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320
R. Miller and S. Clarke
Palpable inguinal lymphadenopathy is a possible differential diagnosis; however both the history and examination
are different. With a lymph node, there is unlikely to be fluctuations in size, and examination will reveal a discrete rubbery swelling that is noncompressible, non-reducible and
anatomically distant from the external ring. It may be tender
in the context of an acute infection but is unlikely to be persistent. However, palpable inguinal lymphadenopathy is not
common, and a local source of infection might be sought, or
the examiner should proceed to palpate the other lymph
nodes to detect generalised lymphadenopathy.
Specific Considerations and Complications
Although in infants and children the majority of inguinal
hernias are indirect, they can rarely have direct inguinal hernias. These occur due to defects in the transversalis fascia
and presents as a bulge more medially in the groin (medial to
the inferior epigastric vessels). They are often misdiagnosed
as indirect hernias. A direct hernia may not be obvious while
the patient is anaesthetised; however it should be suspected if
a typical patent PV couldn’t be found. If not spotted intraoperatively, patients may return with what appears to be a
recurrent indirect inguinal hernia [30]. If this is the case, it is
repaired using interrupted non-absorbable sutures between
the inguinal ligament and conjoined tendon. Occasionally a
mesh repair is required in the older child.
The predominant complication of inguinal hernias is
incarceration (Fig. 21.4) and, depending on the structures
involved, the potential relevant sequelae. A number of structures can be involved and may ‘slide’ in and out of the hernial sac without becoming incarcerated. In infants, the
bladder may be pulled with the hernial sac, or a bladder
diverticulum may become incarcerated [43]. Alternatively
the caecum or appendix [44] may share a wall with a rightsided hernial sac and bowel can become incarcerated. In
Fig. 21.4 Incarcerated inguinal hernia
girls, a fallopian tube, uterus, mesosalpinx and ovary may
share a wall with the sac [45].
As stated previously, incarceration may be the first presentation of an inguinal hernia, or it may develop in a child
awaiting elective hernia repair. The incidence of incarceration ranges widely from 3.4 to 31% (Table 21.3). Within this
variability, incarceration is more common at younger ages,
with the majority in children around 1 year of age and
younger [3]. However, premature infants have a relatively
lower rate of incarceration rate, possibly due to a stretched
inguinal canal [1]. Interestingly, as illustrated in Table 21.2,
the incidence of incarceration appears to be decreasing over
time with a dramatic difference between studies prior to
1991. This may be due to advances in medical practice and
the ability to operate at younger ages, preventing incarceration occurring.
Incarcerated hernias present as a clearly defined, tense
mass in the inguinal region that may extend into the scrotum.
They are tender and do not spontaneously reduce.
Occasionally, it will transilluminate and must then be distinguished from a tense hydrocele of the cord. Ultrasound may
help to make this distinction. Incarceration of the bowel can
result in strangulation and intestinal obstruction. Bowel
obstruction may occur in up to 9% of non-reducible incarcerated hernias [33]. This will manifest with vomiting, abdominal distension and absolute constipation. Abdominal X-ray
will show evidence of intestinal obstruction, and gas may be
seen within the incarcerated bowel loops in the scrotum. The
overlying skin and the testis may be swollen and tender.
Ischaemia of strangulated incarcerated contents may insure
with prolonged incarceration, manifesting with intensified
pain and significant systemic upset.
It is often possible to safely reduce an incarcerated inguinal hernia in infants and convert a surgical emergency, to a
condition requiring a semi-elective procedure. The success
rate in reducing infant hernias is over 70% [1, 3, 4, 35, 46].
Indeed, Karabulut reports all incarcerated hernias were manually reducible with none requiring emergency surgery [40].
Therefore, the initial management of incarcerated inguinal
hernia without strangulation and ischaemia should be
nonoperative.
In order to achieve reduction, the basic requirements are a
stable environment, adequate monitoring, adequate resuscitation and analgesia. The latter is achieved with morphine.
