chapter 51
INGUINAL HERNIAS AND HYDROCELES
Charles L. Snyder, MD
nguinal hernia repairs are one of the most com-
I mon operations performed by pediatric surgeons,
and consultations for inguinal hernia are among the
most frequent reasons for pediatric surgical referral.
An inguinal hernia in a child usually refers to an indi-
rect inguinal hernia but may include a femoral hernia
and, rarely, a direct inguinal hernia. The diagnosis and
management of inguinal hernias and hydroceles in
infants and children and the attendant complications
and controversies are discussed in this chapter.
HISTORY
Inguinal hernias were first described in the Ebers Papy-
rus in 1550 BC.1 Celsus is thought to have performed
hernia repairs in AD 50.2 Galen, in AD 150, described
the processus vaginalis, defined hernias as a rupture of
the peritoneum, and advised surgical repair.3 Ambrose
Paré advocated repair of inguinal hernias in childhood
in the 16th century.1 There was a flurry of progress
in the 1800s, with Cooper’s 1807 identification of the
transversalis fascia and the ligament associated with
his name and Cloquet’s 1817 observation that the pro-
cessus vaginalis is often patent at birth as well as his
description of femoral hernias.4,5 In 1877, von Czerny
first described narrowing the inguinal canal and tight-
ening the external inguinal ring,6,7 followed by Bassi-
ni’s description of internal inguinal ring tightening
and reinforcement of the posterior canal in 1887.8,9
Bassini’s interest in the subject of inguinal anatomy
was personal because he had sustained a groin wound
with a cecal-cutaneous fistula in 1867.6 Gross reported
a 0.45% recurrence rate in a large series of hernia
repairs (3874 children) in 1953.10
EMBRYOLOGY AND ANATOMY
The processus vaginalis is a peritoneal diverticulum
extending through the internal inguinal ring into the
canal. It can be seen by 3 months of fetal life.11 The
somatic base of this diverticulum is the transversa-
lis portion of the endoabdominal fascia. The gonads
form on the anteromedial nephrogenic ridges in the
retroperitoneum during the 5th week of gestation.
The gonads are attached to the scrotum by the guber-
naculum in the male and to the labia via the round
ligament in the female. Gonadal descent begins by
3 months’ gestation, and the testis reaches the internal
inguinal ring by about 7 months. Descent of the testis
is initiated and directed by release of calcitonin gene–
related peptide (CGRP) from the genitofemoral nerve
(via fetal androgen release).12 CGRP mediates closure
of the patent processus vaginalis (PPV), although this
process is not completely understood.11 The testis
begins to descend down the canal by the 7th month of
fetal life preceded and guided by the processus vagina-
lis.11-13 The processus, which is located anterior to the
cord structures, gradually obliterates, and the scrotal
portion forms the tunica vaginalis. The female anlage
of the PPV is the canal of Nuck, a structure that leads
to the labia majora. This also closes by about 7 months
of fetal life, and ovarian descent is arrested in the
pelvis.11 The precise incidence of PPV in newborns is
unknown and depends on gender and gestational age.
The incidence has been estimated to be 40% to 60%
but may be lower.14 However, at autopsy, only 5% of
adults have a PPV.11 PPVs at birth can still close, but
this becomes less likely with increasing age. It is failure
of the PPV to close that results in an indirect inguinal
hernia. As mentioned, the factors driving PPV closure
are incompletely understood. Intra-abdominal pressure
probably plays a role because disorders with increased
abdominal pressure/fluid (e.g., ventriculoperitoneal
shunts) are associated with an increased incidence of
indirect inguinal hernia and with increased bilateral-
ity.15 Indirect inguinal hernias are more common on
the right. The various clinical findings related to the
processus vaginalis are illustrated in Figure 51-1.
The layers of the abdominal wall contribute to the
layers of the testis and spermatic cord as the gonad
descends. The internal spermatic fascia is a continuation
of the transversalis fascia, the cremaster muscle derives
from the internal oblique, and the external spermatic
fascia originates from the external oblique aponeurosis.
The processus vaginalis envelops the testis as the vis-
ceral and parietal layers of the tunica vaginalis.
