Table of Contents
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.
The bilateral inguinal hernia repair on the other twin can be seen at jomi.com/article/268.13
Pediatric surgery, inguinal hernia repair, trends, 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 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 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.7 This phenomenon would explain the discovery of the right ovary in the present case within the hernia sac. If left untreated, the contents of the hernia can become strangulated, ischemic, and potentially necrotic. 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 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 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.
- Manoharan S, Samarakkody U, Kulkarni M, et al. Evidence-based change of practice in the management of unilateral inguinal hernia. J Pediatr Surg 2005;40(7):1163–6.
- Lloyd D. Inguinal and femoral hernia. In: Ziegler M, Azizkhan R, Weber T, editors. Operative pediatric surgery. New York: McGraw-Hill; 2003. p. 543–543
- Kurkchubasche A, Tracy T. Unique features of groin hernia repair in infants and children. In: Fitzgibbons R, Greenburg A, editors. Nyhus and Condon’s hernia. Philadelphia: Lippincott Williams & Wilkins; 2002. p. 435–51.
- Toki A, Watanabe Y, Sasaki K, et al. Adopt a wait-and-see attitude for patent processus vaginalis in neonates. J Pediatr Surg 2003;38(9):1371–3.
- Stylianos S, Jacir NN, Harris BH. Incarceration of inguinal hernia in infants prior to elective repair. J Pediatr Surg 1993;28(4):582–3.
- 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.
- 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.
- Kawshala Peiris, MBChB FRCA, David Fell, MBChB FRCA, The prematurely born infant and anaesthesia, Continuing Education in Anaesthesia Critical Care & Pain, Volume 9, Issue 3, June 2009, Pages 73–77
- Levitt MA, Ferraraccio D, Arbesman MC, Brisseau GF, Caty MG, Glick PL. Variability of inguinal hernia surgical technique: A survey of North American pediatric surgeons. J Pediatr Surg. 2002 May;37(5):745-51. doi: 10.1053/jpsu.2002.32269. PMID: 11987092.
- S.H. Ein, I. Njere, A. Ein Six thousand three hundred sixty-one pediatric inguinal hernias: a 35-year review J Pediatr Surg, 41 (5) (2006), pp. 980-986
- D. Ozgediz, K. Roayaie, H. Lee, et al. Subcutaneous endoscopically assisted ligation (SEAL) of the internal ring for repair of inguinal hernias in children: report of a new technique and early results Surg Endosc, 21 (8) (2007), pp. 1327-1331
- M.B. Antonoff, N.S. Kreykes, D.A. Saltzman, et al. American Academy of Pediatrics section on surgery hernia survey revisited J Pediatr Surg, 40 (6) (2005), pp. 1009-1014
- Alzahem A. Laparoscopic versus open inguinal herniotomy in infants and children: a meta-analysis. Pediatr Surg Int 2011;27:605–
- Esposito C, Giurin I, Alicchio F, et al. Unilateral inguinal hernia: laparoscopic or inguinal approach. Decision making strategy: a prospective study. Eur J Pediatr. 2012; 171: 989-991.
- Ponsky TA, Nalugo M, Ostlie DJ. Pediatric Laparoscopic Inguinal Hernia Repair: A Review of the Current Evidence. J Laparoendosc Adv Surg Tech A. 2014; 24(13): 183-187.
Table of Contents
- Mobilize and Externalize Hernia Sac
- Ligate Hernia Sac and Close with Purse-String Technique
- Mobilize and Externalize Hernia Sac
- Ligate Hernia Sac and Close Internal Ring
Is that the ovary? Yes, that's the ovary. Maybe not. This is part of the sac.
This is the hernia sac of the baby. Forceps?
Yeah, it's a big one, this is where the ovary came out.
There's the ovary right there. So what I'm doing is I'm going to- see, there's the head of it. So, we're gonna tuck this in, we're going to ligate the- see, there's the fallopian Tube. This is the fallopian tube right here. The ovary. So, we're going to put the stitch right there.
No, we can see without the light.
Okay. Now we're going to put a purse string around the base.
Okay, now- we’re going to tuck this in, can i have a forceps?
See this, see what I just did?
Okay, now you're going to first push this in and then tie that purse string. We're going to tie the purse string, see? See, that will prevent all the problem- instead of, instead of doing a- you know, a dissection and all that, see? See how that is? Have you seen that technique before? No sir. Have you ever seen that? No sir. No, that’s mine. Okay, so that’s why I haven’t seen it. That's my technique, and you can have it, you can own it. Just put me in a- just put me in a footnote. I'm going to put you in. Okay, when you start doing this procedure and you make a paper, because this procedure has never been described. So you have to describe it and just put me in the footnote.
My attendings were making small incisions, so I said, well... are they doing? How can you, how can you do this operation in small incision, and then when I learned the philosophy and principles of it, I made my incisions even smaller. And then my attendings were making big incisions, bigger incisions than mine, so- so, my attendings got mad at me. So, my chapter one is incisions. Yes, correct. See, you think you can- look at this needle I have here and if you don't know how to use it in through a small incision, you'll be fumbling around like crazy. You’ll be sewing up everything that you see in sight, but you see how big this needle is compared to the incision, but you’ve got to know how to use it. You have to know where- strategically, where the needle is going to be, to the- to the needle holder and all that. So all- it's all strategic. Yeah. And I have to be careful, because this needle holder is- is also a scissors, so it's a mean- it's a mean needle holder. Yeah. Because if I'm not paying attention, I cut the suture in the middle of the procedure.
Okay. Then let's go ahead and close the whole way, while we- before we do the other side.
See what I did, I just did is I just used the needle holder as a retractor by putting it here strategically. Like so, and then you can- at the same time make a move to, to go ahead and go through whatever tissue you want to put together.
All in one swoop. And 4-0 Monocryl is next.
You catch the edge of the wound and you go down and you walk deep and you come out to the surface, just like that, same level as you went in. And then you can tie this in here. The whole concept is just approximate the wound.
Yes, this is Scarpa’s.
You’re there. Yeah, expose the external oblique. Yes, that's them
Yes, there’s the sac. Yeah, pull it up, then push that- another clamp.
Where's the nerve, the nerve is- it’s not there, push the nerve away, there's a nerve.
Yeah. Cauterize that one. Okay, all right, just suture ligature the sac and you're done, you don’t have to do- the maneuver I showed you, just put a high ligation there, at the bottom. Okay?That's it. Suture, 3-0 Vicryl
Yeah, go ahead.
Okay, we're going to close.
That one. Yes, that's the one.
You didn't get the other side yet. You're going to come up, come out.
Okay, yes, yes, you got it this time.
This should be it.
March all- go all the way.
Because then they’ll see two different kinds of closure.