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Current Concepts in Neonatal and Pediatric Inguinal Hernia Repair
31
Figure 3. Cord structures mobilized without opening the external oblique in infant less than 6 months of
age (the “Mitchell-Banks” technique).
Figure 4. The proximal sac has been dissected away from the vas deferens and vessels. The next step
involves twisting it on its axis and transfixion ligation at the base.
Bogdan Protyniak, Diana Thaung and Sathya-Prasad Burjonrappa
32
Figure 5. The distal sac is left untouched in cases of inguinal hernia. The anterior wall can be opened
widely to drain any concomitant hydrocele without disturbing the intimate relation to the vas deferens
and spermatic vessels.
Figure 6. Dressing in place following repair. An alternative particularly useful for children in diapers is
to use a waterproof skin glue.
Complications
Despite the low rate of reported complications, patients can experience hernia recurrence,
infection, injury to cord structures, and testicular atrophy [Lao et al., 2012]. Ein et al. [2006]
reviewed a single surgeon’s experience of 6361 inguinal hernia repairs over 35 years. The
authors found 1.2% recurrences, 1.5% wound infections, and 0.3% testicular atrophy. The
Current Concepts in Neonatal and Pediatric Inguinal Hernia Repair
33
recurrence rate was within the 0-3.8% range reported in the literature. Further, the authors
suspected the use of a dissolvable suture for the high ligation of the sac to play a role in
recurrences. Wound infections were due to stitch abscesses and seldom required incision and
drainage, and this problem was eliminated when the “L-stitch” was introduced by excluding
the initial and finishing suture knot. Half of the patients who developed testicular atrophy had
an incarcerated inguinal hernia.
Contralateral Groin Exploration
Many studies have been done assessing the risk of a metachronous contralateral inguinal
hernia (MCIH) after unilateral repair. Literature analysis reveals that approximately 50% of
infants have a patent processus vaginalis, with 20-40% children having a patent processus
into adulthood [Lao et al., 2012]. Therefore, a patent processus vaginalis does not always
become an inguinal hernia. Age less than 6 months at the first unilateral herniorrhaphy is a
high risk factor for the development of MCIH [Wang et al., 2012]. Proponents of contralateral
exploration argue that diagnosing and repairing a contralateral asymptomatic hernia during
initial unilateral repair prevents future incarceration and allows the patient to forego the risks
of a second procedure [Wang et al., 2012]. However, opponents to routine contralateral
exploration argue that it increases the risk of bilateral injury to the vas deferens and testes
[Lao et al., 2012]. Wang et al. [2012] analyzed the incidence of MCIH in 2,129 patients ≥1
year-old undergoing ipsilateral herniorrhaphy. The authors found a 5.2% incidence of MCIH
and no significant gender difference. Most MCIH developed within two years after initial
hernia repair. Risk factors included young age (less than two years-old) and male gender with
initial left-sided unilateral inguinal hernia.
The low incidence of MCIH has led some surgeons to adopt a “wait and see” policy with
a close 2-year follow-up, thus forgoing the morbidity associated with contralateral exploration
[Wang et al., 2012]. However, patients with the aforementioned risk factors may benefit from
a less invasive approach to contralateral groin exploration, popularized by the advent of
laparoscopy. The technique involves inserting a laparoscope through the hernia sac to identify
a contralateral patent processus vaginalis without the need for contralateral open groin
exploration [Hall et al., 2012; Wang et al., 2012]. If the contralateral deep inguinal ring is
found to be open, it can be repaired laparoscopically with a low risk of injury to the vas
deferens and testicular vessels [Hall et al., 2012]. A study by Saad et al. [2011] of 1001
clinical unilateral inguinal hernias showed that laparoscopic transhernia exploration spared
56% of children younger than 1 year from unnecessary open exploration.
Laparoscopic Approach
Laparoscopic techniques have been uniformly incorporated in pediatric surgery over the
last decade [Dingemann and Ure, 2013]. The learning curve for laparoscopic herniorrhaphy
needs a minimum of 20 procedures to obtain comparable results described in the literature
[Bertozzi et al., 2013]. The procedure begins by achieving pneumoperitoneum through the
umbilicus and evaluating bilateral internal inguinal rings. Once the hernia is identified, a needle
is passed through a stab incision over the internal ring. Care is taken to pass the needle
Bogdan Protyniak, Diana Thaung and Sathya-Prasad Burjonrappa
34
superficial to the peritoneum around the internal ring, thereby avoiding cord structures. The
abdomen is desufflated and the non-absorbable suture is tied extracorporeally [Lao et al., 2012].
Turial et al. [2010] have demonstrated the safety and feasibility of laparoscopic inguinal
herniorrhaphy in 58 premature infants with a median weight of 3,900g (range: 1,450-5,000g).
