1. Introduction

a. Incision

b. Locate Spermatic Cord

c. Locate Hernia Sac and Separate from Cord

2. Dissection

3. Radical Inguinal Orchiectomy and Removal of Hernia Sac

4. Close Internal Ring

5. Closure

6. Post-op Remarks

An inguinal hernia is a condition where intra-abdominal organs bulge through the abdominal muscles or the inguinal canal. It is more common in males than in females and can occur at any age. Most adult inguinal hernias are considered acquired defects caused by weakness in the abdominal wall musculature due to excessive straining from heavy lifting, weight gain, coughing, or difficulty with bowel movements and urination. Inguinal hernias present as a bulge in the groin area that can become more prominent when coughing, straining, or standing up, and disappears when lying down. Symptoms are present in around 66% of affected people which may include pain or discomfort especially with coughing, exercise, or bowel movements. Medical history and physical examination are key to diagnosing inguinal hernias; however, imaging tests such as ultrasound, CT scan, or MRI can aid in the diagnosis when findings are equivocal. Inguinal hernias are generally classified as indirect, direct, or femoral based on the site of herniation relative to surrounding structures. In adults, watchful waiting is usually recommended for small and reducible inguinal hernias; however, inguinal hernias that enlarge, cause symptoms, or become incarcerated or strangulated are treated surgically. Surgical treatment can be divided into tissue repair and mesh repair with the latter being preferred due to having a lower recurrence rate.
 
An undescended testicle is a testicle that never moved to its proper position in the scrotum. The majority of these cases involves only one testicle, but around 10% can involve both. Complications involved with this condition include testicular cancer and infertility, and surgical correction is recommended before the child reaches 18 months old.
 
Here, we present a 78-year-old male who was diagnosed with a right inguinal hernia. Upon exploration, the right testicle was noted to be undescended  and involved with the hernial sac. Based on the patient's age, and the risk for future malignancy, the hernia repair also included an orchiectomy.

<h4>CHAPTER 1</h4>

This is a 78-year-old male complaining of a bulge in the right inguinal area, so our impression for this patient is a probable indirect inguinal hernia the right. We're doing a mesh hernioplasty for this patient, okay?

<h4>CHAPTER 2</h4>

We start the procedure by looking for the crease and doing a transverse incision.

As you go to the skin, you - you'll preceded with the subcutaneous area.

Army-Navy, please? Most of the time, there are two vessels running around here - so they have to look for that. There it is - thank you Dr. Ranjan for showing me the - Mosquito, please? Sorry?

Okay, until we reach the - actually probably the external oblique aponeurosis already - you can't identify it already, okay? This is probably the inguinal ligament here. There. There's the inguinal ligament. So the first thing to do is look for the spermatic cord.

yeah - recharge - the cautery's too high. Can somebody turn it down a bit? This is the external oblique aponeurosis.

Okay.

Let's separate it. There.

You just have to clean the… Clean the medial side so you can also prepare the - the - laying down of the mesh, the conjoint tendon here, meaning medial side. You have to clean up also the lateral side, being the inguinal ligament. Yeah, put it down. Doctor, thank you. There, there. There. Thank you. Thank you very much.

So this is probably the - spermatic cord.

Okay, there. Okay, good…

Yeah. It's the sac. It's probably the sac, yeah. Thank you. The sac showed up. It's usually located anteriomedially, so we had an easy time to identify it... Yeah.

Prepare a Penrose drain, please?

Yeah, this is the spermatic cord. Penrose, please? The Penrose acts as a tag for the - so you won't get lost, okay? Some of the contents of your spermatic cord is the sac itself, some pampiniform plexuses, testicular artery and vein, and most importantly the vas deferens. So you have to identify where the vas deferens is. It's a tubular structure that you can really palpate with your - with your two fingers, probably here. This is the… Okay? So now we look for the - for the sac. I would just go and open the... Yeah. The sheath, investing layer of the cremasteric fascia. Yeah. Pickup, please?

We separate the sac from the spermatic cord. The idea is to ligate only the sac and spare the important structures at the - of the spermatic cord, okay? Actually, at his age, we could even think about the permanent repair…

Mosquito?

