Pediatric Bilateral Indirect Inguinal Herniotomy
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Table of Contents
Inguinal hernias are a common pediatric condition, with an estimated incidence of 1–4% of all neonates, with premature infants potentially having a 30% incidence rate.1 Remarkably, nearly all inguinal hernias encountered in children are of the indirect type, characterized by the protrusion of abdominal contents through a patent processus vaginalis.2 This congenital defect, resulting from the failure of the inguinal canal to close properly during embryonic development, is the most frequent condition requiring surgical intervention in childhood. Interestingly, a high familial incidence of inguinal hernias has been observed, suggesting a strong genetic predisposition to this developmental abnormality.3 Recognizing the clinical signs indicative of a hernia containing compromised contents is crucial to prevent the development of severe complications, such as intestinal perforation, testicular atrophy, and ovarian damage.4 Additionally, other common pediatric conditions, including hydrocele and undescended testis, may occasionally be mistaken for an inguinal hernia, underscoring the importance of a thorough clinical evaluation.1
When a child presents with an inguinal hernia, surgical intervention is universally required as the definitive treatment.5 The urgency for surgical repair may vary, however, depending on the child's age and the severity of the hernia. In certain cases, more timely surgical correction may be necessary to prevent potentially serious complications.
Surgical repair, known as herniotomy or high ligation of the hernial sac, is the standard treatment for pediatric inguinal hernias.6,7 This procedure aims to close the patent processus vaginalis and prevent the risk of incarceration or strangulation of the herniated contents. The surgical approach differs from that employed in adults, where direct or acquired hernias are more common and often require mesh reinforcement due to muscular weakness.
The debate between laparoscopic and open inguinal hernia repair revolves around several factors. Laparoscopic repair, performed in children of all ages, may have advantages such as lower risk of cord damage causing testicular atrophy and lower rate of postoperative complications like wound infection, hydrocoele, and scrotal oedema. It also facilitates easy detection of a patent contralateral internal inguinal ring, potentially preventing the need for a second operation or incision. However, only 5–7% of patients with a contralateral patent processus vaginalis develop a contralateral hernia later in life.8
Open unilateral inguinal surgery may require less anesthetic time and can avoid general anesthesia. Laparoscopic approach enters the peritoneal cavity, posing potential risks. A meta-analysis found no difference in recurrence, complications, recovery time, or length of stay between open and laparoscopic techniques. Long-term outcomes for laparoscopic surgery are unknown. It’s a controversial topic for inguinal hernia repair in children, but is becoming routine in many centers.9
This video presents a case of bilateral open indirect inguinal herniotomy. The patient, a 12-year-old male, presented to our medical facility with complaints of bilateral protruding masses in the inguinal regions. These masses have been causing him discomfort and pain, particularly during physical exertion. Upon palpation, the masses exhibited an elastic consistency, increased in size during bearing in a standing position, and were found to be reducible when the patient was in a supine position. The patient's mother reported that these bulges have been present since his birth. Following a comprehensive clinical evaluation, a clinical diagnosis of congenital bilateral inguinal hernia was made. Consequently, a decision was made to perform a bilateral open inguinal herniotomy with high ligation of the hernia sac.
The surgical procedure for inguinal hernia repair in children can be performed under either general anesthesia or a caudal block with associated local anesthesia. The patient is positioned in the supine position for the operation. A small incision is made in the left inguinal crease, above the suprapubic area, while marking the midline and suprapubic region as anatomical landmarks. The skin is cut, exposing the subcutaneous tissue layers, including the Camper's and Scarpa's fascia. It is important to be careful to prevent harm to the genital branch of the genitofemoral nerve. The external oblique muscle is exposed, and the inguinal ligament, a shelving edge formed by the curled external oblique aponeurosis, is identified as a crucial landmark. The external inguinal ring, located medially to the inguinal ligament, is the targeted site for hernia sac dissection.
