Right Inguinal Hernia Repair on a 1-Year-Old Boy During a Surgical Mission

CHAPTER 1

This is a one-year-old Honduran boy who I saw in the clinic with a huge swelling in his scrotum. You can reduce it, and when he cries, the swelling comes back. And he had it since two months of age. And this is much bigger than you normally see in the US because in the USA, when a hernia shows up, right away the family knew something was wrong, they go to the doctor, and they get referred to me right away, so most of the hernias we see are not large. So I call this a mission hernia, typically, when you see this, and in a mission hernia, the anatomy is disrupted because the cremasteric fibers, this is a muscle that's around the cord, it gets very thick - we call it hypertrophy, and so, you can get confused, but this one's not so bad here. I've seen worse. So this is not as bad as what I've seen in the past, so it's a lot easier. The name of this procedure - it's just a simple right inguinal herniorrhaphy, but it's much more complex in the way that - this is my own technique because most people, what they do is they do what they call a high ligation, so when they do a high ligation, they just go as far as they can go. They're afraid to touch the cord because you can injure the cord, but what I do is I actually go as high as I can go, where I can see the vas deferens go medially and the vessels go laterally. If you don't see that, you are not high enough because then you're not in the internal ring, because you have to close that internal ring - when you have a large hernia, the internal ring is large - so when you do a young adult, it's a similar technique, you really have to go high and actually, you really have to see the vas going medially and the vessels go laterally. If you don't see that, you haven't done your job. You're going to have a recurrence. And the important thing about the dissection is to perform the dissection of the sac distally. That's the key because most surgeons, they start - when they see a hernia sac, they get excited, and they start dissecting it proximally, up in the belly area. When that happens in a child, you can disrupt the sac so quickly and then you get lost because you don't know where the back side of the sac or the front part of the sac is - it is completely disrupted, but if you dissect distally first, then you identify the sac, and if you open the sac - at that point, you're distal, you still have a lot of sac to dissect. And the key is that there is a structure we call gubernaculum. And that - that structure belongs to the scrotum, and the sac and the gubernaculum are adhered to one another, but you can separate them, and if you could separate them carefully, you don't need any technology, you don't need cautery or tying any blood vessels because that's an avascular space, and you can actually separate them. And once you - when you separate them, what you do is you put the sac on tension with your finger and lift up the sac towards the sky, I call it. That's the best way to describe it. You can put a hemostat or whatever means you have, but mostly your finger and you lift it up to the sky. And once you lift it up to the sky, and you can see the back end of the posterior wall of the sac, you can then see the cord, and then you start dissecting the cord away from the sac. There's an actual separation between the cord and the sac. If you just put a DeBakey forceps in those layers, you can actually go in like a tunnel and you just push it away, and it just is pulled away from the sac. And then the main thing is the vas deferens - and it's really adhered to the sac, but again, there's a complete separation, if you know where that layer is. And unless you're a seasoned surgeon in pediatric surgery, you'll just get lost. And if you disrupt any sac that's close to the vas, you're going to be in trouble. It's going to take you a long time to recover. That's why it's important to start the dissection of the sac distally - because you can recover if you get a hole, you can recover, but if you do your dissection proximally, it's hard to recover because then everything is just falling apart. So, in this case, we explored the opposite side after we did the primary operation because the child's hernia came at two months of age, so that - typically, when the hernia is seen under two years of age - a hernia one side - the chances of finding a potential hernia on the opposite side is higher when you see a child, in males, under two years of age, to see a hernia sac on the opposite side. So beyond two years, you don't explore anymore, you just do the one side that you see unless there's a clinical hernia on the opposite side. We're going to make the incision.

CHAPTER 2

The first lesson is that we're going to - I mark the area of incision with the hemostat, and we're going to want a skin line. Okay. And then we're going to do a perpendicular incision so it doesn't bleed that much. Okay, scissors. Okay, cauterize it. DeBakey. Go ahead. Retractor. So we went through Scarpa's fascia. Yeah, we... And we're trying to get to the external obliques now? Yes. Perfect. Okay. So... Can you get the light adjusted? And you have the aponeurosis over there? Yeah. It's the external oblique - it's right here. Mm hmm. So we're seeing the external oblique aponeurosis now, right here. And I'm going to make an incision on it, so we can see the cord. Not like that. I want to see distal, like that. Okay, knife. Oh, the knife is not cutting. There. Okay, scissors. So what we have to look - what we look for are the nerve - the ilioinguinal nerve - not yet - There's the nerve right there. You can see the ilioinguinal nerve exposed. You may go towards the external ring. Just cut it a little. Okay? Then I'm going to retract the external oblique. So what we do now is we go through the - cremasteric fascia to get to the sac. It should be a very good size sac.

