A Colour Atlas of Inguinal Hernias and Hydroceles in Infants and Children [Reprint 2023 ed.] 9783112695906, 9783112695890

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inguinal Hernias and Hydroceles in infants and Children

Single Surgical Procedures A Colour Atlas of

inguinal Hernias and Hydroceles in infants and Children Caroline M. Doig

W G DE

Walter de Gruyter • Berlin • New York 1984

3

Caroline M. Doig Ch. M, FRCSE, FRCS; Senior Lecturer in Paediatric Surgery, University of Manchester and Booth Hall Children's Hospital Manchester Copyright © Caroline M. Doig 1983 Original Publishers: Wolfe Medical Publications Ltd., • London Exclusive co-publishers for the Federal Republic of Germany and Austria: Walter de Gruyter & Co., Genthiner Strasse 13, D-1000 Berlin 30.1984. Printed by Royal Smeets Offset b.v., Weert, Netherlands Cover design: Rudolf Hübler General Editor, Wolfe Surgical Atlases: William F. Walker, DSc,ChM, FRCS (Eng.), FRCS (Edin.), FRS (Edin.) CIP-Kurztitelaufnahme

der Deutschen

Bibliothek

Doig, Caroline M.: A colour atlas of inguinal hernias and hydroceles in infants and children / Caroline M. Doig. Berlin; New York: de Gruyter, 1984. (Single surgical procedures; 3) ISBN 3-11-010011-8 ISBN 3-11-010010-X (Subskr.-Pr.) NE: GT

All rights reserved. T h e c o n t e n t s of this b o o k , b o t h p h o t o g r a p h i c a n d t e x t u a l , m a y n o t be r e p r o d u c e d in any f o r m by print, p h o t o p r i n t , p h o t o t r a n s p a r e n c y , m i c r o f i l m , m i c r o f i c h e or any o t h e r m e a n s , n o r m a y i t b e i n c l u d e d i n a n y c o m p u t e r retrieval s y s t e m , w i t h o u t written p e r m i s s i o n of t h e publisher. D i e W i e d e r g a b e v o n G e b r a u c h s n a m e n , W a r e n b e z e i c h n u n g e n u n d d e r g l e i c h e n in d i e s e m B u c h berechtigt nicht zu der A n n a h m e , d a ß s o l c h e N a m e n o h n e weiteres v o n j e d e r m a n n b e n u t z t w e r d e n d ü r f e n . V i e l m e h r h a n d e l t es sich h ä u f i g u m gesetzlich g e s c h ü t z t e , e i n g e t r a g e n e W a r e n z e i c h e n , a u c h w e n n sie nicht eigens als s o l c h e g e k e n n z e i c h n e t sind.

Contenis Page Acknowledgements

7

Introduction

9

Diagnosis

12

Operation of elective inguinal herniotomy

15

Postoperative management and complications

44

Emergency surgery

46

Hydroceles

47

Surgery on hydroceles

50

Postoperative course

57

References

59

Index

61

To my Mother for her constant support and encouragement.

6

Acknowledgements I am indebted to my numerous teachers in Paediatric Surgery who taught me the management of baby hernias and hydroceles. My grateful thanks to my photographer who patiently took numerous photographs of inguinal herniotomies and hydrocele operations, and to my secretary for typing the manuscript. I wish to acknowledge the help of the Manchester North District Area Health Authority for allowing the use of slides of children admitted to Booth Hall Children's Hospital, Manchester.

Introduction The operations described in this book are those commonly performed by most paediatric surgeons and those general surgeons, who have a wide experience in dealing with hernias and hydroceles in children. No surgery should be undertaken in children, let alone babies, without the surgeon having had adequate surgical training. The importance of the team in looking after these children cannot be over emphasised - this includes the anaesthetist, ward and theatre nurses, and surgeons. Inguinal hernias in children are congenital in nature and therefore are almost always indirect. The hernial sac passes through the deep inguinal ring, the inguinal canal and the superficial ring within the coverings of the cord. By virtue of the anatomy in the baby and infant, the deep and superficial rings are almost superimposed with very little potential inguinal canal. Because of this it is possible to deal with the hernial sac through both inguinal rings without opening the inguinal canal. Such hernias are more likely to become irreducible, because it is easy for bowel to enter the sac, leading to eventual strangulation. In view of this, hernias in babies and infants under two years of age should always be operated on urgently. In my practice, they undergo surgery on the first available operating list.

