History
Inguinal hernias are among the oldest medical conditions documented in recorded history. They have been recognized and described in various historical texts and medical writings dating back centuries. The Egyptian Ebers Papyrus from 1550 BCE is one of the oldest known records of the diagnosis and treatment of inguinal hernias. , The mummy of Ramses the fifth, who lived in 1151 BCE, exhibited a large inguinal hernia sac. In 1224 BCE, Pharaoh Merneptah’s mummy displayed signs of a possible inguinal hernia repair, including an incision above the groin and a missing testicle on that side. ,
Hernias were mentioned in the Hippocratic Corpus in ancient Greece. The term “hernia” itself has ancient origins, traceable back to Greek and Latin medical literature, meaning prolapse. Hippocrates (400 BCE) distinguished between hernia and hydrocele: hernia was reducible, while hydrocele was transilluminable. , During the Roman Empire, Celsus (c. 25 BCE to c. 50 AD) described hernia reduction and treatment (ligation sparing the testis) in “De Re Medica”. , Early physicians and healers may not have fully understood the underlying anatomy and causes but recognized the condition’s existence. Galen (129 AD) described the processus vaginalis, defined hernias as peritoneal ruptures, and recommended ligation of the sac and cord with testicle sacrifice; a practice followed for centuries. ,
Arabic surgeons, including Albucasis (1114–1187), recommended cauterization for inguinal hernia treatment, a method later adopted by some Western surgeons in the Middle Ages.
Until the 19th century, treatment for inguinal hernias in both adults and children was similar, but children received more conservative care, often involving bandages and pagan healing rituals. The advent of anesthesia and antisepsis in the mid-1800s paved the way for refinements in the treatment of inguinal hernias. Bassini recognized the need to strengthen the posterior wall of the inguinal canal. The Bassini procedure, popular for inguinal hernia treatment, was described in 1887. It involved internal inguinal ring tightening and reinforcement of the posterior wall. The Bassini procedure marked a significant advancement due to its lower recurrence and infection rates, fundamentally changing hernia treatment strategies. , Early modifications of the Bassini procedure were introduced by William Stewart Halsted and Edmund W. Andrews, called the “North American Bassini Repair,” which gained global recognition. In a 1938 monograph titled “Hernia,” L. Watson listed 248 surgical methods for inguinal hernias from 1872 to 1935, with over 90% of them being variations of the Bassini technique.
In 1941, William E. Ladd and Robert E. Gross introduced the “Ladd and Gross technique” in the first pediatric surgery textbook, “Abdominal Surgery of Infancy and Childhood.” This method is still widely used for pediatric “open” inguinal hernia repair. Gross reported a 0.45% recurrence rate in a large series of hernia repairs in 3874 children in 1953.
Ralph Ger is often credited as the first to perform laparoscopic inguinal hernia repair in 1982, but he recognized Dr. Fletcher as the true pioneer. , , In 1979, P. Fletcher performed first inguinal hernia laparoscopic repair, focusing on strengthening the deep inguinal ring in a direct inguinal hernia. Ger’s contributions included the first detailed analysis of the benefits of laparoscopic inguinal hernia repair, such as better cosmetics, less postop pain, lower risk of neuralgia, minimal spermatic cord damage, and simultaneous treatment of bilateral hernia. The first laparoscopic inguinal hernia repair in children was described by Montoupet in 1993 and the first case reports were published by Montoupet and Esposito in 1998.
Inguinal hernia repair has gone through various stages, from conservative approaches to highly advanced and anatomically based repair techniques. The modern era brought a better understanding of the inguinal anatomy, leading to surgical techniques for pediatric inguinal hernia repair associated with less postoperative complications.
Incidence and Epidemiology
Inguinal hernia repair is one of the most frequent surgeries performed by pediatric surgeons.
A 2016 Taiwanese study used a national health insurance database covering 98% of the population (79,800 newborns) to estimate the incidence of inguinal hernia repair in children. The findings indicated a cumulative incidence of 6.62% in boys and 0.74% in girls up to the age 15. Incidence in preterm infants ranged from 9% to 30%. , The highest incidence of inguinal hernia repair occurred before the age of 1 in males and around 4.7 years in females.
Incarceration has been reported in 4%–12% of pediatric inguinal hernia presentations, which may increase to 30% in infants. Sigmund Ein in his Canadian cohort of 6361 inguinal hernia repairs described up to 39% of incarceration in preterm infants (12% overall).
