Inguinal & Femoral hernias
Hydrocoeles

Key points

Peak incidence: Males 1-year, Females 4.7-years

If left sided hernia -10% risk of having right sided one, if right - 6% risk of left

12-17% risk of incarceration

1-2% female hernias will have Congenital Androgen Insensitivity Syndrome (CAIS)

75% of CAIS present with hernia (NO increased risk with bilateral)

2-4% will be direct hernias (in laparoscopic series)

Adrenal rests in 1.7%

Laparoscopic hernia repairs will visualise a contralateral PPV in 40% but not all will be symptomatic in future

JPS 2017 series:1548 infants and children undergoing laparoscopy: total incidence of incidental PPV 20%

Only 13% of these developed a clinical hernia at median of 9 months from the original laparoscopy

Pathophysiology

Patent processus vaginalis (PPV) - hernia sac

Male: Gubernaculum develops 8-12 weeks

Testicular descent: Abdominal phase 8-15 weeks, Inguinoscrotal phase 25-35 weeks

Hormones:

Insulin-like hormone 3: Swelling of gubernaculum during abdo phase

Testosterone: Regression of cranial suspensory ligament

Calcitonin gene-related peptide: Gradient to guide gubernaculum

Female: Canal of Nuck leads to labia Majora, closes at week 28

Associations

Conditions with increased abdominal pressure + ascites

CF (cough + ?genetic lack of vas) - 15% risk of hernia

Prematurity (made worse by Chronic Lung disease)

Ventriculoperitoneal shunts

Anatomy

Eponyms:

Cooper's ligament: Iliopectineal/pectineal ligament

Poupart's ligament: Inguinal ligament

Nerves:

• Ilioinguinal L1 (also contributions from T12/L2)

  • Path: Follows the spermatic cord and exits through the external ring

  • Function: Cutaneous sensory - front of thigh and anterior genitalia

• Iliohypogastric L1

  • Path: Superior aspect of canal

  • Supply: Cutaneous sensory - suprapubic area

  • Motor: lower rectus muscle

• Genitofemoral L1/2

  • Path: Exits internal ring, running deep to the spermatic cord

  • Supply: Cutaneous sensory - scrotum and labia majorum

  • Motor: Cremasteric muscle

• Cremasteric reflex

  • Afferent - ilioinguinal + femoral branch of genitofemoral

  • Efferent - genital branch of genitofemoral

Other hernia subtypes

Pantaloon - both direct + indirect inguinal hernia

Littres - Meckels diverticulum in hernia sac

Amyand - Appendix in inguinal hernia sac

Richter - Ischaemic antimesenteric border

Sliding hernia - more common in girls - mesosalpinx

Maydls - 2 loops of bowel in hernia sac

Procedures

Indirect inguinal hernias:

Open inguinal herniotomy vs laparoscopic repair

Similar outcomes in experienced practitioners

Complications:

Testicular atrophy - 1% elective, 2-3% Incarcerated

Recurrence <1% (Worse if associated syndrome)

Injury to vas/vessels <1%

If vas repaired: 60% patency rate, 25-40% pregnancy rate

Ascending testis: approx 1:2000

Direct inguinal hernias:

Bassini’s repair

Open the transversalis fascia from the deep ring

Suture the transversalis fascia, the internal oblique and the external oblique to the inguinal ligament

Good for both direct and indirect hernia repairs when mesh is not available such as low resource settings

Laparoscopic

Excise lipoma, then repair defect with interrupted sutures

Femoral

Lockwood (Infrainguinal)

Incise below inguinal ligament, medial to artery pulsation

Find and ligate hernia sac

Suture inguinal ligament/conjoint tendon to iliopectineal (Coopers) ligament or plug with mesh

Lotheissens (Transinguinal)

Open inguinal canal, then open transversalis fascia

Dissect out neck of sac and ligate

Suture conjoint tendon to iliopectineal ligament (Coopers, posterior border of femoral ring) or plug with mesh

McEvedy’s High approach

Incision above inguinal ligament lateral to rectus

Can be intra or extra peritoneal

Resect bowel if needed

Dissect out neck of sac and ligate

Suture conjoint tendon to iliopectineal ligament (Coopers, posterior border of femoral ring) or plug with mesh

McVay’s repair

A sutured inguinal and or femoral hernia repair

Can be used to temporise in cases of infected mesh

Open inguinal canal and transversalis fascia

Instead of approximating the conjoint tendon to the inguinal ligament as in a Bassinis' repair, the conjoint tendon is sutured to the iliopectineal ligament medially and the inguinal ligament laterally

