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Inguinal Hernia in Girls: Surgical Management and Surgical Complications
51
Recurrent Inguinal Hernia
The reported rates of inguinal hernia recurrence have ranged from 0% to 0.8%. Hernia
recurrence is more common in patients who are premature, have an incarcerated hernia at the
time of first operative procedure, and have associated complications. Since long-term follow-
up was not performed in many series, the true incidence of recurrent inguinal hernia is
unknown, and it is probably higher than has been reported.
The causes of recurrences include infection, missed hernia sac, unrecognized hernia sac
tears, failure to repair an excessively large internal ring, and previous surgery for an
incarcerated hernia. Occasionally recurrent inguinal hernias are of the direct type, suggesting
damage to the floor of the inguinal canal at the primary herniorrhaphy [Kurkchubasche and
Tracy, 2002; Fonkalsrud, 2003; Weber et al., 2005; Glick and Boulanger, 2012].
Because identifying the hernia orifice is the key to successful repair of recurrent inguinal
hernia, the laparoscopic approach is thought to be useful.
Tubal Occlusion and Ovarian Injuries
Traditional cut-down herniorrhaphy is thought to be safer and easier to perform in girls
than in boys. Obstruction of the vas deferens is a widely known complication of childhood
inguinal herniorrhaphy in males, and tubal occlusion has been reported after inguinal hernia
repair in girls.
In female infants, the sliding ovary is hidden by the hernia sac wall out of the external
inguinal ring, and ventral dislocated attachment of the ovarian suspensory ligament occurs in
more cases of inguinal hernia in girls under 2 years old than generally expected. This
predisposes the patient to tubal occlusion and injury of the ovary as a postoperative
complication. During both traditional and laparoscopic repair, surgeons must check to see that
the fallopian tube is not at the closed hernia orifice and the ovary is not present in the distal
hernia sac [Hirabayashi et al., 2012] (Figure 9).
Injury to the Urinary Bladder
The rounded belly of the rectus muscle may be mistaken for the inguinal canal during
herniorrhaphy in infants and younger children, especially in female infants, because in the
female inguinal canal there is no characteristic structure like the spermatic cord in males. In
this area, medial to the inguinal canal, the posterior sheath of the rectus muscle is lacking and
only the transversalis fascia exists above the bladder wall; and some attempt to grasp the
bladder wall at that point, leading to damage. Bladder injuries do not lead to serious
complications if recognized intraoperatively and are appropriately repaired. Unrecognized or
ignored bladder injuries may lead to clinical difficulties [Condon and Nyhus, 1989]
(Figure 11).
Takeshi Hirabayashi
52
Figure 11. Schematic view of our hypothesized mechanism of bladder injury during traditional inguinal
hernia repair in girls. The external oblique aponeurosis is opened cranially and medially (A). The
anterior rectus sheath is then opened, and the rectus abdominis muscle is misidentified as the internal
oblique muscle (B). The rectus abdominis muscle is split, and the bladder wall is picked up (C). The
bladder wall is mistaken for the hernia sac, and opened (D). The small letters c, r, and q indicate the
position of the external oblique aponeurosis, rectus abdominis muscle, and bladder wall, respectively.
CONCLUSION
The standard goal of surgical treatment of indirect inguinal hernias in children is the
definitive closure of the patent processus vaginalis (PPV). The traditional cutdown method of
inguinal hernia repair in children is well established, and it is thought to be safer and easier to
perform in girls than in boys. 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 the surgeon loses sight of the surgical anatomy during operations in girls, it is
difficult to reorient. Several surgical complications, including urinary bladder injury and tubal
occlusion, have been reported. The risk of complications exists as a result of entering the
abdominal cavity when the laparoscopic approach is used, but the laparoscopic approach is
generally associated with fewer complications. Endo’s laparoscopic method may be one of
the simplest methods of inguinal hernia repair in girls, not only for experts but for novices as
well [Endo and Ukiyama, 2001].
Inguinal Hernia in Girls: Surgical Management and Surgical Complications
53
REFERENCES
Borley, N. R. (2008). Anterior abdominal wall. In “Gray’s Anatomy, 40
th
Edition,” S.
Standring, Ed. Pp. 1055-1067. Churchill Livingstone Elsevier, Phildelphia.