Most inguinal hernias are on the right side (50%–60%), 30% on the left, and 12% bilateral. Females tend to have more bilateral inguinal hernia than males (25.4 vs. 12.9%, P < .01).
In premature infants, the pattern differs, with 40% on the right, 26% on the left, and 35% bilateral aligning with the common understanding of a higher incidence of bilateral inguinal hernias in premature infants.
A Danish Systematic review and meta-analyses on groin hernia inheritance found an increased risk with a family history of hernia repair, suggesting complex inheritance patterns—potentially polygenic or multifactorial. Notably, sex-specific associations were observed, particularly between mothers and daughters, as well as sisters. A retrospective cohort of 28 monozygotic and 12 dizygotic twins with inguinal hernia, along with a prospective study’s 8 monozygotic and 17 dizygotic pairs, demonstrated different concordance rates—14% versus 25% and 13% versus 12%, respectively—suggesting a weak genetic influence.
Embryology
During fetal development, the abdominal cavity is lined by the parietal peritoneum. The processus vaginalis is a pouch of the peritoneum that aids in the descent of the testes in males during fetal development. , In females, it is called the canal of Nuck and contributes to the development of the labia majora. It is first seen in the second or third month of gestation and should typically close after testicular descent.
The inguinal canal (IC) undergoes dynamic development linked to gonadal differentiation and migration, particularly during testis descent. Germ cells appear in the urogenital ridge by the 6th week, and testicular differentiation begins by the 7th week. Testicular descent occurs in two phases: an abdominal phase (8–15 weeks’ gestation) involves swelling and strengthening of the distal gubernaculum, induced by insulin-like 3 hormone (Insl3). Simultaneously, fetal testosterone leads to the regression of the cranial suspensory ligament, anchoring the testis to the internal ring as the abdominal cavity enlarges. In the inguinoscrotal phase (25–35 weeks), the gubernaculum extends to the base of the scrotum. Androgenic hormones prompt the release of neurotrophins, guiding the gubernaculum through the inguinal canal to the scrotum.
Following testicular descent, the patent processus vaginalis (PPV) usually closes. Closure begins at the internal inguinal ring, followed by closure superior to the testis. The last to close is the residual space between the cranial and caudal portions (funicular process). Incomplete obliteration of this tract is responsible for the spectrum of inguinoscrotal pathologies ( Fig. 49.1 ). Factors influencing PPV closure are not fully understood, but conditions causing increased abdominal pressure or fluid are associated with an elevated risk of indirect inguinal hernias and bilaterality. Prematurity is linked to an increased incidence of inguinal hernia, depending on the degree of prematurity. In females, the gubernaculum transforms into the round ligament, and ovarian descent does not reach the abdominal wall. , The canal of Nuck closes around 7 months of fetal life, leading to the arrest of ovarian descent in the pelvis.
From left, configurations of hydrocele and hernia in relation to patency of the processus vaginalis.
Layers of the abdominal wall contribute to the formation of the inguinal canal and spermatic cord as they descend. The internal spermatic fascia continues from the transversalis fascia, the cremaster muscle derives from the internal oblique, and the external spermatic fascia originates from the external oblique aponeurosis. The processus vaginalis envelops the testis, forming the visceral and parietal layers of the tunica vaginalis.
Associations and Risk Factors
Numerous conditions correlate with inguinal hernias ( Table 49.1 ). The most prevalent association is prematurity, stemming from disrupted testicular descent, compounded by comorbidities like chronic lung disease in this population.
Table 49.1
Conditions Associated With Inguinal Hernia
| Prematurity (hazard ratio 6) |
| Family history (hazard ratio 2.92 for mother with inguinal hernia) |
| Cystic fibrosis (hazard ratio 3) |
| Hydrocephalus (ventriculoperitoneal shunt) |
| Peritoneal dialysis |
| Genitourinary abnormalities (e.g., vas deferens absence, CAIS—complete androgen insensitivity syndrome) |
| Congenital collagenopathies (hazard ratio 2.237) |
| Mucopolysaccharidoses |
| Glycogen storage diseases |
| Abdominal-wall defects |
| Chronic lung disease |
A 2022 Montreal study involving over 786,322 children revealed that children with mothers having inguinal hernias had a 2.92 times higher risk of developing inguinal hernias compared to those without maternal disorders. Notably, maternal history was more impactful for girls, with a 5.34 times’ higher risk. On the other hand, maternal connective tissue disorders increased the risk by 1.35 times in boys, but showed no association with hernias in girls.