Care must be taken to retract the external iliacs

Abdomino-scrotal hydrocoele

Abnormality of the PPV

2x intercommunicating extraperitoneal sacs - may be multilocular

Coverings are usually transversalis fascia

Unknown aetiology - possible pressure differences in hydrocoele developing abnormal plane

Abdominal sac can tort

Differentiate from lymphatic malformation, tumour

Multiple described surgical techniques:

• Laparoscopic marsupialisation or excision, followed by inguinal excision of sac

• Jaboulay procedure alone

• USS guided drainage +/- sclerotherapy

Standard scenario - Incarcerated inguinal hernia

IV morphine or intranasal sedative

Sustained pressure for up to 30 mins

If reduced: admit and repair in 24-48h to allow oedema to settle

If irreducible - emergency theatre - laparoscopic and open both acceptable approaches

Open - attempt to reduce hernia under anaesthetic, if fails, isolate sac, place sling and then try and reduce, if fails, carefully place clips around then open sac and manually reduce contents

Special scenario - unable to find vas deferens

Check sac again before dividing, look at vessels, look in inguinal canal

If truly absent, possible diagnoses are:

• Cystic Fibrosis - Check history, inform parents, refer for testing

• Wolfian duct abnormalities - USS to check for renal agenesis

  
  

Special scenario - genital abnormalities

Examples include finding a testis within a hernia sac in a female, and finding Mullerian structures (Fallopian tube, Uterus) in a male

Close hernia sac ensuring structures are not damaged, a gonad can be reduced into the abdomen if necessary and operated at a later date once an MDT decision is made

Inform parents, perform karyotype, DSD investigations and take to MDT

Special scenario - Chyle in hernia sac

Suggestive of chronic volvulus

Repair hernia

Assess patient for failure to thrive/vomiting

Perform UGI contrast

Ladd's procedure if confirmed

Special scenario - Giant inguinal hernia in a neonate

Main concern is respiratory compromise and abdominal compartment syndrome on reduction

Unlikely to incarcerate

Management: Wait for term - rule out connective tissue disorders, mucopolysaccharidosis, CF

Repair just before ready for home

Consent for repair including laparotomy and staged procedure

Under anaesthetic reduce hernia - check ventilation pressures/volumes at 2 minute and discuss with anaesthetist

If pressure ok: groin incision and herniotomy

If increased pressures: laparotomy - close internal ring from inside - may need extra layers and suturing of transversalis fascia

If unable to close abdomen: Laparostomy, silo or goretex patch depending on how much bowel will not reduce

Special scenario - Vas found on histology of hernia sac

1992 paper - 4% of sacs have accessory ductal structures which are not significant

Ensure that histologist measures diameter of structure as will be smaller in calibre compared to actual vas deferens

If actual vas: Apologise to patient and parents, reassure that other side is intact

If other side is compromised: Discussion at Urology MDT - groin exploration and repair

Page edited by Mrs Charnjit Seehra BSc November 2024

References

Holcomb and Ashcraft’s Pediatric Surgery, 7th edition, 2020, Chapter 50

Tse, Wayne et al. Bassini inguinal hernia repair: Obsolete or still a viable surgical option? A single center cohort study. IJS Open 36():p 100415, October 2021. | DOI: 10.1016/j.ijso.2021.100415

Sorelli PG, El-Masry NS, Garrett WV. Open femoral hernia repair: one skin incision for all. World J Emerg Surg. 2009 Nov 30;4:44. doi: 10.1186/1749-7922-4-44. PMID: 19948016; PMCID: PMC2789711.

Gadelkareem RA. Abdominoscrotal hydrocele: A systematic review and proposed clinical grading. African J Urol. 2018 Jun 1;24(2):83–92.

Smeyers KM, Hutting KH. Congenital unilateral absence of the vas deferens with ipsilateral renal agenesis encountered during laparoscopic totally extraperitoneal inguinal hernia repair in an adult patient: A case report. Ann Med Surg (Lond). 2021 May 27;66:102449. doi: 10.1016/j.amsu.2021.102449. PMID: 34141420; PMCID: PMC8184504.

Gill B, Favale D, Kogan SJ, Bennett B, Reda E, Levitt SB. Significance of accessory ductal structures in hernia sacs. J Urol. 1992 Aug;148(2 Pt 2):697-8. doi: 10.1016/s0022-5347(17)36697-1. PMID: 1640549.