Table of Contents
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.
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.
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 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 was deemed unnecessary in this case. Bilateral hernias were clearly visible and palpable.
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.
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.
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.
Infants, in particular, are at increased risk for apnea and bradycardia following anesthesia, therefore close monitoring postoperatively is indicated.7
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.
No specialized equipment was used in this case.
Nothing to disclose.
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.
- Puri, P, Hollwarth, ME. 2006. Pediatric Surgery. Berlin (NY): Springer. doi:10.1007/3-540-30258-1.
- 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.
- 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.
- 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.
- 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.
- Chamberlain, JW, Anomalies and accidents complicating repair of inguinal hernias in infancy and childhood. Boston Med Q. 1956;7:23-26.
- 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.
- 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.
Table of Contents
- Mobilize and Externalize Hernia Sac
- Ligate Hernia Sac and Close Internal Ring
- Mobilize and Externalize Hernia Sac
- Ligate Hernia Sac and Close Internal Ring
Yeah, we just did a- twin babies who were born premature. The one baby weighed 2.5 pounds, and this baby we're doing is- weighed 1.5 pounds. The mother's 17, 4' 10". And so they did a C-section to deliver the babies at the time of birth. And then of course they, they grew with the mom's breast milk, and for the whatever it is, the grace of God, the baby survived. The babies survived in spite of prematurity, but then they, they developed a hernia. The tiny baby that we're doing now, the twin- I call it twin B- had a hernia where the ovary was stuck in the hernia sac for- for I don't know how long. And what happens when that happens that is you can lose the ovary actually, but in this case, the ovary survived. It just got swollen because- you pinch, you- have a tourniquet on the blood supply and it doesn't on the vein, and they are, and the lymphatics, so the ovary swells so it doesn't get, doesn't reduce. The other baby had no such thing, she just had swelling, the ovary comes in and out, but it goes back in, so it was not a critical thing. But if the ovary comes out in a hernia in a girl, then you can lose the ovary. So that's why we have to fix it as soon as possible. So they were fortunate that we are here because they don't have any surgeons in this area that can do babies, especially this type of surgery. And also they don't- they don't anesthesia- Anesthesia is also important in situations like this where you have- anesthesiologists who are comfortable or competent in- in giving anesthesia to babies.
You go through Scarpa's fascia. Now we're looking for the hernia sac. Hemostat? And the ovary was trapped in the hernia sac for a long time. I don't know how long. Hemostat? And this is the hernia sac now. Pushing all the other tissues away from the hernia sac. So we can save the ovary from getting trapped. I think this is the ovary right here. And Lissa, cauterize this slowly. Okay. Yeah- I think the ovary is reduced. Yeah, that. There's the round ligament. Okay, good. Perfect. Perfect.
Good. Now she's suturing the hernia sac now, and we're doing it above the ovary, or distal to the ovary. The ovary is ready, almost to the belly. All right. Now we load up another suture. You stick- you put the needle in the needle holder, and go through the tissue. Go towards here, towards me. Okay, now tie that. For a tiny baby, you can see the hernia sac is large. And- the ovary's been stuck there for I don't know how long. But it's viable, It's not- it's not affected by it. Hemostat? What we're going to do now is we're going to put a purse-string suture on the base. You're going to put the purse-string suture on the base of the sac, so we can tuck this in. See? You can see there, just- catch the thick part of the sac. Yeah. Yeah, you go a little deeper. Yeah, even deeper. Where the white- you can see the nice white, pearly white tissue. Yeah. Good. Get that, there's a nice one. Good, perfect. Okay. Good. Good. Okay. Let me have the other one. Now you watch for the epigastric vessels. Go as far as you can go, the vessels are- I can see the vessels. Go as far as you can go on the pearly white tissue. Yeah, that's it. Good. Good, perfect. You know, this- this technique, they can apply it in adult patients as well. And it'll make it easier for them to do the procedure. You need to go one more. See, right at the pearly white tissue. You can do the same for young adults. Right there. Good. Yeah, that's a good bite. I like that. Yeah, do it again. Yeah, that's good. Push this whole thing, push that all the way in. Okay, tie- now you tie the purse-string. That should close it, so see? And we got- we got two objectives there, we- ligated the sac and also- closed the internal ring at the same time. Okay, good. Okay, now we can close the external oblique.
Actually, that should be enough. And we just have the- distal portion Yeah. God, this one doesn't have the- is this- this is the one that was on the- tie it, just tie it, we don't need anymore. So, I'll do it your style. Yeah- yeah, that's right, interrupted subcuticular, yeah, you can… You'll like that better anyway because it's a lot easier, you only need 3 stitches, and sometimes you only need 2, and then that's it, you're done. You have to be- You have to be equal and even. So they don't have overlapping, and it heals better because there's less foreign material in the… Yeah, in the sub-Q area. Yeah. So you wont have- you'll have less redness. Now let me show you- let me show you a trick. Okay. The trick, the trick for this kind of of suture is you catch the edge, you catch the edge of the wound. Edge, like that, and you go down, and then you rotate, see? See how the needle rotates? Then you come out. See? And then you make that little twist on the wrist. And then- see how big that bite is? Nice one. And then you go, you move your body just a little, see watch, watch- watch my body, See? I rot- rotate my body, so that I can catch the edge of the wound like that.
Perpendicular wound. Incision. Go ahead. A little bit more. Yeah, right here. See if you can- no bleeding, just lean, lean, lean, lean a little bit more. Okay, good. Perfect.
Retractor. Yeah, I can see the bulge now. Just pull it up high when you get the clamp.
Okay, and then just- just cauterize that.
Perfect. Okay. Good. All right, good. You just put a single stitch there? Yeah- A figure of eight. Okay, you can get the 4-0.
The procedure's done, we're just going to close the last wound. Yeah.
So we, we did the procedure, and we took the sac and also preserved the ovary. And there's a certain technique that I developed over the years where instead of opening the sac, look at the ovary that's stuck, and try to release it away from the sac, and then push it in, and then for the suture, that takes a long time and can be bloody. And also it, it gives the anesthesiologists a challenge because it hurts more when you're doing all that. So when the baby starts bucking, then you have to do other things to- to maintain your airway and keep the baby alive. Whereas this technique, I just put a- after I ligate the sac, high and away from the ovary, I put a purse-string suture at the- at the base of the, of the sac, catch the fascia or tissue that's very thick, and then I invert the whole thing, with the sac and the ovary into the belly. And then tie the purse-string suture, and the hole is closed. And that seems to be very effective in this situation. It makes the operation much quicker, and much safer, and less complications for anesthesia. And so that's why we can do this operation very quickly and safely in a setting like this. Thank you.