CHAPTER 3

And you pick up the sac, and then you look for the - the critical point here is to look for the gubernaculum. And this area of the gubernaculum, you can see that, if you could separate that away, you can pull the sac up towards the sky, basically. See? See? By seeing this structure, you can bring the sac up much better, so you don't disturb this structure right here. This is where most people get into trouble because they disrupt the anatomy right away. You can see how the cremasteric fibers are - are very well developed because this kid's hernia has been here since he was two months of age, so it's been stretching. Get a hemostat in here, and - hemostat. See, the key is to do your dissection distally. You try to, now that I got the sac, I can pull it up like this, and peel, I call this a peel, you peel the tissue. This tissue here belongs to the scrotum. This tissue here belongs upwards. You can see as you bring up the tissue, upwards, the sac becomes more visible. And then you can put your finger underneath. Put another hemostat right here. And this is what I meant. You see, the cremasteric fibers are very well developed in a mission hernia, we call it a mission hernia. And that confuses people, many times. So here, this tissue is avascular, this part. And once in a while you might see like - you can see a blood vessel in there, you might cauterize it, or immolate it, or something, but we'll see if you don't have to do that. There, you can see the sac is developing now. Mm hmm. And this should be a - I'm not sure whether this communicates with the tunica or not. The... This goes all the way down to the scrotum, to the sac, because I saw it - it was big, it was a big sac. But this is the tissue that I'm peeling off, see? Right here, you can see the demarcation, you can see that structure. That's the gubernaculum remnant, see? There's - that's all going - that belongs to the scrotum. And then, you see, my finger? I'm pushing the sac, and you can see the cord starting to show up. Using this technique will save you a lot of time and trouble. You see? I'm... See, the testicle is starting to show up too, but see it right here, this - see how the structure peels off? The sac's very thin - actually, paper thin, so if you're not careful, you can disrupt it, but I do all the dissection initially distally, towards the scrotum, but not up here. I'm not even at the internal ring. The mistake I find is people start to dissect up here. That's bad. Start way back there. Okay. You start distal, and you can see, everything will separate in a second. Doing fine. And if you just peel it, it will literally push away. It'll push away until you see the cord structures separate. Yeah. We're still intact. We haven't disrupted the sac yet. When you disrupt the sac, there'll be fluid coming out, so when you have disrupted it... Now you can see the cord structure there, part of the spermatic vessels. And you should see the vas posterior to all this. Should show up soon. And there's actually a close separation between the sac and the cord, so you find that separation, it'll come out intact, you see? Just by doing this, peeling this off - gubernaculum remnant, the whole sac will come out to the surface. I haven't seen the vas yet, so we have to... I don't need this anymore, so you can take that out. Now you can see, I'm around the cord on the sac now, so we're going to find where the vas is located. It should be visible anytime soon. Yeah, should be in there. So what I do, usually, is I just get a gauze to hold that. See, that's the cord, part of it. And the vas, I think it's right in here. There's your cord, you see? That's it, there's the vas. Right there's the vas. Mm hmm. Your vas is right there. There, there's the vas. Tiny little thing. You can - this - part of this cord, these are just the vessels. I don't have the vas yet around it. Just go like that, gently. And then I'm going to put the vas on top of that. Okay, not quite yet. There, you got it. So now we got the cord protected. Now you can divide this with cautery - you go ahead.

So we're dividing the sac first? We're going to divide the sac now because we have the cord protected. Okay, good. So now we got the sac here. This is the distal component of the sac - we're going to separate it from the cord structure. You can pull this up this way.

