Kocher's method of invagination in children has shown better and more brilliant results any of the other methods at present in use. All authors admit that in infantile hernia', which are generally reducible, the simplest methods of closure are the best, in view of the existing ten dency of nature to effect a cure. The pillar suture of 1C01fier and ordi nary ligation and burying of the hernial sac are sufficient in many eases (Notzel). But in order safely to prevent relapses, only the methods of Bassini and Kocher can be considered. Space prevents mentioning the innumerablo modifications of these methods. All the later methods of closure are based on one of these and variations are only needed to suit the skill of the operator and the diversity of the eases.
Bassini's Method.—Skin incision along the entire inguinal canal, exposure of the outer hernial ring, cleavage of the aponeurosis of the obliquus externus extending to the internal inguinal ring, exposure of the hernial neck at the internal pillars, isolation of the sac after dis section of the tunics vaginalis cornmunis. In isolating the hernial sae, difficulties may easily be encountered in children, chiefly owing to the fibrinous nature of the structures of the seminal cord.
The easiest way to effect the separation is the blunt method with the aid of cotton tips. Forceps may easily tear the hernial sac, as it is often very thin. The vicinity of the inguinal ring is the best locality to begin the separation, proceeding distally from this point. If the tip of the hernial sac is difficult to separate, as in complete congenital hernia, the hernial sac should he opened and its contents reduced, leaving the remnants of the sac in the scrotum. After reduction of the contents, the hernial sac is ligated or closed with a purse-string suture. The muscular mass of internal oblique and transversalis is sutured to Poupart's liga ment behind the seminal cord and the aponeurosis closed over the cord. In this way the termination of the seminal cord is placed upon the inner inguinal ring and the oblique direction of the muscular inguinal canal is corrected. This serves to give the inguinal canal a firm posterior wall.
Kocher's Displacement Method.--The hernia is exposed, the sac is isolated, the aponeurosis remains uncleft, the hernial contents are reduced, and the free hernial sac is passed through a small opening laterally from the inner inguinal ring, \ vh ere it is ligated and sutured into the opening. In this way it is laterally displaced.
In Kocher's inragination method the isolated and unopened hernial sac is caught at the top with a curved crenated forceps, inverted into itself, the point of the crenated forceps pushes the inverted top through both the outer and inner inguina] rings into the peritoneal space, passe,: along of them for about gem. beyond the inner inguinal ring, until
it pushes with its beak against the anterior abdominal wall. The fascia with the layers underneath, including the peritoneum, arc opened over the protruding head of the crenated forceps, and the inner wall of the anteverted hernial sac is pushed forward through the small opening. It is caught by forceps and vigorously pulled forward, two other artery clamps engage the lips of the peritoneal incision, in close proximity to which the hernial sac is perforated and ligated, and with the same thread the peritoneal and abdominal wounds are united. The wide inguinal canal, which now contains nothing but the structures of the seminal cord, is narrowed, if necessary, by interrupted sutures (canal suture).
It will be seen from a comparison of both methods that the invagina tion method can be carried out without difficulty in children, their herniae being generally free and small. The inguinal ring is not so large as in adults, where a muscular closure is necessary at the posterior sur face of the inguinal canal. Besides, in infants there is but an aperture, and seldom a canal, so that narrowing the hernial ring is sufficient to reduce its size. Muscular suturing is beset with great difficulties in infants, there being usually only fibrous bundles which easily tear. If these are gathered up transversely to obtain a better hold, they would of course become necrotic between the sutures when tying them to Poupart's ligament, and the object of the operation would be frustrated.
In Kocher's method the aponeurosis is not cleft. Lodging the seminal cord out of its natural bed is not devoid of disadvantage, later investigations of the results having in many cases shown an elevated position of the testicle on the side operated upon after Bassini's method. It should also be considered that this method requires a much larger quantity of buried suture material, which always impairs the chances of cure, however perfect the asepsis. The great liability to infection in this region, together with the persistent friction of the abdominal walls against each other, although not actually productive of traumatic disturbances, may easily lead to breaking of the sutures.