Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1562_Библиотеки_им_академика_М_И_Перельмана.pdf
The Inheritability and Genetic Aspects of Groin Hernias
21
Morris-Stiff, G., Coles, G., Moore, R., Jurewicz, A. & Lord, R. (1997). Abdominal wall
hernia in autosomal dominant polycystic kidney disease. Br. J. Surg., 84, 615–617.
Nataraja, R. M. & Mahomed, A. A. (2011) Systematic review for paediatric metachronous
contralateral inguinal hernia: a decreasing concern. Pediatr. Surg. Int., 27, 953-961.
Nyhus, L. M. (1993). Individualization of hernia repair: a new era. Surgery, 114, 1–2.
Oğuzkurt, P. Kayaselçuk, F., Tuncer, I., Alkan, M. & Hiçsönmez, A. (2007). Evaluation of
extracellular matrix protein composition in sacs associated with undescended testis,
hydrocele, inguinal hernia, and peritoneum. Urology, 70, 346–350.
Ozdemir, S., Ozis, E. S., Gulpinar, K., Aydin, S. M., Eren, A. A. & Demirtas, S. (2011). The
value of copper and zinc levels in hernia formation. Eur. J. Clin. Invest., 41,
285–290.
Ozdogan, M., Yildiz, F., Gurer, A., Orhun, S., Kulacoglu, H. & Aydin, R. (2006). Changes in
collagen and elastic fiber contents of the skin, rectus sheath, transversalis fascia and
peritoneum in primary inguinal hernia patients. Bratisl. Lek. Listy., 107,
235–238.
Palumbo, L. T., Sharpe, W. S., Gerndt, H. L., Maglietta, E. D. & Eidbo, W. B. (1963).
Primary inguinal hernioplasty; our experience with 3,572 operations. Arch. Surg., 87,
949–956.
Pans, A., Albert, A., Lapière, C. M. & Nusgens, B. (2001). Biochemical study of collagen in
adult groin hernias. J. Surg. Res., 95, 107–113.
Pascual, G., Rodríguez, M., Mecham, R. P., Sommer, P., Buján, J. & Bellón, J. M. (2009).
Lysyl oxidase like-1 dysregulation and its contribution to direct inguinal hernia. Eur. J.
Clin. Invest., 39, 328–337.
Pathak, S. & Poston, G. J. (2006). It is highly unlikely that the development of an abdominal
wall hernia can be attributable to a single strenuous event. Ann. R. Coll. Surg. Engl., 88,
168–171.
Peevy, K. J., Speed, F. A. & Hoff, C. J. (1986). Epidemiology of inguinal hernia in preterm
neonates. Pediatrics, 77, 246–247.
Phillips, W. & Goldman, M.. (2004). Groin hernia. In "Health Care Needs Assessment: The
Epidemiologically Needs Based Assessment Reviews - First Series Update," (A. Stevens,
J. Raftery, J. Mant, and S. Simpson, eds.), 671-721. Radcliffe Medical Press, Abingdon.
Powell, T. G., Hallows, J. A., Cooke, R. W. & Pharoah, P. O. (1986). Why do so many small
infants develop an inguinal hernia? Arch. Dis. Child., 61, 991–995.
Primatesta, P. & Goldacre, M. J. (1996). Inguinal hernia repair: incidence of elective and
emergency surgery, readmission and mortality. Int. J. Epidemiol., 25, 835–839.
Pyeritz, R. E. (2000). Ehlers-Danlos syndrome. New Engl. J. Med., 342, 730–732.
Pyeritz, R. E. & McKusick, V. A. (1979). The Marfan syndrome: diagnosis and management.
New Engl. J. Med., 300, 772–777.
Read, R. C. (2004). Inguinal herniation in the adult, defect or disease: a surgeon’s odyssey.
Hernia, 8, 296–299.
Rodrigues, A. J., Rodrigues, C. J., Da Cunha, A. C. P. & Jin, Y. (2002). Quantitative analysis
of collagen and elastic fibers in the transversalis fascia in direct and indirect inguinal
hernia. Rev. Hosp. Clin. Fac. Med. Sao Paulo, 57, 265–270.
Ron, O., Eaton, S. & Pierro, A. (2007). Systematic review of the risk of developing a
metachronous contralateral inguinal hernia in children. Br. J, Surg., 94, 804–811.