Condon, R. E. & Nyhus, L. M. (1989). Complications of groin hernia. In “Hernia, 3
rd
Edition,”L. M. Nyhus, and R. E. Condon, Eds. Pp. 253-269. J.B. Lippincott Company,
Philadelphia.
Endo, M. & Ukiyama, E. (2001) Laparoscopic closure of patent processus vaginalis in girls
with inguinal hernia using a specially devised suture needle. Pediatr. Endosurger. Innov.
Tech., 5, 187-191.
Fonkalsrud, E. W. (2003). Disorders of the inguinal canal. In “Principles of Pediatric
Surgery, 2
nd
Edition,” J. A. O’Neill, Jr., J. L. Grosfeld, E. W. Fonkalsrud, A. G. Coran,
and A. A. Caldamore, Eds. 437-450. Mosby, St. Louis.
Glick, P. L., & Boulanger, S. C. (2012). Inguinal hernias and hydroceles. In “Pediatric
Surgery, 7
th
Edition,” A. G. Coran, N. S. Adzick, T. M. Krummel, J-M. Laberge, R. C.
Shamberger, and A. A. Caladamone, Eds. 985-1001. Mosby, St. Louis.
Hirabayashi, T., Sakoda, A. & Kawano, T. (2012) Ventrally dislocated attachment of the
ovarian suspensory ligament, a risk factor for tubal occlusion as a postoperative
complication of inguinal hernia repair: efficacy of laparoscopic inguinal hernia repair for
preventing tubal damage. Pediatr. Surg. Int., 28, 1089-1094.
Kurkchubasche, A. G. & Tracy, T. F., Jr. (2002). Unique features of groin hernia repair in
infants and children. In “Nyhus and Condon’s Hernia, 5
th
Edition,” R. J. Fitzgibbons, Jr.
and A. G. Greenburg, Eds. Pp. 435-451. Lippincott Williams & Wilkins, Phliadelphia.
Moore, K. L. & Dalley, A. F. (2006). “Clinically Oriented Anatomy, 5
th
Edition” Lippincott
Williams & Wilkins, Philadelphia
Shoenwolf, G. C., Bleyl, S. B., Brauer, P. R. & Francis-West, P. H. (2001). “Larsen’s Human
Embryology, 7th Edition.” Churchill Livingstone Elsevier, Philadelphia.
Snell, R. S. (2004). “Clinical Anatomy, 7
th
Edition.” Lippincott Williams & Wilkins,
Philadelphia.
Turner, P. T. (1912). The radical cure of inguinal hernia in children. Proc. R. Soc. Med., 5,
133-140.
Weber, T. R., Tracy, T. F., Jr. & M. S. Keller (2005). Groin hernias and hydroceles. In
“Pediatric Surgery, 4
th
Edition,” K. W. Asccraft, G. W. Holcomb, III, and J. P. Murphy,
Eds. 697-705. Elsevier Saunders, Philadelphia.
In: Hernias ISBN: 978-1-62948-441-9
Editor: Mark A. Suckow © 2014 Nova Science Publishers, Inc.
Chapter 4
METACHRONOUS CONTRALATERAL INGUINAL
HERNIA IN THE PAEDIATRIC POPULATION
Ramesh M. Nataraja
*
and Shehryer Naqvi
Royal London Hospital, London, UK
ABSTRACT
The treatment of the asymptomatic side with a paediatric unilateral inguinal hernia
remains controversial. In this chapter we demonstrate that although there is no evidence
for routine bilateral exploration using the open technique, an open contralateral inguinal
ring that has been visualised laparoscopically should be closed to prevent a metachronous
contralateral inguinal hernia (MCIH).
Keywords: Paediatric inguinal hernia, metachronous contralateral inguinal hernia, childhood
hernia, child hernia, laparoscopic hernia repair, hernia repair complications
INTRODUCTION
The repair of an inguinal hernia in childhood is one of the most common operations that a
paediatric surgeon will perform. Despite this there are still controversies that exist around the
management of the contralateral asymptomatic side and the prevention of a future metachronous
contralateral inguinal hernia (MCIH). In a previously conducted systematic review of the
literature on this subject, we determined that there was an overall risk of 5.8% for the
development of a MCIH and that 18 contralateral explorations were required for the prevention
of one MCIH [Nataraja and Mohammed, 2011]. This systematic review included 49,568
paediatric patients, but patients were only included if they had undergone a unilateral inguinal
herniotomy via the open technique without a routine contralateral exploration. In recent years
many paediatric surgical centers have begun performing this operation via minimally invasive
*
Corresponding author: Department of Paediatric Surgery, Royal London Hospital, Whitechapel Road, London E1
1BB, United Kingdom E-mail: nataraja@doctors.org.uk.
