Ans. a. Herniotomy (Ref: Sabiston 191120-1126; Schwartz 9/1318-1331, Bailey 26/111, 1382; Schackelford 7/568-579)Management of hydrocele of the hernia sac (congenital hydrocele) in a 3 years old child is herniotomy."A patent processus vaginalis may allow only peritoneal fluid to track down around the testis to form a hydrocoele. Hydrocoeles are unilateral or bilateral, asymptomatic, non-tender scrotal swellings. They may be tense or lax. but typically transilluminate. The majority resolve spontaneously as the processus continues to obliterate, but surgical ligation is recommended in boys older than three years of age. "--Bailey 26/e p111"In congenital hydrocele, the processus vaginalis is patent and connects with the peritoneal cavity. The communication is usually too small to allow herniation of intra-abdominal contents. Pressure on the hydrocele does not always empty it but the hydrocele fluid may drain into the peritoneal cavity when the child is lying down; thus, the hydrocele may be intermittent. Ascites should be considered if the swelling are bilateral. Congenital hydroceles are treated by herniotomy if they do not resolve spontaneously. " Bailey 26/e p1382HerniotomyLigation of hernial sacQHerniorrhaphyHerniotomy with posterior wall repair using in-situ structuresQHernioplastyHerniotomy with strengthening of posterior wall using exogenous material like meshQManagement of Inguinal HerniaObjectives of treatment: Treatment of hernia sac and Inguinal floor reconstructionManagement of Inguinal HerniaTreatment of Hernia SacInguinal Floor Reconstruction* Basic operation is inguinal herniotomy, which entails dissecting out & opening the hernial sac, reducing any contents and then transfixing the neck of the sac and removing the remainderQ.* Direct sacs are usually too broad for ligation and should not be opened but instead are simply inverted into peritoneal cavityQ.* Management of the hernia sac is sufficient for children and young adultsQ* Reconstruction (repair or strengthening) of the inguinal floor is necessary in all adult hernias to prevent recurrenceQ.* Types of repair:1. Primary tissue repairQ2. Anterior tension-free mesh repairQ3. Pre-peritoneal repairs: Open & laparoscopic approachQ Inguinal Floor ReconstructionPrimary Tissue RepairAnterior Tension-Free Mesh RepairLaparoscopic and Pre-Peritoneal Repairs* Posterior wall of inguinal wall is strengthened by approximation of tissues with suturesQ.* There is no use of prosthetic materialQ.* Advantages: Simplicity of the repair & absence of any foreign body in groin* Disadvantage: Higher recurrence rates due to tension on the repair and slower return to unrestricted physical activityQ.* Types:- Bassini repairQ- Haisled repair- McVayQ (Cooper ligament) repair Shouldice repairQ- Dam repair* Current practice in hernia management employ synthetic mesh to bridge the defect* Recurrence is very low* Types:* Lichtenstein repair0: Mesh is used to reconstruct the inguinal floor.* Patch and plug repair(r): Plug of mesh is inserted into the hernia defect and sutured in place. Then another piece of mesh is placed over the inguinal floor.* Pre-peritoneal space is reached by either trans-abdominal laparoscopy (TAPP) or by totally extra-peritoneal repair (TEP).* Both techniques are similar In actual repair but differ in the manner by which the preperitoneal space is accessed.* TAPP (Trans-abdominal Pre- PeritoneaI)(r): Peritoneal space is reached by conventional laparoscopy and pre-peritoneum overlying the inguinal floor is dissected away as a flap.* TEP (Totally Extra-Peritoneal) (r): Pre-peritoneal space is accessed without entering the peritoneal cavity Gibbon's hernia* Hernia with hydroceleQBerger's hernia* Hernia into pouch of DouglasQBedard's hernia* Femoral hernia through opening of saphenous veinQAmyand's hernia* Inguinal hernia containing appendixQOgilive's hernia* Hernia through the defect in conjoint tendon just lateral to where it inserts with the rectus sheathQStammer's hernia* Internal hernia occurring through window in the transverse mesocolon after retrocolic gastrojejunostomyQPeterson hernia* Hernia under Roux limb after Roux-en-Y gastric bypassQ