Pediatric Inguinal Hernia Repair 
Jason Fader, Jason Axt 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Pediatric inguinal hernia repairs are among 
the most common pediatric surgical procedures 
performed. In a resource-limited setting, the timing 
of repair is limited by safety of anesthesia. We 
usually defer large and easily reducible hernias until 
one year of age. If the child presents earlier than this 
with a reducible hernia, the family needs to be taught 
how to recognize and reduce it.  If the hernia cannot 
be reduced the patient needs immediate medical 
evaluation for possible strangulation. When a hernia 
is difficult but ultimately reducible, I generally 
operate as soon as a rested team and competent 
anesthetist are available. The tissues may be 
inflamed and more delicate immediately post 
reduction.  If the hernia is non-reducible, it needs to 
be operated on immediately. 
Diagnosis is made by a history of an 
intermittent swelling of the inguinal canal and/or 
scrotum. This may or may not be evident in clinic. 
The parents can be asked to take a photo of the bulge. 
On physical exam, the surgeon’s index finger or 
thumb rolls over the cord to determine its size and to 
feel the presence of a sac.  If the cord is larger than 
normal, this means there is likely a hernia sac as part 
of the inguinal cord. A typical cord in an infant is 
about 2 or 3 mm and an enlarged one is 5+ mm, so 
the difference is not always easy to distinguish. Note 
that this is different than the method of diagnosing a 
hernia in an adult. 
Infantile hydroceles may spontaneously 
resolve up to one year of age. Any new hydrocele in 
a child merits and abdominal ultrasound to evaluate 
for a neoplasm causing the hydrocele. If the child is 
above one year of age and has been evaluated for 
tumor, they can be addressed in the same way as 
inguinal hernias. Most hydroceles have a persistent 
processus vaginalis that can be ligated, just like an 
indirect hernia. 
The operation consists of: 
• 1.5cm incision 
• Identify and isolate the sac from the other cord 
structures 
• High ligation of the sac 
• Subcutaneous and skin closure 
 
Steps: 
1. General or spinal anesthesia may be used, 
Ketamine is often utilized. 
2. Prepare and drape the inguinal area, including the 
scrotum. 
3. Palpate the cord and make a 1.5 cm incision in an 
inguinal crease superficial to the cord and lateral 
to the pubic symphysis, going through the dermis. 
Note: a scalpel makes a much nicer closure than 
a diathermy. A diathermy is not necessary for this 
case. 
 
Palpate the cord to locate the area you will make an incision. 
 
 
Measure to approximately 1.5cm in a skin crease using an open 
hemostat.  
 
4. Identify and generously cut Scarpa’s fascia 
 
Pediatric Inguinal Hernia Repair 
Jason Fader, Jason Axt 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
Opening Scarpa’s fascia allows access to the plane containing 
the external inguinal canal and the spermatic cord.  
 
5. Use two small retractors (Ragnell or Senn) to 
separate the subcutaneous tissue and then use a 
fine hemostat find the cord as it exits the external 
inguinal ring. The cord and sac usually bulge up 
into the field and should be lightly grasped and 
“wiggled” up out of the incision. The correct 
structure will lift as fat is gently dissected off. 
 
Opening of the external ring with fat protruding. The cord 
structures and hernia sac will be found under this bulge. 
 
As the cord comes into the field a forceps or hemostat can be 
passed under it. 
 
6. The sac is then bluntly dissected from the other 
cord structures (vas deferens, testicular artery, 
pampiniform venous plexus, and cremaster 
muscles.) We use a fine toothed (Adson) forceps 
for this, keeping the forceps open and just 
hooking the tissues with one of the teeth. 
 
The cord is separated from the sac. A flat instrument is placed 
under the vas, testicular artery, and venous plexus, and the vas 
is confirmed by palpation.  It is firm like a hard spaghetti noodle. 
 
Pediatric Inguinal Hernia Repair 
Jason Fader, Jason Axt 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
With the cord under gentle tension, the sac is dissected toward 
the external opening until preperitoneal fat comes into view.  
 
7. The sac is separated from the other structures 
until preperitoneal fat is seen. After confirming 
that all the vital structures are isolated from the 
sac, it is doubly ligated 3-0 or 2-0 braided 
absorbable suture (Vicryl) and divided. 
 
The sac is doubly ligated with absorbable suture while 
protecting the vas. This suture is preserved for later use with 
skin closure.  
 
8. The distal sac does not need to be dissected and 
removed. It should be emptied of fluid if there is 
a hydrocele. Dissecting the residual sac increases 
the risk of hematoma without any other benefit. 
9. Pull testicle to the bottom of the scrotum to guide 
the cord into place. 
10. Place one suture in Scarpa’s fascia and then two 
or three inverted intra-dermal stitches in the skin 
using the same suture– only 1 suture is needed 
for the entire case. 
 
Pediatric Inguinal Hernia Repair 
Jason Fader, Jason Axt 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Pitfalls 
• Take your time to dissect out the sac from the 
other structures. It is friable and easily damaged.  
• Dissect the sac off the cord near the external 
inguinal ring, otherwise you will find yourself in 
the scrotum at a point where the sac balloons out 
and is more difficult to isolate. 
• Clearly identify the vas deferens and protect it. 
 
 
Jason Fader, MD  
Kibuye Hope Hospital  
Kibuye, Burundi  
 
Jason Axt, MD, MPH 
AIC Kijabe Hospital 
Kijabe, Kenya 
 
July 2023 
 
