|Year : 2015 | Volume
| Issue : 4 | Page : 170-173
A new, simple operative approach for bilateral inguinal hernia repair in girls: A single transverse supra-pubic incision
Abdalla E Zarroug1, Antar M Alkhebel2, Waleed O Gibreel3, Mohammed Almassry2
1 Divisions of Pediatric Surgery, Mayo Clinic, Rochester, Minnesota, USA
2 European Gaza Hospital, Palestinian Territories, Gaza, Palestine
3 General Surgery, Mayo Clinic, Rochester, Minnesota, USA
|Date of Web Publication||2-Sep-2015|
Dr. Abdalla E Zarroug
Division of Pediatric Surgery, Mayo Clinic, 200 First Street South West, Rochester - 55905, Minnesota
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Inguinal hernia repair remains one of the most common operations performed by pediatric surgeons. We described a new surgical approach for treating bilateral inguinal hernias in girls through a small single transverse supra-pubic incision. Materials and Methods: A new approach was performed on female children 12-years-old and younger with bilateral inguinal hernias between January 2005 and April 2012. Technique: A single transverse suprapubic incision (1-1.5 cm) was made. Using sharp and blunt dissection bilateral hernias were exposed and repaired using a standard high ligation. Results: Ninety-nine girls with a preoperative clinical diagnosis of bilateral inguinal hernia were included. Median age was 2 years (range: 1 month to 12 years). All patients underwent general anesthesia. Median operative time was 12 minutes (range 5-22). There were no intra-operative complications or misdiagnosis. Two patients had bilateral sliding hernias and the remainder had indirect hernias. Post-operatively two patients developed non-expanding small hematomas, both treated non-operatively without sequelae. There were zero hernia recurrence and median follow-up was 5 years (range: 1-8 years) on 99% of patients. Conclusion: We described a new, safe, simple, and rapid approach for bilateral inguinal hernia repair in female pediatric population. A single transverse suprapubic skin incision was adequate for exposing both inguinal regions with excellent postoperative results.
Keywords: Bilateral, bilateral inguinal hernia, females, herniotomy, inguinal hernia, supra-pubic incision
|How to cite this article:|
Zarroug AE, Alkhebel AM, Gibreel WO, Almassry M. A new, simple operative approach for bilateral inguinal hernia repair in girls: A single transverse supra-pubic incision. J Indian Assoc Pediatr Surg 2015;20:170-3
|How to cite this URL:|
Zarroug AE, Alkhebel AM, Gibreel WO, Almassry M. A new, simple operative approach for bilateral inguinal hernia repair in girls: A single transverse supra-pubic incision. J Indian Assoc Pediatr Surg [serial online] 2015 [cited 2020 Feb 23];20:170-3. Available from: http://www.jiaps.com/text.asp?2015/20/4/170/154649
| Introduction|| |
Inguinal hernia repair remains one of the most common operations performed by pediatric surgeons. , The reported incidence of inguinal hernia in those younger than 18 years old varies from 0.8-4.4%. Males are more likely to have hernia with 3:1-10:1 ratio.  Approximately 6 % of females present with bilateral inguinal hernia. 
Although there is variability in the way pediatric surgeons perform some of the technical aspects of inguinal herniotomy, we know of no technique that describes a single suprapubic incision to repair bilateral inguinal hernia in girls. Current technical differences from Drs. Ladd and Gross' original description of pediatric hernia repairs likely result from evolving techniques, experiences, and analysis of outcomes that suite the local community, population, or surgeon. ,, The specific technique described in this manuscript was adopted to fill a need for its local community by local surgeons in Gaza, but is applicable to the wider pediatric surgical population. We are describing a new approach for bilateral inguinal hernia repair in female children through a small 1-1.5 cm transverse suprapubic midline incision.
