Irreducible and strangulated inguinal hernias

You can relieve a strangulated inguinal hernia and resect gut through the ordinary incision for an inguinal hernia. Unlike a femoral hernia, there is no need to open a patient's abdomen through a separate incision to get better access.

BISTOURY, guarded, one only. This is a curved probe with a cutting edge on its concave surface near the tip (B, in Fig. 14-18). It is the safest instrument for enlarging the inguinal ring.

IRREDUCIBLE OR STRANGLATED INGUINAL HERNIAS THE DIFFERENTIAL DIAGNOSIS. is seldom difficult.

Suggesting torsion or inflammation of an inguinal testis [md]absence of the testis from the scrotum. A retained testis is often associated with an interstitial hernia.

Suggesting inflamed inguinal nodes[md]the swelling is more diffuse, there is sometimes redness and oedema of the overlying tissues. Vomiting and abdominal pain are minimal or absent.

TAXIS [s7]FOR IRREDUCIBLE INGUINAL HERNIAS INDICATIONS. An inguinal hernia which has only been caught in its sac for an hour or two. Taxis is dangerous in all other hernias, besides being painful, and usually impossible.

CONTRAINDICATIONS. The patient is suspected to have had a an irreducible hernia for more than 3 hours. Any obvious signs of strangulation.

METHOD. If the patient is a child see Section 14.5. If he is an adult, give him morphine and put him to bed in a steep Trendelenburg position. Wait for at least half an hour, or even up to one hour. Often, a hernia reduces spontaneously. If it does not, use gentle sustained pressure to push the contents of his hernial sac back into his peritoneal cavity.

CAUTION ! Don't do anything which may rupture it, or risk reducing it ''en masse'.

The inguinal canal passes obliquely through the abdominal wall, so try to push his hernia back in an oblique direction. Try pressing the fundus of the sac with one hand, and gently manipulating his internal ring with the other. If you succeed, he can have an operation later in the next elective list. About a quarter of otherwise irreducible hernias will reduce spontaneusly like this. If you fail after an hour in a steep Trendelenburg position, proceed as follows.

CAUTION ! Watch him carefully for signs that any nonviable tissue has been reduced. This is unlikely to have happened, and if it has, the tissue is more likely to be omentum than gut. If you are in any doubt treat him as a strangulated hernia.

OPERATION [s7]FOR IRREDUCIBLE OR STRANGULATED INGUINAL HERNIAS PERIOPERATIVE ANTIBIOTICS. Give these as in Section 2.9.

ANAESTHESIA. (1) Local anaesthesia is satisfactory and safe (A 6.12). Infiltrate the medial aspect of the sac, and his cord, as you reach them. (2) Subarachnoid, or, (3) epidural anaesthesia. (4) General anaesthesia with tracheal intubation.

INCISION. Incise his skin 2 cm above his inguinal ligament, and open his inguinal canal as in Section 14.2.

CAUTION ! When necessary surround the operation site with large swabs (''lap pads') to prevent the soiling of his peritoneal cavity by the contents of the hernial sac, which is likely to contain virulent aerobic and anaerobic organisms.

OPENING THE SAC. You will see a tense mass emerging from his internal ring and passing towards his scrotum. If oedema and congestion make identifying the overlying structures difficult, use blunt-tipped scissors and the ''push and spread technique' (4- 8) to incise the first two layers[md]his external spermatic fascia and his cremaster muscle. If they dissect off easily, good, if they don't, leave them, except for a small area near the fundus. Incise this between a pair of fine haemostats, just as you would if you were opening his peritoneum for a laparotomy.

Pick up each layer in forceps, and carefully incise it. When you reach his peritoneum fluid will run out, and you will see gut or omentum.

RELEASING THE CONSTRICTION RING. Use scissors or a bistoury (14-18) to slit his external oblique, and open his inguinal canal towards his internal ring. Feel for the constriction with your finger. If you can insert an instrument through it and nick its lateral margin, good. If not, retract its the upper edge with a retractor, and cut down on it from outside.

Alternatively, push your little finger into the ring. While your assistant holds the contents of the sac out of the way, push a large haemostat into the ring lateral to the neck (unless you suspect a direct hernia, rare) and open it so that its jaws push the sides of the ring apart and dilate it. Divide the lateral side of the ring with scissors or a bistoury.

When you have opened the sac, apply several haemostats to its peritoneal margins to prevent them retracting into his abdomen.

Gently deliver the contents of the sac. If it extends to his scrotum, it may be easier to deliver his testis also. His gut or omentum may be blue, purple, or black.