10

Types of inguinal hernia

a

1 a) b) c)

Types of inguinal hernia in infants and children. Normal anatomy Complete scrotal indirect hernia Incomplete indirect inguinal hernia

The incidence is 1:50 in boys and 1:400 in girls. Baby hernias occur on the right side in 60 per cent of cases and in 25 per cent on the left side. Because only 15 per cent occur bilaterally, routine bilateral exploration is not carried out unless there is a history of swelling or a wide inguinal ring is felt on the contralateral side.

11

Diagnosis Diagnosis is easy in a reducible inguinal hernia, because it is a swelling over the superficial inguinal ring and in the scrotum which reduces with gentle pressure. Differential diagnosis includes hydrocele of the cord, undescended testis and enlarged lymph glands. Even if no swelling is found, I feel that surgery should be undertaken if there is a good history from the parents of a recurring swelling in the groin. Often, either the superficial inguinal ring can be felt to be enlarged or, on palpating the cord and coverings at the superficial ring, a silky sensation can be felt i.e. rolling the hernial walls against each other.

2 Large scrotal inguinal hernia. Such a hernia is easily reducible into the superficial inguinal ring.

12

3 Bilateral, incomplete inguinal hernias with elevation of testes out of the scrotum.

The commonest complication of baby inguinal hernias is incarceration of bowel leading to obstruction, reduction in blood supply and ischaemic bowel. This occurs especially in the very young and premature baby. If missed it leads to perforation, peritonitis, septicaemia and death. Compression of testicular vessels leading to ischaemia and gangrene of the testes can also occur very quickly. The differential diagnosis in such cases include lymphadenitis, acute hydrocele and torsion of testes.

Treatment Because of the risk of incarceration, baby hernias should be dealt with as soon as they are diagnosed. They should not be put on a waiting-list, but need surgery as a semi-emergency on the next available list. In the older child the risk of damage to bowel or testis is less acute and surgery can be carried out in an elective manner. Sedation of the child with elevation of the foot end of the bed is usually all that is necessary to allow the more difficult baby hernias to reduce. Gentle traction may also be used. When hernias are reduced by conservative measures, we keep the child in hospital for two to four days to allow oedema to settle, and then perform elective herniotomy before discharging the patient. The risk of conservative management of incarcerated bowel in a hernial sac is that the necrotic bowel may be returned to the peritoneal cavity following the manual reduction of the hernia. Such children, who are treated conservatively, must be observed closely for the next 6 to 12 hours and may require surgery if it becomes incarcerated again or if physical signs suggest peritonitis. However, if the hernia does not reduce easily, emergency surgery must follow because of the risk to both the bowel within the hernial sac and the blood supply to the testis.

4 Gas bubble in scrotum. Xray of a gas bubble (arrowed) in the scrotum indicative of bowel in the scrotum, which suggests an irreducible hernia. Urgent surgery is a must.

14

Operation of elective inguinal herniotomy The following operation can be performed for elective repair of inguinal hernias in all babies and children up to their early teens. It may be necessary in the older child to open the inguinal canal to allow the hernial sac to be completely dissected - the operation becoming similar to that performed in adults. In the case of elective surgery, the children are admitted as day cases, or at the most for an overnight stay. All children are operated upon under general anaesthesia. No premedication is given to children under one year. Trimeprazine tartrate is used in the older infant and child. All children are intubated and monitored, either on assisted ventilation or spontaneous ventilation with a paediatric circuit. Postoperatively, intramuscular pethidine is given.

f

!/

5 Prevention of hypothermia. In the baby, especially aged under three months, there is a risk of hypothermia during surgery. These children should be placed on an electric or hot-water blanket. During surgery they are covered with warm, sterile gamgee, under the sterile drapes. A hole is cut to allow the operation to be carried out. With the older child four gamgee pads can be used, leaving the operative field clear.

15

6 and 7 Invagination of scrotum. By invaginating the s c r o t u m , the wide superficial inguinal ring, above and lateral to the pubic tubercle, can b e felt and d e l i n e a t e d . A short incision can b e m a d e o v e r the superficial inguinal ring in the line of the skin crease as indicated by the skin m a r k e r .