Jakob Burcharth and Jacob Rosenberg
22
Rosch, R., Klinge, U., Si, Z., Junge, K., Klosterhalfen, B. & Schumpelick, V. (2002). A role
for the collagen I/III and MMP-1/-13 genes in primary inguinal hernia? BMC Med.
Genet., 3, 2
Rosemar, A., Angerås, U. & Rosengren, A. (2008). Body mass index and groin hernia: a 34-
year follow-up study in Swedish men. Ann. Surg., 247, 1064–1068.
Roubicek, M., Gehler, J. & Spranger, J. (1985). The clinical spectrum of alpha-L-iduronidase
deficiency. Am. J. Med. Genet., 20, 471–481.
Ruhl, C. E. & Everhart, J. E. (2007). Risk factors for inguinal hernia among adults in the US
population. Am. J. Epidemiol., 165, 1154–1161.
Rutkow, I. M. (2003). Demographic and socioeconomic aspects of hernia repair in the United
States in 2003. Surg. Clin. North Am., 83, 1045–1051.
Sanders, D. L., Porter, C. S., Mitchell, K. C. D. & Kingsnorth, A. N. (2008). A prospective
cohort study comparing the African and European hernia. Hernia, 12, 527–529.
Sawaguchi, S., Matsunaga, E. & Honna, T. (1975). A genetic study on indirect inguinal
hernia. Jinrui Idengaku Zasshi, 20, 187–195.
Shenker, N. S., Huynh, J., Farmer, P. J. & Hutson, J. M. (2006). A new role for androgen in
testicular descent: permitting gubernacular cell proliferation in response to the
neuropeptide, calcitonin gene-related peptide. J. Pediatr. Surg., 41, 407–412.
Skandalakis, J. E., Colborn, G. L., Androulakis, J. A., Skandalakis, L. J. & Pemberton, L. B.
(1993). Embryologic and anatomic basis of inguinal herniorrhaphy. Surg. Clin. North
Am., 73, 799–836.
Smigielski, J., Brocki, M., Kuzdak, K. & Kołomecki, K. (2011). Serum MMP 2 and TIMP 2
in patients with inguinal hernias. Eur. J. Clin. Invest., 41, 584–588.
Smigielski, J., Kołomecki, K., Ziemniak, P., Drozda, R., Amsolik, M. & Kuzdak, K. (2009).
Degradation of collagen by metalloproteinase 2 in patients with abdominal hernias. Eur.
Surg. Res., 42, 118–121.
Smith, M. (1965). Familial inguinal hernia. Surgery, 57, 809–812.
Sorensen, L. T., Friis, E., Jorgensen, T., Vennits, B., Andersen, B. R. & Rasmussen, G. I.
(2002). Smoking is a risk factor for recurrence of groin hernia. World J. Surg., 26, 397–
400.
Sundström, A., Mortimer, O., Akerlund, B., Karlsson, A., Flamholc, L. & Håkangård, C.
(2010). Increased risk of abdominal wall hernia associated with combination anti-
retroviral therapy in HIV-infected patients-results from a Swedish cohort-study.
Pharmacoepidemiol. Drug Saf., 19, 465–473.
Tam, P. (1990). Inguinal hernia. In "Neonatal Surgery," 3rd Edition (J. Lister, ed.), 367-375.
Butterworths, London.
Tanyel, F. C. (2004). Obliteration of processus vaginalis: aberrations in the regulatory
mechanism result in an inguinal hernia, hydrocele or undescended testis. Turk. J.
Pediatr., 46, 18–27.
Tassabehji, M., Metcalfe, K., Hurst, J., Ashcroft, G. S., Kielty, C. & Wilmot, C. (1998). An
elastin gene mutation producing abnormal tropoelastin and abnormal elastic fibres in a
patient with autosomal dominant cutis laxa. Hum. Mol. Gen., 7, 1021–1028.
Tok, E. C., Ertunc, D., Dilek, U., Pata, O., Erdogan, O. & Aydin, S. (2004). The prevalence
of stress urinary incontinence among women operated on for abdominal wall hernias.
Acta Obstet. Gynecol. Scand., 83, 962–964.
The Inheritability and Genetic Aspects of Groin Hernias
23
Tsai, T. C., Huang, F. Y., Hsu, J. C., Lee, M. L. & Chou, L. H. (1996). Continuous
ambulatory peritoneal dialysis complicating with abdominal hernias in children.
Zhonghua Min Guo Xiao Er Ke Yi Xue Hui Za Zhi, 37, 263–265.