669
670 section 5  INGUINAL REGION AND SCROTUM
Peritoneal
cavity
Process
vaginalis
Normal Hydrocele
Figure 51-1. From left, configurations of hydrocele and hernia in relation to patency of the processus vaginalis.
INCIDENCE AND ASSOCIATIONS
Approximately 0.8% to 4.4% of all children will
develop an inguinal hernia, with a positive family
history in about 11.5%.16 In reviewing cases at our
hospital over the past 4 years, there were 15,321 gen-
eral surgical operations. Within this group, there were
1991 (13%) inguinal hernia repairs. Fifteen percent
were performed in infants younger than 6 months
of age, 54% of patients were between 6 months and
5 years of age, and 31% were 5 years of age or older. In
another series of 6361 pediatric herniorrhaphies per-
formed by a single surgeon, the male-to-female ratio
was 5:1.17 Right-sided hernias were twice as common
as those on the left. The mean age in this series was
3.3 years.
The incidence of inguinal hernia varies directly
with the degree of prematurity. The overall incidence
of inguinal hernia in premature infants is estimated to
be 10% to 30%, whereas term newborns have a rate
of 3% to 5%.18-20 Co-morbidities such as chronic lung
disease associated with prematurity may play a sub-
stantial role in the development of an inguinal hernia
in this population.
Other entities associated with an increased inci-
dence of inguinal hernia (Table 51-1) include crypt-
orchidism, abdominal wall defects, connective tissue
disorders (Ehlers-Danlos syndrome), mucopolysac-
charidoses such as Hunter’s or Hurler’s syndrome,
Table 51-1 Conditions Associated with an
Increased Incidence of Inguinal
Hernia
Prematurity
Cryptorchidism
Connective tissue disorders, mucopolysaccharidoses,
congenital hip dislocation
Cystic fibrosis
Ascites, ventriculoperitoneal shunt, peritoneal dialysis
Abdominal wall defects
Meningomyelocele
Communicating Inguinal Complete
hydrocele hernia inguinal hernia
cystic fibrosis, ascites, peritoneal dialysis, ventricu-
loperitoneal shunts, congenital hip dislocation, and
meningomyelocele.
Patients with cystic fibrosis have an increased risk
(eightfold in one report) of inguinal hernia,21 with an
incidence as high as 15%. This heightened risk may
be due to elevated intra-abdominal pressure from
respiratory problems, but developmental/embryo-
logic factors may also play a role because the risk of
hernia is increased in unaffected siblings and par-
ents. Ventriculoperitoneal shunts are associated with
an increased incidence of inguinal hernia as well as
increased bilaterality, increased incarceration risk, and
increased recurrence.15 In a series of 430 children who
underwent placement of a ventriculoperitoneal shunt,
15% developed hernias and hydroceles occurred in
another 6%.22 Injury to the shunt and shunt infection
are other problems specific to these children.
CLINICAL PRESENTATION
Most hernias are asymptomatic except for inguinal
bulging with straining. They are often found by the
parents or by the pediatrician on routine physical
examination. The diagnosis is clinical and rests squarely
on the history and physical examination. Maneuvers
such as having the child raise the head while supine
or “blowing up a balloon” with a thumb in the mouth
may be helpful in small children. Standing the child
upright may also help demonstrate the hernia. The dif-
ferential diagnosis includes a retractile testis, lymph-
adenopathy, hydrocele, and prepubertal fat. In older
children, neoplasia must be considered.
A common occurrence is a normal examination in
combination with a suggestive history. Some surgeons
have the child return for a second examination in
2 to 3 weeks, whereas others accept a good history as
an indication for operation. Although subjective and
dependent on the experience of the surgeon, our pref-
erence is for the latter course. False-negative explora-
tions should be rare. In a series of 6361 hernia repairs
by a single surgeon (definitive inguinal hernia on
 Chapter 51  INGUINAL HERNIAS AND HYDROCELES 671

examination was the indication for operation), there
was only one false-negative exploration (0.02%).17
Ancillary findings such as a “silk glove sign” (feel-
ing the thickened peritoneum of the patent processus
as the cord is palpated) are of variable reliability.23,24
Radiologic diagnostic aids are not generally necessary
or helpful. Herniograms are of historic interest. Ultra-
sonography can be used to identify a PPV indirectly via
widening of the internal inguinal ring (more than 4 to
5 mm is positive), but the technique is highly opera-
tor dependent and not in widespread use.25,26 It is not
generally necessary to restrict an asymptomatic child’s
activities until repair is scheduled, but prompt repair
may decrease interim incarceration.
