Hernias and hydroceles

Abstract Hydroceles and hernias develop when the processus vaginalis remains patent. Bowel protruding through the inguinal canal within the hernial sac may cause discomfort and strangulate. In contrast, hydroceles tend to be completely painless. Hernias never resolve spontaneously, unlike hydroceles, which usually do. A hernia presents as a lump in the groin, with about 10% extending into the scrotum (inguinoscrotal hernia). An ‘irreducible inguinal hernia’ has to be assumed to be strangulated. The differential diagnosis includes an encysted hydrocele of the cord, an undescended testis, and rarely superficial inguinal lymphadenitis. Disimpaction of the strangulated hernia at the external ring, in conjunction with pressure along the direction of the inguinal canal, enables most to be reduced. Surgeons performing herniotomy must be competent to deal with a torn sac, the apparent absence of a vas deferens, a sliding hernia, a femoral hernia, spleno-gonadal fusion, and finding a testis in a girl during herniotomy. Key outcome measures after herniotomy are the rate of recurrence of the hernia (0.6%), testicular atrophy (0.8%), acquired cryptorchidism (0.4%), and injury to the vas deferens (0.1%). Predictors of outcome include the surgical approach (open vs laparoscopic), prematurity, large inguinoscrotal hernias (neonatal), strangulation, and surgical expertise. Controversial areas relate to indications for bilateral herniotomies and the justification for a laparoscopic approach. Hydroceles only need repair by herniotomy if they persist beyond 2–3 years.