Van Maldergem, L., Ogŭr, G. & Yüksel, M. (1989). Facial anomalies in congenital cutis laxa
with retarded growth and skeletal dysplasia. Am. J. Med. Genet., 32, 265.
Van Wessem, K. J. P., Simons, M. P., Plaisier, P.W. & Lange, J. F. (2003). The etiology of
indirect inguinal hernias: congenital and/or acquired? Hernia, 7, 76–79.
Viner, R. M., Teoh, Y., Williams, D. M., Patterson, M. N. & Hughes, I. A. (1997). Androgen
insensitivity syndrome: a survey of diagnostic procedures and management in the UK.
Arch. Dis. Child., 77, 305–309.
Von Kodolitsch, Y. & Robinson, P. N. (2007). Marfan syndrome: an update of genetics,
medical and surgical management. Heart, 93, 755–760.
Wagh, P. V., Leverich, A. P., Sun, C. N., White, H. J. & Read, R. C. (1974). Direct inguinal
herniation in men: a disease of collagen. J. Surg. Res., 17, 425–433.
Weber, T. & Tracy, T. (1993). Groin hernias and hydroceles. In "Pediatric Surgery," 2nd
Edition (K. Aschaft and T. Holder, Eds), 562-570. W. B. Saunders, Philidelphia.
Weimer, B. R. (1949). Congenital inheritance of inguinal hernia. J. Hered., 40, 219.
West, L. (1936). Two pedigrees showing inherited predisposition to hernia. J. Heredity, 27,
449–455.
Wraith, J. E., Rogers, J. G. & Danks, D. M. (1987). The mucopolysaccharidoses. Austr.
Paediatr. J., 23, 329–334.
Young, I. D. & Harper, P. S. (1983). The natural history of the severe form of Hunter’s
syndrome: a study based on 52 cases. Dev. Med. Child Neurol., 25, 481–489.
Zollinger, R. M. (2004). An updated traditional classification of inguinal hernias. Hernia, 8,
318–322.
In: Hernias ISBN: 978-1-62948-441-9
Editor: Mark A. Suckow © 2014 Nova Science Publishers, Inc.
Chapter 2
CURRENT CONCEPTS IN NEONATAL AND
PEDIATRIC INGUINAL HERNIA REPAIR
Bogdan Protyniak
1,2
, Diana Thaung
1,2
and Sathya-Prasad Burjonrappa
2*
1
Department of Surgery, Monmouth Medical Center, Long Branch, New Jersey, US
2
Department of Surgery, Newark Beth Israel, Newark, New Jersey, US
ABSTRACT
Inguinal hernia continues to be the most common operation performed by pediatric
surgeons. It is present in 3-5% term infants and in 13% of premature infants [Grosfeld,
1989]. The incidence is nearly 10 times more common in males than in females and
occurs bilaterally in 15-20% of children [Ein et al., 2006; Brandt, 2008]. The etiology is
most often an error in the normal embryologic descent of the testes and/or failure of the
processus vaginalis to close, permitting communication between the intra- and extra-
abdominal compartments. Diagnosis depends on history and clinical exam. Most inguinal
hernias are minimally symptomatic and present as intermittent bulges in the groin, labia,
or scrotum and become pronounced upon straining or crying [Glick and Boulanger,
2012]. Physical exam may reveal a silk glove sign [Lao et al, 2012]. Delay in prompt
repair may result in increased morbidity due to incarceration or strangulation of the
hernia, particularly in infants less than six months of age [Glick and Boulanger, 2012].
Inguinal hernias in older children and adolescents may be performed electively due to a
lower risk of incarceration. However, repair in term and premature infants should be
performed promptly due to increased risk of incarceration, which has been documented to
be as high as 30% [Lao et al, 2012]. Premature infants carry a risk of apnea and
bradycardia with general anesthesia and require overnight monitoring [Wang, 2012]. The
gold standard for repair remains high ligation of the sac at the level of the internal ring
[Levitt et al, 2002]. The distal sac is not resected because of concern for testicular
damage, but is opened to prevent postoperative hydrocele [Lao et al, 2012]. The presence
of a patent processus vaginalis on the contralateral side in 40-60% of infants with
unilateral hernia as well as the 10-30% risk of metachronous contralateral hernia after
*
Corresponding author: Department of Surgery, Newark Beth Israel Medical Center & Children’s Hospital of New
Jersey, Newark, NJ 07112. E-mail: sathyabc@yahoo.com.
