Surgical treatment.
Hiatal hernia is unlikely to heal on its own and may become embedded or strangulated, so it should be treated surgically. However, in children within one week of age, the abdominal wall increases in strength with growth and development and may heal spontaneously, so surgery can be postponed. In elderly and frail children with other serious illnesses who are not suitable for surgery, the hernia ring can be tightly compressed with a hernia brace after retracting the hernia mass and removed at night when resting. Long-term use of a hernia brace may cause adhesion of the hernia contents to the hernia sac neck and is generally not recommended.
The surgical principles for hiatal hernia are high ligation of the hernia sac and hernia repair. In children, only high ligation of the hernia sac is performed to avoid affecting the development of the spermatic cord and testes and disrupting the physiological occlusion mechanism of the inguinal canal. Hernioplasty is usually rarely performed unless there is a large defect in the abdominal wall.
High ligation of the hernia sac.
In order to destroy the residual peritoneal sheath, the hernia sac must be transected and then dissected proximally to the internal ring, where the extraperitoneal fat layer can be seen and its deep surface is the mural peritoneum. At this level, the hernia sac neck is ligated at a high level with a silk thread, and the distal hernia sac is usually not removed and the sac is left open.
Hernia repair.
As the hiatal hernia develops, the internal ring is gradually stretched and the strength of the peritoneum is further weakened. Therefore, a hernia repair must be performed after high ligation of the hernia sac. Hernia repair should include two concepts: repair of the stretched internal ring and repair of the weak inguinal canal. The inguinal canal must be explored and repaired before repairing the stretched internal ring, otherwise recurrence will be inevitable. For this reason, the levator muscle must continue to be dissected after the hernia sac is forcibly tied at a high level and cut at the root to better expose the enlarged internal ring and the intercondylar ligament, and the intercondylar ligament must be sutured so that the internal ring is reduced to accommodate only the passage of the spermatic cord.
The main procedures for repair of weak inguinal canal are as follows.
1.Ferguson method
The Ferguson method is used to strengthen the anterior wall of the inguinal canal by suturing the inferior border of the internal oblique muscle, the transverse tendon arch and the joint tendon to the inguinal ligament on the superficial side of the spermatic cord.
(1) The spermatic cord remains in its original position and the levator muscle is sutured
(2) Suture of the inferior border of the internal oblique abdominal muscle, the transversus abdominis tendon arch and the joint tendon to the inguinal ligament
(3) Overlapping sutures of the tendon membrane of the external abdominal oblique muscle
2.Bassini method
The spermatic cord is lifted free, and the inferior border of the internal oblique muscle, the transversus abdominis tendon arch and the joint tendon are sutured to the inguinal ligament on its deep side to strengthen the posterior wall of the inguinal canal, and the spermatic cord is displaced between the tendon membrane of the internal oblique muscle and the external oblique muscle. The strength of the posterior wall of the inguinal canal, the transversus abdominis tendon membrane, and the transversus abdominis fascia can be determined intraoperatively by reaching into the internal ring with a finger to jack out the abdominal wall medial to the body surface to appreciate its strength. This procedure is now more commonly used.
(1) The spermatic cord is lifted, transposed between the internal and external abdominal obliques, and the inferior border of the internal oblique, the transversus abdominis tendon arch and the joint tendon are sutured to the inguinal ligament on its deep side
(2) Overlapping suture of the tendon membrane of the external abdominal oblique muscle
3.Halsted method
The spermatic cord is lifted free, and the inferior border of the internal oblique muscle, the transversus abdominis tendon arch and the joint tendon are sutured to the inguinal ligament on its deep side, then the upper and lower lobes of the external oblique tendon membrane are sutured or overlapped on the deep side of the spermatic cord, and the spermatic cord is displaced subcutaneously. This procedure further enhances the posterior wall of the inguinal canal than the Bassini method. The indications are the same as for the Bassini method, but it is generally not used in adolescents because the subcutaneous displacement of the spermatic cord may interfere with its development and that of the testes.
