Paediatric inguinal herniotomy

Why are we operating?

Ligation of a patent processus vaginalis through a groin crease incision, the commonest paediatric operation, and the purest lesson that children's hernias are a different disease from adults'.

Indication: Any inguinal hernia in a child, repaired promptly because of the incarceration risk, urgently in infants, where the risk is highest.

The operation in 4 steps

1. 01Groin crease incision

   A small transverse incision in the lowest skin crease, through Scarpa's fascia, onto the external oblique and the superficial ring.

2. 02Isolating the sac

   The cord is delivered, its coverings opened, and the sac gently separated from the vas deferens and testicular vessels along its posteromedial border.

3. 03High ligation

   The sac is dissected to the deep ring, twisted to reduce any contents, transfixed and ligated flush, and the distal sac left open in situ.

4. 04Testis check and closure

   The testis is drawn back into the scrotum, the layers closed with absorbable sutures, and the skin glued or closed subcuticularly.

Danger zones

• Ilioinguinal nerve

  Entrapment in mesh or sutures causes chronic groin pain, the commonest serious complaint after hernia repair.

• Inferior epigastric vessels

  The landmark separating direct from indirect, and a bleeding hazard at the triangle's lateral border.

• Vas deferens & testicular vessels

  Skeletonised with the cord at every repair; injury threatens fertility and the testis.

• Femoral vein

  Just below the inguinal ligament at the femoral canal, the structure a too-deep medial stitch finds.

Anatomy you need

The abdominal wall the processus vaginalis tunnels through; in an infant the canal is short and the rings nearly overlap.

What can go wrong

• Surgical-site infection

  Wound erythema, warmth, discharge, and pain out of proportion, typically from postoperative day 4–7.

• Postoperative bleeding

  Tachycardia first, hypotension late; falling urine output; a distending abdomen or rising drain output.