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Inguinal Hernia in Girls: Surgical Management and Surgical Complications
41
The vas deferens and testicular vessels, in males, and the round ligament of the uterus, in
females, pass through the inguinal ring and enter the inguinal canal. The inferior border of the
deep inguinal ring is formed by the iliopubic tract. The superior border is formed by the
transversus abdominis arch, and the medial border is formed by the inferior epigastric vessels.
The anatomy of the inguinal canal varies slightly with age. In both children and adults,
the canal is an oblique passage whose weakest areas, i.e., the superficial ring and deep ring,
lie some distance apart.
The presence of separate anterior and posterior canal walls create a flap valve effect.
Increases in intra-abdominal pressure transmitted through the deep inguinal ring are
supported by the anterior wall of the inguinal canal, the aponeurosis of the external oblique
muscle, reinforced by the internal oblique muscle just above the deep inguinal ring [Snell,
2004; Moore and Dalley, 2006; Borley, 2008] (Figure 3).
Figure 3. Flap valve effect of the deep and superficial inguinal rings. The superficial inguinal ring and
the deep inguinal ring of both children and adults lie some distant apart. Increases in intra-abdominal
pressure transmitted through the deep inguinal ring are resisted by the anterior wall of the inguinal
canal (A). In both newborns infants and older infants, however, the deep inguinal ring and the
superficial inguinal ring are nearly superimposed. Since this results in a defect in the abdominal wall,
increases in intra-abdominal pressure are transmitted directly through this defect (B). The small letters
b, c, d, k, l, and n indicate the position of the external oblique aponeurosis, internal oblique muscle,
transversus abdominis muscle, deep inguinal ring, superficial inguinal ring, and conjoint tendon,
respectively.
Takeshi Hirabayashi
42
Inguinal Hernias in Infants and Children
The deep inguinal ring and superficial inguinal ring of newborn infants are nearly
superimposed, and the inguinal canal is extremely short. Since this results in a roughly oval-
shaped defect in the abdominal wall, increases in intra-abdominal pressure act directly on the
abdominal wall through this defect, and herniations through this defect (i.e., indirect inguinal
hernias, are easily induced). Closure of the processus vaginalis may be disturbed easily
(Figure 3).
Most congenital inguinal hernias and postnatal inguinal hernias in infants and children
are indirect inguinal hernias. The hernia sac (i.e., the abnormal persistent processus vaginalis)
enters the inguinal canal through the deep inguinal ring lateral to the epigastric vessels and
passes distally through the superficial inguinal ring into the scrotum in males or the labium
majus in females (Figure 4).
In girls, only the round ligament penetrates into the inguinal canal so that the inguinal
canal and the deep ingunal ring is narrow [Kurkchubasche and Tracy, 2002; Fonkalsrud,
2003; Weber et al., 2005].
Figure 4. The processus vaginalis usually degenerates during the first few weeks after birth (A). Most
inguinal hernias in infancy and childhood are related to persistence of the processus vaginalis (B). In
some female infants the fallopian tube lies within the hernia sac (C), and the ovary is hidden beyond the
external ring (D). The small letters a, b, c, c’, d, e, f, f’, g, g’, h, h’, i, j, k, l, m, and n 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, and conjoint tendon, respectively.
Inguinal Hernia in Girls: Surgical Management and Surgical Complications
43
EMBRYOLOGY
Embryology of the Inguinal Canal
The formation of the inguinal canal occurs during the fifth to the thirty-second week of
fetal development, and is very similar in both sexes until week 28.
Gonadogenesis in both sexes occurs during the fifth week of fetal development. As the
mesonephros degenerates, a ligament called the gubernaculum descends from the inferior
pole of the gonad and passes obliquely through the developing anterior adominal wall at the
site of the future inguinal canal. The gubernaculum attaches caudally to the internal surface of
labioscrotal swellings (future halves of the scrotum or labia majora).
The formation of the inguinal canal begins with forward protrusion of a peritoneal
evagination called the processus vaginalis during the migration of the gubernaculum. As the
processus vaginalis pushes forward into the transversalis fascia followed by the migration of
the gubernaculum, it acquires a tubular fascia called the internal fascia and creates an opening
in the abdominal wall called the deep inguinal ring.
The processus vaginalis followed by the migration of the gubernaculum generates the
inguinal canal by pushing forward, first passing beneath the arching fibers of the transversalis
abdominis muscle, and then pushing forward into the internal oblique muscle to create the
cremasteric fascia. The processus vaginalis followed by the gubernaculum penetrates the
external oblique fascia and then creates the superficial inguinal ring [Shoenwolf et al., 2001]
(Figure 5).