Cystic fibrosis has a 15% hernia incidence (at least three times the general population), suggesting genetic involvement alongside the mechanical effects of chronic lung disease and heightened intraabdominal pressure. The elevated risk of hernias in unaffected fathers and siblings implies a genetic component. Vasal abnormalities in children with cystic fibrosis support an embryologic contribution. Also, cystic fibrosis is a risk factor for bilaterality and recurrence. During male inguinal hernia repair, encountering a small or absent vas should prompt an elective renal ultrasound (US) for assessing ipsilateral renal agenesis. Vasal abnormalities also warrant a cystic fibrosis evaluation ( Fig. 49.2 ). Congenital vas absence, attributed to mutations in the cystic fibrosis gene, exhibit differing genotypes in isolated versus associated cases with renal anomalies.
This child with cystic fibrosis is undergoing diagnostic laparoscopy. Note the vas deferens ( arrows ) is atrophic on both sides. (A) Left, (B) right. This is commonly seen in boys with cystic fibrosis.
Ventriculoperitoneal shunts (VPSs) for hydrocephalus are associated with a 15%–25% increased hernia incidence, coupled with higher rates of bilaterality, incarceration, and recurrence. Neonates with VPS are more susceptible, particularly boys. The average time from VPS placement to hernia repair spans 5–12 months. Conditions featuring excess intraabdominal fluid (peritoneal dialysis, ascites, hydrops) share similar associations.
Classification
The term “inguinal hernia” encompasses indirect inguinal hernias, direct hernias, and femoral hernias. Among children, indirect inguinal hernias, which are located lateral to the inferior epigastric vessels, are the most common. Even in young adults (16–18 years old), direct inguinal hernias are infrequent. Femoral hernias, situated below the inguinal ligament, account for less than 1% of pediatric inguinal hernias.
Sliding hernias involve viscera (such as the bowel, bladder, or reproductive structures) within the hernia sac. Pantaloon hernias ( Fig. 49.3 ), more common in neonates, consist of both direct and indirect inguinal hernias.
This infant was undergoing open repair of a large right inguinal hernia. Upon mobilization of the hernia sac, the appendix could be seen through the wall of the sac. The eponym for this finding is an Amyand hernia.
Eponymous inguinal hernias have specific names based on their characteristics. Amyand hernias involve the appendix in the hernia sac ( Fig. 49.4 ), Littre hernias involve Meckel diverticulum in the sac, and Richter hernias feature ischemic antimesenteric bowel border in the hernia.
This laparoscopic view shows evidence of a pantaloon hernia (hernia-en-pantaloon) that is composed of a direct ( asterisk ) and indirect ( arrow ) hernia on the same side.
Clinical Findings
The diagnosis of an inguinal hernia is typically made through clinical evaluation, which includes a thorough history and physical examination. In children, hernias often present as painless, intermittent, and unilateral inguinal bulges. Bilateral hernias (12%) are less common.
Activities that raise intraabdominal pressure, such as crying, coughing, or defecation, can trigger the protrusion of abdominal contents toward the hernia. Usually, they are identified during diaper change or after bathing by parents or during routine physical examinations conducted by primary care providers. In girls, a small mobile mass often appears in the groin or labia, typically representing a sliding ovary ( Fig. 49.5 ).
Labial bulge. Wright indirect inguinal hernia containing sliding ovary in a girl.
Intermittent inguinal bulging can sometimes result in a normal examination despite suggestive historical accounts. Today, parents often use cell phone pictures to document the bulge, aiding in diagnosis. A compelling history can justify surgery, especially when diagnostic laparoscopy is utilized for definitive diagnosis and repair in uncertain cases.
Key elements of the history include prior prematurity, family medical history, and previous genitourinary anomalies (undescended testis, hypospadias, and hydrocele). In addition to considering the presence or absence of associated risk factors outlined in Table 49.1 , the differential diagnosis includes retractile testis, lymphadenopathy, hydrocele, varicocele, and prepubertal fat.
Although imaging is often unnecessary, ultrasound can provide valuable insights, especially in more obese children. It can confirm the presence of bowel or omentum in an incarcerated hernia, distinguish tense hydroceles of the cord from solid masses or large epididymal cysts, and identify a nonpalpable testicle surrounded by hydrocele fluid.
