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Pediatric Infant Bilateral Open Inguinal Hernia Repair - Twin B

Casey L. Meier, RN1; Lissa Henson, MD2; Domingo Alvear, MD3

1Lincoln Memorial University, DeBusk College of Osteopathic Medicine
2Philippine Society of Pediatric Surgeons
3World Surgical Foundation

Abstract

Indirect inguinal hernia repair is a common procedure for premature infants because of the frequency of a patent processus vaginalis. Prompt surgical correction decreases the risk of incarceration, strangulation, and necrosis in children. There are various techniques for herniorrhaphy. This repair demonstrates an open bilateral indirect inguinal hernia repair in an infant that avoids high ligation by closing the internal inguinal ring, utilizing a purse-string method to keep the hernia sac intact. This approach limits the amount of anesthesia used and prevents excess bleeding, making it safe, effective and efficient.

Case Overview

Background

Inguinal hernias are exceptionally common in preterm infants. The incidence rises to 60% when birth weight is between 500 and 750 g.1 Premature infants are at increased risk of indirect inguinal hernias because of patency of the processus vaginalis after birth. Incarceration risk is about 12% for infants and young children, and approaches 30% in infants less than 1 year of age.2 This risk can increase rapidly in relation to surgical wait time. Therefore, prompt intervention to reduce infant inguinal hernias is necessary. Female infants are at risk of strangulation of the ovaries, resulting in infertility. This video depicts a transperitoneal closure of the internal ring to repair bilateral indirect hernias on a female infant. The right ovary was found to be incarcerated within the hernia sac.

Focused History of the Patient

A twin premature female infant presented with bilateral hernias of unknown duration. She had been delivered by Cesarean section weighing 680 g. The infant had no excessive vomiting, abdominal distension, bloating, or fever. She had been having normal bowel movements.

Physical Exam

Physical examination revealed a healthy-appearing, well-nourished female infant. Bilateral bulges were visible in both groin areas. She had a reducible left inguinal hernia and an irreducible right inguinal hernia. There was no apparent pain on palpation of both hernias. The bulges appeared to enlarge during crying. The skin over the bulges was pink and well-perfused.

Imaging

Imaging was deemed unnecessary in this case. Bilateral hernias were clearly visible and palpable.

Natural History

A timeline of events during embryological development explains the origin of inguinal hernias in infants. Normally, between weeks 25 and 35, the processus vaginalis obliterates and involutes. When the infant is premature, there remains a patent processus vaginalis.4 This region can allow fluid or abdominal contents to herniate, passing through the spermatic cord in the case of an indirect inguinal hernia. The processus vaginalis typically closes on the left side earlier in development than does the right.4 This phenomenon would explain the incarceration of the right ovary in the present case. If left untreated, the contents of the hernia can become strangulated, ischemic, and potentially necrotic. Prompt surgical correction is necessary to prevent this occurrence.

Options for Treatment

Elective surgical intervention is the standard treatment option to repair inguinal hernias in infants. There is convincing data supporting prompt surgical repair to prevent incarceration and other complications of infant inguinal hernias. Zamakshary et al. conducted a study of 1065 infants and children less than 2 years old and found that the risk of incarceration in infants doubled if surgery was delayed for 14 days or more.2 Another study analyzed data from 49,000 preterm infants and showed that the risk of incarceration was highest in infants whose surgery was delayed beyond 40 weeks corrected gestational age.5 Taken together, the evidence base supports early surgical intervention to correct infant inguinal hernia to prevent further complications.

Approaches for hernia repair can vary. Both laparoscopic and open hernia repair is possible for infants; however, in the context of the surgical mission where this procedure occurred, laparoscopy was not possible. In the past, open hernia repair in children consisted of high ligation of the indirect hernia sac. This technique can cause excess bleeding, extended anesthesia time, damage to structures in the area, and an increased risk of recurrence.6 An approach to keep the hernia sac intact by using a purse-string suture in the internal ring fascia can prevent these complications.