0.1 mg/kg is given intravenously to infants and 0.2 mg/kg as
an oral preparation for children over 6 months of age. The
dose should be reduced to 0.025 mg/kg for the premature
infant. Midazolam 0.1 mg/kg may be added for the older
child. Sedation should only be conducted by those trained to
do so with monitoring of respiratory rate and pulse throughout. After allowing adequate time for the infant to settle,
spontaneous reduction may occur. If not, gentle bimanual
compression with gentle and sustained pressure should be
21 Inguinal Hernias in Babies and Children
Table 21.3 Overview of incarceration rates in published studies
Age Sample size Incarceration (%) Year published Reference
0–17 years 2100 18.1 1957 [30]
0–16 years 2764 12.7 1971 [17]
<1 years 511 31.0 1984 [43]
<2 months 100 31.0 1984 [44]
<2 months 384 24 1991 [45]
4 years (mean) 1582 9.7 2003 [31]
<18 years (mean, 3.3) 6361 12 2006 [32]
<2 years 1065 11.9 2008 [33]
Short-wait group, 25.52 days Short-wait group: 25
Long-wait group, 55.0 days Long-wait group: 16
Total cohort, 46.6
(postconceptional age—weeks)
Repair before NICU discharge,
27.8 weeks
Elective repair, 31.7 weeks
20 days to 16 years 402 8.7 2011 [36]
32 months (mean) 3776 3.4 2012 [15]
Boys, 2.71 years (mean)
Girls, 3.70 years (mean)
<15 years 79,794 4.19 2016 [14]
3.5 years (mean) 6826 6.10 2017 [38]
a
Referenced in Groseld 1989 analysis of incarceration rates in different ages [6]
b
Study of premature infants (28–35 weeks gestation) comparing short and long waits for operative intervention
c
Retrospective review of premature infants with a mean birth weight of 1428 g
92,308 (3881 operations) None reported 2013 [37]
172
45
127
12 (n = 3)
56.2 (n = 9)
4.6
11
2
2010 [34]
2011 [35]
a
a
a
a
b
c
321
used. Flexing the ipsilateral hip with external rotation can aid
reduction. A gurgling sensation will indicate emptying of the
bowel and subsequent reduction. Preferably an elective
repair should then be scheduled within approximately
24–48 h [1, 35, 46]. This time allows some resolution of the
oedema, minimising the difficulty of the dissection and
decreasing the risk of complications.
Failure to reduce the hernia is an indication for an immediate operation. The operative approach is that for the elective procedure but the external inguinal ring must be opened
to allow reduction of the contents of the hernia. Further operative management is determined by the viability of the intestine. If the incarcerated contents are viable, it is reduced into
the abdominal cavity and a high ligation of the sac is performed. However, if the content is no longer viable, it should
be resected, either though the sac or through a separate entry
into the peritoneal cavity via the same skin incision.
Prolonged incarceration can lead to intestinal resection in
3–7% of cases [33]. Some authors report testicular ischemia
in almost one-third of boys with incarcerated hernia, while
other authors suggest that the problem has been much overemphasized [35]. Gonadal infarction secondary to incarceration was found to be more common in infants younger than
3 months [47] compared to similar cases in older age groups
[3]. However, an incarcerated hernia in an infant is technically more difficult since the hernial sac is typically oedema-
tous and fragile and so also has a higher complication rate
[16]. The testicular vessels and the vas deferens are particularly susceptible to injury because of the oedema and an
often-challenging dissection. These procedures are safest in
the hands of experienced surgeons.
The overall complication rate in patients with incarcerated hernia has been reported to range from 11 up to 33%
[35]. Reducible incarcerated hernias have a complication
rate of 4.5%, compared to 33% for those that were irreducible and required an emergency operation [3]. Rescorla and
Grosfeld noted a slightly higher complication rate in very
low birth weight infants younger than 2 months of age at the
time of their operation [33].