A mosquito clamp is applied to the external inguinal ring, and the opening is widened to gain access to the inguinal canal. The spermatic cord, containing the hernia sac, spermatic vessels, and vas deferens, is a vital structure that must be identified and isolated. The cremasteric fibers that envelop the hernia sac can be carefully split along their longitudinal axis superior to the spermatic cord. This maneuver helps to expose the sac, allowing it to be grasped with dissection forceps. It is important to avoid the use of electrocautery during this step to prevent any thermal injury to the delicate structures of the spermatic cord. The hernia sac is located anteromedially within the spermatic cord. It is carefully separated from the spermatic vessels and vas deferens using clamps and dissection. The hernia sac is dissected proximally towards the internal inguinal ring, guided by the preperitoneal fat and the peritoneal line. Once the hernia sac is fully isolated, it should be carefully inspected to ensure that it does not contain any intestinal elements. After confirming the absence of any such contents, the sac can then be clamped using a hemostat. An absorbable constrictor knot is subsequently placed at the neck of the sac, at its most proximal aspect, close to the peritoneal cavity. This step effectively closes the patent processus vaginalis and corrects the indirect inguinal hernia and it is crucial to prevent the risk of hernia recurrence.
If the external inguinal ring is opened during the incision of the external oblique fascia, it should be closed using a running absorbable suture, taking care to avoid injury to the genital branch of the genitofemoral nerve and the spermatic cord. The superficial fascia is then closed with interrupted sutures using the same absorbable suture material. Finally, the skin is closed with an intradermal absorbable suture. At the conclusion of the procedure, it is important to check the position of the testicle within the scrotum.
Subsequently, a larger incision is made in the right inguinal crease due to the presence of a larger hernia on this side. Similar to the left side, the external oblique aponeurosis and inguinal ligament are identified, leading to the location of the external inguinal ring. The external inguinal ring is opened, providing access to the inguinal canal and spermatic cord structures. The cremaster muscle is pushed away, and the spermatic cord is identified by gently tugging on the testicle and following the cord's anatomical course. The entire spermatic cord is carefully delivered out of the wound to avoid creating a direct hernia defect. The spermatic fascia, which envelops the spermatic cord structures (hernia sac, vessels, and vas deferens), is split open. Each component is meticulously separated, with the vas deferens typically being the last structure to be isolated. The hernia sac is identified and clamped, ensuring no other structures are inadvertently included. The proximal aspect of the hernial sac is dissected until the preperitoneal fat is visualized, indicating the level of the internal inguinal ring. An absorbable suture is used to perform a high ligation of the sac at this level, effectively closing the patent processus vaginalis.
The external oblique aponeurosis is closed using an absorbable suture, and a subcuticular continuous suture technique is employed for the subcutaneous tissue and skin, similar to the left side. Throughout the procedure, care is taken to handle the delicate structures gently and to avoid injury to the vas deferens and testicular vessels.
Overall, this video demonstrates the essential steps of a bilateral indirect inguinal herniotomy in a pediatric patient, highlighting the importance of proper anatomical dissection, identification of crucial structures, and the high ligation technique for successful hernia repair in children. The detailed procedural description, coupled with the emphasis on anatomical landmarks and technical nuances, makes this video a valuable educational resource for surgical trainees, who are learning the principles and techniques of pediatric inguinal hernia repair.
The parents of the patient referred to in this video have given their informed consent for surgery to be filmed and were aware that information and images will be published online.
Citations
- Poenaru D. Inguinal hernias and hydroceles in infancy and childhood: a consensus statement of the Canadian Association of Paediatric Surgeons. Paediatr Child Health. 2000;5(8). doi:10.1093/pch/5.8.461.
- Davies M. Jones' clinical paediatric surgery. J Paediatr Child Health. 2010;46(6). doi:10.1111/j.1440-1754.2010.01788.x.
- Öberg S, Andresen K, Rosenberg J. Etiology of inguinal hernias: a comprehensive review. Front Surg. 2017;4. doi:10.3389/fsurg.2017.00052.
- Yeap E, Nataraja RM, Pacilli M. Inguinal hernias in children. Aust J Gen Pract. 2020;49(1-2). doi:10.31128/AJGP-08-19-5037.
- Ravikumar V, Rajshankar S, Kumar HRS, Nagendra Gowda MR. A clinical study on the management of inguinal hernias in children on the general surgical practice. J Clin Diagnost Res. 2013;7(1). doi:10.7860/JCDR/2012/4868.2690.