Another question that has arisen in the laparo-
scopic era is what to do with an incidentally discovered
PPV in a child undergoing operation for an unrelated
problem. A common scenario is that of unilateral or
bilateral PPV discovered during the course of a lapa-
roscopic appendectomy. A hernia repair should not
be performed concomitantly in that setting. The child
and the family should be informed of the findings and
instructed to watch for symptoms.
monitoring is necessary. The postconceptual age (ges-
tational age + chronologic age) is commonly used to
decide which infants require admission. Several stud-
ies have addressed this issue.28,29 Sixty weeks postcon-
ceptual age is used at our hospital, because a less than
1% risk of postoperative apnea was found in former
premature infants of more than 56 weeks’ postcon-
ceptual age in a comprehensive analysis of eight pro-
spective studies.30
Timing
Because premature infants have an increased inci-
dence of inguinal hernia, this is a common diagno-
sis in the neonatal intensive care unit. The incidence
of bowel incarceration in premature infants is sig-
nificantly increased (threefold in one large series).17
Many institutions use 2 kg as a lower limit for repair in
asymptomatic and otherwise relatively healthy new-
borns. We usually repair the hernia before discharge
to avoid the need for readmission to repair the hernia
and to decrease the risk of incarceration.31-33 However,
this decision is surgeon-dependent and often depends
on other co-morbidities.

OPERATIVE MANAGEMENT Operative Technique

Anesthesia
There are no good data comparing regional to general
anesthesia for pediatric inguinal hernia repair. A 2003
Cochrane meta-analysis of available data regarding
this issue in premature infants concluded: “There is no
reliable evidence from the trials reviewed concerning
the effect of spinal as compared to general anaesthe-
sia on the incidence of post-operative apnoea, brady-
cardia, or oxygen desaturation in ex-preterm infants
undergoing herniorrhaphy.”27
Overnight stay is not necessary after inguinal
hernia repair for healthy children or term infants.
However, the risk of postoperative apnea and brady-
cardia is increased in premature infants and overnight
Pediatric indirect inguinal hernias are usually repaired
through an inguinal crease incision by splitting the exter-
nal oblique aponeurosis up to the level of the internal
inguinal ring. After the ilioinguinal nerve is identified,
the anterior hernia sac is grasped and the vas and ves-
sels (in the usual male hernia) are pushed away from
the sac (Fig. 51-2A). The sac is clamped and divided (see
Fig. 51-2B). A high ligation is performed after the sac
is opened and inspected. If contralateral laparoscopic
evaluation is performed, a small cannula can be gently
advanced through the opened sac (see Fig. 51-2C). A
70-degree, 2.7-mm laparoscope allows examination of
the contralateral side (Figs. 51-3 and 51-4).
There is an uncommon but disturbing incidence of
late inguinal abscess formation related to the use of

Hernia sac

Vas deferens Transverse

inguinal
A B Vessels of the cord incision C
Figure 51-2. A, After a right inguinal incision in an infant boy, the sac has been separated from the vas and vessels by grasping the
sac and “teasing” the cord structures away. The hernia sac, located anteromedial to the cord, has been carefully separated from the vas
and vessels (vessel loop) and is clamped in preparation for division of the sac. B, In preparation for diagnostic laparoscopy to evaluate
the contralateral internal ring, the sac is opened. A vessel loop is around the cord structures. C, A cannula has been introduced into
the opened hernia sac and the sac has been tied (solid arrow) to keep the abdomen insufflated. The cord structures (dotted arrow) are
retracted with the vessel loop.