A specific complication to consider in females is ovarian
incarceration. The management of an asymptomatic irreducible incarcerated ovary is unclear. In a survey of the variability of technique in inguinal hernia management and repair,
Levitt et al. found that management of an incarcerated nontender ovary still varied from repair at the first available
elective time (50%), repair that week (28%) or repair that
day as an emergency (10%) [48]. The herniated ovary and
fallopian tube are at a risk of vascular compromise either due
to incarceration or, more likely, torsion. The reported incidence of strangulated irreducible ovaries is as high as 32%
[6]. It is therefore our opinion that the risk to the ovary is
indeed significant and should be managed as an emergency.
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R. Miller and S. Clarke
Management Options
From an understanding of the anatomical causes of inguinal
hernias in infants and children, it is clear that they will not
spontaneously resolve. Surgical management is therefore the
gold standard, and long-term conservative management is
never indicated, due to the high rate of associated complications [49, 50]. Ideally surgery should be carried out in an
elective/semi-elective setting. However, complicated hernias
presenting acutely should be managed urgently, as discussed
above.
Regarding elective surgical management, there are some
specific considerations for infants and children. This includes
the timing of the operation, which is particularly pertinent
for premature or low birth weight infants. Secondly, what
should be done about metachronous hernias and finally the
operative approach: open vs. minimally invasive.
Timing of Surgery
As stated above, even without incarceration, elective repair
should occur promptly after diagnosis, taking into consideration the age of the child and associated anaesthetic risks.
Some reports suggest that the great majority of complications can be avoided if repair is done early with an increased
incarceration risk with time from diagnosis. After diagnosis,
a wait time over 14 days was associated with a doubling of
incarceration risk [37].
Furthermore, the premature and low birth weight infant
presents a unique challenge. Premature infants show an
increased risk of post-operative life-threatening apnoea after
inguinal hernia repair [51, 52], although the risk is still
thought to be low [39]. Unlike older children who may be
treated on a day- case basis, monitoring of these high-risk
infants for 12–24 h after operation is strongly recommended
[52, 53]. It has been suggested that prematurity, rather than
age at operation, or even incarceration, has the greatest
impact on inguinal hernia repair complication rates [54], and
low birth weight is an independent risk factor for emergency
inguinal hernia repair surgery [55]. The optimal timing of
surgical repair in these neonates is controversial [46]. In a
small premature infant, the operation is technically more
challenging and associated with a higher morbidity.
Furthermore, the anaesthetic risk is higher. For those already
admitted to a neonatal intensive care unit, it has been suggested that they should have their hernia repaired prior to
discharge [1], but this is a simplistic proposal and on review
of 172 premature infants undergoing inguinal hernia repair
Lee et al. found that repair prior to neonatal intensive care
unit discharge was associated with prolonged hospital admis-
sion [39]. This is echoed by Vaos et al., who advocate an
early elective herniotomy in premature infants [38]. However,
although the risk of incarceration is still relatively low in premature infants [39], there is a significant financial burden
associated with emergency repair in this group, with a difference in cost of €1,183 in favour of elective repair [56].
Many factors such as gestational age, birth weight, actual
weight, comorbidities, pulmonary status and history of incarceration are all factors that should be taken into consideration in order to formulate an individualised approach to
determine the optimal time for surgical repair [53]. However,
in general terms, early elective inguinal hernia repair, with
appropriate precautions, is recommended for premature
infants [46]. For infants diagnosed after discharge and who
are expected to require ventilatory support or experience episodes of apnoea and/or bradycardia, elective repair has been
recommended to be delayed for up to 44–60 weeks of corrected conceptional age [33]. Locally determined guidelines
and resources will ultimately influence this.
Metachronous Contralateral Inguinal Hernia (MCIH)
If patients are observed after ipsilateral hernia repair, a metachronous hernia will appear on the contralateral side in
1–31% of the time [57]. In a recent 17-year analysis of
31,100 unilateral inguinal hernia repairs in Taiwan, the overall MCIH rate was 12.3%, with 91.7% requiring repair within
5 years [58]. This is a higher figure than a meta-analysis of
six studies (1669 children) in 2015, which gave a MCIH rate
of 6% [59]. This risk appears to be greater when the original
hernia is on the left side [57, 59].