- Rafiei M, Jazini A. Is the ligation of hernial sac necessary in herniotomy for children? A randomized controlled trial of evaluating surgical complications and duration. Adv Biomed Res. 2015;4(1). doi:10.4103/2277-9175.156665.
- Morini F, Dreuning KMA, Janssen Lok MJH, et al. Surgical management of pediatric inguinal hernia: a systematic review and guideline from the European Pediatric Surgeons’ Association Evidence and Guideline Committee. Eur J Ped Surg. 2022;32(3). doi:10.1055/s-0040-1721420.
- Kokorowski PJ, Wang HH, Routh JC, Hubert KC, Nelson CP. Evaluation of the contralateral inguinal ring in clinically unilateral inguinal hernia: a systematic review and meta-analysis. Hernia. 2014;18(3):311-324. doi:10.1007/s10029-013-1146-z.
- Feng S, Zhao L, Liao Z, Chen X. Open versus laparoscopic inguinal herniotomy in children: a systematic review and meta-analysis focusing on postoperative complications. Surg Laparosc Endosc Percutan Tech. 2015;25(4):275-280. doi:10.1097/SLE.0000000000000161.
Cite this article
Espineda B. Pediatric bilateral indirect inguinal herniotomy. J Med Insight. 2024;2024(278.4). doi:10.24296/jomi/278.4.
Procedure Outline
Table of Contents
- Locate Inguinal Ligament and External Inguinal Ring
- Open External Inguinal Ring
- Locate and Isolate Spermatic Cord
- Locate and Isolate Hernia Sac
- High Ligation of Hernia Sac
- Locate Inguinal Ligament and External Inguinal Ring
- Open External Inguinal Ring
- Isolate and Locate Spermatic Cord
- Isolate and Locate Hernia Sac
- High Ligation of Hernia Sac
Transcription
CHAPTER 1
We have a 12-year-old boy, with an indirect inguinal hernia, which presented at birth, meaning to say that this child has a bulging mass at the left inguinal area since birth. He was seen by a physician and it was a clinical diagnosis of inguinal hernia. Inguinal hernia is the most common pediatric surgical conditions, not only in the Philippines, but also in other parts of the world, in the US and other countries. And most common procedures that we are doing is repair of the inguinal hernia or we term as herniotomy or high ligation of the sac. So, now we have marked the type of incision- and by the way, this boy has a bilateral hernia. So, we'll do the operation on both sides, me first and next is by Dr. Rahdu, okay?
CHAPTER 2
We'll start now, after marking the incision, this will be in the crease line, on or above the suprapubic area. So, these are the markers, the suprapubic area and the midline. And we do an incision from this side for the left, inguinal hernia. So, we'll start the incision. Cutting. So we are now cutting the skin.
CHAPTER 3
So the- we expose the subcutaneous tissue. The subcutaneous tissue is composed of the following layers: this is the Camper's and we are now exposing the Scarpa's fascia. So we do the incision and opening layer by layer. So we expose now the external oblique, So we are now at the level of the external oblique, we're looking for the inguinal ligament, that's the landmark. So, if you can- the shelving edge of the inguinal ligament, we're trying to expose this one and that will be the marker where- to look for the external ring. So this is now the part where we will open and to look for the external…
So, we have put the clamp on the opening of the external inguinal her- ring- the external inguinal ring. We're trying to open it. Mosquito clamp.
So we have opened the external ring, and now we're- and now we're looking for the... We're looking now for the spermatic cord. This is a very important landmark in the inguinal dissection, where you have to look for the spermatic cord. Spermatic cord is where the hernia sac, spermatic vessels, and the vas deferens is the composition of the... So, I have... Put my clamp on the spermatic cord. I'm trying to separate each component. As I mentioned, the components are the hernia sac, and the spermatic- spermatic vessels, and the vas deferens. No. The hernia sac- the origin of this is the processus vaginalis, which came from the peritoneum or the peritoneum as the testis goes down embryologically, it carries with it part of the peritoneum. So, the peritoneum that goes down with the- with the testis is called the tunica vaginalis. We're pushing away the cremaster muscle. Yes, we're separating the spermatic cord, which is now covered, or you'd say it's enveloped, by the- sperm- cremasteric muscles. That's what we're doing now, so that we can totally isolate the spermatic cord. Maybe I was pulling the wrong testis, this one. Yes, this one. So you can see here in the camera that we have exposed now the spermatic cord, which is composed, as I mentioned, the spermatic vessels, that's what I'm holding now.
