Home | About Us | Current Issue | Ahead of print | Archives | Search | Instructions | Subscription | Feedback | Editorial Board | e-Alerts | Login 
Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
Official journal of the Indian Association of Pediatric Surgeons         
 Users Online:773 
  Print this page Email this page   Small font sizeDefault font sizeIncrease font size


 
ORIGINAL ARTICLE
Year : 2009  |  Volume : 14  |  Issue : 2  |  Page : 66-67
 

Is ligation of hernial sac during orchiopexy mandatory?


Department of Pediatric Surgery, Medical College and Hospital, Kolkata, West Bengal, India

Date of Web Publication22-Aug-2009

Correspondence Address:
Veena Kumari
LHQ, Medical college & Hospital, 88 College Street, Kolkata-73, West Bengal
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9261.55155

Rights and Permissions

 

   Abstract 

Aim: Traditionally, ligation of hernial sac during orchiopexy is considered mandatory to prevent postoperative development of hernia. A prospective study was carried out to see if it is actually required based on the fact that any peritoneal defect closes within 24 hours by metamorphosis of the in situ mesodermal cells. Methods: Fifty cases of undescended testis, age ranging from eight months to 12 years were enrolled. All of them underwent standard orchiopexy without ligation of the hernial sac. Results: Follow up of all cases ranged between 1.5 years to three years. Not a single case was reported with evidence of hernia. Conclusions: It is unnecessary to ligate the hernial sac during orchiopexy.


Keywords: Hernia Inguinal, orchiopexy, undescended testis


How to cite this article:
Kumari V, Biswas N, Mitra N, Konar H, Ghosh D, Das SK. Is ligation of hernial sac during orchiopexy mandatory?. J Indian Assoc Pediatr Surg 2009;14:66-7

How to cite this URL:
Kumari V, Biswas N, Mitra N, Konar H, Ghosh D, Das SK. Is ligation of hernial sac during orchiopexy mandatory?. J Indian Assoc Pediatr Surg [serial online] 2009 [cited 2020 Apr 3];14:66-7. Available from: http://www.jiaps.com/text.asp?2009/14/2/66/55155



   Introduction Top


The conventional and accepted technique of orchiopexy recommends that ligation of the hernial sac is mandatory for prevention of postoperative development of hernia. However, it has been seen that during laparoscopic orchiopexy there is no difference to simple suturing when peritoneum is incised, hernia sac dissected and left alone. This may be due to the fact that any peritoneal defect closes within 24 hours by metamorphosis of the in situ mesodermal cells. We report the results of a study on nonligation of hernia sac during conventional orchiopexy.


   Materials and Methods Top


This prospective study was conducted between April 2004 and 2007. Fifty children with an age range of eight months to 12 years with a diagnosis of undescended testis were included. Of the 50 cases, 38 were unilateral and 12 bilateral cases. Of the 38 unilateral undescended testis, 22 were right-sided and 16 left-sided. In all the cases, testis was palpable. Clinically, no cases presented with hernia. After the baseline investigations, informed consent of the parents was taken and the procedure explained to those parents who were able to understand. All children underwent standard orchiopexy without the ligation of the hernia sac. No special investigative workup was done.

The hernia sac was dealt with after complete mobilization of the testis through an inguinal incision. The sac was first opened up, divided and the proximal end of the divided sac was very gently peeled off with dissecting forceps as high as possible without damaging the cord structures. It was left as such without ligation. Standard orchiopexy was then performed by making subdartos pouch.


   Results Top


All the patients were followed up for 1.5 years to three years. No inguinal hernia was detected during the regular follow-up in any child.


   Discussion Top


Hernia sac has been routinely dissected and meticulously freed from the cord structures and suture ligated proximally during inguinal orchiopexy. This is done to achieve adequate length of the cord to bring down the testes to the scrotum to its normal position and prevent development hernia postoperatively.

In cases of inguinal hernia in children, Mohta et al . [1] suggested that nonligation of hernia sac during herniotomy in children has no untoward effect on the early complications and recurrence rate. The study was based on the fact that peritoneal defect closes by metamorphosis of the in situ mesodermal cells. Earlier, Shulman et al . [2] showed that ligation of hernia sac in adult herniorrhaphy is a needless step. A prospective study of laparoscopic inguinal hernia repair in children by Schier [3] showed that there is no difference to simple suturing when peritoneum was incised and hernia sac resected . He stressed that an open internal inguinal ring is not an inguinal hernia. [4] During laparoscopic orciopexy, Handa et al . [5] showed that closure of the internal ring is not necessary. Mobilization of undescended testes leaves a raw surface which coupled with the presence of the pulled through spermatic cord results in effective closure of the internal inguinal ring.