Exploration of the asymptomatic side can be used to
detect a patent processus vaginalis or non-evident clinical
hernia. The goals of identifying these two entities are to
avoid a second anaesthesia, minimise parental and patient
inconvenience, avoid the chance of incarceration and reduce
costs. However, there is no current support for contralateral
exploration in any child with a unilateral inguinal hernia and
a clinically normal, asymptomatic contralateral groin
[60–62].
In 2007, a systematic review on the risk of developing a
MCIH acknowledged that ‘the success of contralateral
exploration cannot be measured by how many PPVs are
closed, but by how many MCIHs are prevented’ [62]. The
results of the review stated that the risk of MCIH for all children having open hernia repair is 7.2%. Overall, 14–17%
contralateral explorations are required to prevent one MCIH
[59, 62] and the complication risk of contralateral exploration is still 2–16% [63].
21 Inguinal Hernias in Babies and Children
323
However, laparoscopy offers a significant advantage
regarding the assessment of contralateral hernias, as the contralateral deep ring can be examined with no increase in morbidity or mortality. If a patent PV is found, the decision can
then be made to close it.
Although not routinely offered, another process, which
may be beneficial in unilateral inguinal hernias, as discussed
previously, is the use of ultrasound. In one study, the development rate of contralateral inguinal hernias after unilateral
herniorrhaphy was reduced from 10.2 to 1.5% with the use of
contralateral USS ± repair [27].
Preoperative Considerations
As discussed above, preoperative considerations will change
if the hernia is incarcerated or not on presentation. This will
then dictate whether preoperative reduction is warranted
or not.
Consent
Consent will require the use of a parental consent form but
with involvement of the child if they are of a suitable age.
The parents should be fully informed regarding the procedure including the incision, the nature of the repair (open vs.
minimally invasive), potential complications (discussed
later) and post-operative management. It is important to consider consenting for the exploration ± repair of the contralateral side, if this is intended.
Complications may be intraoperative or post-operative
and all should be discussed. In general terms, the consent
process is the same for incarcerated and non-incarcerated
hernias. However, the risk of complications is increased with
incarceration, as is the necessity to perform the procedure
sooner. One series quotes a complication rate of 3.6% in
elective repairs compared to 14.4% in incarcerated hernias
[16]. This may be in part due to operative difficulty but also
possible systemic upset in incarcerations.
Important intraoperative complications include damage
to the vas deferens (1–2%) and damage to testicular vessels
(1.6%) [16]. Damage to these structures may result in subsequent testicular atrophy and should therefore always be
mentioned during the consent process. Atrophy occurs more
commonly in incarcerated hernias with an incidence
reported to be up to 20% [49]; however in elective repair, it
is rare at around 4% [64]. Given that most injuries to the vas
result from crushing or vascular impairment [1, 65], they
might go unnoticed intraoperatively. However, if the vas
deferens is divided, it should be repaired with interrupted
7/0 or 8/0 monofilament sutures. An experienced practitioner utilising adequate magnification will make the repair
more precise.
Regarding incarcerated hernias, it is important to mention the possibility of damage to the hernia contents.
Structures include the intestine, omentum, appendix and
ovaries.
Although rare, deaths have been reported in association
with inguinal hernias. In 1978 the quoted mortality rate of
elective inguinal hernia was 0.1% rising to 3.0% with incarcerated inguinal hernias [66]. However, in more recent series,
almost no deaths have been recorded, and mortality appears
to be associated with coexisting risk factors such as cardiac
disease and prematurity [64, 67], rather than the inguinal
hernia per se.
Post-operative complications include wound infections,
hydrocele formation, iatrogenic undescended testes, recurrence and altered fertility. These will be addressed later.
It is important to mention that all operative sites should
also be marked. Correct site surgery relies on adequate preoperative marking on the abdomen with parental agreement
as to the affected side. This is important even if laparoscopic
repair is planned, in case pneumoperitoneum is not
possible.
Anaesthesia for Inguinal Hernia
General anaesthesia is usually required. In addition local
anaesthesia using 0.25% bupivacaine (0.8 ml/kg) within the
fascia or a pararectal block is recommended. Some evidence
exists for reduced post-operative pain requirement with a
preoperative caudal anaesthetic [68].