This is probably the sac, here.

Yeah, that feels like sac. There's a feel for the sac, right? You usually feel it - Mosquito? There. New Mosquito, please?

No. There are times that really it's difficult to look for the sac.

This has to be sac, what else could it be? Or in case we don't find the sac, it might be a direct hernia. So what is a direct hernia, like what's… Direct hernia is, the cause is the weakness of the floor, weakness of the muscles. Okay, got you. So it doesn't go behind the scrotum, okay? Yeah. So you just need to repair the hernia floor then? Yeah. Mosquito?

Yeah, that - hemostat, please? That is looking like the sac. And then you suddenly see the sac, just like that. Yeah I thought there is no sac, and then suddenly you see it. This is the sac, okay? It goes all the way in. It's not blind. Pickup, please? There, it goes all the way in.

So you can see, it's consistent that the patient claims that it doesn't go to the scrotum much because the sac is up to this level only, okay? You can see inside. One is going towards the scrotum, and the other other entry is to the peritoneum, okay? So it's still indirect hernia. Again, the idea again is to - to preserve as much structures. So, this is the question. Do we want to preserve the testicle here, or not? Since... He's Consented. That's the importance of the preoperative conference with the patient, to tell all possible... Yeah, I already did that. Yeah. So he consented for possible orchiectomy. Considering the age, we might do as well orchiectomy, or removal of the testis.

So if we are going to do that, then just... the testicle, and get done with it. Yeah. I think I was able to palpate earlier a small testis.

I'm sorry...

So this is testicle here, right? Yeah. No doubt. So we divide distally, and then... Okay. Mosquito? Here, so - divide all this. Take the bovie, dissect it off. Yeah. Pickup? Pickup? And we may find the indirect sac in there, so we could - be prepared for that. Bovie?

Probably this is the end of the sac. Yeah.

Do you have a silk 2-0? For a heavy tie. Because there's nothing proximally. Tie? Another tie, please? For the ligation, we use usually a nonabsorbent suture material. So now, what we have... Is the sac and the spermatic cord. Yeah, so, this is all going towards the internal ring. So just find the internal ring, just ligate it, dissect it off, close to the sac - close to the cord, and let's be done with this, right? There's one more attachment distally. Tie? Tie, please? Mosquito? Mosquito? Scissors?

Okay, you have heavy ties? Okay, so now we'll dissect it off. Yeah. Because we cannot take it in one bunch. Mosquito? So...

So where's the internal ring? Have you felt the internal ring? Yeah. Because we need to do it close to the inguinal ring, right? Yeah. High ligation. High ligation, yeah.

Please? Bovie?

Okay. Here we can individually ligate it. Yeah. Go.

Bovie?

Yes, this fat tells you that we're near the internal ring. Yeah Okay, now... So that's preperitoneal fat. So then just ligate it right here. Open, please?

Tie?

Just tie it twice. Yeah. I'll bring it up.

Away from my tie.

You're coming to the sac there, see that? Bovie, please?

We do a suture ligation of this one. Of the Sac. Yeah, okay. Dissect it off. Yeah.

These are all cremasterics.

Mosquito?

Tie it.

Okay, suture? Get close to the… Pickup, please?

I think you have a pretty clean tie there, so - I would have just - usually just purse-string, not a… I usually - go around the - also. I think I'll do another one. A free tie. Scissors? One more. Heavy tie? So this is the sac. So we just suture-ligate it, right? Yeah. So we need to separate the sac from the remaining cord structures. I'll just put another one here. Okay.

So now that we're doing that way, I would feel better if we suture-ligate it one... Yeah, fine with me. So let's just divide it here, pull the end, and suture-ligate the rest of it, okay? Yeah.

Scissors?

<h4>CHAPTER 3</h4>

This is what size it is? This feels like a 3-0. It's important for us to use a heavy suture - that will hold all the structures. Okay, so let's put a hemostat on top and divide it. Hemostat, please? This hernia repair includes also orchiectomy. I just want to make it clear. We're taking out all the structures of the spermatic cord.