| Materials and Methods|| |
Approval from the Administrative Review Board Committee (IRB equivalent) was obtained for this retrospective chart review. The new approach was performed on 99 consecutive female children aged 12 years or younger with bilateral inguinal hernias at a single institution at the European Gaza Hospital, Gaza, Palestinian Territories between January 2005 and April 2012. Informed consent was obtained from the parents after explaining the goals, benefits, risks, and alternatives for this approach. All patients had a pre-operative clinical diagnosis of bilateral inguinal hernia based on history and physical exam. No radiologic procedures were performed to diagnose any hernia. Any actively incarcerated or strangulated hernias were intentionally excluded from this new operative approach; however a history of incarceration or strangulation did not prevent using this approach. The one exception is an incarcerated ovary; this did not prevent using this approach. Sliding hernias also did not prevent using this approach.
Description of the approach/technique
After general anesthesia, in a supine position, a 1-1.5 cm midline transverse suprapubic skin incision is made along the skin crease [Figure 1]. Incision is carried down through the dermis to expose the subcutaneous fat, Camper's fascia. Using sharp and blunt dissection, Scarpa's fascia is identified, grasped and incised in the direction of the targeted hernia (right or left). Gentle retraction is needed laterally to maintain excellent exposure. The sac is exposed and elevated off the inguinal floor [Figure 2] and [Figure 3]. From this point onwards, the steps of standard hernia repair with a high ligation are followed according to the surgeons' technique. The external inguinal ring was not opened in any of the patients. After finishing the repair of one side, the same steps are repeated on the contralateral side through the same skin incision. This new modification changes the skin incision, exposure and approach and does not alter the technical aspects of the high ligation. Subcutaneous tissue and skin are subsequently closed [Figure 4]. Since electricity was intermittently available, no electrocautery was used, as a matter of preference. Also, we neither dissected the round ligament from the sac, nor did we tack the round ligament to any structures.
|Figure 2: Shows the exposure of the round ligament and right hernia sac. The sac is subsequently separated from the round ligament and ligated using a high ligation approach|
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|Figure 3: Shows the exposure of the round ligament and left hernia sac. The sac is subsequently separated from the round ligament and ligated using a high ligation approach|
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|Figure 4: Shows the midline incision closure at the completion of the procedure|
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| Results|| |
Ninety-nine girls with a pre-operative clinical diagnosis of bilateral inguinal hernia were included. Median age was 2 years (range: 1 month-12 years). All patients underwent general anesthesia (95% by hand-bag mask ventilation, 5% with laryngeal mask). Median operative time was 12 minutes (range 5-22). There were no intra-operative complications or misdiagnosis. One patient had an incarcerated, but viable ovary. Two patients had bilateral sliding hernias and the remainder had indirect hernias. One surgeon (MA) was scrubbed for every procedure as surgeon, first assistant, or teaching surgeon. Post-operatively 2 patients developed non-expanding small hematomas, both treated non-operatively without sequelae or intervention. There were zero hernia recurrence and on follow-up was achieved in 99% of patients. Median follow up was 5 years (range: 1-8 years).
| Discussion|| |
The idea of exposing the bilateral inguinal hernia through a single small midline incision, to our knowledge, has not been described previously in pediatric surgical literature. We report 99 girls age 12 or younger that have undergone this approach with no recurrences, few complications and a reliable, excellent median follow-up of 5 years. We believe infant hernia repairs are particularly suited to this approach because the anatomy of the inguinal canal passes through a series of changes from infancy to adulthood that favors a single midline incision. In infants the internal and external inguinal rings almost overlap, therefore if the retractor exposes the external ring, it is easy to expose the internal ring by retracting a few millimeters more. As children grow, the internal inguinal ring becomes more lateral in position compared to the external ring. Thus, the midline transverse incision can easily be used to expose both superficial and deep inguinal rings in younger patients. Furthermore, exposing both inguinal canals through a transverse midline incision allows for simultaneous correction of the bilateral hernia through one incision. Although not the only reason, this approach was initially considered as a mean of shortening the anesthetic time. When considering operating room scheduling, time is of the essence in Gaza as trauma often can disrupt an elective schedule. Thereafter, the cosmetic result was considered superior to standard bilateral standard incisions, although we did not tabulate data to test this latter hypothesis.