Ramesh M. Nataraja and Shehryer Naqvi
56
techniques that include laparoscopic and hernioscopic techniques following open repair. This
means that our understanding of the development and treatment of paediatric MCIH is evolving.
Many surgeons will close a contralateral inguinal ring if it appears open on laparoscopic
examination, though intervention would not have been undertaken if the open technique had
been ultilised. Our aim for this chapter is to, therefore, perform a comprehensive review of the
literature to identify all relevant articles on the laparoscopic repair of paediatric inguinal hernias
and combine this them with our previous systematic review to improve the evidence base for
clinical approaches to this common condition.
METHODOLOGY
Review Focus and Design
The main review interests were determination of the incidence of open contralateral
inguinal canal and therefore potential future paediatric MCIH following laparoscopic repair,
and the number of patients required to treat for the prevention of a single MCIH. Secondary
interests included comparison of the MCIH rate as revealed by the laparoscopic technique
with the established incidence following open repair, the recurrence rate following
laparoscopic repair, and the incidence of MCIH formation after visualisation of a closed
inguinal ring laparoscopically.
The National Health Service (NHS) Centre for Reviews and Dissemination (CRD)
guidelines on conducting a systematic review were used in the formulation of this chapter
[CRD, 2010].
Data Sources and Search Strategy
A comprehensive review of the literature was performed to identify all published
evidence relating to the laparoscopic repair of paediatric inguinal hernia; or laparoscopic
contralateral visualisation following open herniotomy, which included data on the incidence
of patent contralateral inguinal canal, recurrence, and occurrence of MCIH. To ensure that all
the relevant articles were identified and therefore included in the final analysis, broad search
terms were utilised (including variations of multiple keywords), and multiple databases were
screened (Table 1). The search was limited to journal articles from the years 1940 to the
present (May, 2013). Databases such as the Trip Database were included to ensure that the
evidence collected was as accurate and evidenced-based as possible.
Study Selection
Once potentially relevant articles were identified in the databases, two reviewers screened
the abstracts. Abstracts that related to paediatric laparoscopic inguinal hernia repair with data
on contralateral hernias, a suitable follow up and recurrence or MCIH data were included.
Metachronous Contralateral Inguinal Hernia in the Paediatric Population
57
Studies that included laparoscopic visualisation of the contralateral ring following open repair
were also included. Once the titles and abstracts had been screened and the relevant articles
identified, full text articles in English were then retrieved, and screened in greater detail.
Abstracts relating to conference presentations that had not been published in a peer-reviewed
journal were not included in the final analysis. The review was limited to studies reporting
data on patients who had undergone laparoscopic hernia repair, as our previous systematic
review had included all patients who had undergone unilateral herniotomy by the traditional
open technique.
Inclusion and Exclusion Criteria
All studies, which involved a cohort of paediatric patients having undergone a
laparoscopic inguinal hernia repair or laparoscopic visualisation of the contralateral inguinal
canal, were included. The full inclusion criteria are summarized in Table 2.
Studies were excluded if the cohort described laparoscopic recurrent inguinal hernia
repair. Studies were also carefully examined for the presence of duplication of previously
published data; and in such cases, only the publication for this cohort of patients that included
an increased level of data analysis was then used for the systematic review [Schier et al.,
2002; Schier, 2006].
Data Analysis
Data analysis was performed using either a Chi-square with Yates' correction or a
Fisher’s exact test. A p-value of < 0.05 was considered to be significant. The numbers needed
to treat (NNT) in each group were calculated with the assumption that a laparoscopic closure
of a patent processus vaginalis reduced the relative risk of a MCIH to zero. 95% confidence
intervals (C.I.) are also presented.