16

8 In a female child the incision is made over the superficial inguinal ring. If the incision is correctly positioned, neither the superficial epigastric artery nor the ilio-inguinal nerve can be damaged.

9 Two mosquito clips are placed on either side of the incision on subcutaneous tissues. There is rarely any bleeding. If bleeding does occur, a clip is left for a few minutes and twisted off so as to prevent any need for diathermy. Ligation of vessels is not normally necessary.

17

10 The clips are held up by the assistant and blunt dissection, using M c l n d o e scissors, carried down t h r o u g h the d e e p fascia t o w a r d s the superficial inguinal ring.

18

11 After the deep fascia has been opened the superficial ring can be palpated. Blunt dissecting forceps are used to bring out the cord and coverings t h r o u g h the w o u n d . This is possible, even if the child is fat, because t h e r e is only the spermatic cord with its coverings coming through the superficial inguinal ring. In a girl, only fat and the hernial sac a p p e a r at the ring.

12 By blunt dissection, the cord with associated hernia, is freed of surrounding fat, so that it is possible to pass the index finger of the o p e r a t o r through the tissue to allow these structures to lie on top of the index finger.

20

13 Two clips are placed on the coverings i.e. the external spermatic fascia and cremasteric muscle. The clips are held up to put the tissue on tension.

21

14 This allows the vas to be visualised. Division of these coverings with a knife can then be carried out safely without damage to the vas or testicular vessels. Here the knife is pointing to the vas deferens.

22

15 Dissection is then carried out proximally to the superficial inguinal ring. The fascia and muscle are lifted up by forceps to allow them to be cut and to give a clear view of the inguinal ring.

16

16 In the case of an incomplete hernial sac the outline of the sac can be seen and picked up by mosquito clips.

17 By putting traction on the sac, blunt dissection can be carried out easily using either a dry swab or blunt broad forceps. Care should be taken during this manoeuvre not to damage the vas deferens and the vessels.

23

18 Even if the hernia is of the more common scrotal type, t h e sac can be visualised ( a r r o w e d ) and s e p a r a t e d f r o m the vas and vessels which are lying posterolateral. If care is t a k e n with the very fine sac, it is possible to dissect it f r e e without d a m a g e .

19 Once free, damage to testicular vessels and the vas deferens can be p r e v e n t e d by use of an Allis forceps to k e e p t h e m clear of the dissection.

20

m&mt^M wJMMsm Wm&A

20 Two clips are put on the hernial sac which is then divided distally. Careful dissection downwards towards the inguinal ring can then be carried out as before with a dry swab and the sac on tension.

26

27

22

22 Hernial sac damage. H o w e v e r , the hernial sac can be d a m a g e d easily during dissection, especially in the case of a very fine sac which can be difficult to visualise. In that case clips may be put on at right angles to t h e line of the sac to prevent the sac f r o m tearing f u r t h e r t o w a r d s the peritoneum.

28

23 If this happens the very fine sac can be dissected bit by bit, clearing it away f r o m the vas and vessels with care, so as not to d a m a g e t h e m .

29

24 By careful dissection, eventually the complete 'ring' of the sac can be seen, lying free from the vessels. In some very small children with 'tissue paper'-like sacs, this may be time consuming.

30

25 Two clips are placed across the hernial sac which is then divided distally. Dissection is then carried out as before towards the superficial inguinal ring.

26

26 The sac whether opened or closed is twisted to return any contents to the peritoneal cavity. A D e n i s B r o w n e spoon is used to k e e p the vas and vessels s e p a r a t e f r o m the hernial sac.

27 A Denis Browne spoon. This is an ordinary t e a s p o o n with a g r o o v e cut into it.

31

28 A transfixion suture is placed through the hernial sac, avoiding vas and vessels, using 3/0 or 2/0 black silk (size d e p e n d s on t h e age of the child and the thickness of the sac).

32

29 Tension of hernial sac. While this suture is being tied the hernial sac is kept on tension so that the suture lies as n e a r t h e d e e p inguinal ring as possible.

33

32 and 33 If adequate tension has been applied, the s t u m p will disappear into the d e p t h s of the w o u n d t h r o u g h the d e e p inguinal ring once the suture is cut.

36

34 Ovary in sac. In f e m a l e children, w h e n the sac is o p e n e d , an ovary may be f o u n d in the sac. It should be r e t u r n e d to the abdominal cavity and t h e hernial sac closed as b e f o r e .