Rationale for Treatment

This infant presented with bilateral inguinal hernias of unknown duration. Because of the potential length of delay in surgical repair, correction during the surgical mission was indicated. Laparoscopic equipment was unavailable because of the remote location and the temporary operating conditions. The high ligation approach was avoided to prevent prolonged operating time, excess bleeding and unnecessary risk of recurrence and damage to vessels. We chose to complete a purse string suture on the internal ring dilation point on the right inguinal hernia after reducing the ovary. The left inguinal hernia was then reduced via high ligation technique afterward.

Special Considerations

Infants, in particular, are at increased risk for apnea and bradycardia following anesthesia, therefore close monitoring postoperatively is indicated.7

Discussion

Prompt surgical intervention was necessary to correct this infant’s bilateral inguinal hernias in order to prevent further incarceration, strangulation, and potential necrosis of abdominal contents. The World Surgical Foundation was able to provide this care to an infant who otherwise would not have been able to undergo the procedure.

Traditionally, high ligation of the hernia sac was performed to repair the congenital defect. This method was shown to cause unnecessary risks, detailed above. In females, this would normally entail dissecting the fallopian tube to separate it from the hernia sac. In 2000, Applebaum et al. described an alternative method that closed the internal inguinal ring without affecting the cord structures to keep the hernia sac intact.8 A similar method was performed on this infant.

We started on the procedure on the right side containing the incarcerated ovary. A small incision was made and the hernia sac was located. We then dissected the distal attachment off the pubic bone, leaving the sac intact. The hernia sac was then ligated as far from the ovary as possible to prevent damage. A purse-string suture was used to catch the transversalis and internal ring fascia. The intact hernia sac containing the ovary and fallopian tube was reduced into the abdominal cavity and the tie was made to close the internal ring. This repaired the abdominal floor by avoiding a high ligation on the right. The left hernia was quickly ligated high and the procedure was completed. The patient remained hospitalized overnight to monitor for apnea or bradycardia.

Equipment

No specialized equipment was used in this case.

Disclosures

Nothing to disclose.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Citations

  1. Puri, P, Hollwarth, ME. 2006. Pediatric Surgery. Berlin (NY): Springer. doi:10.1007/3-540-30258-1.
  2. Zamakhshary M, To, T, Guan J, Langer, J. Risk of incarceration of inguinal hernia among infants and young children awaiting elective surgery. CMAJ. 2008 Nov 4;179(10):1001-1005. doi:10.1503/cmaj.070923.
  3. Misra, D, Hewitt, G, Potts, SR, Brown, S, Boston, VE. Transperitoneal Closure of the Internal Ring in Incarcerated Infantile Inguinal Hernias. J Pediatr Surg. 1995; 0(1)95-96. doi:10.1016/0022-3468(95)90619-3.
  4. Wang, KS, and the Committee on Fetus and Newborn and Section on Surgery. Assessment and Management of Inguinal Hernia in Infants. Pediatrics. 2012; 130 768-773. doi:10.1542/peds.2012-2008.
  5. Lautz TB, Raval MV, Reynolds M. Does timing matter? A national perspective on the risk of incarceration in premature neonates with inguinal hernia. J Peds. 2011;158(4):573-577. doi:10.1016/j.jpeds.2010.09.047.
  6. Chamberlain, JW, Anomalies and accidents complicating repair of inguinal hernias in infancy and childhood. Boston Med Q. 1956;7:23-26.
  7. Rescorla, FJ, Grosfeld, JL. Inguinal Hernia Repair in the Perinatal Period and Early Infancy: Clinical Considerations. J Pediatr Surg. 1984;19(6):832-837. doi:10.1016/S0022-3468(84)80379-6.
  8. Applebaum, H, Bautista, N, Cymerman, J. Alternative Method for Repair of the Difficult Infant Hernia. J Pediatr Surg. 2000;30(2):331-333. doi:10.1016/s0022-3468(00)90034-4.