CAUTION ! (1) Don't damage his spermatic cord as you open the sac. (2) Don't nick the medial side, or you may cut his inferior epigastric artery. Don't cut his gut!

Examine the contents of his hernia. If his gut has been trapped, withdraw a few centimetres of the afferent and efferent loops. Assess its viability by the methods in Fig. 9-8 and Section 9.3.

If viable gut or omentum are present, replace them.

If you are wondering whether to invaginate or resect gut, see the end of Section 14.2 on Busoga hernias. Invagination, if it is indicated, reduces mortality, especially if you are not skilled.

If gut is strangulated, resect it.

If omentum is strangulated, pass long haemostats across the healthy part, cut off the gangrenous part distal to them, transfix the healthy omentum with a needle, and then tie it off. You may need more than one haemostat and transfixion suture.

CAUTION ! Be sure to control all bleeding before you return anything to the peritoneal cavity.

CLOSURE. Depends on what you have done.

If he has had an obstructed hernia or a short term strangulation with viable gut, do a herniorrhaphy, preferably only a Bassini repair; a Tanner slide will open up new tissue planes to possible infection.

If you have had to resect gut: (1) If his strangulation is recent, continue with herniorrhaphy. (2) If his strangulation is late, for example with peritonitis present, do a herniotomy at this stage and advise him to return for a formal repair later. Close his skin by delayed primary closure (9.8). If he has had an obvious perforation, drain the canal.

DIFFICULTIES [s7]WITH IRREDUCIBLE OR STRANGULATED INGUINAL HERNIAS If he PRESENTS LATE with oedema of his abdominal wall, or scrotum, over the gangrenous contents of a strangulated inguinal hernia, a faecal fistula is about to form. Expect this if he lives beyond the 4th day. It can form: (1) In his inguinal region, where his prognosis is better, especially if his hernia is of the Richter type (14-1) and the obstruction to his gut incomplete. (2) In his scrotum, where his prognosis is worse.

If a fistula is going to form, encouraging it to do so may be safer than immediately resecting gut in the usual way. Open the gangrenous gut in his hernia, as in Fig. 14-13. If faeces do not immediately discharge, probe the tissues until they do and pass a catheter proximally. Observe him carefully.

If he improves, defer further surgery for the moment.

If he deteriorates, operate immediately. Make an abdominal incision somewhat higher than a normal hernia incision and open his peritoneum. Make a side-to-side anastomosis between loops of gut above and below the hernia. Do the minimum of surgery, and avoid disturbing the gut in the hernial sac. If he recovers, reconstruct his gut later and do an end-to-end anastomosis.

If he presents very late with an ESTABLISHED FAECAL FISTULA, following a strangulated hernia weeks or months ago, don't attempt local repair. Do a laparotomy and resect the involved loop of his gut. Make the incision well away from the discharging area, and resect enough gut (about 30 cm) to let you apply clamps outside the abdomen, where they will be less likely to slip off. Pack off the area of his internal inguinal ring, and remove the gut from the fistula. Curette the fistula track, taking care not to damage any local structures. Leave the skin opening unsutured to allow it to drain; it will close itself.

If, in an indirect inguinal hernia, you CANNOT BRING DOWN ENOUGH GUT through his internal ring, enlarge the opening by cutting the fibres of his internal oblique upwards and laterally.

If, in a Busoga hernia, you CANNOT BRING DOWN ENOUGH GUT through the narrow opening in his conjoined tendon, extend the incision in his external oblique a little more laterally, and then split his internal oblique and transversus muscles about 5 cm above his internal ring level with his iliac spine, as in the muscle splitting approach for an appendicectomy (C, 12-1). Open his peritoneal cavity, withdraw his gut, and if necessary, invaginate or resect it. This approach is useful in a strangulated Busoga hernia and avoids enlarging the opening in the conjoined tendon and weakening it.

If, when you operate on a strangulated Busoga hernia, you find STRANGULATION OF THE SAC, but no gut in it, there is probably no need to open his abdomen and examine his gut. If it has slipped back, it is unlikely to be seriously nonviable. Postoperatively, observe him carefully for signs of peritoneal irritation and general deterioration.

If you CANNOT RETURN HIS GUT to his abdominal cavity, (1) tilt the table head downwards, (2) put a retractor under the anterior lip of the wound to raise it, (3) gently return his gut to his abdomen, a little at a time, starting at one end and gently squeezing it between your finger and thumb. (4) Decompress it as in Fig. 10-9.

See also the ''Difficulties' at the end of Section 14.3.