672 section 5  INGUINAL REGION AND SCROTUM

Figure 51-3. Laparoscopic evalu-

ation of the contralateral inguinal
region is used by many pediat-
ric surgeons. A, A view of the left
internal ring shows the inverted “V”
of the laterally located gonadal ves-
sels and the medial vas. At the apex
of the “V,” the left internal inguinal
ring is completely closed. B, A right-
patent process vaginalis is seen
in a 7-year-old with a known left
inguinal hernia.
A B

silk suture material.34,35 Therefore, absorbable suture
material is now preferred. The sac may be twisted
before ligation, but too much twisting may draw the
vas and cord structures up into the base of the sac,
where they risk being inadvertently ligated. It is not
necessary to remove the distal sac. Removing the
distal sac may increase the risk of injury to the cord
structures and the testis. Distal hydroceles should be
opened widely and drained. It is important to ensure
that the testis is in the scrotum at the conclusion of the
procedure to avoid iatrogenic cryptorchidism.
Sliding hernias are uncommon but are more fre-
quent in females, with an incidence as high as 20% to
40%. A fallopian tube or ovary may be involved. The
bladder may constitute the medial wall of the sac in
infants.36 The appendix (Amyand’s hernia) may form
a sliding component on the right. Distal ligation of the
sac with proximal purse-string inversion is our pre-
ferred management of sliding inguinal hernias.37
Laparoscopic hernia repair has been used in chil-
dren in both Europe and the United States.38,39 In
one recent series of 712 inguinal hernia repairs in
542 children (median age, 1.6 yr), operative times
were similar to those for open procedures. A 5-mm
umbilical port was inserted and two 2-mm cannulas
were used for suturing. The recurrence rate was 4.1%,
with a median follow-up of just over 3 years. This rate
dropped to 2% in the latter part of the study. Hydro-
celes occurred in 0.7%.40
Mesh or prosthetic materials are almost never
required in children. One exception may be recurrent
hernias in children with connective tissue disorders or
mucopolysaccharidoses.
Contralateral Hernias
Contralateral exploration for unilateral inguinal her-
nia in children has a long and controversial history.
Meta-analyses, cost analyses, and decision-tree analy-
ses have all been performed.41-44 The results are dis-
cussed in more detail later, but a succinct summary of
the conclusions is that routine contralateral explora-
tion is not justified.
Surveys of pediatric surgeons have demonstrated a
decrease in the practice of routine contralateral explo-
ration over time, but laparoscopic evaluation of the
contralateral side via the hernia sac has grown in pop-
ularity.45.46 In the more recent survey, nearly half of
the respondents said they would routinely explore the
contralateral side in boys younger than 2 years old and

A B C
Figure 51-4. A, In a small percentage of cases, a veil of peritoneum will cover the contralateral internal ring and obscure the laparo-
scopic findings such that the surgeon is not completely certain whether a contralateral patent processus vaginalis (CPPV) is present. In
this situation, a technique has been reported to retract the veil of tissue. B, A silver probe is introduced in the contralateral lower abdo-
men/flank and used to retract the veil medially so that the 70-degree telescope can then look down the possible CPPV. C, In this patient,
a significant CPPV was visualized once the veil of peritoneum was retracted medially. (Adapted from Geiger JD: Selective laparoscopic probing
for a contralateral patent processus vaginalis reduces the need for a contralateral exploration in inconclusive cases. J Pediatr Surg 35:1151-1154,
2000.)

in girls younger than 4 years old. Contralateral explo-
ration was more likely in females. Approximately one
third of surgeons performed laparoscopic evaluation of
the contralateral side.
Many reports have addressed the incidence of a
contralateral clinical hernia after unilateral repair.47
A prospective study of 548 patients followed for a
mean of 2 years found that 8.8% developed a contra-
lateral hernia, with an average interval of 6 months.