Repair was delayed until the infant was otherwise stable for discharge, except in the case of
irreducible incarceration. The authors reported a 3.6% recurrence rate at 25-month follow-up,
which is comparable to open repair. The major disadvantage of laparoscopy in preterm infants
remains the requirement for endotracheal intubation and mechanical ventilation [Turial et al.,
2010]. Premature infants are already susceptible to apnea and bradycardia, which can be
worsened with general anesthesia. Anesthesia complications in this study included one case
of prolonged apnea and six cases of perioperative respiratory or hemodynamic instabilities.
Proponents of laparoscopic inguinal hernia repair claim improved cosmesis, ability to
easily evaluate the contralateral side, and decreased injury to the vas and vessels due to better
visualization [Lao et al., 2012; Shalaby et al., 2012]. A systematic review of level one
evidence confirmed a shorter operative time for bilateral hernia repair, longer operative time
for unilateral hernia, and lower rate of metachronous contralateral hernia [Dingemann and
Ure, 2013]. The randomized controlled trials were split as to the effect the laparoscopic
technique had on postoperative pain [Dingemann and Ure, 2013]. The laparoscopic
recurrence rate is comparable to open repair (0.7%-4.5% versus 0.8-3.8%, respectively) in
experienced hands [Shalaby et al., 2012]. Furthermore, laparoscopic herniorrhaphy does not
affect testicular perfusion or growth at 6-month follow-up [Parelkar et al., 2011]. The data
show that the procedure is safe and effective but by no means has replaced open
herniorrhaphy.
CONCLUSION
Despite being the most common pediatric surgery performed, many aspects surrounding
inguinal hernia repair continue to be controversial. Surgeons have a variety of preferences
when it comes to surgical technique, timing of operation, and contralateral groin exploration.
The reasons for this remain rooted in surgeons’ clinical practice, training, and experience
[Levitt et al., 2002]. Most importantly, there is a lack of level one evidence to establish clear-
cut practice guidelines. Large, prospective, randomized, controlled trials must be organized to
tackle these questions going forward [Wang et al., 2012].
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In: Hernias ISBN: 978-1-62948-441-9
Editor: Mark A. Suckow © 2014 Nova Science Publishers, Inc.
Chapter 3
INGUINAL HERNIA IN GIRLS: SURGICAL
MANAGEMENT AND SURGICAL COMPLICATIONS
Takeshi Hirabayashi
*
Tokai University School of Medicine, Japan
ABSTRACT
Inguinal hernias are common in infants and children, and inguinal hernia repair is the
most frequently performed surgical operation in the pediatric age group. The standard
goal of surgical repair of indirect inguinal hernias in children is definitive closure of the
processus vaginalis. The traditional cutdown method of inguinal hernia repair in children
is well established. It is thought to be safer and easier to perform in girls than in boys, and
it is minimally invasive when performed by expert pediatric surgeons. The operation time
is usually around 10 minutes, and the cosmetic result is excellent.
The surgical anatomy of the inguinal region in girls is simple, but there are fewer
anatomical landmarks for traditional inguinal herniorrhaphy in girls than in boys. Once a
surgeon loses sight of the surgical anatomy during operations in girls, it is difficult to
reorient. The worst surgical complications reported in girls have been urinary bladder
injuries. Tubal occlusion has been reported after inguinal hernia repair in girls and, while
not immediately apparent, it is not negligible. This chapter reviews the surgical anatomy
of the inguinal region in girls and the surgical management of inguinal hernias in girls,
including laparoscopic management.
Keywords: Inguinal hernia, girl, operation, laparoscopy, tubal occlusion
INTRODUCTION
All indirect hernias, regardless of the age of the patient at presentation, are likely to have
occurred secondary to failure of the processus vaginalis to close completely during fetal and
neonatal development.
*
Corresponding author: Department of Surgery, Pediatric Surgery, Tokai University School of Medicine.,
E-mail: thirabay@gmail.com.
Takeshi Hirabayashi
38
Most inguinal hernias in infants and children are indirect inguinal hernias. The reported
incidence of inguinal hernia in children ranges from 0.8% to 4.4%, and children with inguinal
hernias most commonly present during the first year of life, with most presenting clinically
during the first few months. Premature infants are at much higher risk of developing an
inguinal hernia, and risk rates of 16% to25% have been reported. The risk rates in premature
infants correlate fairly well with the processus vaginalis patency rates of premature infants.
The processus vaginalis of 80% of newborn infants is patent bilaterally, and the rate decreases
dramatically by 6 months of age. Inguinal hernia is much more common in boys than in girls.
There does not appear to be a significant difference in premature infants. Approximately 60%
of inguinal hernias are on the right side, and bilateral hernias at presentation may be more
common in girls [Kurkchubasche and Tracy, 2002; Fonkalsrud, 2003; Weber et al., 2005].
The standard goal of treatment of indirect inguinal hernias in children is definitive
closure of the patent processus vaginalis (PPV). The traditional cutdown method of inguinal
hernia repair in children is well established. It is thought to be safer and easier to perform in
girls than in boys, and it is minimally invasive when performed by expert surgeons, but
several surgical complications including urinary tract injury and tubal occlusion have been
reported [Condon and Nyhus, 1989; Hirabayashi et al., 2012]. This paper reviews the surgical
anatomy of the inguinal region in girls and the surgical management of inguinal hernias in
girls, including laparoscopic management.
