The hernial sac can usually be found on the anterosuperior aspect of the cord. Subsequent management depends on the nature of hernial contents upon opening the sac:
- no contents:
- an empty sac is carefully dissected out back to its origin on parietal peritoneum
- it is twisted about its axis and then transfixed at the level of the deep ring with vicryl or chromic catgut
- the sac is excised
- small bowel/omental contents:
- if not infarcted, the small intestines are returned to the abdominal cavity
- any adhesions are carefully divided
- ischaemic bowel is resected and anastomosed
- ischaemic omentum is excised
- the sac is sutured and closed
Very large inguinoscrotal hernias present two potential problems:
- dissection from the cord and testis may devascularise these structures
- more extensive dissections predispose to postoperative haematoma Consequently, one approach is to:
- not dissect the sac
- reduce the contents of the sac to the internal ring
- transfix the sac at its neck ensuring that all contents are still reduced
- leave the distal wall of the sac in situ