I. Surgical incision level and anatomical path.
1. Adult method: the skin incision is an oblique incision (3-4 cm) in the line from one transverse finger above the midpoint of the inguinal ligament to the pubic symphysis, and the Camper’s fascia and Scarpa’s fascia are opened in turn, and then the extra-abdominal oblique tendon membrane is opened, that is, the spermatic cord is exposed, the thickened and whitened hernia sac is found on the anterior medial side of the spermatic cord, and then a high ligation of the hernia sac is performed. this method is applicable in adults, and because of excessive trauma, it should be This method is applicable in adults and should be discarded in pediatric surgery because it is too invasive.
2.Internal loop incision (incision of the external oblique tendon membrane) (recommended): the skin incision is a transverse incision (1 cm) along the transverse abdominal stripe one finger above the midpoint of the inguinal ligament, opening the Camper’s fascia, Scarpa’s fascia, and then the external oblique tendon membrane, which exposes the spermatic cord, finds the thickened and whitened hernia sac on the anterior medial side of the spermatic cord, and then performs a high ligation of the hernia sac.
3.Inner circumferential incision (without incision of the extra-abdominal oblique tendon membrane): the skin incision is a transverse incision (1 cm) along the transverse abdominal stripe one finger above the midpoint of the inguinal ligament, the Camper’s fascia and Scarpa’s fascia are opened in turn, the extra-abdominal oblique tendon membrane is submerged on the surface, the spermatic cord is raised at the outer circumferential opening, the thickened and whitened hernia sac is found on the anteromedial side of the spermatic cord, and then a high ligation of the hernia sac is performed.
4. External ring incision: The skin incision is a transverse incision (1 cm) of the body projection of the external ring opening above the pubic symphysis, and the Camper’s fascia and Scarpa’s fascia are opened in turn, below which the spermatic cord is located. The thickened and whitened hernia sac is found on the anteromedial side of the spermatic cord and then a high ligation of the hernia sac is performed. This procedure is recommended only in small infants and is not recommended in those older than 1 year because the incidence of postoperative scrotal swelling is higher than with the internal loop incision (incision of the external oblique abdominal tendon) approach.
II. Whether to completely dissect the hernia sac or to transect it.
1. complete stripping of the hernia sac: the hernia sac is completely stripped, freed to a high level and then ligated; the disadvantage is that postoperative scrotal swelling is obvious and this method is basically abandoned
2. Transection of the hernia sac (recommended): the hernia sac is transected from the middle of the hernia sac, the distal hernia sac is left open after strict hemostasis, and the proximal hernia sac is free to a high position and then ligated. The advantage is that the postoperative scrotal swelling is mild or basically non-swollen.
III. Closed or open free hernia sac.
1.Closed release (recommended): without opening the hernia sac, the vas deferens and spermatic vessels are released immediately outside the hernia sac.
2. Open free: Open the anterior wall of the hernia sac and separate the posterior wall of the hernia sac close to the vas deferens and the spermatic cord vessels. Advantage: suitable for beginners, not easy to accidentally damage the vas deferens and spermatic vessels; disadvantage: individual children with ultra-thin hernia wall may easily tear the hernia sac, increasing the difficulty and time of surgery.
IV. Incision closure.
1.One stitch of ordinary silk suture and stitch removal after surgery.
2.5-0 absorbable thread continuous intradermal suture, no stitch removal after surgery (recommended).
3.5-0 non-absorbable slip suture continuous intracutaneous suture with postoperative suture removal (recommended).
4.Tissue glue to bond the skin.
V. Required instruments: needle electric knife, non-invasive forceps, mosquito forceps, pediatric pulling hook, 5-0 absorbable thread.
VI. Recommended age for surgery.
1. In children with recurrent incarcerated hiatal hernia, because the incarcerated may produce intestinal necrosis or testicular or ovarian necrosis, and the recurrent incarcerated compresses the spermatic cord vessels, which is unfavorable to the development of the testis, the recommended age of surgery is 6 months or even earlier.
2.If the child is born prematurely and has a large internal ring opening and relatively large hernia, it is recommended to perform surgery when found.
If the hernia has no obvious history of incarceration and the hernia is small, the age of surgery is 1 year old because there is a certain chance of self-closing before 1 year old.