ANATOMY
The inguinal region extends between the anterior superior iliac spine (ASIS) and the
pubic tubercle. The processus vaginalis exits and enters the abdominal cavity through the
inguinal canal in the inguinal region. The processus vaginalis is a potential pathway for
herniation. Since the majority of abdominal hernias occur in the inguinal region, this region is
important anatomically and clinically [Moore and Dalley, 2006] (Figure 1).
Inguinal Canal
The inguinal canal extends from the deep inguinal ring, an opening in the fascia
transversalis, downward and medially to the superficial inguinal ring, an opening in the
aponeurosis of the external oblique muscle.
The inguinal canal is present in both sexes, and it is an oblique passageway in the
inguinal region through which the spermatic cord passes in the male, the round ligament
passes in the female, and the obliterated or patent processus vaginalis and ilioinguinal nerve
pass in both sexes (Figure 2). In males, the inguinal canal is formed in relation to the descent
of the testis during fetal development. The anatomy in females is similar except for the
presence of the round ligament of the uterus instead of the spermatic elements, and the
inguinal canal is narrower in females than in males.
The anterior wall of the inguinal canal is formed by the aponeurosis of the external
oblique muscle. The lateral third of the anterior wall of the inguinal canal, where the anterior
wall lies opposite the weakest part of the posterior wall (i.e., the site of the deep inguinal ring)
Inguinal Hernia in Girls: Surgical Management and Surgical Complications
39
is reinforced by the muscle fibers of the internal oblique muscle just above their origin from
the inguinal ligament. The posterior wall of the inguinal canal is formed by the transversalis
fascia. The medial third of the posterior wall, where it lies opposite the weakest part of the
anterior wall, i.e., the site of the superficial inguinal ring, is reinforced by the conjoint tendon,
the common tendon of insertion of the internal oblique muscle and transversus abdominis
muscle. The inferior floor of the inguinal canal is formed by the union of the transversalis
fascia with the inguinal ligament, the rolled-under inferior edge of the aponeurosis of the
external oblique muscle. The superior roof of the inguinal canal is formed by the arching
lowest fibers of the internal oblique muscle and transversus abdominis muscle.
The round ligament in females is a narrow, somewhat flattened band that is attached
medially to the upper part of the uterus. Laterally, the round ligament enters the deep inguinal
ring, traverses the inguinal canal, and then fans out from the superficial inguinal ring. The
medial border of the round ligament of the uterus continues as the ovarian ligament [Snell,
2004; Moore and Dalley, 2006; Borley, 2008].
Superficial Inguinal Ring
The superficial (external) inguinal ring is the exit through which the spermatic cord, in
males, and round ligament, in females, emerges from the inguinal canal. The ring is smaller in
females.
The superficial ring is a triangular shaped defect in the aponeurosis of the external
oblique muscle and lies immediately above and medial to the pubic tubercle. Both the lateral
margin (crus) and the medial margin (crus) attach to the pubic tubercle. The lateral crus is
stronger and is reinforced by fibers of the inguinal ligament that insert at the pubic tubercle.
The medial crus is thin [Snell, 2004; Moore and Dalley, 2006; Borley, 2008].
Figure 1. Photo of the right inguinal region of a female infant. The inguinal region lies between the
anterior superior iliac spine (ASIS) and the pubic tubercle. The inguinal ligament extends from the
ASIS to the pubic tubercle. The superficial ring is a triangular defect in the external oblique aponeurosis
and lies above and medially to the pubic tubercle. The deep inguinal ring is an oval opening in the
fascia transversalis and lies just cranial and lateral to the point where the femoral artery pulse is
palpated.
Takeshi Hirabayashi
40
Figure 2. Panel A is a schematic view of the inguinal canal. The internal oblique muscle usually covers
the deep inguinal ring. Panel B is a laparoscopic view of the inguinal region. The deep inguinal ring lies
ventral and medial to the external iliac artery, which continues as the femoral artery. Panel C is a
schematic view showing the interrelationships between the inguinal canal, uterus, ovary, and fallopian
tube.
The small letters a, b, c, c’, d, e, f, f’, g, g’, h, h’, i, j, k, l, m, n, o, and p indicate the position of the skin,
external oblique aponeurosis, internal oblique muscle, so-called cremaster muscle, transversus
abdominis muscle, fascia transversalis, peritoneum, processus vaginalis, uterus, fallopian tube, round
ligament of the uterus, ovarian ligament, ovary, pubic tubercle, deep inguinal ring, superficial inguinal
ring, inferior epigastric vessels, conjoint tendon, inguinal ligament, and ilioinguinal nerve, respectively.
Deep Inguinal Ring
The deep (internal) inguinal ring is an oval opening similar to the entrance to a cave, in
the fascia transversalis and is located superior to the middle of the inguinal ligament and
lateral to the inferior epigastric vessels.