37

37 Undescended testis. As seen in some of the previous photographs, with dissection, the testis may have been brought out of the scrotum. In some children, the testis may be undescended because of the presence of the hernia.

38 By dealing with the hernia the testis is released. It must be replaced in the scrotum to prevent an iatrogenic undescended testis occurring after hernia repair. This is achieved by gentle traction on the scrotum. The vas and vessels must be orientated correctly, so as not to cause torsion and therefore lead to late atrophy of the testis.

39

40

40 Closure of superficial fascia. These clips are held up clear of the deep dissection to allow closure of the superficial fascia. Interrupted subcutaneous sutures of Dexon (3/0) are used to approximate this. Usually only two or three are necessary.

41

42 and 43 Cosmetic appearance. Subcuticular continuous Dexon suture (3/0) is used for skin closure to give a more cosmetic result. This obviates the necessity for suture removal in very young children. Very occasionally, the use of Dexon may give an indurated scar. A plastic spray (acrylic resin) may be used with or without a gauze strip as dressing.

43

Postoperative management and complications There may be some swelling of the scrotum and the wound, especially if the testis has been brought out of the scrotum. This settles within 24 to 48 hours. The baby or infant can be fed some six to eight hours after surgery, once the patient has recovered completely from the anaesthetic. Normal practice is for the child to be allowed to go home the following day and be seen at follow-up four to six weeks later.

Postoperative complications Complications are rare and consist of: i) Haematoma, if there has been much dissection, especially in the scrotum. ii) Wound infection rarely occurs in the elective case, and is usually associated with a previous nappy rash. iii) Undescended testes should be avoidable if the proper technique is used. The importance of ensuring the testis is returned to the scrotum cannot be over emphasised. If the testis is left at the superficial inguinal ring, it will become fixed by scar tissue requiring further surgery to return it to the scrotum. In many large hernias in babies, there is an associated undescended testis because the hernial sac prevents proper descent of the testis. In these cases the testis should

44

be placed and fixed in the scrotum at the time of herniotomy. If the testis has been involved with ischaemia as a result of incarceration of the bowel, the testis will atrophy over the next few years. iv) If structures are dissected with great care, damage to ovaries, testes, bowel and bladder is unlikely. The risk of damage to cord structures and sac contents is increased if the operation is performed as an emergency. Remember that the bladder may be involved as part of the medial wall of a direct hernia. This can look like peritoneum and only the production of urine gives the hint of the true abnormality. Once the mistake is recognised, suture of the bladder and catheterisation is all that is necessary. v) The chance of recurrence is reduced by performing elective rather than emergency operations, by careful technique in handling and identifying structures and by avoiding elaborate 'muscle repairs'. These are totally unnecessary in children and lead to damage to spermatic cord, testes and femoral vessels. Recurrence is rare (0.3 per cent) and usually happens only if it has been a complicated dissection.

44 Scar placement. A correctly placed scar should be practically invisible some six m o n t h s later.

Emergency surgery

45

In the case of the irreducible h e r n i a , the s a m e surgical a p p r o a c h may be possible as in the elective case, but usually the inguinal canal needs to be o p e n e d to f r e e the neck of the hernial sac and to allow the return of the bowel to the peritoneal cavity. I would suggest a low incision in the iliac fossa which allows dissection at the external inguinal ring, but also entry into the a b d o m i n a l cavity for resection of the necrotic bowel, if that is necessary.

45 Incision in emergency operation. In the e m e r g e n c y o p e r a t i o n for an o b s t r u c t e d inguinal hernia, a larger incision is necessary a n d t h e testis must b e b r o u g h t out. W h e n t h e hernial sac is o p e n e d , if the bowel is g a n g r e n o u s , resection must be carried o u t . A f u r t h e r a b d o m i n a l incision may be necessary as a b o v e - (a) the testis at the inguinal incision and (b) necrotic bowel at the a b d o m i n a l incision. A l t h o u g h it is t e m p t i n g a f t e r resection of necrotic bowel to r e a n a s t o m o s e t h e bowel, in the very young a n d / o r p r e m a t u r e baby, the fashioning of s t o m a s m a y be safer. Closure of the s t o m a s can be carried out within the next t h r e e t o six w e e k s , w h e n the child is in a far b e t t e r condition. 46

Hydroceles

Congenital hydroceles occur because of the persistence of the processus vaginalis. Different types of hydrocele occur depending on the part of the processus remaining.