Hydrocele
Hydrocele is the presence of fluid around the testicle and cord. These are commonly seen in infancy, with a secondary peak in adolescent boys. In children, hydroceles mainly occur due to the presence of a patent processus vaginalis (PPV), which differs from the causes in adults. When fluid passes from the abdominal cavity through a PPV, it is referred to as a communicating hydrocele ( Fig. 49.6 ). In contrast, a noncommunicating hydrocele does not have any connection to the abdominal cavity. Another variation of this same phenomenon is the cord cyst (hydrocele of the cord) ( Fig. 49.7 ). In girls the equivalent to the processus vaginalis is known as the “canal of Nuck,” which follows the round ligament of the uterus that passes through the inguinal canal and extends into the labia majora. Failure to complete obliteration of PPV or canal of Nuck may result in a variety of groin anomalies.
Left communicating hydrocele (A) with transillumination (B).
Cord cyst. (A) Child with a cord cyst. (B) Cord cyst surgery.
Communicating hydroceles are inherently associated with inguinal hernias, sharing a common etiology and a similar surgical repair approach. Both conditions stem from the presence of a PPV. Hydrocele is frequently concomitant to inguinal hernia; Ein’s 2006 publication involving 6361 children with inguinal hernia noted that 19% had also hydrocele. , Numerous studies have explored the occurrence of metachronous contralateral inguinal hernias, particularly in infants. However, compared to inguinal hernias, metachronous contralateral hydroceles are relatively uncommon (4.9%).
Distinguishing between a hernia and a hydrocele is crucial. In a communicating hydrocele, there is painless swelling extending from the cord to the scrotum, typically larger in the evening. Clinical examination reveals fluctuant, painless swelling, which may or may not be reducible. Transillumination shows a fluid-filled scrotum, which can be bilateral, especially in infants ( Fig. 49.6A ).
Most hydroceles resolve with age. In infants under 1 year of age the PPV closes spontaneously in roughly 89% of cases. Hence, surgery is considered when the hydrocele persists until the age of 2 years (does not decrease in size) and when it is associated with inguinal hernia. Also, increased tensile force from a very large hydrocele can potentially disrupt blood circulation in the testis, resulting in testicular atrophy. In such instances, surgical intervention is warranted, regardless of age.
The treatment of communicating hydrocele requires the same surgical procedure as for inguinal hernia repair. After high ligation of the PPV, an attempt is made to empty the distal fluid of a hydrocele if not already drained. To release any remaining fluid, the distal part of the hydrocele is widely opened to avoid injury to the testicle instead of completely removing the hydrocele sac. This often involves making an incision down to the scrotal tunica vaginalis.
Laparoscopic surgery for communicating hydrocele can be considered an option. A 2017 Chinese publication compared 950 extracorporeal video-asissted high ligations of the PPV to 382 open repairs of hydrocele. There were no significant differences in recurrence after 3–4 years of follow-up and decreased operative time (16 minutes vs. 28 minutes for lap vs. open repair, respectively), less scrotal edema (0% vs. 18.6% for open repair), fewer incisional infections (0.1% vs. 1.6%), and fewer metachronous hernias or hydroceles (0.2% vs. 1.8%) for the laparoscopic group. No other complication was described. They managed residual scrotal hydrocele by aspiration.
Hydroceles that resolve spontaneously in infancy or appear during or after puberty are usually noncommunicating, arising from delayed fluid absorption or abnormal fluid dynamics within the tunica vaginalis. They may also stem from tumor, trauma, or inflammation. Simple scrotal hydroceles are found in at least 5% of male neonates, are often bilateral, and typically resolve via fluid reabsorption. Persistent or new noncommunicating hydroceles should be assessed operatively. Performing a scrotal approach for hydrocele repair offers advantages over the inguinal approach, including improved cosmesis, shortened operative time, and elimination of the risk of ilioinguinal nerve damage by avoiding dissection involving the spermatic cord.
The risks of nonoperative management in hydrocele include scrotal enlargement and potential hernia formation. While hydrocele is generally considered a benign condition, untreated abdominoscrotal hydrocele may impact testicular morphology, leading to flattening or elongation. In adults, hydrocele can also be associated with an arrest of spermatogenesis.
Incarceration
Indirect inguinal hernias are the most common incarcerated pediatric inguinal hernias, although incarceration of other pediatric hernias, such as femoral, umbilical, Spigelian, epigastric, direct inguinal, and lumbar, has been reported in the literature. The risk of incarceration in children with indirect inguinal hernia is variable and age dependent and ranges from 4% to 12%, although it is as high as 39% in premature infants, with most occurring within the first year of life. , A 2021 publication including 12,190 patients suggested females were more likely to present an incarcerated inguinal hernia (1.25% vs. 0.52% incarceration rate in males). Prematurity is widely recognized in the literature as a risk factor for incarceration, with studies suggesting it can double , or even triple the likelihood of future imprisonment.
