Pediatric Bilateral Indirect Inguinal Herniotomy

Case Overview

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.

Statement of Consent

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.