Okay. Okay, so Allis clamp, please, before we let go. Allis clamp?

And the Allis clamp?

We good? Yeah, just release that. Just make sure it's not going to bleed. Army? Good? Yeah. Okay with that? Yeah.

<h4>CHAPTER 4</h4>

Pickup, please? Just reduce it inside.

So let's close the ring, close the floor, and we are done. Feel the conjoint tendon? So we will not do mesh then, right? Yeah. We don't need to do mesh if there's no... We can just do the inguinal ligament. Allis? Okay, put an Allis on the conjoint tendon on my side.

Suture, 2-0? 2-0. Start with the internal ring, just start it. Just close the internal ring, and then, that's most important for us now.

Scissors? Because now we don't need an internal ring, right? So we can just close the damn thing off, and then there's no inguinal canal after that. Okay, so let's bring the repair more medially, then we can, then we are… I'll hold on to this. Suture to Dr. Eric.

Yeah. Yeah. Feel good to you when you are tying? Yeah. Does it? Yeah. Okay. Scissors to me, please? So one more wide, deep here. You're getting close to Cooper's ligament there. Remember the femoral vessel is not too deep there so be careful.

Yeah, no hernia. So we can close the external oblique on top of it. Yeah.

<h4>CHAPTER 5</h4>

You want to run it? Yeah.

Hemostat to me, please? And the other hand on this. Look at that exposure. It's exposure for the kings.

Can we take some Marcaine in the end? Marcaine? How much do you put Marcaine, in the skin? How much do you put? I usually put about 5 to 10 mL. So I divide between two edges. Most important to inject some in the medial corner because that's where the nerves are coming in. Yeah. Actually, we're just closing the external oblique aponeurosis now, and then we'll put 1 or 2 sutures in the subcutaneous area. And then the skin, that's it.

The short Pickup, just the short Pickup. And whenever you have the Marcaine? Are we running it, or interrupting it? Just 1, 2, 3... Interupteds? Yeah.

<h4>CHAPTER 6</h4>

This is the case of a 78-year-old male with a history of bulging in the right inguinal area. So the primary impression is a probable indirect inguinal hernia on the right, okay? What we did is a herniorrhaphy, repair of the floor, and we did a high ligation of the sac, okay?

As you can see, the patient has a previous operation. This is the old incision, we call it
the old incision because probably it was done in the 80's, okay? Because nowadays, we usually
do the Rocky-Davis incision, or more recently, we do a laparoscopic appendectomy, okay? If you ask me if it will affect the the nature of the operation, probably because the proximity of the adhesions, probably created by this adhesion, is close to the right inguinal area, okay? In most instances, we just do a - high ligation of the sac and repair of the floor, but in this case, we also found out that the patient is having an undescended testis on the right. So based on his age of 78, probably it's more prudent for us to do the orchiectomy plus the hernioplasty because undescended testes are prone to have testicular cancer in the future. So, right after the procedure, the patient eats after, a regular diet, and it there's no problems tomorrow, we'll send him home, and just keep him away from 2 things: 1 is doing strenuous exercises, and 2 is lifting heavy weights, both of which contribute to increasing of intra-abdominal pressure. That's why patients should refrain from those activities for like 1 or 2 months.

Key steps of the procedure: Number 1 is to isolate the sac. The sac contains your vas deferens, contains your pampiniform plexuses, it contains your cremasteric muscles. The important part of saving these structures is for a person, for a patient in their reproductive age group, especially preserve the vas deferens. Again, this patient is a 78-year-old male, so we didn't bother saving it because probably he has reached the number of children that he's supposed to have, okay? And one more thing after the isolation of the sac, you need to do a high legation of the sac, so it will be up there to the to the peritoneum so it won't budge again, okay? And the last thing is to do a good hemostasis. Why? Because inguinal hernia operations are prone to hematoma formation after the procedure so it's very prudent for you to make your hemostasis very good.

Watch this full-length, narrated procedure of an indirect inguinal hernia repair that also includes a radical inguinal orchiectomy.

Romblon Provincial Hospital