Pediatric Infant Bilateral Open Inguinal Hernia Repair - Twin B

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 with an incarcerated right ovary.

A 10-month-old twin female infant (corrected gestational age: 66 weeks) presented with bilateral hernias of unknown duration. She had been delivered via Cesarean section at 25 weeks of gestation, weighing 680 g. The infant exhibited no signs of excessive vomiting, abdominal distension, bloating, or fever and 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 as the bilateral hernias were clearly visible and palpable. However, ultrasonography can be useful when physical findings are inconclusive or to assess blood flow in the hernia contents, particularly to differentiate between a sliding hernia and an incarceration and strangulation. In low-income settings, the utility of ultrasonography may be limited due to the lack of access to functional or modern ultrasound machines, making clinical examination the primary diagnostic tool in such contexts.

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 are possible for infants; however, in the context of the surgical mission where this procedure was performed, laparoscopy was not an option. 

High ligation is the standard technique for repairing indirect inguinal hernias in children. However, in the case of sliding hernias, this technique can cause excessive bleeding, prolonged anesthesia time, damage to surrounding structures, and an increased risk of recurrence. An alternative approach to ligate the sac distal to the contents and close the internal ring using a purse-string suture can prevent these complications. Woolley described this technique in 1978.⁹ Additionally, Goldstein and Potts outlined a method for safely treating fallopian tubes that have adhered to the hernia sac. This procedure involves creating a tongue-shaped flap on the hernia sac with the adnexa attached, reducing the flap into the peritoneal cavity, and then closing the remaining sac with a purse-string suture before excising it.¹⁰ In 2000, Applebaum et al. described an alternative method that involved closing the internal inguinal ring with a purse-string suture without disturbing the cord structures, thus preserving the hernia sac.⁸

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. 

General anesthesia with mask ventilation was used in this case. However, caudal, spinal, or local anesthesia are also viable options for premature infants, depending on the clinical scenario and available resources. We chose to complete a purse-string suture on the internal ring dilation point on the right inguinal hernia after reducing the ovary. This technique is used for female inguinal hernias in order to expedite the procedure and avoid tearing the sac and injuring the ovary or the fallopian tube. 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.

As a standard, high ligation of the hernia sac is performed to repair the congenital defect. However, in sliding hernias, this method may pose unnecessary risks, as detailed above. In females, this often requires dissecting the fallopian tube to separate it from the hernia sac. A similar method, as described by Wooley, was performed on this infant. The educational merit of this article lies in the fact that this procedure is useful for infants born prematurely with similar hernias.

We started on the procedure on the right side containing the incarcerated ovary. A small incision was made, the external oblique was opened, 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 parents of the patient referred to in this video have given their informed consent for surgery to be filmed and were aware that information and images will be published online.