The World Health Organization (WHO) Checklist
The WHO checklist should be completed with a sign-in,
time-out and sign-out.
Regarding the time-out, in a straightforward inguinal herniotomy, there are no critical steps, minimal anticipated
blood loss and an estimated duration of 30–40 min. There is
no essential imaging and little evidence for the use of antibiotic prophylaxis. We would recommend the use of prophylactic antibiotics only for acute incarcerated hernias requiring
emergency surgery.
If a minimally invasive approach is being used, it is
important to discuss the necessary equipment and set-up
required, depending on the technique being used and surgeons’ preference.
324
R. Miller and S. Clarke
Operative Options
Hernias can be fixed via an open approach or using minimally invasive techniques. Laparoscopy was first applied to
paediatric inguinal hernias to evaluate the contralateral side
for the presence of a patent processus vaginalis (PPV) and
to confirm the diagnosis of an inguinal hernia [69–71].
However, there has been a recent emphasis on minimally
invasive techniques for the fixation of inguinal hernias.
It is important to mention that the chosen option of course
depends on the competencies of the surgeon performing the
operation and the resources available at the given centre.
The International Pediatric Endosurgery Group (IPEG)
Evidence-Based Review Committee recently chose to review
minimally invasive approaches to inguinal hernia repair providing the most up-to-date assessment of the literature both
in terms of evidence availability and also evidence quality
for the use of minimally invasive techniques [72].
As identified by the IPEG review, to date there are four
meta-analyses [73–75] but only one meta-analysis providing
level 1a evidence [63] for the use of laparoscopic vs. open
hernia repair [72].
Several advantages were identified for the use of laparoscopic repair of inguinal hernias from the IPEG review.
Operative time for bilateral hernia repair is reduced and post op complication rates are lower. As mentioned previously, it
offers the advantage of facilitating easy inspection of the
contralateral side for identification of metachronous hernias.
However, the recurrence rate is comparable with open hernia
repair. A disadvantage for consideration is that peritoneal
thickening from chronic irritation may hinder the identification of cord structures and put them at risk of damage. Nerve
entrapment is also a possibility [76]. There are also the added
risks of intra-abdominal organ damage associated with laparoscopic port insertion. Laparoscopy has been reported to be
equally advantageous in cases of recurrent inguinal hernias
after open surgery [46] allowing the surgeon to avoid previously operated tissue planes and potentially lowering the
risks of injury to the vas and/or vessels. In addition, the
pneumoperitoneum may widen the internal ring and help in
reduction of incarcerated hernias [77], the viability of which
can be easily assessed and addressed if needed.
Within minimally invasive inguinal hernia repair, there are
several options. The IPEG committee classifies these according to suture placement [72]. This may be either intracorporeal or extracorporeal and both may have single of multiple
suture sites. Examples of intracorporeal suture placement
include purse-string or ‘z’ sutures, flip-flap peritoneal coverage or inversion with ligation in females. Examples of extracorporeal suture placement include subcutaneous
endoscopically assisted ligation (SEAL) and the use of various instruments to pass a suture around the internal ring, for
example, a Reverdin needle or Endoneedle. Intracorporeal
suturing is purely laparoscopic and may include dissection of
the hernial sac. Extracorporeal suturing uses a groin incision
and the suture insertion into the preperitoneal plane with laparoscopic visualisation. Several additional steps or variations
on these methods have been described to ease the passage of
the suture in this plane and improve hernia closure, such as
hydrodissection or traumatisation of the peritoneum.
There is a variety of evidence assessing these techniques
from level 4 case series to 1b randomised control trials, but the
IPEG committee conclude that there is insufficient evidence to
support one method over another [72]. One randomised control trial did specifically compare intra- vs. extracorporeal
suture placement and found that extracorporeal suture placement was a significantly faster technique but had no statistically significant improvement in outcomes [78].
In summary, in the right hands, minimally invasive surgery for inguinal hernia repair can be very effective, but open
repair should not be abandoned.