Prolonging the interval for elective hernia repair during infancy heightens the risk of incarceration. Incarceration can indeed lead to significant morbidities like testicular or ovarian infarction, atrophy, bowel obstruction, strangulation or perforation, wound infections, and recurrence. It is crucial to address such concerns promptly to prevent further complications.
A child with an incarcerated hernia may exhibit irritability or inconsolability, along with a persistent, irreducible, tender, and possible erythematous enlarged bulge that does not spontaneously reduce ( Fig. 49.8 ). Additionally, they may experience decreased appetite and show signs of bowel obstruction, such as nausea and vomiting, lack of bowel function, abdominal distention, and absence of flatus or stool. Peritoneal signs suggest strangulated bowel. If strangulation occurs, peritonitis, bloody stools, and hemodynamic instability may develop. Conditions like retractile testis, lymphadenopathy, and hydrocele can be mistaken for incarcerated hernias; however, hydrocele typically lacks tenderness in the absence of previous attempts to “reduce” it. Abdominal radiographs may reveal dilated bowel loops and/or air-fluid levels indicative of bowel obstruction. Complications of a nonpromptly treated incarcerated inguinal hernia might be devastating, ranging from testicular or ovarian atrophy, high recurrence rate, wound infection, bowel ischemia, peritonitis, hemodynamic shock, and death. The risk of intestinal damage related to incarcerated hernia ranges between 0.1% and 12.8% in children ( Fig. 49.9 ).
Male infant with a nonreducible incarcerated right inguinoscrotal hernia.
(A) Infant that underwent inguinal exploration due to incarcerated hernia (B) bowel necrosis associated with incarcerates inguinal hernia.
In the absence of evidence indicating bowel compromise, peritonitis, or hemodynamic instability, nonoperative reduction should be considered. This approach has a success rate of 70%–95% for incarcerated inguinal hernias. During manual reduction, the patient can be positioned in mild Trendelenburg to facilitate reduction. One hand is positioned above the external ring with fingers encircling the hernia neck to stabilize it and prevent the hernia contents from sliding back through the inguinal canal. Simultaneously, the other hand applies moderate and steady pressure on the hernia contents, directing them toward the abdominal cavity along the inguinal canal and internal ring axis ( Fig. 49.10 ). Consistent pressure may assist in alleviating bowel edema, while delicate movements of the fingers on the hernia sac can aid in the reduction process. Reduction attempts typically involve sedation and analgesics, although there is no standardized protocol, and pharmacotherapy should be decided by the provider. Caudal epidural anesthesia is extensively used in pediatric practice for both preemptive and postoperative pain relief in elective inguinal hernioplasty procedures.
Manual reduction of incarcerated hernia.
Courtesy of Dr. José Manuel Campos.
If manual reduction is unsuccessful, questionable, or there are concerns regarding incomplete reduction, emergent reduction under anesthesia or surgical reduction and hernioplasty should be promptly pursued. While successful reduction of gangrenous bowel is improbable, it has been documented in the literature. Hence, close postprocedure patient monitoring and hospitalization with subsequent hernioplasty prior to discharge must be considered.
The optimal timing of inguinal hernia repair after successfully reduced incarcerated hernia is not totally established. The decision for early or delayed repair must be weighed against the risk of postoperative complications and will be discussed further in this chapter.
Laparoscopic reduction is often easier than open reduction, providing the opportunity to assess the status of the bowel before closing the defect ( Fig. 49.11 ). With laparoscopic traction and manual external pressure, hernia contents can typically be reduced. In rare cases requiring resection, the intestine or appendix can be exteriorized through the umbilicus for examination or procedures like bowel resection or appendectomy. A 2011 series of 63 patients in Great Ormond Street Hospital for Children demonstrated that laparoscopic hernioplasty is a valid and safe option for incarcerated inguinal hernia. In that series, there was a 14% incidence of serious complications in the open group (Vas transaction, acquired undescended testis, testicular atrophy, and inguinal recurrence) versus 4% in the laparoscopic group. A 2023 meta-analysis including 8 studies with a total population of 584 (339 underwent laparoscopic repair and 245 underwent open repair) had similar results: fewer major complications for laparoscopy compared to open repair (OR 0.56: 95% CI; P = .56), reported testicular atrophy of 0.002% versus 2.3%–30% in open repair, and shorter hospital stay in patients who underwent laparoscopic repair for incarcerated inguinal hernia. There was no statistically significant difference in recurrence rate between both techniques.
