Modified Marcy repair of large indirect inguinal hernia in infants and children

Definition of giant inguinoscrotal hernias in infants and evaluation of reliable surgical approach in a single-center study

Objective

Inguinal hernia surgery is the most common surgery performed by pediatric surgeons. Giant inguinoscrotal hernia has not been clearly defined yet. The definition of giant inguinoscrotal hernia and the reliability of the surgical procedure were investigated in this study.

Materials and methods

Sixtyfour of totally 1548 male patients who have been operated with inguinal hernia from May 2015 to January 2018 were included in the study considering the diagnosis of giant inguinoscrotal hernia. The criteria for the diagnosis of giant inguinoscrotal hernia were determined as, observing that the hernia sac was filled with intestinal loops from the inguinal region to the scrotum during the physical examination, herniation of the intestines to the scrotum again as soon as the hernia was reduced and 2 cm and above inner ring diameter. High ligation and hernioplasty to 29 (45.3%) patients and hernioplasty using Zig maneuver to 35 (54.6%) patients were performed during the study.

Results

Postoperative wound infection was observed in 2 patients (6.8%) with high ligation and 1 (2.8%) patient with hernioplasty with Zig maneuver. Scrotal edema was detected in all the patients, which persisted until postoperative month 1. Recurrence was seen in 6 (20.6%) of 29 patients who operated using the high ligation method while it was seen in 2 (5.7%) of other 35 patients. None of the patients had testicular atrophy and/or iatrogenic undescended testis.

Conclusion

Giant inguinoscrotal hernias should be defined and evaluated as a group apart from classical inguinoscrotal hernias. Recurrence and morbidity rates were lower in patients who underwent hernioplasty using Zig maneuver.

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The definition of giant inguinoscrotal hernia and the reliability of the surgical procedure were investigated clearly in this study.

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Giant inguinoscrotal hernias should be defined and evaluated as a group apart from classical inguinoscrotal hernias.

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Giant inguinal hernias are rare in children and the treatment require surgical experience.

A simplified technique for giant inguinal hernia repair in infants

Repair of giant inguino-scrotal hernia (GISH) in male infants is a difficult operation, even in experienced hands. It requires an immaculate technique to avoid known complications such as tearing of the sac, injury to delicate testicular vessels and dividing of vas deferens. Moreover, a recurrence rate of 9% is noted in a number of reports. This article describes a new surgical maneuver to simplify the procedure. All GISH repaired by the author, over a 5-year period (October 2001-September 2006), were reviewed retrospectively. In total, 89 infants with 106 GISH underwent uni- or bilateral herniotomies. A standard inguinal incision is made and Scarpa's fascia is sharply opened; the external inguinal ring and the cord is identified. By gentle manipulation and blunt dissection, the spermatic cord together with the testis is exteriorized. The assistant applies gentle traction to the cord, which allows for easy identification of the inguinal sac and its subsequent separation from vas and vessels. Testis is replaced in the scrotum, hernial sac suture ligated at its base and the wound closed in layers. All cases were managed with the above approach. The average length of the procedure was 11 min for unilateral and 19 min for bilateral cases. Except for minimal scrotal swelling post-operatively, no other surgery-related complications were noted during or immediately after the operation. Testicular atrophy or iatrogenic undescended testes were not encountered in the follow-up period. Ipsilateral recurrent hernia was noted in one infant after 6 months which required re-operation with the same technique. In cases of GISH; dislocating the testis into the wound and applying a gentle stretch on the cord allows for a safe dissection of the hernial sac and subsequent herniotomy. This maneuver converts a difficult procedure into a relatively simple one.

Large Inguinal Hernia in Infants: Is Laparoscopic Repair The Answer?

PURPOSE

Infants with large hernias present a challenge to the pediatric surgeon. We present our experience of laparoscopic repair of large hernias in 16 infants, the youngest aged 40 days. Fifteen of the infants were younger than 18 months and one was < or = 2 years old.

