Difficulties with inguinal hernias [s8]see also 14.4[nd]6

These are not quite as bad as they look[md]fortunately, many of them are rare. As with so many other diseases, one of your difficulties will be the fact that patients commonly present so late. Giant inguinal hernias are described in the next section.

DIFFICULTIES [s8]WITH INGUINAL HERNIAS DIAGNOSTIC DIFFICULTIES [s7]WITH INGUINAL HERNIAS If you work in an area where ONCHOCERCIASIS is endemic, expect to see ADENOLYMPHOCELES in advanced cases (14-11). These are masses of oedematous fibrous tissue which hang from the groins and arise from enlarged inguinal nodes as the result of progressive lymphatic obstruction. Look for microfilariae in skin snips. Treat the disease medically before you operate. Although adenolymphoceles are easy to remove, the wound heals badly because so many lymph vessels are severed.

PREOPERATIVE DIFFICULTIES [s7]WITH INGUINAL HERNIAS If a patient presents with a HYDROCELE AND A HERNIA, deal with the hernia as usual. Either open the hydrocele and leave its top end open, or dissect and excise it, as in Section 23.23.

If he also has an UNDESCENDED TESTIS, see Section 23.25a.

PERIOPERATIVE DIFFICULTIES [s7]WITH INGUINAL HERNIAS If you CANNOT FIND THE SAC, and you are operating under local anaesthesia, ask him to cough. If that does not demonstrate the hernia, lift his cord and dissect it out carefully, using scissors to spread it proximally. Examine it carefully between your finger and thumb. Look for something like the finger of a glove, but made of tisssue like amnion. That's it. If you still cannot find it, confess to this in his notes, and narrow his internal ring. Refer him if his hernia recurs. Next time, consider operating under subarachnoid or local anaesthesia.

If the SAC IS LARGE and goes into his scrotum, dissecting it out distally will be difficult. Dissect it out proximally as usual, and clamp and transfix its proximal end. Divide it and leave its distal end open. If you leave its distal end closed, a hydrocele may form.

If the POSTERIOR WALL OF HIS INGUINAL CANAL WILL BE WEAK, if you do a Bassini repair, even with a Tanner slide, darn it with slings of No. 1 monofilament, as in Fig. 14-14.

Fig. 14-12 YOU MAY FIND A DIRECT AND AN INDIRECT HERNIA in the same patient. A, the patient's external oblique has been split in the line of its fibres. His cord is exposed with his ilio-inguinal nerve on its surface. The aponeurosis of his external oblique has been freed, medially to its fusion with his internal oblique, and laterally to his inguinal ligament.

B, his cord has been freed and retracted. The sac of a large indirect hernia, with some fat attached to it, has been freed from his cord up to his inguinal ring. His pubic tubercle has been exposed. A small direct hernia protrudes through his transversalis fascia. Few of your patients will be as fat as this. After Estes, as reproduced in Maingot R, ''Abdominal Operations', (4th edn 1961), p. 889 Figs. 15 and 16. HK Lewis, with kind permission.

If you have mistakenly passed the NEEDLE THROUGH INTO HIS FEMORAL VEIN, remove it and press the bleeding area for 5 minutes until the puncture seals itself. If it does not, you have a major problem. Press hard for another 10 minutes. If this fails, open up his inguinal area about 2 cm distal to his inguinal ligament. Use an aneurysm needle to encircle it with ''0' silk, and tie it off. His leg will be oedematous postoperatively, but this is usually only temporary. Don't tie his saphenous or femoral veins distal to the profunda branch, because this will not control bleeding.

If you think that you have INJURED HIS BLADDER, repair its mucosa with plain catgut, and its muscle with chromic catgut. Tuck it back and continue with the repair. Drain the wound and leave an indwelling catheter in for 2 weeks.

If a hernial SAC CONTAINS PUS, which has drained from the peritoneal cavity, do a laparotomy (9.2).

If you find an inflamed or GANGRENOUS APPENDIX in a hernial sac, excise it. Close the wound by delayed primary closure (9.8).

If a piece of gut has a WHITE RING on it and you return it to his abdomen, a stricture may develop later at the site of the ring. Record this in his notes.

If a LOOP OF GUT ESCAPES into his peritoneal cavity, and you are not sure if it is viable or not, make a paramedian incision and examine it. This will be much safer than leaving it.

If his TESTIS IS TWISTED, see Section 23.24.

If a woman's OVARY AND TUBE appear in the sac (rare), untwist them. If they are viable, return them. If they are gangrenous, tie the pedicle and excise them.

POSTOPERATIVE DIFFICULTIES [s7]WITH INGUINAL HERNIAS If a HAEMATOMA forms, you probably failed to tie his superficial vessels adequately, or used blunt dissection forcefully. Next time, prevent this by delicate technique and carefully controlling bleeding at every stage. Release blood from the haematoma by removing 1 or 2 skin sutures, and ease the wound open with sinus forceps.

If a FAECAL FISTULA forms, you have injured his gut. This is a serious problem. If it is not obstructed distally, wait; it will probably close, see Section 9.14.

If his SCROTUM SWELLS postoperatively (common), you can reassure him that the swelling will probably only be transient, provided you have not tied off the lower end of the sac of an inguinoscrotal hernia. Swelling often follows the repair of such a hernia, and may be due to venous obstruction.

If his TESTIS SWELLS POSTOPERATIVELY (not uncommon after a difficult hernia repair), this is usually due to thrombosis of his spermatic veins. This usually settles and leaves a normal testis.

If his TESTIS ATROPHIES, you have probably interrupted the circulation in his spermatic artery by handling it roughly, or strangulated it with sutures at his internal ring.

If his SYMPTOMS OF INTESTINAL OBSTRUCTION PERSIST after you have reduced a hernia, you may have reduced it ''en masse'[md]his hernial sac has slipped back into his abdomen with its constriction ring, so that it is not properly reduced. This is unusual, but is more likely to happen after a strangulated hernia. Do a laparotomy. You will find a loop of gut trapped in a constriction ring. Isolate the part with packs, divide the neck of the sac, and dissect out the loop(s) of gut. If it is not viable, or is very fibrosed, a resection is necessary. Repair his internal ring with 2 or 3 monofilament sutures from inside his abdomen.

CAREFUL TECHNIQUE WILL REDUCE THE RISK OF RECURRENCE Fig. 14-13 SOME SCROTAL SWELLINGS. A, if a strangulated hernia presents so late that the scrotum is oedematous, you may be justified in puncturing the mass to form a faecal fistula, as has been done here. B, bilateral giant hydroceles. If, with a finger and thumb you can get above a scrotal swelling, as you can here, as shown by the arrow, it cannot be a hernia. C, and D, a giant indirect inguinoscrotal hernia. Repair will be more secure and recurrence less likely if the patient will allow you to excise his testis. B, C, and D, after Lade Worsornu, by kind permission of the Editor of Tropical Doctor. D, after Charles Bowesman. ''Surgery and Pathology in the Tropics'. E and S Livingstone, with kind permission.