These two infants underwent emergent laparoscopic repairs for incarcerated right inguinal hernias. On the left (A) the bowel could be reduced, and a laparoscopic hernia repair was performed. On the right (B) the bowel was able to be reduced, but a short segment of it was infarcted. The bowel was exteriorized by enlarging the umbilical incision, and an extracorporeal bowel resection was performed. Both infants recovered uneventfully.
An apparently necrotic ovary or testis during surgery is not always indicative of irreversible damage or a lack of future functionality. Multiple studies show that even with evidence of ovarian ischemia or ischemic-appearing testes, most organs remain viable with evidence of follicular development or survival. Testicular atrophy occurs in 2.3%–15% of incarcerated hernias, but some cases may be iatrogenic from the repair, emphasizing the importance of discussing this eventuality with the family preoperatively. Postoperative monitoring is recommended, as well as avoidance of unnecessary testicular resection unless frank necrosis is present.
The presence of an edematous sac with ill-defined tissue planes can be a pitfall for even the most experienced of surgeons.
Timing of Repair
The optimal timing of hernia repair in preterm infants is debated due to the challenge of balancing the risk of incarceration with intraoperative and postoperative complications. Traditionally, it was advised that premature infants with inguinal hernias undergo hernia repair prior to discharge from the neonatal intensive care unit. However, a recent study suggests that some premature infants might benefit from delayed repair after neonatal intensive care unit discharge. A 2024 randomized control study that included 39 US medical centers compared the outcomes for 159 premature infants (median age of 41 postconceptional weeks) who underwent early inguinal hernia repair prior NICU discharge versus 149 premature infants who underwent later inguinal hernia repair (median age 57 postconceptional weeks). The early repair group had a 28% incidence of major events (defined as respiratory, cardiac, and surgical complications and death) versus 18% for the delayed repair group. The rate of apnea was the highest for the early group (17.6% vs. 9%), who were also younger. However, the late repair group had the highest rates of incarceration (4% vs. 1.3%), reoperation (2% vs. 1.3%), cardiac arrest (2% vs. none), unplanned intubation (0.7% vs. none), and death (2% vs. 1.3%). Similar results were found in a 2022 meta-analysis, which included six studies and 2549 preterm infants: patients in the early group had lower odds of developing incarceration as compared to those in the delayed group (OR 0.43, 9% vs. 18% rate of incarceration), higher odds of postoperative respiratory complications (OR 4.36, 95% CI 2.13–8.94, I2 = 40%, P < .001), and no significant difference in postoperative complications between groups.
A 2024 survey of the European Pediatric Surgeons’ Association evaluated the practice patterns 180 surgeons, specifically regarding the timing of inguinal hernia (IH) repair in premature infants. Due to the high risk of incarceration, the prevalent practice was to perform IH repair before discharge (57%–95% regardless of incarceration). The most common reason for delaying surgery was the lower risk of postoperative apnea.
Excluding hospitalized infants, we recommend that those younger than 3–6 months with inguinal hernias should be scheduled for early repair. Older children with inguinal hernias and minimal symptoms can undergo elective surgery. If an incarcerated hernia is reducible under anesthesia before emergency surgical repair, it could be acceptable to delay the surgery for 1 or 2 days if laparoscopic equipment is unavailable or if the surgeon lacks sufficient experience with the laparoscopic procedure. This could be considered if there are no signs or suspicion of bowel compromise or complications due to the incarceration and to avoid an open procedure in the presence of acute edema, which could make the surgery more complex or difficult. Waiting 24–48 hours with the patient in the hospital may allow the edema to resolve before proceeding with open surgery. Performing the IH repair prior to discharge is advisable in such cases as incarcerated hernias that are reduced have an incidence of reincarceration as high as 15% if definitive repair is delayed for more than 5 days.
Operative Technique
Open Repair
In open repair of an indirect inguinal hernia (OHR) in children, the focus is on high ligation of the hernia sac at the internal inguinal ring. A transverse inguinal crease incision is made. The Scarpa’s fascia is opened, and the external oblique aponeurosis is identified. Care is taken to locate and preserve the ilioinguinal nerve, which is responsible for skin sensation in the anterior thigh.
