It has been said that there are two kinds of inguinal hernias in the tropics[md]those above the knee and those below it! This section deals mainly with those below it, which may have been present for as long as 50 years.
If a patient has a very large indirect inguinal hernia, or a recurrent direct one, the posterior wall of his inguinal canal will be very weak and its anatomy deformed. It will be difficult to repair, and much more likely to recur. Repair will be more secure if you can divide and transfix his spermatic cord just below his deep inguinal ring, so that you can close it and reinforce the posterior wall of his inguinal canal more securely. If he will allow it, you can excise his cord and his testis completely. He will probably be old, so that he may well let you do this. If not, you can divide his cord and leave his testis in place, in the hope that collateral vessels will nourish it.
Fig. 14-14 REINFORCING THE POSTERIOR WALL of a weak inguinal canal. Do this if you think that it is going to be weak, after you have done a Bassini repair, perhaps with a Tanner slide. Use No.1 monofilament to make the darn.
GIANT INGUINAL HERNIAS If possible, refer the patient. Even if the journey is difficult, the swelling will be such that he is likely to agree to travel. If his hernia is reducible, you may be justified in operating on him.
ANAESTHESIA. Good anaesthesia is essential; use subarachnoid or general anaesthesia with long-acting muscle relaxants (A 14.3).
METHOD. Proceed as in Section 14.2. You will almost certainly have to do a Tanner slide. If the posterior wall of his inguinal canal is weak, which is likely, reinforce it as in Fig. 14-14.
If he will let you remove his testis, do so, and tie and divide his cord at his internal inguinal ring.
If he wishes to retain his testis, but will let you divide his cord, tie, transfix, and divide it as near his internal ring as you can. Leave its distal part untouched, so that you do not disturb the collateral vessels. Be gentle, or you will destroy them, so that his testis will atrophy.
If he wishes to retain his testis and will not let you divide his cord, close his external oblique aponeurosis behind his cord.
Fig. 14-15 ABNORMALITIES OF THE PROCESSUS VAGINALIS. A, when it remains completely open, a complete inguinal hernia forms. B, if it closes distally, and leaves the tunica vaginalis covering the testis, an incomplete inguinal hernia forms. C, when the processus vaginalis becomes narrow, but does not disappear, fluid passes down it from the peritoneal cavity and forms a hydrocele around the testis. D, if there is a wider area in the course of the processus vaginalis, it may form a hydrocele of the cord. Operate on a congenital hernia and on a congenital hydrocele[md]tie and divide the processus vaginalis. After Bailey and Love.