And now I'm trying to look for the hernia sac, which usually is located on anteromedial. This is the medial portion. And we're trying to separate it from the vessels. Why? Because we have to ligate the hernia sac, as I mentioned. The high ligation is the correction of inguinal hernia in children, which is very different from the adults. So, anatomically you can identify the vas deferens - this is the vas deferens. This is the spermatic- pampiniform plexus. Those spermatic vessels, and now we're looking for the hernia sac. The sac is the one to be ligated. Should we separate them? It's not under. We didn't go through it, but isolate... So, this is the- so identifying again, the structures of the spermatic cord, we have put the clamp on the hernia sac. This is the structure we have to ligate. And next is the vas deferens. Yes. Which they couldn't do it where the sperm goes to the testicles, and this is the vessels, pampiniform plexus, so we'll separate it from the hernia sac. Okay, so, now we... Now, dissect the hernia sac down more approximately up to the level of the internal ring. We have to do the ligation as high as possible, and the landmark for this is the peritoneal line. Or as the peritoneum exits the internal ring. So we have now cut the part of the sac, and we're- I'm trying to- to do a farther dissection- farther dissection so I can identify the preperitoneal fat or- the, what we call the white line of Toldt. So, this is still- so this is the part where it goes down to the peritoneal cavity.
So that will end our dissection, and I will now ligate this structure. We use Vicryl. It's an absorbable suture. So I place my suture on the most proximal part of the hernia sac. So, it's called high ligation. So we call it high ligation of the sac, the proper terminology for the correction of inguinal hernia in children. It's an indirect inguinal hernia, which is different from the adult inguinal hernia, which are usually a direct type of hernia. A direct type of hernia, secondary to weakness of the muscles. So this is the cystal side, so we just leave it. So we have finished now the ligation, and practically that ends the hernia repair, now we, we'll now close the layer- each that we have incised, okay?
CHAPTER 4
So, again, identifying the external oblique muscles, and now- close it by layers. So we just approximate the layers of the external... Spermatic vessels. We're closing now the subcutaneous tissue. So we're doing a subcuticular continuous suture on this side. So, we're almost done with the repair of the hernia on the left side. Almost done, and- we're now going to the other side, the right side.
CHAPTER 5
So we're going to start now with the operation on the right side. So I make an incision through the skin. A bigger incision because it's a bigger hernia.
CHAPTER 6
So, this is your Camper's fascia, it's actually- part of your sub-q. So, we look for the Scarpa's fascia, which is actually still part of your subcutaneous tissue, but it can sometimes fool us into thinking that it's- because it's thick in children, so we mistake it for the external oblique aponeurosis. Retractor, yes retractor. Retractor. Other retractor, please. So that's your external oblique aponeurosis. So we dissect - we clean up the external oblique. And we go lateral to look for your inguinal ligament. So it's your external oblique aponeurosis that curls in on itself. So your external oblique aponeurosis will curl in to form your inguinal ligament. So, that's what we call... That's what we call our shelving edge. And if you follow that down and medial, then you will see your external inguinal ring. This is the external ring. Knife, please.
Clamp? In children, the aponeurosis is soft, so, it indents when you try to clamp. Metz. So we open it up, towards the ring.
So, open up the cremaster muscle and look for your spermatic cord. And so you slowly push away the spermatic - the cremaster muscle. So occasionally, when you have difficulty in identifying the spermatic cord, you have to... tug on the testicle and try to, and try to- push it up and down, like what I'm doing. So we can identify- the- spermatic cord. Spermatic goes down directly to the testes, to this scrotum, so when you hold the scrotum - it goes scrotum, then you can more or less identify the spermatic cord. So, now she's holding the spermatic cord. I'm trying to separate the other layers again, layers as I mentioned, the hernia sac, the spermatic vessels, and the vas deferens. Another DeBakey, please? It looks very thin. And we'll just push the muscles away. Small retractor. There's nothing inside. Yes. Let me pull it out some more. See, I like transferring my pickup. This side, it's kind of big, and the cord, so, we tried to deliver the sac - the whole cord out of the wound, so that we don't touch the- clamp, please? We don't touch the floor and create a direct hernia, because the floor in children is still intact. So this is your cord, much bigger than the other side.