The incidence was higher in younger infants, prema-
ture infants, and females.48 Another series of infants
younger than 1 year of age who underwent unilateral
inguinal hernia repair reported that only 7.7% devel-
oped a contralateral hernia during follow-up ranging
from 5 to 10 years. Median time to occurrence was
18 months.49 Another similar study of patients younger
than 1 year of age found a 9% incidence of contralat-
eral hernia, also after a mean of 18 months.50 A meta-
analysis of 15,310 patients in combined studies found
a 7% incidence of a metachronous hernia.43
Although dated, a meta-analysis by Sparkman in
1962 showed 57% of children with a contralateral
patent processus vaginalis at the time of unilateral
hernia repair.51 Also, perhaps the best study in terms
of a controlled cohort was by MacGregor, who per-
formed 148 unilateral inguinal hernia repairs in chil-
dren younger than age 10 years over a 32-year period.
Ninety-six percent of those were followed for a mean
of 20 years of age. Over this length of time, he found
that 28% returned with a symptomatic contralateral
inguinal hernia.52
Left-sided initial hernia repairs may be associated
with an increased risk of contralateral disease. Younger
patient age and prematurity are also, albeit less fre-
quently, identified as markers for a metachronous
hernia. Although female gender carries a lower risk
of contralateral exploration, and possibly a higher risk
of PPV or clinical hernia, a study of 300 girls followed
after unilateral herniorrhaphy found a metachronous
hernia developed in only 8%.53 Younger age, female
gender, and a left-sided unilateral hernia have been
used as selection criteria for diagnostic contralateral
laparoscopy as well as open exploration.
The advent of laparoscopy has not clarified the
situation but has added additional information. Theo-
retical benefits of diagnostic contralateral laparoscopy
in children with unilateral hernia include identifica-
tion of a contralateral PPV (and potential future her-
nia) without the attendant risks of contralateral open
exploration. The mean additional operating time in
one analysis was 6 minutes. There is some economic
justification for this approach as well.42,44
One critical decision point is the incidence of PPV
in children with a unilateral hernia. Probably the most
accurate assessment is via diagnostic contralateral lap-
aroscopy (See Figs. 51-3 and 51-4), with the caveat
that (1) many of these PPVs will not develop clinically
symptomatic hernias and (2) it may be difficult to dis-
tinguish a peritoneal fold from a true PPV. This tech-
nique was initially described in the early 1990s by Lobe
and Holcomb.54,55 The only significant change is that
these original reports described umbilical laparoscopy
Chapter 51  INGUINAL HERNIAS AND HYDROCELES 673
rather than repair through the ipsilateral inguinal her-
nia sac.
Contralateral laparoscopic evaluation cannot be
performed in 4% to 5% of children because of a small
or thin sac or poor visualization.23 Large combined
laparoscopic series document a 30% to 40% overall
incidence of contralateral PPV.23,42 However, it remains
unclear how many will develop a symptomatic contra-
lateral hernia throughout their lifetime.
Pain Management
A randomized prospective trial of local instillation of
long-acting analgesics (e.g., bupivacaine) versus cau-
dal block for postoperative pain control after pediatric
inguinal hernia repair demonstrated no significant dif-
ference in pain control.56 Instillation of local anesthet-
ics into the wound (“splash technique”) is effective as
well.
COMPLICATIONS
Incarceration
The incidence of incarceration is variable and ranges
from 12% to 17%.17,57,58 Younger age and prematu-
rity are risk factors for incarceration.59 The mean age
of patients with incarceration is significantly lower
than that of those who have elective repair.17,60
Symptoms of incarceration are manifested as a fussy
or inconsolable infant with intermittent abdominal
pain and vomiting. A tender and sometimes erythema-
tous irreducible mass is noted in the groin. Abdominal
distention is a late sign, as are bloody stools. Peritoneal
signs indicate strangulation. Incarceration may be the
presenting sign of the hernia. It can be difficult to dis-
tinguish a hydrocele of the cord from an incarcerated
hernia. A happy infant with no tenderness suggests
the former diagnosis, but if several examiners have
vigorously attempted to “reduce” the hydrocele, the
distinction can be difficult and ultrasonography may
be helpful.
