ring.

Progress the dissection deeper into the inguinal canal, staying close to the posterior edge of the external oblique aponeurosis, until the ilioinguinal nerve is seen. Adjacent and deeper to this, the cord is identified.

Clear the cremateric fascia over the cord. Use the internal spermatic fascia to obtain a grip on the cord. Rotate the cord posteriorly. Incise the internal spermatic fascia. Sweep away the vas deferens and vessels, taking care not to grasp these structures in forceps, to avoid crush injury.

Isolate an area of the sac, place a clip across and divide the sac distal to the forceps. Let the distal sac retract into the scrotum.

Continue to clear the vas and vessels more proximally along the sac margin until you see the inferior epigastric vessels.

Ensure the cord is empty. Ligate it. Then transfix just distal to the ligature. Use a 4-0 absorbable suture.

Close the layers appropriately. Ensure the testis is secure in the scrotum.