So, the whole cord is usually covered by your spermatic fascia. Everything in the hernia sac, the spermatic vessels, the vas deferens so, you try to split open your spermatic fascia and separate your cord structures from the sac. So this is now your sac, and these are your vessels, your pampiniform plexus, your spermatic, your testicular artery, and your vas deferens, so we hold onto the sac until we peel out the cord structures, and as you slowly, as you slowly separate, you usually encounter to the vas last. So this is your vas deferens here. And, trying not to pinch the vas so you don't injury it. There, that's your vas deferens. Clamp, please. So once you've separated the other cord structures, you isolate... Where's my vas deferens? So, you isolate the cord structures, so you do not ligate them- ligate the structures together with your- clamp, please. They're stuck, so... Excluding the cord structures. So we can open this up, just to check if there are no structures inside. Okay, so you make sure that your cord structures are not close. Opening up the sac. So this is your hernia sac, another clamp? So, this is your distal sac. It's almost closed. And this is your proximal. It goes down to the peritoneal carvity. Clamp, please. Okay, so making sure there are no cord structures, we separate the proximal sac from your distal sac. See that, clear? Clear, so, close it. Okay, so... We pull away... Retractor. Retractor. We free the sac until we see the preperitoneal fat. Here, preperitoneal fat. And that's... The end. That means you're at the level of your internal inguinal ring, which is the level for your high ligation.
And you tie it up. Okay, so that's... Metz? Okay. So now we're going to what? So, we're just going to trim the sac, and just drop it in, and that's it. That's it. And for the distal, just check... There's some hydrocele. It's very small, I think it's almost- about to become non-communicating. Let's see if there's any fluid, and there's none. So we just leave the sac as it is. Check for bleeders. So, we have ligated the sac on the right side, so we're now trying to close the external oblique again.
CHAPTER 7
Another clamp. Layer by layer, we're closing. We're closing the external oblique aponeurosis. And then, I don't usually close the sub-q separately. In hernial repair in children, you don't use non-absorbable suture, you usually use absorbable sutures. Because it's difficult to remove sutures in children when they're awake. You have to do a subcuticular sutures. And it's an absorbable one. So these are bilateral incisions- the other incision is the bigger one, because it's the hernia side, it's a bigger sac, and a smaller sac.
CHAPTER 8
Inguinal hernia is the most common pediatric surgical conditions that we have, as i may- not only in the Philippines, but also all over. So, herniotomy or hernia repair in children, it's practically just high ligation, it's very different from hernia surgery in adults. So, the- usually, the- on adult side, is a direct type where the muscle overlying the hernia is usually weak. So, you have- in adults you, you have to repair the, the muscle. But in children, you don't touch that one, just ligate the sac, and that's it, that's finished it now. We don't use mesh, as you can see the hernia repair in adults, later on there will be hernia repair in adults, and if you see that they're using a mesh structure to overlay, this more or less strengthen the muscle layer, that is the weakness of the hernia in adults. So, practically it's very- not really simple, but a very short procedure of hernia repair in children. And- this also can be present in, in a- in female, or in girls. So maybe 1 out of 10 of hernias in children are usually female. And the cause of the majority of these are genetics, meaning there's- passes genes from generation, maybe from the father or grandfather to his children. So, if you asked the parents, maybe his father, or his mother, or one way or the other, the siblings also had inguinal hernia. And in some cases, you can see that the mother, the- maybe the father, and all the children have inguinal hernias. So, that's the genetic point of hernias in youth. In adults, the majority of these are acquired causes, meaning those related to work, like lifting heavy objects, those are very athletic, and those with other collagen diseases, so these are the main causes that we see in adults. As I mentioned, these are the 2, even in adults, I think the most common, surgical diseases or repairs or procedures that they do in practice, is also a hernia repair. In children, just the same statistics. Whether you're in the rural or in the- city level or in the university, the procedure is the same, the same. The only difference is- maybe it- is in adults, because some now are using a laparoscopic repair of hernia, that we never do in children. Okay? Laparoscopic procedures in hernia is now the trend of hernia repair in adults, but they never do laparoscopic hernia repair in children.