Operative Steps: Open Repair (Figs. 21.5 and 21.6)
Patient Position and Theatre Set-Up
The child is placed supine on the operating table. Preparation
with a careful aseptic technique combined with betadine or
chlorhexidine will suffice. Drapes are applied so that the
inguinal area is exposed throughout the operation. The surgical site mark must be visible after draping.
Incision and Access
An incision is made in the lowest inguinal crease along Langer’s
lines. The Scarpa’s fascia is incised and spread. The rounded
edge of the external oblique and external inguinal ring should
then be identified. The external oblique can then be incised and
spread in the line of the fibres. Alternatively the spermatic cord
can be accessed from the external ring. However, it is not
essential to open the external inguinal ring when opening the
external oblique aponeurosis. The ilioinguinal nerve should
always be identified on the inner surface of the external oblique
aponeurosis in order to avoid its entrapment. The cremasteric
fascia is then opened to expose the cord structures.
Key Steps
Care is taken not to grasp either the vas deferens or the vessels. Only loose connective tissue may be handled until the
hernial sac is identified. At this point, the latter is grasped
with a pair of non-toothed forceps and the remaining cord
External oblique
Scarpa’s fascia
ab
cd
21 Inguinal Hernias in Babies and Children
Deep ring
325
Testicular vessels
Vas deferens
Fig. 21.5 (a–d) Open inguinal herniotomy. (a) The cremasteric fascia
is opened to expose the cord structures. (b) The sac is grasped with a
pair of non-toothed forceps and the remaining cord structures pushed
away bluntly separating them from the hernial sac. This creates a ‘window’ between the sac and cord structures. This is illustrated far better in
structures pushed away bluntly. In boys, delivery of the testicle into the wound is usually unnecessary.
Once free from the vas and vessels, the sac can be divided
between clamps and the proximal end dissected superiorly to
the level of the internal inguinal ring. This is identified by
appearance of the preperitoneal fat. If necessary, the contents
of the sac are reduced; the sac is twisted and then transfixed
using a braided absorbable suture. The distal end of the sac is
left open. Further dissection of this distal sac is discouraged.
Some authors prior to ligation check for a contralateral hernia via hernioscopy. This can be done by insertion of a 30° or
children than adults. (c) The sac is divided between clamps and the
proximal end dissected superiorly to the level of the internal inguinal
ring. (d) The contents of the sac are reduced and the sac twisted and
transfixed
70° scope via the hernial sac following insufflation via a
nasogastric tube through the hernial sac [79].
In boys, the testicle should be confirmed to be in a normal
intrascrotal position at the end of the procedure. It is equally
important to document this on the operation note. In girls,
the absence of vital cord structures makes repair simpler. The
surgical approach to the sac is the same. However, it is
important to routinely open the sac in girls because as many
as 21% [80] have a sliding component and to exclude complete androgen insensitivity syndrome (CAIS) where an ovotestis may be present.
326
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R. Miller and S. Clarke
a
c
Fig. 21.6 (a–d) Open inguinal herniotomy. (a) Skin incision with dis-
section through the Scarpa’s fascia and external oblique. (b) The sac is
identified (held in the non-toothed forceps) wrapping around the cord
structures. This is bluntly dissected away creating a window between
Closure
the sac and cord structure—see ‘b’ in Fig. 21.5. (c) The sac is divided
and the proximal end dissected superiorly to the level of the internal
inguinal ring. (d) The contents of the sac are reduced and the sac
twisted and transfixed
Alternative Open Approach: The High Scrotal ‘Bianchi’ Approach
Unlike in adults, the infantile inguinal hernia does not need reinforcement. Exception is made for children with an underlying
collagen disease [14]. The external oblique (if opened) should
be closed with a continuous suture. Scarpa’s fascia can then be
closed with interrupted absorbable sutures. Finally, the skin is
closed with a subcuticular absorbable suture.
In 1989, Bianchi and Squire hailed the use of their scrotal
approach for a palpable undescended testis as an acceptable alternative to the groin incision. A high scrotal
crease incision exposes the cord structures. The hernial
sac is dissected in the usual manner. Upward traction
21 Inguinal Hernias in Babies and Children
allows access to the neck of the hernial sac for transfixation. Age may be a limiting factor to this approach. The
older the child, the bigger retraction necessary to reach
the neck of the hernial sac. Some published reports support this approach [81, 82].