In this study we did not ligate the hernia sac during inguinal orchiopexy. After dissecting the hernia sac free from the cord, we simply gently peel off the proximal cut end of the hernia sac as high as possible. We have performed 50 cases of inguinal orchiopexy with this procedure and followed up for 1.5 to three years. We did not find any complication or untoward effect. So we conclude that ligation of hernia sac is not necessary in inguinal orhiopexy. We found a few other advantages also: Time saving: Several minutes of operating time are saved as we can avoid the holding of the proximal cut end of the hernial sac with multiple small haemostatic forceps and suture ligating it, especially when the sac is very thin and tends to tear very easily.

Length of testicular vessel: It is found that the most important criteria for bringing down the testes in the scrotum is the length of the testicular vessels; in our procedure extra length of the testicular vessel can be achieved by peeling off the peritoneum as high as possible. Accidental ligation of the cord structures is avoided.

Our experience suggests that routine ligation of the hernial sac is not mandatory. This reduces the operative time in all cases and eliminates the possibility of accidental ligation of cord structures.

 
   References Top

1.Mohta A, Jain N, Irniraya KP, Saluja SS, Sharma S, Gupta A. Non ligation of hernial sac during herniotomy: A prospective study. Pediatr Surg Int 2003;19:451-2.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Shulman AG, Amid PK, Lichtenstein IL. Ligation of hernial sac- A needless step in adult hernioplasty. Int Surg 1993;78:152-3.  Back to cited text no. 2  [PUBMED]  
3.Schier F. Laparoscopic inguinal hernia repair- A prospective personal series of 542 children. J Pediatr Surg 2006;41:1081-4.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Schier F. An open internal inguinal ring is not an inguinal hernia. Pediatr Surg Int 2007;23:825.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Handa R, Kale R, Harjai MM. Laparoscopic orchiopexy: Is closure of the internal ring necessary? J Postgrad Med 2005;51:266-8.  Back to cited text no. 5  [PUBMED]  Medknow Journal



This article has been cited by
1 Orchidopexy without ligation of the processus vaginalis is not associated with an increased risk of inguinal hernia
S. Ceccanti,A. Zani,E. Mele,D. A. Cozzi
Hernia. 2013;
[Pubmed] | [DOI]
2 One third of patients with a unilateral palpable undescended testis have a contralateral patent processus
Himanshu Aggarwal,Barry A. Kogan,Paul J. Feustel
Journal of Pediatric Surgery. 2012; 47(9): 1711
[Pubmed] | [DOI]
3 Risk of hernia occurrence where division of an indirect inguinal sac without ligation is undertaken
Blackburn, S.C. and Adams, S.D. and Mahomed, A.A.
Journal of Laparoendoscopic and Advanced Surgical Techniques. 2012; 22(7): 713-714
[Pubmed]
4 One third of patients with a unilateral palpable undescended testis have a contralateral patent processus
Aggarwal, H. and Kogan, B.A. and Feustel, P.J.
Journal of Pediatric Surgery. 2012; 47(9): 1711-1715
[Pubmed]
5 Risk of Hernia Occurrence Where Division of an Indirect Inguinal Sac Without Ligation Is Undertaken
Simon C. Blackburn,Stephen D. Adams,Anies A. Mahomed
Journal of Laparoendoscopic & Advanced Surgical Techniques. 2012; 22(7): 713
[Pubmed] | [DOI]
6 Orchidopexy san ligation technique of orchidopexy
Jain, V.K., Singh, S., Garge, S., Joshi, M., Sanghvi, J.
African Journal of Paediatric Surgery. 2011; 8(1): 112-114
[Pubmed]



 

Top
Print this article  Email this article
Previous article Next article

    

 
  Search
 
   Next article
   Previous article 
   Table of Contents
  
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (633 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    Introduction
    Materials and Me...
    Results
    Discussion
    References

 Article Access Statistics
    Viewed2831    
    Printed111    
    Emailed1    
    PDF Downloaded303    
    Comments [Add]    
    Cited by others 6    

Recommend this journal


Contact us | Sitemap | Advertise | What's New | Copyright and Disclaimer 

  2005 - Journal of Indian Association of Pediatric Surgeons | Published by Wolters Kluwer - Medknow 

Online since 1st May '05