46

46 Types of hydroceles. a) Intact processus vaginalis. b) Normal anatomy. c) Hydrocele. d) Hydrocele of the cord. As long as no associated inguinal hernia is involved, there is no urgency to treat hydroceles in infants, because most resolve when the processus vaginalis atrophies. It is usually unnecessary to operate before the child reaches two years of age. However, when an acute hydrocele occurs, especially in the infant or child, the possibility that it is masking torsion of the testis must be kept in mind. In all cases, the superficial inguinal ring must be checked thoroughly to exclude an indirect inguinal hernia. 47

47 It is possible to palpate above the swelling which will not reduce. In the case of a hydrocele of the cord a similar swelling is p a l p a b l e at the inguinal ring. T h e arrow indicates the side to b e o p e r a t e d on and not the swelling.

48

48

48 The swelling can be transilluminated - in this case in bilateral hydroceles.

49

Surgery on hydroceles49

T r e a t m e n t is by ligation of the proximal part of the processus allowing drainage of the distal portion. T h e o p e r a t i o n for dealing with hydroceles in children is similar to that for baby hernias. T h e incision is the s a m e , with dissection towards the superficial ring, u p to 14.

50

49 Hydroceles of the cord may bulge out through the wound even b e f o r e dissection of the cord is carried out.

50 However, in the more common scrotal hydrocele the processus (arrowed) can be visualised, when the cord is brought out of the wound and placed over the index finger as before.

51

52

52 A clip is placed across the processus which is then divided distally. There is no need for the testis to be brought out into the wound.

53 Two clips are used so that the processus vaginalis can be dissected proximally to the deep inguinal ring. Again under tension, the processus is doubly ligated as near the ring as possible.

53

54

55

54 After division of the processus the freed distal portion will allow drainage of the fluid. However, some hydroceles may not empty spontaneously. They should be allowed to bulge into the wound.

54

55 Care being taken to prevent damage to vas or epididymis; the hydrocele is incised to allow drainage. No further surgery is required on the distal portion in children.

56

56 Here the clear fluid is draining from a small incision in the tunica vaginalis. The testis is returned to the scrotum and the closure is the same as for closure following surgery for hernias (see 35 onwards).

55

57 Instruments operations.

most

commonly

used

in hernia

and

1 2

No. 3 Bard Parker handle with No. 15 blade Curved Halstead's mosquito forceps

3 4

Cryle-Wood needle holder Metzenbaum scissors 7"

5

Suture scissors

6 7

Adson's toothed dissecting forceps Blunt ended non-toothed dissecting forceps

8

Adson's diamond jaw non-toothed dissecting forceps

56

hydrocele 9

Allis tissue forceps Rampley's sponge-holding forceps

10 11 12

Backhaus towel clips Small Langenbeck retractors

13 14 15

Split spoon (Denis Browne) 2/0 silk atraumatic suture on round-bodied needle 3/0 Dexon on multi-purpose needle

Postoperative course

Postoperative care a f t e r hydrocele o p e r a t i o n is the s a m e as for a child w h o has had an inguinal herniotomy. Complications arising a f t e r hydrocele surgery are similar to those m e n t i o n e d following inguinal h e r n i o t o m y . Swelling of the scrotum almost always occurs, but this settles within two to three days. W h e n the processus vaginalis has b e e n left intact by treating the hydrocele either by aspiration or by o p e n i n g it via t h e s c r o t u m , the hydrocele will recur. T h e risk of iatrogenic u n d e s c e n d e d testis also follows hydrocele surgery.

58

References 1 Atwell, J., PaediatricSurgery (Ed. Nixon, H.H.) (Rob, C. and Smith, R.) 'Operative Surgery', Butterworths, 1978.

2 Jones, Peter G., Clinical Paediatric Surgery - Diagnosis and Management, Wright & Sons, 1970.

3 Holder, T.M. and Ashcraft, K.W., Pediatric Surgery, W.B. Saunders, 1980.

4 Nixon, H.H., Surgical Conditions in Paediatrics, Butterworths, 1978.

John

60

Index Numbers in medium indicate page numbers; those in bold indicate caption and figure numbers.

