1. Introduction

2. Left Incision

a. Mobilize and Externalize Hernia Sac

b. Ligate Hernia Sac and Close Internal Ring

3. Dissection

4. Left Closure

5. Right Incision

6. Dissection

7. Right Closure

8. Post-op Remarks

Indirect inguinal hernia repair is a common procedure for premature infants because of the frequency of a patent processus vaginalis. Prompt surgical correction decreases the risk of incarceration, strangulation, and necrosis in children. There are various techniques for herniorrhaphy. This repair demonstrates an open bilateral indirect inguinal hernia repair in an infant that avoids high ligation by closing the internal inguinal ring, utilizing a purse-string method to keep the hernia sac intact. This approach limits the amount of anesthesia used and prevents excess bleeding, making it safe, effective and efficient.

<h4>CHAPTER 1</h4>

<p>Yeah, we just did a- twin babies who were born premature. The one baby weighed 2.5 pounds, and this baby we're doing is- weighed 1.5 pounds. The mother's 17, 4' 10". And so they did a C-section to deliver the babies at the time of birth. And then of course they, they grew with the mom's breast milk, and for the whatever it is, the grace of God, the baby survived. The babies survived in spite of prematurity, but then they, they developed a hernia. The tiny baby that we're doing now, the twin- I call it twin B- had a hernia where the ovary was stuck in the hernia sac for- for I don't know how long. And what happens when that happens that is you can lose the ovary actually, but in this case, the ovary survived. It just got swollen because- you pinch, you- have a tourniquet on the blood supply and it doesn't on the vein, and they are, and the lymphatics, so the ovary swells so it doesn't get, doesn't reduce. The other baby had no such thing, she just had swelling, the ovary comes in and out, but it goes back in, so it was not a critical thing. But if the ovary comes out in a hernia in a girl, then you can lose the ovary. So that's why we have to fix it as soon as possible. So they were fortunate that we are here because they don't have any surgeons in this area that can do babies, especially this type of surgery. And also they don't- they don't anesthesia- Anesthesia is also important in situations like this where you have- anesthesiologists who are comfortable or competent in- in giving anesthesia to babies.</p>

<h4>CHAPTER 2</h4>

<p>[No Dialogue]</p>

<h4>CHAPTER 3</h4>

<p>You go through Scarpa's fascia. Now we're looking for the hernia sac. Hemostat? And the ovary was trapped in the hernia sac for a long time. I don't know how long. Hemostat? And this is the hernia sac now. Pushing all the other tissues away from the hernia sac. So we can save the ovary from getting trapped. I think this is the ovary right here. And Lissa, cauterize this slowly. Okay. Yeah- I think the ovary is reduced. Yeah, that. There's the round ligament. Okay, good. Perfect. Perfect.</p>

<p>Good. Now she's suturing the hernia sac now, and we're doing it above the ovary, or distal to the ovary. The ovary is ready, almost to the belly. All right. Now we load up another suture. You stick- you put the needle in the needle holder, and go through the tissue. Go towards here, towards me. Okay, now tie that. For a tiny baby, you can see the hernia sac is large. And- the ovary's been stuck there for I don't know how long. But it's viable, It's not- it's not affected by it. Hemostat? What we're going to do now is we're going to put a purse-string suture on the base. You're going to put the purse-string suture on the base of the sac, so we can tuck this in. See? You can see there, just- catch the thick part of the sac. Yeah. Yeah, you go a little deeper. Yeah, even deeper. Where the white- you can see the nice white, pearly white tissue. Yeah. Good. Get that, there's a nice one. Good, perfect. Okay. Good. Good. Okay. Let me have the other one. Now you watch for the epigastric vessels. Go as far as you can go, the vessels are- I can see the vessels. Go as far as you can go on the pearly white tissue. Yeah, that's it. Good. Good, perfect. You know, this- this technique, they can apply it in adult patients as well. And it'll make it easier for them to do the procedure. You need to go one more. See, right at the pearly white tissue. You can do the same for young adults. Right there. Good. Yeah, that's a good bite. I like that. Yeah, do it again. Yeah, that's good. Push this whole thing, push that all the way in. Okay, tie- now you tie the purse-string. That should close it, so see? And we got- we got two objectives there, we- ligated the sac and also- closed the internal ring at the same time. Okay, good. Okay, now we can close the external oblique.</p>

<h4>CHAPTER 4</h4>

<p>Actually, that should be enough. And we just have the- distal portion Yeah. God, this one doesn't have the- is this- this is the one that was on the- tie it, just tie it, we don't need anymore. So, I'll do it your style. Yeah- yeah, that's right, interrupted subcuticular, yeah, you can… You'll like that better anyway because it's a lot easier, you only need 3 stitches, and sometimes you only need 2, and then that's it, you're done. You have to be- You have to be equal and even. So they don't have overlapping, and it heals better because there's less foreign material in the… Yeah, in the sub-Q area. Yeah. So you wont have- you'll have less redness. Now let me show you- let me show you a trick. Okay. The trick, the trick for this kind of of suture is you catch the edge, you catch the edge of the wound. Edge, like that, and you go down, and then you rotate, see? See how the needle rotates? Then you come out. See? And then you make that little twist on the wrist. And then- see how big that bite is? Nice one. And then you go, you move your body just a little, see watch, watch- watch my body, See? I rot- rotate my body, so that I can catch the edge of the wound like that.</p>

<h4>CHAPTER 5</h4>

<p>Perpendicular wound. Incision. Go ahead. A little bit more. Yeah, right here. See if you can- no bleeding, just lean, lean, lean, lean a little bit more. Okay, good. Perfect.</p>

<h4>CHAPTER 6</h4>

<p>Retractor. Yeah, I can see the bulge now. Just pull it up high when you get the clamp.</p>

<p>Okay, and then just- just cauterize that.</p>

<p>Perfect. Okay. Good. All right, good. You just put a single stitch there? Yeah- A figure of eight. Okay, you can get the 4-0.</p>

<h4>CHAPTER 7</h4>

<p>The procedure's done, we're just going to close the last wound. Yeah.</p>

<h4>CHAPTER 8</h4>

<p>So we, we did the procedure, and we took the sac and also preserved the ovary. And there's a certain technique that I developed over the years where instead of opening the sac, look at the ovary that's stuck, and try to release it away from the sac, and then push it in, and then for the suture, that takes a long time and can be bloody. And also it, it gives the anesthesiologists a challenge because it hurts more when you're doing all that. So when the baby starts bucking, then you have to do other things to- to maintain your airway and keep the baby alive. Whereas this technique, I just put a- after I ligate the sac, high and away from the ovary, I put a purse-string suture at the- at the base of the, of the sac, catch the fascia or tissue that's very thick, and then I invert the whole thing, with the sac and the ovary into the belly. And then tie the purse-string suture, and the hole is closed. And that seems to be very effective in this situation. It makes the operation much quicker, and much safer, and less complications for anesthesia. And so that's why we can do this operation very quickly and safely in a setting like this. Thank you.</p>

Watch this full-length, narrated procedure of a bilateral open inguinal hernia repair performed during a surgical mission with the World Surgical Foundation in the Philippines.

Romblon Provincial Hospital