And there should be a space here you can - you can cauterize, go ahead. Okay. I can see the vas in there. Yeah, the vas is right here. This one you can divide, this one. Mm hmm. Okay. You can divide this. Mm hmm. Okay, so the sac did not communicate, it did not communicate with anything, so we don't have to do anything with it. No problem. Yeah, no problem with the sac, yeah. It didn't go down to the scrotum. So now we - what we're doing now, we're just separating this... These fibers. Sac away from the... Mm hmm. Okay. The fibers. Mm hmm. And then the preperitoneal fat. Mm hmm. Would you call that a cord lipoma or not really? No, it's just fat, but you can - everybody calls it a lipoma, but it isn't. So we're almost there. And the endpoint will be when you see the blood vessels, the deep epigastric vessels. Get the retractor here. Yeah, the deep one. Yeah, that's good. You go as far as you can until you see the fascia. And then you should see that the vas should go medial, and the vessels should be lateral. Mm hmm. On the way to the retroperitoneum. Correct. Hemostat. So the advantage of starting your dissecting distally is you maintain the integrity of the sac. Okay. Because if you try to dissect proximally, you have a very thick one with a lot of blood vessel, you can get into trouble right away. See, now you can see, you can actually - one trick, you can get a gauze like this, and you push the spermatic cord away - away, like you go retroperitoneal and you just, you don't have to push very hard, just push the gauze. Smooth dissection. Like that, and you see it'll separate, you'll see where the cord is going to go, just push this down. You see? Mm hmm. You see, when I take the gauze off, you'll see the separation, and that's where your suture's going to be because you're doing a very high ligation, which is actually an internal ring repair, not the typical high ligation that they taught us before where you're afraid to do this. Mm hmm. Yeah. that's why you have recurrences in hernias when they don't go very high in their ligation, you see? Okay, you leave some part of the sac. We leave part of the sac, yes. And also, you how a weak internal ring, so here, the difference between the way they are taught and the way I do it is because I really go high, very high. Okay. And see, I'm still doing it. You see that it's starting to create a fold. You see? Mm hmm. This is just a simple technique. Just put this dry gauze... Just do it slowly because the vessels can get disrupted if you're too crass and you're too rough, you can disrupt the blood vessels, and the bleeding can be difficult to control. So this way, you just push. See, you just push, and you push, push, and you see what happens when I take it out. Mm hmm. Now you can see - see quite a bit, it's really way up high. You can see this preperitoneal tissue. See, it goes straight to peritoneal space, right there. That's the retroperitoneal space you're seeing. Now this is not sac, this is still fascia, so you can make that even clearer. So you need 3-0 Vicryl first. 3-0 Vicryl. 3-0 Vicryl. See, I'm pulling it up. See how far I'm pulling? Mm hmm. You can pull up here, you can see there - there, you can see fascia, nice fascia, right there. See, I don't do the twisting of the sac, like what we were taught to do. I don't twist the sac or anything. I just anatomically see what the sac look like.

CHAPTER 4

So what I do is I put my stitch way high, like this. And then I close on the other side. I put the other... Of the fold? Yeah, and that closes the ring. All the way. Tie it, Ronny, tie. Mm hmm. Good. Go ahead, tie - tie one more part. And then what I do is I go over that. There's a knot. Mm hmm. Go here. Mm hmm. And then we'll put a stick - we'll stitch way up high. Hold this. Okay. Hold this retractor. And I get this thick fascia. I don't like to ligate because the people who have been ligating - in fact my ex-partner was ligating, and the hernia recurred because the ligation didn't make it, so I do this. See? Okay. You do a stick-tie. Mm hmm. So you can actually secure your tie by doing this. Okay. This will prevent any recurrence. See? Now you can tie, see? Okay. That would secure it. This will keep your hernias from recurring. Tying, I don't like. I don't like the - I have to put a stitch. Okay. Okay? I don't like that technique, because I've seen problems with that. So the next thing you're going to do is you're going to put another stitch right here, distally. Like here. Now that we secured our internal ring repair, we can - we can put another tie, another stitch, right in there, tie it, and then we go around it. Tie. This secures it. And then we go over it, and there you go. That secures it. See, I loosen up so she can tie tighter. Scissors. Perfect. Okay, and that should make it disappear all the way. Yep. Once we let go because... It goes into the retroperitoneum. Yeah, because - you can divide this, it's not necessary. Tap that around. Now we can bring the testicle back. We didn't do anything with it, so he's not going to have a hydrocele post-op. Because you take off all the sac. Yeah, you got all the sac. Also, the sac did not communicate with the tunica vaginalis. Yeah, here's the testicle now, see? Yeah, and that's the end of the operation. We just close the... The fascia - aponeurosis. You have another one of these Simms? One more?

CHAPTER 5

Okay. Now we got - we preserved the nerve, ilioinguinal nerve right there. Mm hmm. So what you can do is get an apical stitch. Here's another trick, I just do an apical stitch, and then you tie that, and then you pull it up so you can see the layers that you're suturing. I'm going to give you these needle holders. Okay. See this needle holder? Mm hmm. That's mine, so - you can have it for pediatric surgery. Thank you. I got four of them, four different sizes. Okay, cut. Keep the nerve away from there. See, I just get one stitch on the Scarpa's fascia, I don't get too many. Just enough to pull them together. Just approximate. Mm hmm. Okay, tie. Tie. And then I put scissors through it. Then I usually do an interrupted - Monocryl, yeah - interrupted subcuticular. The trick for this stitch is you go edge of the skin. I just need two of them. On the dermis, and walk with the needle and come out to the surface. Good for your private patient, by the way. Mm hmm. Then you make sure you're equidistant to the last needle, to the last suture you have. Edge of the skin, down to dermis, deep. You walk with the needle. It's okay, I got it. Then you walk with the needle and come out to the surface. The whole idea is that you approximate the tissue together. All the tissue. All you need is that - when you tie, they should be approximated. Okay. Nicely. Okay, cut. So it's a - it's called an interrupted subcuticular. Okay, and that's the end of the - that's the incision for the hernia repair. And this will heal properly because it's on the line, and you won't see a scar in about a few months.