A Abdominal cavity 37, 46 - incision 45 Acrylic resin 43 Admission 14 Adults 15 Age 9, 1 3 - 1 5 , 4 7 Allis forceps 25 Anaesthesia 15, 44 Anaesthetist 9 Anastomosis 46 Anatomy 9, 1 1 , 3 8 , 4 7 - of hernia 1 - of hydrocele 46 Artery, superficial epigastric 17 Aspiration 57 Assistant 18 Atrophy of testes 39, 44

B Baby 9, 13, 1 5 , 4 4 , 4 6 , 4 7 Bed 14 Bladder 44 Blanket, electric 15 - hot water 15 Bleeding 17

Blood 38 - supply to bowel 13 - supply to testes 13, 44 Bowel 9, 44 - gangrene 46 - incarceration 13, 14, 44 - ischaemia 13 - necrosis 14, 45 - obstruction 13 - resection 46 Boys 11

c Canal, inguinal 9, 15, 46 Catheterisation 44 Cavity, abdominal 37, 46 - peritoneal 14, 31, 46 Children 9, 14, 15, 43, 44, 47, 50 Circuit, paediatric 15' Clips, mosquito 9, 10, 13, 16, 22, 25, 39, 40, 52, 53 Closure of coverings 35, 36 - fascia 40 - s k i n 4 1 - 4 3 , 55 - stoma 46 Complications, following herniotomy 44 - following hydrocele surgery 57

- postoperative 44, 57 - preoperative 13, 14 Compression 13 Congenital - hernias 1 , 9 - hydroceles 46 Conservative management of hernias 14 Conservative management of hydroceles 47 Contents - of canal 9 - of sac 31, 44 Cord, spermatic 12, 12, 19, 44, 51 Cosmetic appearance 43 - result 43, 44 Course, post-operative 44, 57 Coverings of cord 9, 12, 13-15, 19, 35, 36, 51 Crease, skin 16, 41 Cremasteric muscle 21, 22

D Damage to artery 17 - bladder 44 - bowel 13, 14, 44 - cord structures 44 - epididymis 54 - nerve 17 61

- s a c 22, 23, 2 4 , 4 4 - testes 12, 13, 44 - vas d e f e r e n s 22, 23, 44, 54 - v e s s e l s 13, 1 4 , 2 2 , 2 3 , 4 4 D a y cases 15 D e a t h 13 D e e p fascia 18, 19 D e e p inguinal ring 9, 27, 33, 36, 53 D e n i s B r o w n e spoon 2 6 - 3 1 D e x o n suture 35, 36, 4 0 - 4 3 Diagnosis, differential 12, 13 - of hernia 12 - of hydrocele 48, 49 D i a t h e r m y 17 Direct inguinal hernia 44 Discharge h o m e 14, 15, 44 Display of instruments 57 Dissection 15, 24, 26, 27, 30, 39, 44, 50, 51 - b l u n t 17, 1 8 - 2 0 , 2 0 , 2 3 - complicated 44 Distal portion of processus 54 Division of sac 30, 31 - of processus 53 D r a i n a g e 50, 54, 56 D r a p e s 15 Dressing 43

E Elective surgery of hernia 1 5 - 4 3 Elective surgery of hydrocele 5 0 - 5 5 Electric blanket 15 Elevation 14 E m e r g e n c y 14, 44 - surgery 14, 46 - t r e a t m e n t 14, 46 Epididymis 54 Epigastric artery (superficial) 17 Experience 9 E x p l o r a t i o n , bilateral 11 E x t r a - p e r i t o n e a l fat 21 62

F Fascia, closure 40 - d e e p 18, 19 - external s p e r m a t i c 13, 15 - superficial 40 Fat 19, 20 - extra-peritoneal pad 21 Feeding 44 F e m a l e 17, 37 F e m o r a l vessels 44 Field, operative 15 Finger, index 12, 13, 50, 51 Fluid 54, 56 Follow-up 44 F o r c e p s , Allis 25 - blunt 19, 15 Fossa, iliac 46

G Gamgee pads 5 G a n g r e n e of bowel 46 - testes 13 G a s bubble 4 G a u z e dressing 43 Girls 11, 19, 37 Groin 12

H H a e m a t o m a 44 H e r n i a 9, 1 1 - 4 6 , 4 7 - anatomy 1 - bilateral 11 - complications of 13, 14, 46 - complications following surgery 44 - diagnosis 12 - direct 44 - incomplete 1, 3, 16 - indirect 9, 11, 47

