Pediatric Infant Bilateral Open Inguinal Hernia Repair - Twin A

An inguinal hernia (IH) is a protrusion of intra-abdominal contents through the inguinal canal that can arise at any time from infancy to adulthood. It is more common in males with a lifetime risk of 27% as compared to 3% in females. Most pediatric IHs are congenital and caused by failure of the peritoneum to close, resulting in a patent processus vaginalis (PPV). IH present as a bulge in the groin area that can become more prominent when crying, coughing, straining, or standing up, and disappears when lying down. Diagnosis is based on a thorough medical history and physical examination, but imaging tests such as ultrasound can be used when the diagnosis is not readily apparent. IHs are generally classified as indirect, direct, and femoral based on the site of herniation relative to surrounding structures. Indirect hernias protrude lateral to the inferior epigastric vessels, through the deep inguinal ring. Direct hernias protrude medial to the inferior epigastric vessels, within Hesselbach’s triangle. Femoral hernias protrude through the small and inflexible femoral ring. In infants and children, IH are always operated on to prevent incarceration. Surgical correction in infants and children is done by high ligation of the hernia sac only, called a herniotomy. Here, we present a female infant with bilateral IH. Upon exploration, a hernia sac was found, and ligation was performed bilaterally. In female patients, it is believed that failure of the closure of the canal of Nuck alongside the round ligament of the uterus is the etiology. Oftentimes there is a “sliding hernia” where the ovary and or the fallopian tube is attached to the sac, sometimes the uterus itself is attached.

The bilateral inguinal hernia repair on the other twin can be seen at jomi.com/article/268.13.

Pediatric surgery; inguinal hernia repair; open herniorrhaphy.

Inguinal hernias (IH) account for one of the most common outpatient clinic visits and operative cases for the pediatric general surgeon. The overall incidence of IH in children maybe up to 4.4%,¹ with the incidence increasing inversely to gestational age and prematurity.² IH may be seen in as many as 13% of infants delivered before 32 weeks gestation and in 30% of infants weighing less than 1000 g.³ The most common type of IH is the indirect variant, which develops as a result of failure of closure of the processus vaginalis (PV) in males and failure of closure of the canal of Nuck in females. Inguinal hernias are more common in males than females in a 5 to 1 ratio. In normal development, the PV closes between the 36th and 40th week of gestation, which explains the increased incidence of these IHs in the premature infant.⁴ When diagnosed, surgical repair is recommended promptly due to the risk of incarceration.⁵ Incarceration risk is approximately 12% for infants and young children and approaches 30% in infants less than 1 year of age.⁶ Female infants are at risk of strangulation of the ovaries, resulting in infertility.

The video demonstrates a transperitoneal closure of the internal ring to repair bilateral indirect IHs on a female infant. The right ovary was found within the hernia sac but not incarcerated.

A 10 month-old twin premature female infant presented with bilateral IHs of unknown duration. She had been delivered by Cesarean section weighing 1.1 kg. 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 bilateral groins. She had bilateral, reducible IHs without overlying skin changes. There was no apparent pain on palpation of either hernia. The bulges appeared to enlarge during crying.

Imaging was not performed and deemed unnecessary for this case based on clear diagnosis on physical examination of the infant.

The most common type of IH is the indirect variant, which develops as a result of failure of closure of the PV. In normal development, the PV closes between the 25th and 35th week of gestation, which explains the increased incidence of these IHs in the premature infant. This closure occurs in 2 stages and is usually complete closer to the 35th week.⁷ This region can allow fluid or abdominal contents to herniate, passing through the spermatic cord in the case of an indirect IH. The PV typically closes on the left side earlier in development than it does on the right in the male patient.⁷ This phenomenon would explain why a right inguinal hernia is more frequent than the left in male patients. In the female patients there is no preponderance of either side. If left untreated, the contents of the hernia can become strangulated, ischemic, and potentially necrotic. This becomes important when the ovary is incarcerated and can be mistaken for a lymph node. Prompt surgical correction is necessary to prevent this occurrence.

There is strong data to support expedient surgical repair of IHs to prevent complications such as incarceration.⁶ If delayed, the risk of complications increases proportional to the length of time until surgical intervention.⁸ The approach used may vary and currently entails either an open hernia repair or laparoscopic hernia repair. There is currently no high-quality evidence suggesting a superior approach, and surgeon preference often dictates. Specific patient, environmental, or institutional factors may also dictate the approach. In the context of this case, laparoscopic IH repair was not possible at the institution, and therefore the open approach was utilized.

This infant presented with bilateral IHs of unknown duration. In order to prevent complications such as incarceration, correction during the surgical mission was indicated. Due to the limitation of availability of laparoscopic surgical equipment, the open approach was chosen. The high ligation approach was avoided on the right side 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 IH after reducing the ovary. The left IH was repaired via high ligation.

In premature and low birth weight infants, anesthetic complications such as apnea and bradycardia may occur. Close postoperative monitoring is paramount.⁹

Prompt surgical intervention was necessary to correct this infant’s bilateral IHs in order to prevent incarceration, strangulation, and potential necrosis of abdominal contents. This infant is part of an underserved community and was fortunate to benefit from the care from The World Surgical Foundation.

In all instances of pediatric IHs, prompt surgical repair follows diagnosis. Though not an emergency by any means, the risk of incarceration warrants expedient action. This is especially true in infants under the age of 12 months.⁶ High ligation of the hernia sac is the technique performed in most open IH repairs, commonly attributed to the teachings of Ladd and Gross with multiple modifications since. These modifications are most likely due to the analysis of patient outcomes and increased surgeon experiences.¹⁰ The open approach to IH repair with high ligation of the sac has excellent results as reported extensively in the literature. A single surgeon published one of the largest series (6361 patients), reporting that there was a 1.2% recurrence rate, a 1.2% wound infection rate, and a 0.3% rate of testicular atrophy. There are other series which also report a recurrence rate of 1%.^11,12,13 In modern practice, there has been a focus on comparing the minimally invasive approaches of IH repair to the classic open approaches. Though there is no indication of a new gold standard, many studies have shown an increase in the use of laparoscopy in hernia repair in many centers.¹⁴ Some authors who oppose laparoscopic repair cite higher recurrence rates, increased cost per procedure, steep learning curve, and need for general anesthesia as reasons why an open operation is superior.^15,16  Some of the major cited benefits of the laparoscopic approach in IH repair is the concurrent evaluation of the contralateral patent PV, which decreases the risk of metachronous contralateral IHs. Additionally, laparoscopy allows rapid concurrent diagnosis and possible treatment of pantaloon and femoral hernias.¹⁶ More large-scale, randomized controlled trials are needed to compare the treatment effectiveness between the two approaches.

In this case, the procedure was performed under general anesthesia, it started on the right side where the right ovary was found to be within the hernia sac. High ligation was not performed; instead, the internal inguinal ring was closed while keeping the hernia sac intact. A small incision was made, and the hernia sac was located. The hernia sac was then ligated as far from the ovary and fallopian tube 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 was reduced into the abdominal cavity, and the purse-string was tied to close the internal ring. This repaired the abdominal floor by avoiding a high ligation on the right. The left IH was quickly ligated high. Both wounds were closed in layers, and the procedure was completed. The patient remained hospitalized overnight to be monitored for apnea and bradycardia and was discharged safely in good condition.

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.