Descent of the Ovary
The only significant difference between inguinal canal development in males and females
occurs after formation of the canal itself. In the female fetus, the gubernaculum becomes
attached to the developing uterus at a point between its attachment to the ovary and its
entrance into the anterolateral abdominal wall. The proximal part of the gubernaculum
becomes the ovarian ligament, and the distal part forms the round ligament.
The gubernaculum causes the ovary to descend, and the ovary`s migration ends in a
position lateral to the uterus within the pelvic cavity. In the absence of androgens, the cranial
suspensory ligament persists and anchors the ovary high in the abdomen [Moore and Dalley,
2006] (Figure 6).
Processus Vaginalis
A peritoneal diverticulum, the processus vaginalis, traverses the transversalis fascia at the
site of the deep inguinal ring, forming the inguinal canal as in the male, and degenerates
during the first few postnatal weeks. There is no postnatal gross remnant of the processus
vaginalis in the labium majus that is analogous to the tunica vaginalis in the male. Thus, the
round ligament of the uterus and ilioinguinal nerve are the only major structures remaining in
the inguinal canal of the female a few weeks after birth [Moore and Dalley, 2006].
Takeshi Hirabayashi
44
Figure 5. Formation of the female inguinal canal. After the 7
th
week of fetal development, the
gubernaculum descends from the inferior pole of the gonad to the internal surface of the labioscrotal
swellings through the future inguinal canal (A). After the 8
th
week a peritoneal evagination called the
processus vaginalis forms ventral to the gubernaculum and pushes out a sock-like extension of the
transversalis fascia, the internal oblique muscle, and the external oblique muscle to form the inguinal
canal (B). After forming the inguinal canal, the processus vaginalis degenerates during the first few
weeks after birth (C,D). The small letters a, b, c, c’, d, e, f, f’, g, g’, h, h’, i, j, k, l, m, and n 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, and conjoint tendon, respectively.
CLINICAL MANIFESTATIONS
Examination
The most common initial clinical manifestation of inguinal hernias in girls is a bulge in
the upper portion of a labium. If a nonreducible mass is palpable, it is usually an ovary. If a
mass, i.e., an ovary, is palpable on both sides in a girl, testicular feminization syndrome
should be suspected.
To examine a girl for an inguinal hernia, the patient is placed supine and undressed on an
examining table in a warm room. The examiner first inspects the patient for an inguinal mass
or asymmetry in the groin. The examiner’s index finger is lightly passed over the inguinal
canal from side to side over the pubic tubercle (Figure 7). If no mass is palpable and the child
is old enough to stand, the child should be asked to stand and perform a Valsalva maneuver.
Inguinal Hernia in Girls: Surgical Management and Surgical Complications
45
Infants may be allowed to strain or cry to induce the appearance of an inguinal bulge.
Surgeons are often unable to demonstrate a definite hernia in patients who have been referred
to them after a pediatrician or family member has seen an inguinal hernia bulge. In these
equivocal cases, photographic documentation or recent digital photographs taken by parents
help to make an accurate diagnosis [Glick and Boulanger, 2012].
Incarceration
The most common complication of inguinal hernias is incarceration. An inguinal hernia
is diagnosed as incarcerated when the sac contents (generally, a segment of the bowel in
males, and ovary, fallopian tube, or a segment of the bowel in females) cannot be reduced
non-operatively into the peritoneal cavity. Incarcerations are far more common in the first
year of life, and, occasionally, incarceration is the first manifestation of an inguinal hernia.
Figure 6. Descent of the ovary. By the 2
nd
month of fetal development the primordial ovaries are
located on the dorsal abdominal wall (A). During the 3
rd
month the ovaries descend to some extent, and
the gubernacula attach to the developing uterus (B). At the 15
th
week the ovaries have descended into
the greater pelvis. The gubernacula become the right and left ovarian ligaments and round ligaments of
the uterus (C). In the mature female, the round ligament passes through the inguinal canal (D). The
small letters g, g’, h, h’, i, j, k, and l 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, ovary, pubic tubercle, deep inguinal ring, and
superficial inguinal ring, respectively.
Takeshi Hirabayashi
46
Clinical presentation is characterized by the presence of an acute tender mass at the level
of the external inguinal ring. Infants are typically brought for consultation because of
inconsolable crying, poor feeding, and, eventually, bilious emesis. Older children present with
a complaint of sudden onset of severe pain in the groin.
If the groin mass becomes much more firm, significant tenderness develops, skin redness
and edema appear over the mass, blood appears in the stool, and the infant appears much
more ill and in shock, the term “strangulation” is used to denote the need for immediate
operative intervention. Only a small proportion of inguinal hernias require intestinal resection
because of incarceration.