(1) Lift the spermatic cord, transpose it subcutaneously, and suture the inferior border of the internal oblique abdominal muscle, the transversus abdominis tendon arch and the joint tendon to the inguinal ligament
(2) Overlapping sutures of the tendon membrane of the external abdominal oblique muscle on the deep side of the spermatic cord
4.McVay method
The pubic comb ligament (Cooper’s ligament) is used to replace the inguinal ligament in the Bassini method for repair. The transversus abdominis fascia is incised on the posterior wall of the inguinal canal and the superior border of the inguinal ligament, and the superior border is sutured to the pubic comb ligament along with the inferior border of the internal oblique abdominal muscle, the transversus abdominis tendon arch and the joint tendon to restore the original normal anatomic relationship. The repair suture is deep to the suprapubic branch, which, in addition to strengthening the posterior wall of the inguinal canal, also changes the direction of intra-abdominal pressure propagation and is suitable for giant hiatal and direct hernias. However, it must be noted that this procedure does not also mask the internal ring. If the internal ring is significantly enlarged, it should still be repaired or the superior transversalis fascia should be sutured to the anterior wall of the femoral sheath, narrowing the internal ring so that only the spermatic cord can be passed.
This procedure is a deep and difficult repair and may damage the femoral vessels if care is not taken.
(1) Internal oblique abdominal muscle
(2) Inguinal ligament
(3) External abdominal oblique tendon membrane
(4) Transverse abdominal tendon arch
(5) Pubic comb ligament
The lower edge of the internal oblique muscle, the arch of the transversus abdominis tendon membrane and the pubic comb ligament were sutured together, and then the transversus abdominis fascia was sutured together to reconstruct the inner ring so that only the spermatic cord could pass through.
5.Pre-peritoneal repair
The advantages of this procedure are that the hernia can be ligated higher, the anatomical structure of the inguinal canal and its physiological occlusion mechanism are not destroyed, and the inferior border of the internal oblique muscle, the transversus abdominis tendon arch and the united tendons can be sutured to the inguinal ligament or the pubic comb ligament without incising the transversus abdominis fascia at the inguinal canal. It is particularly suitable for recurrent inguinal hernias, avoiding the adhesions and scar tissue caused by the original surgery. The procedure is performed by taking the Nyhus approach, making a transverse incision of the external oblique tendon, internal oblique muscle, transversus abdominis muscle and transversus abdominis fascia about 6 cm above the inguinal canal, finding the neck of the hernia sac by separating it deep under the peritoneal fascia, incising the wall of the sac, retracting the contents of the hernia, ligating the hernia sac at a high level and performing an anterior peritoneal hernia repair. In case of recurrent inguinal hernia with severe defects in the inguinal region, autologous broad fascia or synthetic fiber mesh can be used for repair. The lower edge of the transplanted patch is sutured medially to the pubic comb ligament across the femoral vessels and continues to be sutured laterally to the inguinal ligament and iliopubic bundle, the lateral edge of the patch is cut into a trouser fork shape, wrapped around the spermatic cord and the inner ring is reconstructed, and the upper and medial edges of the patch are sutured to the transversus abdominis fascia, transverse abdominis muscle and rectus abdominis muscle, respectively.