Table 1. Summary of the databases used during the literature search,
and the number of titles and abstracts yielded
Search Terms / Keywords
(Used for all database
searches)
Database
Titles /
abstracts
screened
(Inguinal AND hernia)
(Paed* OR Ped* OR
Child* OR infant)
(Laparosc*)
(Contralateral OR
metachronous)
Only journal / Review
articles
01.01.1940 – 01.05.13
Science Direct (http://www.sciencedirect.com/)
45
Pubmed (http://www.ncbi.nlm.nih.gov/pubmed/)
153
Embase
(http://www.elsevier.com/online-tools/embase)
149
The Cochrane Library
(http://www.thecochranelibrary.com/)
7
Ramesh M. Nataraja and Shehryer Naqvi
58
Table 2. Systematic review inclusion criteria
Inclusion Criteria for the Systematic Review
Paediatric patient ≤ 18 years old
Primary inguinal hernia repair
Inguinal hernia repair performed by the laparoscopic technique
Laparoscopic examination of the contralateral inguinal ring following open repair
Follow-up with monitoring for MCIH and recurrence in the specified patient cohort of the study
RESULTS
Search Strategy
A total of 354 titles and abstracts were identified from the combined searches from the
databases listed in Table 2. From these, 118 full-text journal articles were retrieved and
reviewed in greater detail. Fifty of these contained data that was relevant and was therefore
included in the review. All of the included articles identified contained Level II-1 or II-2
evidence, with none containing Level I evidence.
Systematic Review Results
The evidence in the 50 relevant studies contained data on 12,150 patients who had
undergone either a paediatric laparoscopic inguinal hernia repair or a laparoscopic
visualisation of their contralateral ring. The articles that were identified are listed in Table 3
along with the relevant cohort information. The paediatric patients ranged from a median
corrected gestational age of 31 weeks to 18 years old. The majority of studies reviewed
included data related to primary laparoscopic inguinal hernia repair (39/50) with the
remaining related to transinguinal laparoscopic examination (11/50). Of the 12,150 patients,
4,189 had a contralateral patent processus vaginalis (CPPV), which was repaired in the
majority of studies (48/50). The overall incidence for the laparoscopic detection of CPPV was
34.5% (95% CI: 32.4 to 36.6%). If it is assumed that all CPPVs have the potential to become
a MCIH, then the NNT with respect to MCIH for all these paediatric patients is 3 (95% CI:
2.8-3.0). This is in contrast to 18 (95% CI: 16.8-18) following unilateral inguinal hernia repair
as revealed in our previous systematic review (Nataraja and Mohammed, 2011].
Recurrence Rate Following Laparoscopic Repair
A total of 44 studies reported data on the incidence of a recurrence following either
primary laparoscopic or transinguinal laparoscopic inguinal hernia repair. These studies
included a total of 10,147 paediatric patients, of which 121 (1.2%) were noted to have a
recurrence on follow-up. There was insufficient level of data in the included studies to
perform a subset analysis on the recurrence rate related to patient age.
Metachronous Contralateral Inguinal Hernia in the Paediatric Population
59
Table 3. Summary of the studies identified that contained data on the outcomes
of paediatric laparoscopic inguinal hernia repair
Study
(First
Author)
Publication
Year
Total
pts.