- inguinal 1 - 3 , 47 - irreducible 9, 14, 46 - reducible 12, 14 - repair 15, 44 - scrotal 2, 11, 18 - t r e a t m e n t , elective 6 - 4 3 - t r e a t m e n t , e m e r g e n c y 46 - types 1 H e r n i a l sac 9, 14, 15, 1 6 - 1 8 , 2 0 - 2 6 , 2 8 - 3 1 , 34, 44, 46 H e r n i o t o m y , elective 14, 1 5 - 4 3 History of swelling 11, 12 Hospital stay 14, 15, 44 H o t w a t e r b l a n k e t 15 Hydroceles 4 7 - 5 7 - acute 13, 47 - a n a t o m y 46 - bilateral 48 - complications following surgery 57 - o f t h e cord 12, 46, 48, 49 - diagnosis 48, 49 - treatment 5 0 - 5 5 - types 46 H y p o t h e r m i a 15

I Iatrogenic u n d e s c e n d e d testes 39, 44, 57 Iliac fossa 46 Ilio-inguinal nerve 17 Incarceration of bowel 13, 14, 44 Incidence 11 Incision 17, 49 - a b d o m i n a l 45 I n d e x finger 1 2 , 1 3 , 50, 51 Indirect inguinal hernia 9, 11, 47 I n d u r a t i o n 43 Infant 9 , 4 4 , 4 7 Infection of w o u n d 44 Inguinal canal 9, 15, 46 - d e e p ring 9, 27, 3 3 , 3 6 , 53

- external ring 46 - superficial ring 9, 11, 12, 1 6 - 1 9 , 2 2 , 4 4 , 4 6 - 4 8 , 50 I n s t r u m e n t s used 57 Intra-muscular injection 15 I n t u b a t i o n 15 Irreducible hernia 9, 14, 46 Invagination 6 I s c h a e m i a , bowel 13 - testes 13, 44

K K n i f e , position of 8, 13, 14, 55

N N a p p y rash 44 N e c k of sac 46 Necrosis of bowel 14, 45 N e e d l e 28, 35, 40, 41 - h o l d e r 28, 35, 40, 41 N e r v e , ilio-inguinal 17 Nurses - theatre 9 - ward 9

o

Ligation of processus 53 - of sac 2 8 - 3 1 - of vessels 17 List, operating 9, 14 - waiting 14 L y m p h a d e n i t i s 13 L y m p h glands 12

O b s t r u c t i o n , bowel 13 O e d e m a 14, 38 O p e r a t i n g list 9, 14 O p e r a t i o n of elective h e r n i o t o m y 6 - 4 3 - of elective hydrocele repair 4 9 - 5 6 O p e r a t i v e field 15 O p e r a t o r 20 O r i e n t a t i o n 39 O u t - p a t i e n t s 44 O v a r y 34, 44 O v e r n i g h t stay 15, 44

M

P

Management - conservative 14, 47 - p o s t o p e r a t i v e 44, 57 M a n u a l reduction 14 M a r k e r , skin 6, 7 M c l n d o e scissors 10 M o n i t o r i n g 15 M o s q u i t o clips 9, 10, 13, 16, 22, 25, 39, 40, 52, 53 Muscle - cremasteric 21, 22 - repair 44

Paediatric - circuit 15 - surgeon 9 Palpation 12, 1 9 , 4 8 P a r e n t s 12 P e r f o r a t i o n 13 Peritoneal cavity 14, 31, 46 P e r i t o n e u m 28, 44 Peritonitis 13, 14 P e t h i d i n e 15 Physical signs - of hernia 12

L

- of hydrocele 48, 49 Plastic spray 43 Postoperative complications of hernias 44 Postoperative complications of hydroceles 57 - course of hernias 44 - course of hydroceles 57 - m a n a g e m e n t 44, 57 P r e m a t u r i t y 13, 46 Pre-medication 15 Pressure 12, 14 Prevention - of complications 44 - of h y p o t h e r m i a 15 Processus vaginalis 47, 50, 5 0 - 5 3 , 53, 54 Pubic tubercle 16