Operative Steps: Laparoscopic
Patient Position and Theatre Set-Up
The child is placed supine on the operating table, either
inline or across the table depending on size of the child.
Careful preparation with an aseptic technique combined and
betadine or chlorhexidine will suffice. Drapes are applied so
that both inguinal and umbilical areas are exposed as well as
the marked side.
For a minimally invasive repair, the theatre must be set
up appropriately. This will depend on both the surgeons’
preferences but also the technique being used. The senior
authors’ preference for laparoscopy in neonates and infants
is to stand at the patient’s head. Therefore, positioning the
patient across the table, with or without an extension, is
preferable. Care must be taken not to insufflate the stomach
too much during anaesthesia or at least provide tubal
decompression as distal intestinal distension decreases
working space.
Incision and Access
Three incisions are needed. Firstly, an open Hassan technique should be used to insert the umbilical port. A pursestring suture is used to secure the 5 mm port and maintain a
pneumoperitoneum. A short 5 mm 30° telescope is inserted
and the deep internal rings assessed. Two further 3–4 mm
incisions are made in the right and left lower quadrants. Ports
are not essential at these points and instruments can be
inserted directly in to the abdominal cavity.
The internal ring can then be closed using a purse-string
suture avoiding vas and vessels. This suture does not seem to
affect testicular viability [83]. The choice of suture material
(absorbable vs. non-absorbable, monofilament vs. braided)
differs according to the surgeon. However, we recommend a
non-absorbable monofilament suture, such as 4-0 prolene
(Fig. 21.7). Some authors incise the peritoneum laterally to
reduce mechanical tension, although the benefit of this step
has been questioned [69, 70]. In addition to the purse-string
suture, a ‘Z’ suture can also be placed over the purse string to
re-enforce the repair. Other groups have reported a needlescopic technique, using one or two lateral ports to assist with
percutaneous, extraperitoneal ligation of the internal ring
[71, 84].
327
Fig. 21.7 Laparoscopic closure of inguinal hernia using 4-0 prolene
Closure
The right and left iliac fossa openings if no larger than 3–4 mm
(size of the needle driver shaft) can be closed with glue alone.
Hernia formation is unlikely if left open [70]. The umbilical port
site is closed with the purse-string suture placed at the beginning
and further suture to close any fascial defect if needed. A braided
suture such as Polysorb (Ethicon) 2-0 or 3-0 can be used. It is
important to make a sound closure to prevent subsequent umbilical hernia formation. Similarly, if an umbilical hernia is present, this should be closed concurrently with a formal umbilical
herniotomy technique (see previous chapter).
Alternative Minimally Invasive Techniques
Flip-Flap Closure
A flap of peritoneum is dissected laterally, flipped and
anchored to cover the hernial opening [88]. Initial reports on
this technique are unsatisfactory due to intraoperative complications (vas injury and flap avulsion) and high rate of
recurrence.
The Reverdin* Needle (RN)
RN is a surgical needle with an eye that can be opened and
closed with a slide. It essentially modifies the delivery of the
suture material, creating extracorporeal knot-tying. It markedly reduces both operative time and technical difficulty [78,
85] (Fig. 21.8).
*Jaques L. Reverdin, Swiss surgeon, 1842–1929
Laparoscopic Inversion Ligation (LIL)
The hernial sac is inverted into the peritoneal cavity and the
base tied with an endo-loop. It is only applicable in girls, as
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R. Miller and S. Clarke
the vas and vessels cannot be excluded from the tie. A series
of 30 females reported no recurrences [89]. Similarly, a
larger series of 241 hernia repairs reported no intraoperative
or wound complications and a recurrence rate of 0.83% [86]
(Fig. 21.9).