Paediatric
Age
(Years)
CPPV
CPPV
(%)
Recurrence
Recurrence
(%)
Kumar
2013
31
≤ 13
5
16
1
3
Tam
2013
959
≤ 18
310
32
2
0.2
Choi
2012
331
≤ 15
160
48
7
2
Abraham
2012
186
≤ 15
53
28
5
2.6
Li
2012
1036
≤ 12
221
21
6
0.5
Boo
2012
189
≤ 15
74
39
0
0
Tatekawa
2012
13
≤ 9
4
30
0
0
Lazar
2011
453
≤ 17
173
38
NR
NR
Chan
2011
16
≤ 12
3
19
0
0
Kastenberg
2011
21
≤ 12
7
33
0
0
Saad
2011
1001
≤ 18
237
23
3
0.3
Tsai
2011
138
≤ 16
55
40
4
2.8
Montupet
2011
596
≤ 15
95
16
11
1.8
Parelkar
2010
411
≤ 9
87
21
14
3.4
Lipskar
2010
156
≤ 18
53
34
2
1.2
Guner
2010
48
≤ 18
9
19
2
4
Niyogi
2010
135
≤ 15
26
21
2
1.4
Giseke
2010
346
≤ 17
101
29
4
1
Esposito
2009
315
≤ 8
123
39
2
0.6
Toufique
Ehsan
2009
363
≤ 18
144
40
3
0.8
Koivusalo
2009
47
≤ 15
12
25
2
4
Dutta
2009
162
≤ 18
63
39
4
2
Watanabe
2008
211
≤ 16
108
51
NR
NR
Maddox
2008
286
≤ 18
115
40
NR
NR
Oak
2007
16
≤ 2
2
12
0
0
Ozgediz
2007
171
≤ 16
63
37
13
7.6
Valusek
2006
1157
≤ 18
451
39
0
0
Patkowski
2006
94
≤ 15
22
23
3
3
Shalaby
2006
116
≤ 18
12
10
0
0
Takehara
2006
602
≤ 18
450
70
6
1
Sozubir
2006
211
≤ 14
41
19
0
0
Chinnaswamy
2005
35
≤ 13
7
20
2
5.7
Tamaddon
2005
81
≤ 10
32
40
0
0
Oue
2005
115
≤ 13
40
35
0
0
Chan
2005
40
≤ 18
12
30
0
0
Becmeur
2004
68
≤ 12
5
7
0
0
Bhatia
2004
284
≤ 18
85
30
NR
NR
Eller Miranda
2002
100
≤ 10
21
21
NR
NR
Schier
2002
504
≤ 14
299
59
23
4
Geiger
2000
75
≤ 18
19
25
0
0
Van Glabeke
1999
88
≤ 1
41
47
0
0
Schier
1998
14
≤ 10
8
57
0
0
Ramesh M. Nataraja and Shehryer Naqvi
60
Table 3. (Continued)
Study
(First
Author)
Publication
Year
Total
pts.
Paediatric
Age
(Years)
CPPV
CPPV
(%)
Recurrence
Recurrence
(%)
Gardner
1998
24
≤ 14
4
16
0
0
Pavlovich
1998
37
≤ 12
8
22
0
0
Yerkes
1998
627
≤ 18
262
42
NR
NR
Gursoy
1997
20
≤ 4
6
30
0
0
Pellegrin
1996
42
≤ 8
13
31
0
0
Wulkan
1996
70
≤ 12
27
39
0
0
Kaufman
1996
24
≤ 12
13
54
0
0
Grossman
1995
43
≤ 16
8
19
0
0
Totals
-
12,108
0.1-216
4189
34.5%
121
1.2%
NR = Not reported.
Subsequent MCIH
A total of 28 studies reported the incidence of MCIH following unilateral laparoscopic
repair. These studies revealed a MCIH incidence of 0.4% (n = 13/3,957). The majority of
these patients had been noted at the initial laparoscopic repair to have a closed contralateral
inguinal ring and therefore had not undergone initial laparoscopic repair.
DISCUSSION
The paediatric surgical community remains divided as to the optimum management of a
paediatric unilateral hernia [Levitt et al., 2002; Antonoff et al., 2005]. Levitt et al. [2002]
found that 40% of paediatric surgeons would explore the contralateral side in boys less than 2
years old, 39% would do so in a girl less than 5 years old, and 51% would in a premature
infant. Historically, bilateral explorations were routinely performed, although this probably
originates from the anaesthetic risks rather than potential surgical ones [Rothenberg and
Barnett, 1955].
In our previous systematic review of unilateral open inguinal herniotomies, contralateral
hernia incidence of 5.8% was revealed [Nataraja and Mohammed, 2011] and the NNT was 18
for MCIH prevention. Based on this, there is a poor evidence base for routinely exploring the
contralateral asymptomatic side in children. The follow-up periods for the included studies
ranged from 1 to 36 years in that review, and although there was no significant risk in the
MCIH incidence with studies including longer follow-up, this analysis was limited by patient
numbers. An indirect inguinal hernia is a common adult pathology and therefore only a
lifelong follow-up of these patients would reveal the true incidence of a MCIH.
In this chapter, we show that with a current laparoscopic systematic review the incidence
of CPPV is 34.5%, which decreases the NNT to 3 for paediatric MCIH prevention. This
would certainly be a possible indication for bilateral laparoscopic repair. The natural history
of CPPV in an asymptomatic paediatric patient is unclear, however. It is not known whether