R R a s h , nappy 44 R e a n a s t o m o s i s 46 R e c u r r e n c e 44 R e d u c t i o n , m a n u a l 14 R e m o v a l of sutures 43 Repair - hernia 15 - muscle 44 R e s e c t i o n , bowel 46 Resin, acrylic 43 Ring, d e e p inguinal 9, 27, 33, 36, 53 - external 46 - superficial inguinal 9 , 1 1 , 12, 1 6 - 1 9 , 22, 44, 4 6 - 4 8 , 50

s Sac, hernial 9, 14, 15, 1 6 - 1 8 , 2 0 - 2 6 , 2 8 - 3 1 , 34,44, 46 Scar 44 Scissors 31 - M c l n d o e 10 Scrotal hernia 2, 11, 18 63

Scrotum 6, 13, 16, 38, 39, 39, 44, 4 7 - 4 8 , 55, 57 Sedation 14 Sensation 12 Septicaemia 13 Side - bilateral 11 - contralateral 11 - left 11 - right 11 Signs, physical 2, 3, 12, 48, 48 Skin - closure 4 1 - 4 3 , 55 - crease 16, 41 - incision 16, 17 - m a r k e r 6, 7 S p e r m a t i c cord 12, 12, 19, 44, 51 - fascia 13, 15 S p o o n , Denis B r o w n e 2 6 - 3 1 Spray, plastic 43 Stay - hospital 14 - overnight 15, 44 Sterile d r a p e s 15 - gamgee 5 Stoma 46 - closure 46 Strangulation 9 S t u m p 32 S u b c u t a n e o u s suture 41 S u b c u t a n e o u s tissue 9 Subcuticular suture 42, 43 Superficial epigastric artery 17 Superficial fascia 40 Superficial inguinal ring 9, 11, 12, 1 6 - 1 9 , 22, 44, 4 6 - 4 8 , 50 Surgeon - general 9 - paediatric 9 Surgery - elective 1 4 - 4 3 - emergency 14, 44, 46 - semi-urgent 14 64

Suture - black silk 2 9 - 3 2 , 32, 53 - D e x o n 35, 36, 4 0 - 4 3 - removal 43 - second 30, 31, 53 - s u b c u t a n e o u s 41 - subcuticular 43 - transfixion 28 S w a b 20, 23 Swelling 11, 1 2 , 4 4 , 4 8 , 4 9 , 5 7

T r i m e p r a z i n e t a r t r a t e 15 T u b e r c l e , pubic 16 Tunica vaginalis 5 4 - 5 6 T y p e s of hernia 1 Types of hydrocele 46

u U n d e s c e n d e d testes 3, 12, 37, 44, 57 U r g e n c y 14, 47 U r i n e 44

T Team 9 T e a r i n g of sac 28 T e a s p o o n 31 T e e n a g e patients 15 Tension 21, 26, 33, 3 5 , 3 6 , 53 Testis 13, 1 4 , 3 9 , 4 4 , 4 5 , 5 5 - g a n g r e n e of 13 - ischaemia of 13, 44 - torsion of 13, 39 - u n d e s c e n d e d 3, 12, 37, 44, 57 Testicular a t r o p h y 39, 44 - vessels 13, 14, 18, 19, 22, 23, 23, 31, 32, 39 Thickness of sac 2 8 - 3 0 , 32 T i m e of discharge 44 Timing of surgery 9, 14 Tissue-paper like sac 30 Tissue, s u b c u t a n e o u s 9 T o r c h 48 Torsion of testis 13, 39, 47 Traction 14, 23, 39 Training of surgeons 9 Transfixion suture 28 Transillumination 48 Treatment - conservative 14, 47, 57 - e m e r g e n c y 46 - of hernia 6 - 4 3 - of hydrocele 4 9 - 5 6

V Vaginalis - processus 47, 50, 5 0 - 5 3 , 54 - tunica 5 4 - 5 6 V a s d e f e r e n s 14, 16, 19, 29, 31, 32, 39, 54 Ventilation - assisted 15 - s p o n t a n e o u s 15 Vessels 17 - f e m o r a l 44 - testicular 13, 14, 18, 19, 22, 23, 23, 31, 32, 39

w Waiting-list 14 Wall of h e r n i a 1 2 , 4 4 Wound 36,41-44,54 - a b d o m i n a l 45 - infection 44 - inguinal 17, 19, 36, 4 1 - 4 4 , 44, 49 - scrotal 57

X Xray, abdomen 4