Anatomical background
Surgical intervention for the congenital form of this pathology requires a clear understanding of the topographical anatomy of the area. Unlike acquired hernias, the hernia sac here is the unclosed processus vaginalis of the peritoneum itself (processus vaginalis).
Key features that dictate the course of surgery:
- The spermatic cord does not merely lie adjacent, but is extremely firmly fixed externally to the wall of the hernia sac. This creates a high risk of iatrogenic injury to the cord elements.
- The testis is covered by the peritoneum mesoperitoneally. It is located directly inside the hernia sac, positioned there alongside the prolapsed abdominal organs.
It is these anatomical features that determine the need for extreme delicacy during tissue dissection and the choice of technique for managing the neck.
Initial steps and exploration
The surgery begins with providing surgical access and performing a thorough exploration. The surgeon makes a longitudinal incision in the hernia sac, after which they carefully reduce its contents back into the abdominal cavity.
A mandatory step is the visual inspection of the inner surface of the sac. This ensures complete organ reduction and prepares the tissues for subsequent manipulation to isolate them from the abdominal cavity.
Methods for managing the neck of the hernia sac
Depending on the severity of adhesions and tissue thickness, one of two main methods for managing the neck is used.
Method 1: Standard technique Used when safe tissue separation is possible.
- A transverse incision of the peritoneum is made on the posterior wall of the neck.
- Blunt separation of the neck from the spermatic cord elements is performed. To do this, the surgeon uses a gauze sponge combined with hydrodissection (injection of procaine solution for tissue dissection).
- The neck is transfixed and securely ligated.
Method 2: In case of dense adhesions If the cord elements are intimately fused with the thinned sac, attempting to isolate them can lead to a rupture. In such situations, a purse-string suture from the inside is applied.
- Technical specifics: The purse-string suture is applied in such a way as to avoid catching the cord in it under any circumstances. The surgeon essentially "steps over" it with the needle. The peritoneum is grasped on both sides, while the spermatic cord itself remains strictly outside the placed suture.
Resection of the sac and prevention of hydrocele
After placing the suture, the sac must be properly resected. To do this, one steps back approximately 1.5–2.0 cm distal to the suture site and incises the sac wall transversely. The distal edge is mobilized downward, and only then is the purse-string or ligature suture finally tightened.
Since the remaining part of the processus vaginalis can cause hydrocele of the testis (hydrocele), one of the preventive measures is performed:
- Option A: A small strip of peritoneum (about 1.5–2.0 cm wide) is excised along the spermatic cord directly around the testis.
- Option B (Winkelmann operation): The sac membranes are everted behind the spermatic cord and testis, after which their edges are sutured together with catgut stitches.
Completion of surgery
At the final stage of the surgery, the testis is carefully placed at the very bottom of the scrotum, restoring its physiological position. The final step is inguinal canal plasty, which in this pathology involves strengthening its anterior wall to prevent recurrence.
Briefly: answers to topical questions
What are the main differences in surgical tactics between congenital and acquired oblique inguinal hernia?
The main differences lie in the specifics of managing the hernia sac and inguinal canal plasty.
| Sign | Congenital inguinal hernia | Acquired oblique inguinal hernia |
|---|---|---|
| Anatomical basis of the sac | Unclosed processus vaginalis of the peritoneum; spermatic cord is firmly fixed externally to the wall of the sac; testis lies inside the sac along with the hernia contents | Sources for oblique inguinal hernia describe Bassini inguinal canal plasty |
| Goal/principle of surgery | Elimination of communication between the hernia sac and the abdominal cavity | Strengthening the posterior wall of the inguinal canal |
| Management of the sac | Longitudinal opening of the sac, reduction of contents, management of the neck; in case of dense adhesions of cord elements to the thin sac, a purse-string suture is applied from the inside | Main stages of sac management: opening, reduction of contents, transfixion of the neck, resection of the sac |
| Inguinal canal plasty | Strengthening the anterior wall of the inguinal canal | According to Bassini: narrowing of a stretched internal inguinal ring and strengthening of the posterior wall of the inguinal canal |
Which nerves can be iatrogenically injured during access and anterior inguinal canal wall plasty?
According to the cited sources, the following branches of the lumbar plexus are described in the inguinal region:
- Ilioinguinal nerve (n. ilioinguinalis) — emerges from the inguinal canal, becomes superficial, and innervates the skin of the scrotum or labia majora.
- Iliohypogastric nerve (n. iliohypogastricus) — branches out in the inguinal and pubic regions.
Both nerves pass between the internal oblique and transversus abdominis muscles and penetrate the rectus abdominis sheath.
To choose the method for managing the neck: if tissues allow — INCISE AND SEPARATE (procaine + gauze sponge). If the sac is thin and the cord is firmly adhered — SUTURE FROM INSIDE (purse-string with the cord "stepped over").
Class and exam questions
What constitutes the hernia sac in a congenital inguinal hernia?
The hernia sac is represented by the unclosed processus vaginalis of the peritoneum (processus vaginalis).
What is the main anatomical difficulty when dissecting the sac?
The spermatic cord is very firmly fixed externally to the wall of the hernia sac, which requires the use of procaine hydrodissection or placement of an internal purse-string suture to prevent cord injury.
How to prevent the development of hydrocele of the testis after surgery?
Either excision of a strip of peritoneum (1.5–2.0 cm) along the cord or the Winkelmann procedure—everting and suturing the sac behind the testis with catgut stitches—is performed.
How is the surgical intervention completed?
The testis is placed at the bottom of the scrotum, followed obligatorily by plasty of the anterior wall of the inguinal canal.
What else to study on this topic
- Rationale for choosing anterior inguinal canal wall plasty
- Technique and physics of tissue hydrodissection with procaine solution
- Detailed review of the Winkelmann operation
- Complications of accidentally catching the spermatic cord in a purse-string suture
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