Laparoscopic Extraperitoneal Closure (LPC)
An Endoneedle [90] devised by the department of Paediatric
Surgery of Saitama Municipal Hospital in Japan is a special
Fig. 21.8 Both components of the Reverdin needle, seen here with
mounted suture. Reprinted with permission from [85]
instrument that has a wire loop to hold the suture material at
the top and can be used for purse-string suturing around the
internal inguinal ring, with extracorporeal knot tying [87].
On analysis of 1257 hernias repaired with laparoscopic
extraperitoneal closure, there was a recurrence rate of 0.2%
[91]. In addition, in conjunction with umbilical ligament
reinforcement, this has been shown to achieve near-zero
recurrence rates [92] (Fig. 21.10).
Percutaneous Internal Ring Suturing (PIRS)
A hollow needle with suture material inside is passed percutaneously under the peritoneum of each half of the internal
ring. It allows extracorporeal knot tying by catching a loop
of the suture material and pulling it to the surface. Patkowski
et al. report some intraoperative and post-operative complications, the most serious of which was bowel strangulation
that required resection and anastomosis. Recurrence occurred
in 3 cases out of 106 children (2.8%) [93]. Another series of
250 patients demonstrated a recurrence of 1.4% and a complication rate of 2.8% in children over 10 kg [94] and a further series of 205 hernia repairs had no recurrences, with a
mean follow-up of 3.6 years [95].
Subcutaneously Endoscopically Assisted Ligation
(SEAL)
A swaged-on needle is inserted percutaneously and passed in
the extraperitoneal space over half of the internal ring. A hollow needle is also inserted percutaneously over the opposite
Fig. 21.9 Laparoscopic
inversion ligation (LIL).
Hernia is identified (a),
peritoneum inverted (b),
twisted and double ligated (c)
and then excised (d).
Reprinted with permission
from [86]
21 Inguinal Hernias in Babies and Children
329
Fig. 21.10 (a–c)
Laparoscopic percutaneous
extraperitoneal closure
(LPEC) of the internal ring.
(a) Half of the purse-string
suturing is started
extraperitoneally, beginning at
the anterior edge and
proceeding to the posterior
edge on the lateral side of the
internal inguinal ring using
the LPEC needle. (b) Suturing
of the medial side of the
internal ring is placed
extraperitoneally using the
same technique, and the
suture material is held in the
wire loop inside the LPEC
needle. (c) The LPEC needle
is then removed from the
abdomen together with the
suture material. The purse
string is tied extracorporeally.
Reprinted with permission
from [87]
a
b
c
half of the internal ring. Mating of the two allows the suture
material to jump over the vas and vessels and encompass
most of the circumference of the internal ring. The swaged
needle is then backed subcutaneously (completing the circumference), retrieved through its entry point and tied extracorporeally [96]. This technique was used in 43 hernia
repairs and no intra- or post-operative complications were
reported [97].
Tissue Adhesives
The use of tissue adhesives as an adjunct to closing paediatric inguinal hernias remains at an experimental level. Sealants
mentioned in the literature include electrocautery and talc
and glue [71, 98]. In a preliminary study on the usefulness of
tissue adhesives in repair of inguinal hernias, Kato et al.
reported that only the laparoscopic injection of octylcyanoacrylate (Dermabond®) is effective and scarless. Interestingly
it also did not affect fertility [99].
Post-operative Management
With the exception of infants who require extended observation, most patients are discharged on the day of surgery.
Premature infants at risk of apnoea may require prolonged
observation or overnight stay based on local protocols [52].
Similarly, an extensive laparoscopic procedure may require
hospital admission. Oral intake may be resumed when the
effects of anaesthesia wear off. The reader is referred to
‘Good practice in post-operative and procedural pain’ for
advice on best practice with regard to post-operative pain
management [100]. Baths can then be resumed on the third
post-operative day. Older children should refrain from bicycle riding, swimming or other vigorous physical activities
for approximately 1 month [4].
Post-operative Complications
Possible post-operative complications are outlined below. As
mentioned previously, these should be considered when consenting patients. However, exact rates will vary depending
on the technique used.
Wound Infection
The wound infection rate at most major paediatric centres is
low, approximately <2% [4]. An increased incidence of
infection would be expected in incarcerated hernias.