6.Shouldice method
The principle is to excise the weak transversus abdominis fascia, suture its upper and lower lobes in a stacked tile pattern, and suture the upper lobe edge to the inguinal ligament, and then suture the joint tendon, transverse abdominal tendon arch, lower edge of the internal oblique abdominal muscle to the deep surface of the lower lobe of the external oblique abdominal tendon membrane or the inguinal ligament. This is done by freeing and lifting the spermatic cord, probing the degree and extent of weakness of the transversus abdominis fascia by reaching into the internal ring with the fingers, incising the transversus abdominis fascia from the internal ring to the pubic tuberosity in the direction of the inguinal ligament and excising its weak part, freeing the lower lobe to the inguinal ligament and the upper lobe to the deep surface of the transversus abdominis muscle medially to the posterior sheath of the rectus abdominis muscle, and suturing the sound upper and lower lobes in a stacked tile fashion, i.e., the cut edge of the lower lobe is sutured continuously outward from the pubic tuberosity to the upper The suture is then sutured to the inguinal ligament in the opposite direction and returned to the pubic symphysis to be knotted with the other end of the first suture. The inferior edge of the internal oblique abdominal muscle, the transverse abdominal tendon arch and the joint tendon are then sutured to the inguinal ligament and the deep side of the external oblique abdominal tendon membrane, and finally the external oblique abdominal tendon membrane is sutured on the superficial side of the spermatic cord. This method emphasizes the enhancement of the transversus abdominis fascia in hernia repair and is suitable for hiatal hernias with posterior inguinal wall, weak transversus abdominis fascia and enlarged internal ring.
(1) Lift the spermatic cord and incise the transversus abdominis fascia along the imaginary line
(2) Free the upper and lower lobes of the transversus abdominis fascia cut edge
(3) The inferior transversus abdominis fascia cut edge was sutured from the pubic tuberosity upward and outward continuously to the deep surface of the upper lobe
(4) The superior transversus abdominis fascial cut edge was sutured to the inguinal ligament in the opposite direction to reach the pubic tuberosity
(5) The inferior border of the internal oblique abdominal muscle, the arch of the transversus abdominis tendon, and the united tendon are sutured to the deep surface of the inguinal ligament or the tendon membrane of the external oblique abdominal muscle
(6) Suture the superficial surface of the spermatic cord to the tendon membrane of the external oblique abdominal muscle
7.Madden method
Only the transversus abdominis fascia is repaired in this procedure. After freeing and lifting the spermatic cord, the internal ring is inserted with a finger to understand its size and the degree and extent of weakness of the transversus abdominis fascia, the transversus abdominis fascia is incised along the inguinal ligament from the internal ring, the upper and lower lobes of the transversus abdominis fascia are dissected to the point of soundness, the weak part is excised, and then the two lobes are intermittently sutured outward from the trap ligament to the root of the spermatic cord to reconstruct the internal ring. The procedure is similar to the Shouldice method, emphasizing the importance of strengthening the transversus abdominis fascia, but without repairing other layers of the abdominal wall, which is more in line with anatomic principles. Because of the low tension at the suture of the transverse abdominal fascia repair, there is no postoperative wound pulling sensation. However, in huge hiatal hernias, this procedure is not indicated because the strength of the transverse abdominal fascia and the abdominal wall in the inguinal region are severely compromised.
The spermatic cord is lifted, the transversus abdominis fascia is incised along the inguinal ligament from the internal ring and the weak part is excised, then the upper and lower lobes are sutured outward from the trap ligament to the spermatic milk, and the internal ring is reconstructed
Hernioplasty.
In giant hiatal hernia, because the posterior wall of the inguinal canal is severely weak and defective, and the transverse tendon arch, transversus abdominis and internal oblique abdominal muscles have atrophied and cannot be repaired using these tissues, hernioplasty can be performed using autologous broad fascia, silk sheets or various synthetic fiber networks. The anterior rectus abdominis sheath can also be sutured to the inguinal ligament by turning it outward and downward to strengthen the posterior wall of the inguinal canal.
An incarcerated hernia should be operated on urgently by incising the stenotic hernia ring, releasing the incarcerated hernia, retracting the hernia contents and performing a high ligation of the hernia sac. Hernia repair can be performed at the same time if there is no edema in the local tissues.
Pediatric incarcerated hiatal hernia can be treated non-operatively on a trial basis. In the case of strangulated hiatal hernia, emergency surgery should be performed regardless of age. The aim of surgery is to release the incarcerated hernia, remove the necrotic hernia contents and ligate the hernia sac in high position. Hernia repair is contraindicated. To increase the safety of surgery for strangulated hernia, preoperative preparation is very important.