Bogdan Protyniak, Diana Thaung and Sathya-Prasad Burjonrappa
26
unilateral repair has prompted surgeons to explore the contralateral groin [Lao et al,
2012]. However, this is an area of debate due to possible injury to bilateral vas deferens
and testes. Controversy exists in various aspects of pediatric inguinal hernia repair,
including: laparoscopic approach, contralateral groin exploration, and timing of repair
[Wang, 2012]. Laparoscopic hernia repair has the benefit of visualization and avoidance
of trauma to the cord structures, ability to evaluate both internal rings, improved pain,
and superior cosmesis over open repair. Reported recurrence rates are comparable to
those associated with open repair [Wang, 2012].
Keywords: Inguinal Hernia; Laparoscopy; Contralateral Exploration; Timing of Repair
INTRODUCTION
Inguinal hernias were initially identified centuries ago in ancient Greece although the
anatomy was not clearly defined until the nineteenth century [Lau, 2002]. A number of
physicians, including Richter, Camper, Scarpa, and Cooper contributed to the description of
the inguinal canal anatomy. An understanding of the anatomy in conjunction with Lister’s
theory of aseptic technique eventually perpetuated the ability to perform surgery, allowing for
inguinal hernia repair. In the late 1800s, Marcy described the technique of high ligation,
which although resulted in a high recurrence rate among adult patients, appeared to be largely
successful in the pediatric population. This technique continues to be used today by pediatric
surgeons [Glick and Boulanger, 2012]. At present, inguinal hernia repair remains the most
common procedure performed by pediatric surgeons. In this chapter, we will discuss the
epidemiology, anatomy, diagnosis, and surgical management of pediatric inguinal hernias.
We will also address current topics of controversy, including the laparoscopic approach to
inguinal hernias and the role of bilateral groin exploration in neonates.
EPIDEMIOLOGY
The incidence of inguinal hernias in children is reported to be 0.8-4.4% and is three to ten
times more prevalent in males than in females
[Bronsther et al., 1972]. The highest incidence
is documented in premature infants, ranging between 16-25% [Walsh, 1962; Rajput et al.,
1992]. Nearly one third of cases will present prior to the age of six months [Wang et al.,
2012]. The majority of these hernias occur on the right side with bilateral hernias (Figure 1)
occurring in 15-20% [Grosfeld, 1989; Ein et al., 2006]. Risk factors for bilateral hernias
include: female gender, presence of a left-sided hernia, less than one year of age at initial
presentation, and history of an undescended testicle in males [Lao et al., 2012]. Family
history has been reported in 11.5% of patients
[Bronsther et al., 1972].
PATHOPHYSIOLOGY
In the pediatric population, inguinal hernias occur as a result of a patent processus
vaginalis. During development in utero, testicular descent has been described as a two-step
Current Concepts in Neonatal and Pediatric Inguinal Hernia Repair
27
process, characterized as intra- or extra-abdominal depending on the location [Wang, 2012].
At three months’ gestation, descent of the gonads starts at the urogenital ridge and migrates
distally toward the level of the internal ring [Lao et al., 2012]. The processus vaginalis is
described as an evagination of the peritoneum through the internal ring; in males, the testis
descends along the processus and into the scrotum between the seventh to ninth month [Glick
and Boulanger, 2012]. Once this process is complete, the testis situates within the scrotum
and normally the processus vaginalis will dissipate. The internal ring will close, leaving
behind the tunica vaginalis [Lao et al., 2012].
However, incomplete closure and persistent patency of the processus may occur,
allowing for communication between the intra-abdominal and extra-abdominal compartments
[Wang et al., 2012]. The extent of patency has been categorized: 1) complete proximal and
distal persistence of the processus vaginalis; 2) persistence of the proximal processus
vaginalis only, with dissipation of the distal; 3) incomplete dissipation of the proximal
processus vaginalis; and 4) complete dissipation of the proximal processus vaginalis with
persistence of distal patency [Lao et al., 2012]. All four instances result in the development of
an inguinal hernia and/or a congenital hydrocele that need surgical correction [Lao et al.,
2012]. In females, the processus is described as the canal of Nuck and communicates with the
labia majora. The canal of Nuck tends to undergo closure earlier than the processus does in
males, occurring around the seventh gestational month [Glick and Boulanger, 2012]. This
may account for the higher incidence in males compared to females. Additionally, closure of
the processus vaginalis occurs in an asymmetric fashion, with the left sided tending to
dissipate earlier than the right, which may explain the tendency to observe more right sided
hernias [Lao et al., 2012].