In boys, the anteromedial hernia sac is carefully separated from the cord structures ( Fig. 49.12A ). In girls, the sac is mobilized up to the internal inguinal ring. In boys, if the sac extends into the scrotum it is clamped after carefully ensuring no involvement of the vas and testicular vessels and then divided. The hernia sac is followed proximally to the internal inguinal ring and doubly ligated with absorbable suture ( Fig. 49.12B ). The distal sac is widely opened but does not need to be removed. A hydrocele, if present, is drained, but again the hydrocele sac does not require to be excised. The closure is in layers, with absorbable continuous suture to the external oblique aponeurosis, Scarpa’s fascia, and subcutaneous tissue. Skin may be closed with intradermic suture with absorbable monofilament and/or glue ( Fig. 49.12C ).
These operative photographs depict the salient features with an open inguinal repair. The hernia sac has been separated from the adjacent spermatic cord (A). The testicular vessels are marked with the solid arrow and the vas deferens is marked with the dotted arrow. In (B), high ligation of the hernia sac has been performed using a 2-0 Vicryl suture followed by a 2-0 Vicryl suture ligature placed distal to the tie. The excess sac was then amputated. On the right (C) the 2-cm left inguinal incision has been closed.
Formal repair of the inguinal floor is rarely necessary in children. In the presence of a sliding hernia, inversion ligation is relatively straightforward after placing a proximal purse-string suture.
Historically, unilateral inguinal hernias in younger infants and children often led to contralateral open inguinal exploration. However, recent reports describe using laparoscopy to assess the contralateral inguinal ring during open hernia repair. A small scope can be inserted through a 2–3 mm port via the ipsilateral hernia sac, looking for a contralateral patent processus vaginalis (PPV) ( Fig. 49.13 ). Even after a negative evaluation, there is a small but definite risk of developing a contralateral hernia ( Figs. 49.14–49.16 ). The necessity of contralateral evaluation is debated, but with the increasing use of transumbilical laparoscopic repair, it may be less relevant. Recent studies lean toward the opinion that contralateral evaluation may not be necessary (potential overuse). However, in one study, when parents were offered the choice of unilateral repair alone or unilateral repair with contralateral evaluation, they overwhelmingly chose contralateral evaluation with laparoscopy.
(A) After a right inguinal incision in an infant boy, the sac has been separated from the vas and vessels by grasping the sac and teasing the cord structures away. The hernia sac, located anteromedial to the cord, has been carefully separated from the vas and vessels ( vessel loop ) and is clamped in preparation for division of the sac. (B) In preparation for diagnostic laparoscopy to evaluate the contralateral internal ring, the sac is opened. A vessel loop is around the cord structures. (C) A cannula has been introduced into the opened hernia sac, and the sac has been tied ( solid arrow ) to keep the abdomen insufflated. The cord structures ( dotted arrow ) are retracted with the vessel loop.
Laparoscopic evaluation of the contralateral inguinal region is used by many pediatric surgeons. (A) A view of the left internal ring completely closed. (B) A slightly open left internal inguinal ring.
(A) In a small percentage of cases, a veil of peritoneum will cover the contralateral internal ring and obscure the laparoscopic findings such that the surgeon is not completely certain whether a contralateral patent processus vaginalis is present. In this situation, a technique has been reported to retract the veil of tissue. (B) A silver probe is introduced in the contralateral lower abdomen/flank and used to retract the veil medially so that the 70-degree telescope can then look down the possible CPPV. (C) In this patient, a significant CPPV was visualized once the veil of the peritoneum was retracted medially.
Adapted from Geiger JD. Selective laparoscopic probing for a contralateral patent processus vaginalis reduces the need for a contralateral exploration in inconclusive cases. J Pediatr Surg . 2000;35:1151–1154.
At 1 year of age, this infant underwent left inguinal hernia repair with diagnostic laparoscopy to evaluate for a right patent processus vaginalis. At laparoscopy, it was felt that a contralateral PPV did not exist. This is the photograph taken at that time. However, 2 years later, he presented with a symptomatic right inguinal hernia. The incidence of false-negative evaluations for contralateral hernia using laparoscopy is approximately 1%.
Laparoscopic Repair
Multiple laparoscopic IH repair techniques have been described, employing either an intraperitoneal or extraperitoneal approach. A two-port extraperitoneal approach will be described. It is a variation of the percutaneous internal ring suturing (PIRS) technique, described by Ponsky. This method includes percutaneous suture placement around the internal ring, like PIRS, but adds hydrodissection and an extra incision for thermal injury to the peritoneum as well as handling of the internal PPV if necessary. Thermal injury enhances closure strength, as observed in a rabbit model study.