It is sometimes stated that gangrenous bowel can-
not be reduced, but exceptions make this a dangerous
“rule” to rely on. The presence of peritonitis or sep-
tic shock is an absolute contraindication to attempted
reduction. Symptoms of bowel obstruction are a rela-
tive contraindication. Monitored conscious sedation is
used after intravenous access and rehydration. Firm
and continuous pressure is applied around the incar-
ceration. Successful reduction is usually confirmed by
a sudden “pop” of the contents back into the peritoneal
cavity. Questionable or incomplete reductions should
be explored. Once an incarcerated hernia is reduced,
a delay of 24 to 48 hours to allow resolution of edema
is recommended. Reliability of the family as well as
clinical (very difficult reduction) and geographic con-
siderations dictate the need for admission and obser-
vation before definitive repair. Overall, 90% to 95%
of incarcerated hernias can be successfully reduced.61
Only 8% required emergency operation in one report
674 section 5  INGUINAL REGION AND SCROTUM
of 743 incarcerated hernias, and two children required
bowel resection.17
Urgent operation is necessary if nonoperative man-
agement fails. The hernia may reduce with induction
of general anesthesia. If so, the hernia sac must be
opened and inspected. The presence of enteric con-
tents or bloody fluid mandates either open exploration
(separate incision or La Roque maneuver) or laparo-
scopic evaluation. It may be necessary to open the
internal inguinal ring laterally to reduce the bowel.
Some surgeons approach an incarcerated hernia via a
transumbilical laparoscopy to both reduce the hernia
and evaluate the bowel.40,62,63 Intestinal injury requir-
ing treatment is rare (1% to 2%), even with incarcera-
tion.57 The hernia sac is often quite edematous and
friable, and repair of the hernia can be quite difficult.
The risk of recurrence is increased. We do not rou-
tinely perform laparoscopy on the contralateral side in
patients with incarceration because of these concerns.
Within a true incarcerated hernia, the testis on the
affected side is often edematous and somewhat cya-
notic. Unless the gonad is frankly necrotic, it should
be preserved. The parents of any boy with an incarcer-
ated hernia should be counseled about the possibility
of testicular loss or atrophy, but in most cases this will
not occur. The incidence of testicular atrophy is 2%
to 3%.33,61 Incarceration of an ovary may not always
impair its blood supply, but most pediatric surgeons
would promptly (but not emergently) repair the her-
nia in a girl with an asymptomatic nontender ovarian
incarceration.62
Recurrence
The risk of recurrence in an elective inguinal hernia
repair is less than 1% in several large series.17,63 It is
higher in premature infants, in children with incarcer-
ated hernias, and in children with associated diseases
(e.g., connective tissue disorder, ventriculoperitoneal
shunt).15,64 Recurrence rates are as high as 50% in
children with connective tissues disorders and muco-
polysaccharidoses. A recurrent hernia even can be the
presenting symptom in these diseases.65 Recurrence
rates may also be increased in teenagers.17
Injury to Cord/Testis
Injury to the cord/testis is a rare occurrence in elective
hernia repairs, with an incidence of approximately 1 in
1000 in large surgical series.17 The true incidence may
be underestimated because, in animal models, instru-
ment manipulation or simply touching/pinching the
cord can cause microscopic injury and scarring. A recog-
nized injury to the vas should be managed by immedi-
ate repair with fine (8-0) suture, and the family should
be informed of the event. In institutions in which her-
nia sacs are routinely examined by a pathologist, meso-
nephric rests or adrenal rests are occasionally seen but
do not indicate injury to the vas. However, a review of
7314 male pediatric hernia specimens over a 14-year
period at a major children’s hospital found either vas
deferens or epididymis in 0.53% of specimens.66
Other Complications
Infection occurs in 1% to 3% of cases, and postopera-
tive hematoma has a similarly low incidence. Persistent
hydrocele can occur, particularly if a very large hydro-
cele was present preoperatively. It is important to
instruct the family about this possibility before repair.
Most postoperative hydroceles are simply observed for
6 to 12 months. If they do not resolve, aspiration may
be tried once or twice. In our experience, aspiration is
not usually permanently successful. Persistent nonre-
solving hydroceles usually require transumbilical diag-
nostic laparoscopy to exclude a recurrent hernia. In
the absence of recurrence, a transscrotal exploration
and obliteration of the hydrocele sac is performed.