DIAGNOSIS
The majority of inguinal hernias are discovered as an incidental finding by parents or
pediatricians during a regular appointment. Often, infants will present with a history of a
bulge in the groin, labia, or scrotum that becomes more pronounced upon crying or straining
[Glick and Boulanger, 2012] (Figure 2). Occasionally, they may also complain of vague
abdominal pain [Lao et al., 2012]. Inguinal hernias are usually asymptomatic and reducible;
however, there is a risk of incarceration, which results in increased pain, inability to reduce
the hernia, and obstructive symptoms. The infant may present with abdominal distension,
vomiting, and lack of bowel function. Should the condition remain untreated, the bowel will
become ischemic and subsequently necrotic, resulting in frank peritonitis. Younger infants
less than six months of age have a higher risk of incarceration, while it occurs less frequently
in older children. The frequency of incarceration in pediatric patients is described as 5-15%
and nearly two times higher among the infant subgroup [Lao et al., 2012]. Because of this
risk, it is important to remain vigilant and to perform a proper physical examination.
Physical examination begins with placing the patient in a supine position on the
examining table. The bilateral groins should be assessed for asymmetry or masses, and in
males, the scrotum should be examined to confirm the presence of testicles [Glick and
Boulanger, 2012]. If no masses or bulges are identified, the patient can be instructed to
Valsalva or strain while standing. If a mass is still not clearly present, the groin can be
Bogdan Protyniak, Diana Thaung and Sathya-Prasad Burjonrappa
28
palpated to identify the spermatic cord in male. Thickening of the cord may suggest the
presence of an inguinal hernia. This is referred to as the “silk glove” sign and should be
compared to the contralateral, unaffected side [Ladd and Gross, 1941; Lao et al., 2012].
Figure 1. Large bilateral hernias in a 3 month-old premature infant.
Figure 2. Clinical exam most often reveals an obvious groin bulge that must be reduced before surgical
correction begins. In other children, diagnosis depends on the more subtle “silk glove sign.”
In equivocal cases where history and physical examination alone cannot readily identify
the presence of a hernia, radiographic imaging has been suggested as a potential method for
attaining and confirming the diagnosis. Two radiologic studies have been observed: contrast
herniography and inguinal ultrasonography. Herniography, an older technique described in
the literature, involves the infraumbilical injection of water-soluble contrast into the
Current Concepts in Neonatal and Pediatric Inguinal Hernia Repair
29
peritoneum under fluoroscopic guidance. Plain radiographic images are then taken at 5, 10,
and 45 minute intervals
[Jewett et al., 1976]. Using this study, hydroceles and contralateral
hernias may be detected. Complications are rare and may include: intestinal perforation,
hematoma, and allergic reactions to the contrast, all of which have been documented
[Jewett
et al., 1976].
The usage of ultrasound has been studied and is gaining increased acceptance and
popularity. While it is operator dependent, it can be performed quickly, is non-invasive, and
does not result in any complications. Erez, et al. [2002] found that a preoperative
measurement of the inguinal canal of 3.6 ± 0.8 mm was associated with normal findings at
surgery, whereas 4.9 ± 1.1 mm was associated with a patent processus vaginalis; a
measurement of 7.2 ± 2 mm was associated with an inguinal hernia. Taking these
measurements into consideration, ultrasound may be a helpful diagnostic tool for inguinal
hernias, particularly if there is high suspicion given the patient’s history.
WHEN TO OPERATE?
Inguinal hernias are seldom self-resolving, and subsequently, nearly all should be
repaired. However, controversy exists regarding timing of surgery and is determined mainly
by patient age at diagnosis. Timing of surgical intervention differs between two age groups:
infants versus older children and adolescents. Term infants are twice as likely to have an
incarcerated inguinal hernia if surgery is delayed, compared to patients older than one year of
age [Zamakshary et al., 2008; Lao et al., 2012]. Incarceration is associated with
complications, including intestinal obstruction, gonadal atrophy, wound infection, hernia
recurrence, and increased length of hospitalization [Chen et al., 2009]. Therefore, expeditious
repair is recommended for term infants diagnosed with inguinal hernia. Asymptomatic older
children and adolescents, however, can undergo repair on an elective basis due to a lower risk
of incarceration [Lao et al., 2012].
