Direct inguinal hernia surprise

All hernias that I have seen in the last few years have been indirect: the defect is lateral to the epigastrics. Indirect hernias are caused by a failure of the processus vaginalis to close. They are not due to fascial or muscle weakness.

Indirect inguinal hernia

Direct hernias, on the other hand, are medial to the epigastric vessels and related to muscle weakness.

Direct Inguinal hernia pediatric

 

Whereas indirect hernias can be easily fixed by high ligation of the open processus vaginalis, direct hernias require a more formal repair of the floor of the inguinal canal — i.e, a Bassini repair.

Today I was surprised to encounter an indirect inguinal hernia upon entering the abdomen with a laparoscope. The muscle weakness/defect was obvious. Laparoscopically, it did not look that different from a direct hernia so I thought I could attempt a laparoscopic closure:

Attempt at laparoscopic closure of a direct inguinal hernia

 

After passing the needle I realized the muscle defect was still there and that the repair will be destined to fail. Thankfully, I have good pediatric surgeon friends and they came to my rescue.

The repair my friend did go as follows:

  • Inguinal incision, 3 cm, same as usual.
  • Identify the shelving edge and then the external ring.
  • Incise the external oblique fascia along the direction of the inguinal canal
  • Get around the spermatic cord outside the external ring.
  • Hernia sac was obvious at this point and large. It was dissected down to its wide base and then twisted, and suture ligated with polyglactin
  • Hernia retractor was then used to retract superiorly the cord as well as the roof of the inguinal canal (external oblique fascia) to expose the floor.
  • Bassini repair: interrupted polyglactin sutures in between the conjoined tendon superiorly (large bites of it) and the inguinal ligament inferiorly (small bites to avoid the femoral vessels).
  • External oblique fascia is put back together.

Here is a laparoscopic picture after the repair:

direct hernia after closure

 

Conclusion

Direct inguinal hernias are rare in the pediatric population. When encountered, a Bassinni repair seems the most appropriate approach.

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