Incarcerated hernias in which there is no evidence of strangulation can be reduced non-
operatively in 80% of the cases. Reduction of incarcerated hernias requires a three-
dimensional understanding of the anatomy of the inguinal canal. Incarceration is caused by
the presence of a tight external inguinal ring or deep inguinal ring. The edematous hernia sac
with its contents is located at the external inguinal ring. The method of performing closed
reduction of incarcerated hernias is to, first, apply pressure on the lateral hemicircumferential
side of the hernia neck with the left index finger, middle finger, and thumb at the level of the
ipsilateral internal inguinal ring. This helps to align the external and internal rings and keep
them open, and it also prevents the hernia sac from overlapping or being caught in these
potential barriers during reduction. Then, with the right index finger, middle finger, and
thumb at the apex of the hernia mass, and with constant lateral hemicircumferential pressure
exerted at the level of the internal ring with the fingers of the left hand, slowly walk the
fingers of the right hand up the groin toward the internal ring, exerting constant medial
hemicircumferential pressure on the bottom of the hernia contents. Reduction may take
several minutes. If the reduction is successful, the hernia contents will gradually disappear
into the internal ring. Ultrasonography may be useful in confirming that the hernia has been
reduced. In children who have difficulty tolerating the procedure, sedation may be used.
Reduction of the bowel under general anesthesia cannot be recommended, because injury to
the bowel may occur or a gangrenous bowel may be placed back in the peritoneal cavity
unrecognized. Reductions of gangrenous bowels has been reported, with the patient closely
observed in the hospital for 2 or 3 hours after a reduction, and for 24 hours after a difficult
reduction [Fonkalsrud, 2003; Weber et al., 2005; Glick and Boulanger, 2012] (Figure 7).
Surgery is indicated when conservative management fails. An incarcerated ovary without
associated incarcerated bowel may be an exception, because the risk to the ovary is not as
extreme. As long as the child is asymptomatic, surgery can safely be delayed. Several
operative approaches have been advocated to treat incarcerated inguinal hernias. Laparoscopy
can be valuable in the management of incarcerated inguinal hernias.
SURGERY
The management and repair of childhood inguinal hernia has a remarkable history. In
1912, Turner documented that high ligation of the sac was the only procedure necessary in
most children. The standard goal of surgical treatment of indirect hernias in children is
definitive closure of the patent processus vaginalis.
Inguinal Hernia in Girls: Surgical Management and Surgical Complications
47
Figure 7. To examine a girl for an inguinal hernia, the examiner’s index finger is lightly passed over the
inguinal canal from side to side (A). Reduction of incarcerated hernias requires a three-dimensional
understanding of the anatomy of the inguinal canal (B). The method of reducing incarcerated hernias
consists of first applying pressure on the lateral hemicircumferential side of the hernia neck with the left
index finger, middle finger, and thumb, and then applying pressure with the right index finger, middle
finger, and thumb at the apex of the hernia sac (C). If the reduction is successful, the hernia contents
will gradually disappear through the internal ring (D).
Traditional Repair
With the patient in the supine position, the midline, pubic tubercle, and anterior superior
iliac spine are marked out. The palpation point of the femoral artery just below the inguinal
ligament is a topographic landmark, because the internal inguinal ring lies just cranial and
lateral to this point. The pubic tubercle is also an important landmark, because the external
ring lies inferior and lateral to the tubercle.
An incision is made in a natural skin fold above the inguinal ligament, and is made long
enough to visualize the necessary structures . The subcutaneous tissue, including Camper’s
fascia and Scarpa’s fascia, is separated by blunt dissection to expose the external oblique
aponeurosis and the inguinal ligament, which is the lower border of the external oblique
aponeurosis. The external oblique fascia is opened by making an incision about 1 cm above
the lower border, and the lower margin of the internal oblique muscle is bluntly retracted
cranially from the inguinal ligament with a retractor. The ilioinguinal nerve, an important
topographic landmark for the inguinal canal, must be identified, because the rounded belly of
the rectus muscle may be mistaken for the inguinal canal.
The hernia sac and the round ligament ensheathed by the so-called internal spermatic
fascia, which is a continuation of the transversalis fascia, can be lifted from the inguinal floor,
Takeshi Hirabayashi
48
demonstrating the V-shaped aperture. Because the hernia sac occasionally may contain an
ovary and/or fallopian tube, the author of this chapter typically opens the sac and inspects its
contents. Since the ovary is sometimes trapped just lateral to the external ring, the distal end
of the sac is checked. The author only closes the hernia sac with round ligament at the level of
the internal inguinal ring by double suture without dissecting the hernia sac (Figure 8).