MATERIALS AND METHODS

Sixteen male infants with large inguinal hernias (hernia extending to the bottom of the scrotum and the diameter of the open internal ring > 2 cm on laparoscopy) underwent laparoscopic hernia repair. Diagnostic laparoscopy was performed under general anesthesia with a telescopic port at the umbilicus. If the internal ring was open, two working ports were introduced pararectally on either side. An open internal ring was considered an indication for hernia repair. The needle, carrying 3-0 nylon nonabsorbable sutures, was introduced through the groin skin at the internal inguinal ring and the internal ring was closed by taking continuous sutures to approximate the edges of the ring. The needle was then taken out through the entry point and the knot was tied extracorporeally and buried in the subcutaneous tissue. In 4 patients in the initial part of the study, intracorporeal (knot tied internally) suturing was done to close the internal ring. A contralateral repair was done if the internal ring was open.

RESULTS

A total of 18 repairs were performed in 16 patients: 10 had a right sided hernia, 4 had a left sided hernia, and 2 had an open contralateral ring (suggestive of contralateral patent processus vaginalis). The contents of the hernia were bowel (1 patient), omentum (3 patients), and bowel adhesions at the internal ring (1 patient). There was 1 conversion. The mean operative time was 23 minutes for unilateral repair and 29 minutes for bilateral repair. The mean follow-up was 19 months (range, 3 months to 3 years). There are no recurrences to date. There was no morbidity or mortality.

CONCLUSION

Laparoscopy is safe and feasible for repair of large inguinal hernias in infants 2 years and provides treatment of contralateral patent processus vaginalis in the same setting with no significant increase in operating time. Extracorporeal knot tying has made the procedure feasible in the limited working space available in these babies. Though there were no recurrences or post-operative hydrocele, the number of patients in the study is too small to comment on rates of recurrence or hydrocele.

The Marcy Repair Modified Using Cremaster Muscle Sparing. A New and Effective Method for Performing Prosthetic Hernioplasty

PURPOSE

The integrity of the internal inguinal ring (IIR) is essential to prevent the occurrence of indirect noncongenital inguinal hernia. Marcy first considered the importance of the IIR and proposed the use of annuloplasty to repair indirect primitive hernias. His procedure involved the resection of the cremaster muscle. We modified Marcy's annuloplasty by sparing the cremaster muscle and herein review our experience.

METHODS

We retrospectively reviewed a group of 213 male adult patients who were treated with annuloplasty of IIR for sliding or large indirect hernias, which was performed under local anesthesia as day cases. The median follow-up was 4.7 years (range 2-7 years).

RESULTS

There were no complications due to annuloplasty and the overall recurrence rate at follow-up was zero.

CONCLUSION

In our hernioplasty we prefer an anterior approach to avoid contamination with prosthetic materials of the zone under the transversalis fascia. The transversalis fascia remains an important anatomical barrier and the cremaster a natural diaphragm between the mesh and funicular structures. We believe that annuloplasty is effective in all types of hernias where a sliding or large indirect hernia is observed.

Surgical treatment of inguinal herniae in children

The aim of this paper was to assess if there is a standard technique for the repair of inguinal herniae in children and to establish if the inguinal canal should be routinely opened during this procedure in different age groups. A postal survey was conducted by sending questionnaires to 264 consultant surgeons who were surgical tutors or advisors to the Royal College of Surgeons of England. Information was sought using a multiple-choice tick-box questionnaire. The surgical techniques of surgeons working in specialist units were compared with those working in general units, and comparisons were also drawn between surgeons performing more operations than those doing only a few and also if the technique varied with the age of the patient. The response rate was 69%. Only 23% working in specialist units and 8% from general units performed more than 30 herniotomies per year. Overall, 15% of surgeons always performed the operation through the inguinal canal, 56% performed it superficial to the external ring, and 29% tended to do both. In children under the age of 2 years, most surgeons performed the operation superficial to the external ring, although a higher proportion of surgeons at specialist units opened the inguinal canal routinely. In the older age groups, the tendency to open the inguinal canal and/or divide the external ring was greater. However, surgeons at specialist paediatric units and those performing more than 30 herniotomies in a year were more likely to open the inguinal canal without dividing the external ring in all age groups. There was quite obviously no standard surgical technique for inguinal herniotomy in children in this survey, and there are only trends.