Loss of domain due to a huge hernia in a tiny
infant can occur and may even require staged repair.
Death directly related to inguinal hernia or its repair is
exceedingly rare.
SPECIAL ISSUES
Hydroceles
A frequent issue is whether the presence of a hydro-
cele in an asymptomatic infant indicates an inguinal
hernia. If the hydrocele was not present at birth, or
dramatically changes in size (communicating hydro-
cele), a PPV is present. Massive hydroceles and those
extending along the length of the inguinal canal may
also require operation. Static hydroceles that fail to
reabsorb also indicate a PPV. Our practice is to observe
these hydroceles until the child is 1 year of age.
Excision of the hydrocele sac is not necessary. The
fluid is evacuated, and the distal sac is opened widely.
Large or thick sacs may be everted behind the cord
(Bottle procedure) if necessary.67
Direct Inguinal Hernias
Direct inguinal hernias are rare in children, even older
teenagers. Some recurrences after indirect inguinal
hernia repair (or negative contralateral exploration)
are direct inguinal hernias. Pediatric direct inguinal
hernias are managed with standard “adult” inguinal
hernia repairs. Our preference is for a McVay repair
(approximation of the transversalis aponeurotic
arch and internal oblique aponeurosis to the ante-
rior ileopubic tract and shelving edge of the inguinal
ligament).
Femoral Hernias
Femoral hernias are relatively equally distributed
by gender68,69 but much less common than indi-
rect inguinal hernias. In two combined series of over
10,000 patients, 0.2% of hernias were femoral.70,71
Most (two thirds) are not suspected before operation
(Fig. 51-5).69,71 A mass below the inguinal ligament
should alert the clinician to this possibility. Ten to
20 percent of femoral hernias are bilateral. Recurrence

A B
is increased after femoral hernia repair compared with
indirect inguinal herniorrhaphy.68
Absent or Atrophic Vas
Occasionally, a small or absent vas is found during
inguinal hernia repair. This should prompt a workup
for cystic fibrosis. Renal ultrasonography is also neces-
sary because ipsilateral renal agenesis is associated.72,73
Congenital absence (bilateral or unilateral) of the vas
is a heterogeneous disorder, largely due to mutations
in the cystic fibrosis gene. Differing genotypes are
noted with congenital absence of the vas as an isolated
entity versus congenital absence of the vas in associa-
tion with renal anomalies.74
Intersex
The finding of a testis during repair of a female her-
nia should raise the question of congenital androgen
insensitivity syndrome (CAIS) or true hermaphro-
ditism. Some authors have reported that as many as
Chapter 51  INGUINAL HERNIAS AND HYDROCELES 675
Figure 51-5. This young girl pre-
sented with symptoms suggestive,
but not conclusive, of a left femoral
hernia. Therefore, diagnostic lapa-
roscopy was performed through the
umbilicus to confirm the diagnosis
prior to an inguinal approach and a
McVay repair. A, The internal open-
ing to the femoral hernia is seen.
B, After the McVay repair, the fem-
oral defect is closed.
1.6% of female infants with inguinal hernias will have
CAIS.31 Bilateral hernias in girls are not associated
with a higher risk of CAIS than is a unilateral hernia.
Conversely, as many as 75% of CAIS patients present
with a hernia.75
Laparoscopy may allow evaluation of the fallopian
tube, ovary, and uterus. The gonad should be sam-
pled. Some advocate rectal examination to attempt
to palpate the uterus. Vaginoscopy is an option. In
the presence of CAIS, an absent cervix will be found.
Karyotyping and pelvic ultrasonography should be
performed. Eventual gonadectomy will be necessary,
although the timing is controversial. Further discus-
sion is found in Chapter 63.
Other Disorders
Incidentally discovered yellow nodules along the sper-
matic cord or testis are due to adrenal rests and may be
safely removed. Splenogonadal fusion is a very rare entity
that may masquerade as a testicular neoplasm. Frozen
section confirmation allows gonadal preservation.