The decision of when to operate becomes more difficult in preterm infants. Specifically,
should the hernia be repaired during the initial neonatal intensive care unit (NICU) stay or
electively? Premature infants carry an inherent operative risk due to a fragile hernia sac and
spermatic cord, predisposing them to recurrence and cord structure injury [Vaos et al., 2010].
Furthermore, the postoperative course can be complicated by apnea and bradycardia,
requiring mechanical ventilation and longer hospital stay [Vaos et al., 2010]. The latest study
on the subject by Lee et al. [2011] analyzed 127 preterm infants, who underwent elective
inguinal hernia repair, with no complications of incarceration. Thirty-five of these patients
were discharged from the NICU with a known inguinal hernia and had no incarceration prior
to elective repair [Lee et al., 2011]. Based on these results, one may assume that elective
hernia repair in premature infants is safe with no complications. However, other surgeons
have shown a 16% overall incidence of incarceration in preterm infants, increasing to 28%
when repair was delayed beyond 40 weeks post-conceptual age [Lautz et al., 2011].
Current surveys of pediatric surgeons have revealed a trend towards early repair in
premature infants [Vaos et al., 2010; Wang et al., 2012]. Most surgeons choose to perform
hernia repair immediately prior to discharge from the NICU, once the premature infant has
recovered from their pathology [Vaos et al., 2010]. The risks of apnea and cord structure
Bogdan Protyniak, Diana Thaung and Sathya-Prasad Burjonrappa
30
injury associated with immediate herniorrhaphy versus incarceration with elective repair must
be carefully weighed before deciding optimal timing of herniorrhaphy in premature infants.
SURGERY
Techniques for pediatric inguinal hernia repair vary among surgeons despite it being the
most commonly performed procedure. Levitt et al. [2002] hypothesized that this variability is
related to a combination of training, experience, clinical practice, and literature review. By
conducting a survey of North American pediatric surgeons, the authors sought to compare
respondents’ techniques to the original procedure described by Drs. William Ladd and Robert
Gross [Levitt et al., 2002]. The original steps and percent of respondents still performing
them were described: incising Scarpa’s fascia (61%), defining the external ring by pushing
down with retractors (34%), incising the external oblique with scissors (18%), identifying the
ilioinguinal nerve (81%), cleaning one underside of the external oblique (22%), bluntly
spreading the cremasteric fibers (90%), elevating the sac with sharp dissection of the vessels
(53%), opening the sac and inserting the forefinger into it (0%), bluntly dissecting the sac
with forefinger and gauze (0%), ligating the sac with single ligature (22%) without twisting it
(34%), leaving the distal sac untouched other than to drain fluid (78%), not inspecting the
testicle (79%), performing a formal floor repair bringing external and internal oblique down
to Poupart’s ligament (10%), tightening the internal ring in both boys and girls (19% and
41%), using no local anesthetic (14%), closing Scarpa’s fascia (94%), closing the skin with
interrupted subcuticular sutures (49%), covering the incision with collodion (48%), using the
Stiles’ dressing (0%), and only exploring the contralateral side if a hernia is suggested by
history or physical examination (87% for boys, 60% for girls) [Levitt et al., 2002]. Despite
surgeons’ preference in technique, high dissection and ligation of the hernia sac at the internal
ring remains the standard [Lao et al., 2012].
The authors of this chapter repair a standard inguinal hernia in the following manner: an
incision is made in the groin crease, Scarpa’s fascia is divided, and cremasteric fibers at the
level of the ring are split. The authors prefer to open the aponeurosis in infants older than six
months to expose the internal ring. In infants younger than six months the short length of the
inguinal canal permits satisfactory high ligation of the sac at the internal ring without any
need to open the external oblique aponeurosis. Once the cord structures are mobilized into the
wound (Figure 3), the sac is carefully separated from the vas and the vessels and transected at
its mid point. Subsequently, the sac is dissected away from the vas and vessels all the way
down to the level of the deep ring. After confirming an empty sac (Figure 4), it is twisted and
doubly transfixed and ligated to the level of the deep ring. Redundant sac is excised and sent
for histopathology, while the distal sac is left untouched (Figure 5). Cord structures are
reduced back into the wound and a single stitch is used to approximate Scarpa’s fascia. Local
anesthetic is infiltrated into the wound and the skin is closed with an absorbable suture in a
subcuticular fashion, followed by steristrips and a sterile dressing (Figure 6).