Figure 8. Traditional inguinal hernia repair. An incision is made in a natural skin fold above the
inguinal ring (1). The subcutaneous tissue is separated in a somewhat cranial direction to prevent injury
to the femoral vessels (2). Reflux of the external oblique aponeurosis (open star asterisk) is confirmed
(3). The external oblique aponeurosis is opened, and the ilioinguinal nerve (closed star asterisk) is
identified (4). The internal oblique and so-called cremaster muscle are bluntly dissected from the
inguinal ligament (5). The so-called cremaster muscle is split, and the hernia sac and the round ligament
are picked up (6). The hernia sac and the round ligament are lifted from the inguinal floor,
demonstrating the revealing a V-shaped aperture (7). The sac is then opened and its contents inspected
(8,9). The hernia sac containing the round ligament is then closed at the level of the deep inguinal ring
by a double suture (10,11). A standard layered closure is then performed with absorbable sutures (12).
Inguinal Hernia in Girls: Surgical Management and Surgical Complications
49
Figure 9. Because hernia sacs occasionally contain an ovary and/or fallopian tube, we inspect the
contents of the hernia sac before closing it (A). If a fallopian tube and/or ovary are present in the hernia
sac (B,C), they are replaced in the peritoneal cavity, and the sac is closed with a double suture at the
round ligament just above the attachment of the fallopian tube (D). The small letters f’, g, h’, i, k, and l
indicate the position of the processus vaginalis, round ligament of the uterus, fallopian tube, ovary, deep
inguinal ring, and superficial inguinal ring, respectively.
If the fallopian tube and/or ovary is in the wall of the sac as a sliding hernia, the fallopian
tube and/or ovary are replaced in the peritoneal cavity, and the hernia sac is closed with a
double suture at the round ligament just above the point of attachment of the fallopian tube
(Figure 9).
Since occasional patients with testicular feminization present with a hernia, if an
abnormal gonad is encountered, biopsy is performed, and definitive procedures are deferred
until the evaluation of the biopsy specimen has been completed.
Laparoscopic Repair
The patient is placed in the spine position, and after tracheal intubation, general
anesthesia is induced and maintained. A 5-mm or 3-mm laparoscope is inserted through the
umbilicus, and a 2-mm Endograsp™ (Covidien, Inc., Mansfield, MA USA) is inserted in the
midline below the umbilicus. We use the laparoscope to examine the anatomical relationships
between the ovary, ovarian suspensory ligament, internal inguinal ring, and round ligament
on both sides, and we routinely examine the asymptomatic, contralateral internal inguinal ring
for the presence of an asymptomatic patent processus vaginalis. If present, the symptomatic
patent processus vaginalis and asymptomatic contralateral patent processus vaginalis are
closed extraperitoneally.
Takeshi Hirabayashi
50
Figure 10. An 18G sheath needle is inserted just above the lateral margin of the internal inguinal ring
(A) and advanced extraperitoneally across the round ligament into the peritoneal cavity on the opposite
side (B). The inner needle is removed, and the tip of the Endoneedle is inserted into the peritoneal
cavity through a sheath. The Endograsp™ (Coviden, Mansfieldm MA USA) catches the suture, and the
needle is withdrawn, leaving one end of the suture in the peritoneal cavity (C). The same sheath needle
is reinserted at the same point, passed into the upper hemicircumference, and pushed out at the point
where the needle was pushed out before (D). The inner needle is removed. The Endoneedle is inserted
through the sheath, catches the free end of the suture, and is drawn out with the suture end (E). The
suture is tied outside the body, thereby achieving completely extraperitoneal ligation of the patent
processus vaginalis (F).
A nonabsorbable 2-0 suture is inserted above the lateral margin of the internal inguinal
ring and advanced extraperitoneally across the round ligament into the peritoneal cavity with
an Endoneedle and an 18G sheath needle. The sheath needle is reinserted at the same point,
advanced in the upper hemicircumference of the internal inguinal ring, where it catches the
free end of the suture, and is drawn out. The suture is tied outside the body, thereby achieving
completely extraperitoneal ligation of the patent processus vaginalis [Endo and Ukiyama,
2001] (Figure 10).
SURGICAL COMPLICATIONS
The most common postoperative complications are wound infection, swelling, and
recurrent inguinal hernia. Tubal occlusion has occasionally been reported after inguinal hernia
repair in girls, the same as obstruction of the vas deferens has occasionally been reported in
males. Rarely, urinary bladder injury has also been reported in both sexes.
Under elective circumstances, incidence of wound infection is less than 1%, with
exception of premature infants having very large hernia or on high-dose steroids. Only a
small proportion of cases require intestinal resection because of incarceration [Fonkalsrud,
2003; Weber et al., 2005; Glick and Boulanger, 2012].