Categories
General

Inguinal hernia

Definition   Hernia: Passage of one organ through a musculo-aponeurotic sheath.
Indirect inguinal hernia:
-herniating organs = bowel, omentum, ovary
– musculoaponeurotic sheath = deep inguinal ring
Typical presentation  Right > Left
Age   Neonates > Infants
Incidence Depends on gestation and age.
1 percent at term neonate
30 percent premature neonate
10 percent bilateral in premature neonate 
 
Sex Male > Female
Genetics   
Aetiology and natural historyPatent process vaginalis (PPV) at the deep inguinal ring communicates with groin leading to accumulation of fluid (hydrocoele) or, if large enough, herniation of bowel , omentum or ovary. Therefore, patent process vaginalis is more common in prematurity.
Not all PPV results in clinically apparent hernia, with  29% patent processus vaginalis on post mortem studies 
Most remain indolent till repaired. However, there is a 10-35% risk of incarceration.
Differentials Male: Hydrocoele, undescended testis, lymph node
Female : Canal of Nuck hydrocoele, lymph node
Classifications    
Severity/Staging           
Assessment   
History : Antenatal  
History : Postnatal    
Examination  
Investigations   
Bedside   Inguinal canal is  0.5 cm in a neonate and 4cm in an adult  
Blds  Hb check for neonates
Xmatch not required
Urine   
Solids/Swabs   
Imaging   USS: may be useful to confirm diagnosis  
Echo   
Special tests  Nuclear:      
Treatment:    
Goals/ Principles   Divide/ligate processus vaginalis and close deep ring to prevent incarceration of hernia.
Conservative    Not an option due to risk of incarceration
Medical    None
Surgical  Indications 
  SurgicalOptions  
1. Open
2. Laparoscopic
Timing:
-Once identified, should be done as soon as feasible to prevent incarceration.
– Incarcerated hernia should be treated as an emergency.
Complications/Consent Consent for open procedure
Intra-op: Injury to vas and vessels, bleeding

Post op: Recurrence, testis atrophy, testis retraction/ ascent, wound infection, pain, scar

Consent for laparoscopic procedure
Intra-op: Conversion to open = 3/ 791 (0.4%)

Post-op: Recurrence, testis atrophy, testis ascent/ retraction, bleeding, wound infection, pain, scars
Severity/ Frequency Matrix
Op note  Open procedure (M):

Laterality:
EUA: Both right and left testes at scrotal base, equal in size. Hernia reduced.
I: groin, skin crease
F: PPV confirmed. Sac [is empty/ contains omentum/ bowel/ovary ]
P: Vas and vessels identified and preserved throughout. Spermatic cord skeletonised, hernia sac defined to deep ring. Hernia sac divided, twisted, transected, ligated (x2 vicryl 3/0).
C: 3/0 vicryl to ext oblique, Scarpas . 5/0 vicryl to skin. Steristrip dressing.
Both right and left testes at scrotal base, equal in size at end.
Post op: Can eat and drink, PRN analgesia, home [ later/ after overnight apnoea monitoring ]. Clinic 6/12.

Laparoscopic procedure (M):
Laterality:
EUA: Both right and left testes at scrotal base, equal in size. Hernia reduced.
I: umbilical-5mm scope, right and left flank-3mm instruments
F: Hernia – deep ring is open. Sac [is empty/ contains omentum/ bowel/ovary ]
Contralateral deep ring inspected- it is [closed/ open].

Procedure below to close [Right/Left/Both] deep ring.

P: Hernia reduced. Vas and vessels identified and preserved throughout. 4/0 prolene purse string closure of deep ring.
C: 2/0 vicryl to umbilical ring, Scarpas . Glue to skin. Steristrip dressing.
Both right and left testes at scrotal base, equal in size at end.
Post op: Can eat and drink, PRN analgesia, home [ later/ after overnight apnoea monitoring ]. Clinic 6/12.
Outcomes  Recurrence rate
Laparoscopic/ Open rate (age subsets)
Operative time
Cost
 Follow-upIndicated, to monitor for recurrence and testis complications (circa 6m).
Key evidence  Laparoscopic vs open inguinal hernia
Risk of metachronous/ contralateral hernia
Approaches to hernioscopy
Approaches to laparoscopic herniorrhaphy
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