Patient preparation and operating room setup are critical: the patient is positioned supine with slightly spread legs. The bladder should be emptied before surgery; encouraging patients to void before surgery prevents the need for urinary catheterization. The Credé maneuver can be considered for younger patients. The operating room table remains flat. A 15–20-degree Trendelenburg position may facilitate optimal visibility, by displacing the bowel. Abdomen and proper scrotal preparation allow for manual pneumoperitoneum expulsion before ligation of the hernia sac. The surgeon may stand on the patient’s left side, irrespective of the hernia location, with the assistant positioned on the same side, closer to the patient’s head. Another option is to stand ipsilateral to the hernia. The laparoscopic monitor is placed at the foot of the operating table.
Trocar position and instrumentation involve initiating the procedure with a 70-degree, 3-mm laparoscope (or a 5-mm, 30-degree laparoscope for larger children) inserted transumbilically. A 3-mm Maryland dissector is introduced percutaneously without a trocar, in the lower abdomen: either on the left side or on the same side as the hernia. The Maryland dissector should have the capability to apply electrocautery. An 18-gauge spinal needle is used in the procedure, with its tip gently bent using two needle drivers ( Fig. 49.17 ). A loop of 3-0 polypropylene suture is loaded onto the needle in a way that situates the suture ends at the back of the needle ( Fig. 49.18 ). At the tip of the needle, a 1-mm loop of suture is left exposed. It is essential for the needle’s curve to be gentle; otherwise, the surgeon will encounter difficulty passing it.
A 18-gauge spinal needle with its tip gently bent.
The spinal needle loaded with a loop of 3-0 polypropylene suture (suture ends at the back of the needle).
The hernia is assessed, and any contents are reduced laparoscopically with gentle tension. The peritoneum is then thermally injured with electrocautery from 8 to 5 o’clock, on the medial, anterior, and lateral edges with caution to avoid the vas deferens and spermatic vessels. Aim to cauterize just inside the internal ring so the cautery line is not in the exact same location as the final resting spot of the suture ( Fig. 49.19 ). However, this may not be critical. Cauterization has been shown to significantly improve the durability of repair in rabbits. One surgeon reported treating small inguinal hernias in girls by inversion of the hernia sac and cauterization alone: the so-called “BURNIA” technique ( Fig. 49.20 ).
(A) Left inguinal hernia and (B) left inguinal hernia with cauterization of the internal inguinal ring avoiding vas deference and cord vessels. M. Guelfand.
Burnia.
A 25-gauge finder needle serves to locate the 12 o’clock position of the internal ring (as viewed through the laparoscope). The needle is inserted perpendicular to the abdominal wall, with external palpation guiding the entry point. An 11-blade scalpel is then used to create a 1-mm skin incision at this precise location. To facilitate smooth and straight needle advancement over the vas deferens and vessels, insert the needle quite laterally, near the patient’s flank.
The next step involves hydrodissection with 0.25% bupivacaine or an alternative long-acting local anesthetic, to dissect the peritoneum away from the cord structures ( Fig. 49.21 ). In smaller patients, the local anesthetic may be diluted to remain within safe dosage limits. If a caudal block was administered by anesthesia, 5 mL of normal saline may be employed. It is crucial to remain just below the peritoneum (between the peritoneum and the vessels) during this process to avoid lifting the vessels with the peritoneum rather than separating them.
(A and B) Hydrodissection of left internal inguinal ring with the spinal needle.
The spinal needle is placed through the incision and then inserted until it can be seen beneath the peritoneum at the 12 o’clock position overlying the internal ring. It is then passed, following the path created by hydrodissection starting at the internal ring’s lateral edge ( Fig. 49.22 ). The needle passes over the vessels and, if possible, the vas deferens before piercing out the peritoneum. The 3-mm Maryland grasper may be used to assist lifting the peritoneum off the cord structures to allow for safer passage of the needle. If needed, the needle may be passed over the vas deferens from the medial side. After passing the vessels, the needle’s tip should pierce the peritoneum at the 6 o’clock position. The polypropylene suture loop is advanced out of the needle, and the needle is withdrawn, leaving the suture in place ( Fig. 49.23 ). The suture ends are secured with a hemostat outside the patient.
