Right Inguinal Hernia Repair on a 1-year-old Boy During a Surgical Mission

Pediatric inguinal hernias are considered a common condition in male children, with an incidence rate of 6.62 % in boys from birth to 15 years old.¹ In male children, the majority of these hernias are congenital, resulting from a failure of the processus vaginalis to close properly during fetal development, as extensively documented in the literature.²

Prompt surgical repair is widely recommended by experts to prevent potential complications, such as incarceration, bowel obstruction, and necrosis. Delayed treatment has been shown to increase the risk of an emergency procedure and associated complications in multiple studies.^3–5

In resource-limited settings, inguinal hernias in infants often remain unrepaired for extended periods, leading to the development of massive hernias. These long-standing hernias can result in significant anatomical distortion, posing unique challenges for surgeons during the repair process.^6,7

As the hernia persists over months or years, the cremasteric muscle fibers become hypertrophied and stretched. This muscular thickening can obscure the normal anatomical landmarks, making it difficult to identify and isolate the various structures within the inguinal canal. The hernia sac itself can become densely adhered to the surrounding tissues, including the vas deferens and spermatic vessels, and this adherence can lead to distortion of the sac's shape and position and increases the risk of iatrogenic injury during dissection.⁷ Inadvertent damage to these structures can lead to complications such as testicular atrophy or ischemia. Additionally, it is important to note that the cremaster muscle, along with the external spermatic fascia and internal spermatic fascia superficial and deep to the cremaster muscle respectively, comprise the wall of the spermatic cord.⁸

To address the challenges posed by giant inguinal hernias in infants, experienced surgeons may employ specific techniques and approaches described in the video.

This comprehensive video is intended to provide a detailed overview of the surgical technique used to repair a right inguinal hernia in Honduras on a 1-year-old boy who presented with a swelling in his scrotum, which had been present since he was two months old. The surgical procedure is narrated by an experienced pediatric surgeon, highlighting the unique challenges and innovative techniques employed in this case, which can be valuable for surgeons facing similar situations. The importance of this video lies in its educational value for surgeons, particularly those involved in surgical missions or practicing in resource-limited settings.

The critical step of initiating the dissection of the hernia sac distally, towards the scrotum, rather than proximally, near the internal inguinal ring, is emphasized by the surgeon. This approach is believed to help maintain the integrity of the sac and avoid disruption, which can lead to fluid leakage and anatomical disorientation.

A key aspect highlighted in the video is the importance of identifying the separation between the cord structures and the hernia sac. A gentle tunneling technique using atraumatic tissue forceps to create a plane between these structures is demonstrated by the surgeon, allowing for the safe dissection and preservation of the vas deferens and spermatic vessels.

A technique of preference for securing the internal ring repair is introduced by the surgeon, which involves placing sutures at a high level and narrowing the internal ring by placing sutures on transversalis fascia, rather than relying solely on ligation. The video also emphasizes the significance of achieving a high ligation of the hernia sac at the level of the internal ring. Also highlighted is the importance of clearly visualizing the vas deferens going medially and the spermatic vessels going laterally, indicating that the proper level of dissection has been reached. Failure to reach this level will result in incomplete narrowing of the internal ring and an increased risk of recurrence.

Furthermore, it is important to explore the contralateral side in children in cases of low birth weight babies, twins, premature babies, girls, increased intraabdominal pressure, and clinically diagnosed hernias on contralateral side.

The surgical technique is concluded with the closure of the external oblique aponeurosis, preservation of the ilioinguinal nerve, and skin closure using an interrupted subcuticular suturing technique.

The repair of inguinal hernias in children, particularly in resource-limited settings, presents unique challenges due to the potential for anatomical distortions and increased surgical complexity. This surgical video and accompanying text serve as a comprehensive guide and offer invaluable insights into the techniques employed by experienced surgeons to overcome these challenges and achieve successful outcomes, contributing to the existing knowledge in this field.

The parents of the patient referred to in this video have given their informed consent for surgery to be filmed and were aware that information and images will be published online.