We intentionally performed this technique on girls and not boys because the technical repair in girls is much easier than male inguinal hernia repair where the vas deferens and testicular vessels need to be spared, whereas there is no need to save the round ligament in girls. Another selection we made was to limit this approach to bilateral hernias; there is probably no advantage to this approach in older children with unilateral hernias. Having stated that, from our experience, it would not be difficult to repair a unilateral hernia using a midline suprapubic transverse incision approach with a laparoscopic contralateral exploration as described by Bhatia et al.,  and thereafter repair the contralateral side through the same incision if needed. However, this approach probably makes sense for younger children such as infants (2-years-old or younger) where there is relatively high risk of a contralateral patent processus vaginalis. We did not perform any unilateral hernia (with a contralateral laparoscopic groin exploration) through our approach since there were no 3-5mm laparoscopic scopes in Gaza at the time of this manuscript. Therefore we recommend this approach to be used in female patients with a confirmed clinical diagnosis of bilateral inguinal hernia. Although an argument can be made that a laparoscopic approach could achieve superior cosmetic results through several 2-3 cm incisions, it can also be argued that remaining outside the peritoneum is the ideal method of hernia repair. Furthermore, even in 2014 most pediatric surgeons across the world has neither developed the skill to perform a laparoscopic hernia repair nor do they have the mini-laparoscopic equipment to perform laparoscopic inguinal hernia repairs.
As children grow, the internal ring becomes more lateral in position compared to the external ring. This anatomic relationship should be considered when repairing the hernia in older children. In this situation, more lateral retraction or making a bigger incision may be needed based on individual surgeon's preference. In our series, a 1.5 cm provided an excellent exposure that allowed adequate hernia repair in children 12 years and younger.
Our follow-up of 5 years compares very favorably to other reports who have published new techniques for inguinal hernia repairs, in particular the laparoscopic approaches.  We believe our follow up is excellent for two reasons. First, Gaza has strict travel restrictions in place since 2005 (beginning of this study) and most patients therefore literally have little option to go elsewhere. Second, there is a single payer system in Gaza and patients are referred back to the initial surgeon if a complication occurs as a matter of practice patterns, therefore all but one patient had excellent follow-up.
This is a retrospective paper with its inherit bias. Clearly there is a selection bias, as this was a retrospective study that selected excellent candidates. However, our paper adds to the literature a small, but significant technical modification that reduces two small incisions to one small incision in well-selected patients, which should reduce surgical time. Although a Pfannenstiel incision has been described as a single case, they entered the peritoneum and had an entirely different approach.  Ideally, the next step is to perform a randomized controlled study comparing our approach to the standard bilateral incision to determine any differences.
| Conclusion|| |
We describe a new, safe, simple, and rapid approach for bilateral inguinal hernia in female pediatric population. A midline suprapubic transverse skin incision was adequate for exposing both inguinal regions with excellent postoperative results. Median patient follow-up of 5 years was excellent and reliable.
| References|| |
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Levitt MA, Ferraraccio D, Arbesman MC, Brisseau GF, Caty MG, Glick PL. Variability of inguinal hernia surgical technique: A survey of North American pediatric surgeons. J Pediatric Surg 2002;37:745-51.
Ladd WE, Gross RE. Abdominal Surgery of Infancy and Childhood, Philadelphia, W. B. Saunders Company, 1941.
Bhatia AM, Gow KW, Heiss KF, Barr G, Wulkan ML. Is the use of laparoscopy to determine presence of contralateral patent processus vaginalis justified in children greater than 2 years of age? J Pediatr Surg 2004;39:778-81.
Garcia-Hernandez C, Carvajal-Figueroa L, Suarez-Gutierrez R, Landa-Juarez S. Laparoscopic approach for inguinal hernia in children: Resection without suture. J Pediatr Surg 2012;47:2093-5.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]