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Incidental Inguinal Hernias on Laparoscopy
Original Article
Incidental Inguinal Hernias on Laparoscopy Rakesh Handa, Ravi Kale and Manmohan Harjai, Department of Paediatric Surgery, Army Hospital (Research & Referral), New Delhi, India.
OBJECTIVE: Laparoscopic examination of the contralateral inguinal ring has been advocated to exclude contralateral hernia in young children. We used the size of the open internal ring and the depth of the patent processus vaginalis as a parameter to decide whether laparoscopic herniotomy was indicated. METHODS: Records of all laparoscopic procedures in children performed in a large tertiary care hospital over a 2.5-year period were retrospectively analysed. RESULTS: Laparoscopy in 346 children revealed the presence of an incidental asymptomatic patent processus vaginalis in 47 cases. Of these, 38 were present as a contralateral hernia among 171 laparoscopies for inguinal hernias. CONCLUSION: The presence of an incidentally detected, asymptomatic but significant-sized open internal ring is not uncommon. The authors recommend that a 1-cm diameter and a 2-cm depth of open internal ring be taken as a significant indication for herniotomy. The authors also emphasize that a reported incidence of contralateral patent processus vaginalis of up to 56.2% justifies the procedure of laparoscopic herniotomy in all children. [Asian J Surg 2006;29(1):28–30] Key Words: contralateral patent processus vaginalis, incidental, inguinal hernia, laparoscopy
Introduction The presence of an asymptomatic patent processus vaginalis has always been an enigma that proponents of routine contralateral inguinal exploration have tried to unravel. The use of laparoscopy has made its detection easier. Observation of an open internal ring was routinely recorded in all laparoscopies performed and the size of the open internal ring and the depth of the patent processus vaginalis was used as a parameter to decide whether laparoscopic herniotomy was indicated. Laparoscopic detection of a contralateral patent processus vaginalis has very high sensitivity and specificity.1
November 2001 to May 2004 were retrospectively analysed. The presence of an asymptomatic patent processus vaginalis recorded during any laparoscopic procedure was noted. The dimensions of the open internal ring, both the diameter and depth, were recorded from markings made on the side of the laparoscopic needle holder. These markings were in the form of scratches on the metallic needle holder at every 0.5 cm, which permitted easy measurement of the diameter by holding the needle holder against the open internal ring and the depth by passing the needle holder into the inguinal canal.
Results Patients and methods Records of all laparoscopic procedures in children performed in a large tertiary care hospital over a 2.5-year period from
The total number of cases undergoing laparoscopy was 346, and an incidental asymptomatic patent processus vaginalis was observed in 47 cases. The age of the patients in this study
Address correspondence and reprint requests to Dr. Rakesh Handa, A-49 New Friends Colony, New Delhi-110065, India. E-mail: [email protected] • Date of acceptance: 22 June 2005 © 2006 Elsevier. All rights reserved.
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ASIAN JOURNAL OF SURGERY VOL 29 • NO 1 • JANUARY 2006
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■ INCIDENTAL INGUINAL HERNIA ■
was between 2 months and 12 years. An asymptomatic patent processus vaginalis was present in 38 of 171 laparoscopies for inguinal hernias, six of 128 laparoscopies for impalpable testes, one of 10 laparoscopic appendectomies and two of 37 laparoscopies for various procedures (Table 1). Of the 171 patients undergoing laparoscopic herniotomy, there were 12 girls and a male-to-female ratio of 12:1. An open internal ring of 1 cm or more in diameter and 2 cm or more in depth was treated using laparoscopic herniotomy in 41 cases. The remaining six cases, who were not subjected to laparoscopic herniotomy because they did not meet the above criteria, have not developed a clinically evident inguinal hernia on that side in a follow-up of 1 year. The demographics of the patients with a contralateral patent processus vaginalis are detailed in Table 2. The additional operative time required to perform laparoscopic herniotomy in those with an incidental contralateral inguinal hernia did not exceed 8 minutes.
Discussion The presence of an incidentally detected, asymptomatic but significant-sized open internal ring is not uncommon. Various authors have reported an incidence of 18–52.6% for contralateral inguinal hernias on laparoscopy,2–4 which sug-
gests the routine performance of laparoscopic herniotomy in children to avoid a second operation at a later date. In a meta-analysis of paediatric inguinal hernia, use of laparoscopy for detection of a contralateral patent processus vaginalis showed a sensitivity of 99.4% and a specificity of 99.5%.1 This effectively relegates the use of open contralateral exploration into the realms of history. This study also silences the critics of laparoscopic herniotomy, since it shows no significant increase in the operating time compared to an open herniotomy.1 In our study, an incidental patent processus vaginalis was seen in 13.6% of laparoscopies (47/346) for a variety of conditions including inguinal hernia, impalpable testis, acute appendicitis, recurrent painful abdomen, ambiguous genitalia and laparoscopy-assisted Hirschsprung’s pull-through. However, the incidence of an asymptomatic contralateral patent processus vaginalis was 22.2% (38/171) of herniotomies for symptomatic inguinal hernia. This incidence of a contralateral patent processus vaginalis is in consonance with numerous published studies.2–4 At laparoscopy, a patent processus vaginalis can be of various configurations. A small depression in the internal ring can appear as a patent processus vaginalis to the uninitiated. However, such internal rings do not require laparoscopic
Table 1. Incidence of patent inguinal ring Laparoscopic procedure Inguinal hernia Impalpable testis (unilateral) Appendicitis Recurrent pain abdomen Ambiguous genitalia Others*
n
Patent inguinal ring
Internal ring < 1 cm wide, < 2 cm deep No herniotomy
1710 1280 10 16 09 12
38 (contralateral) 06 (contralateral) 1 1 1 0
3 2 – 1 – –
*Blunt abdominal trauma, cholecystectomy, laparoscopic-assisted Hirschsprung’s pull-through.
Table 2. Demographics of patients with contralateral patent processus vaginalis Age (yr)
Patent internal ring + laparoscopic herniotomy
Patent internal ring < 1 cm wide, < 2 cm deep No herniotomy
<1 1–2 > 2–5 > 5–10 > 10
8 120 160 4 1
– – 3 2 1
ASIAN JOURNAL OF SURGERY VOL 29 • NO 1 • JANUARY 2006
070/2001
29
■ HANDA et al ■
herniotomy. No literature exists as to what dimensions of open internal ring require treatment. In our study, we used the criteria of 1 cm diameter and 2 cm depth for herniotomy. Six cases of the 47 with a patent processus vaginalis did not undergo surgery, as they did not match these criteria. These six patients were closely followed for 1 year and have not shown development of a clinical inguinal hernia on that side. We hypothesize that an open internal ring of less than 1 cm in diameter and 2 cm in depth does not require a formal herniotomy. We recommend that examination of the complete peritoneal cavity should be routinely performed in all laparoscopies in children. An open internal ring of 1 cm diameter and 2 cm depth is a significant indication for herniotomy. We are of the opinion that the presence of a 22% incidence of contralateral patent processus vaginalis in our series, and a reported inci-
30
dence of up to 52.6%,4 justifies laparoscopic herniotomy in all cases of inguinal hernia, as it is a simple, safe and quick procedure.
References 1. Miltenburg DM, Nuchtern JG, Jaksic T, et al. Laparoscopic evaluation of the pediatric inguinal hernia—a meta-analysis. J Pediatr Surg 1998;33:874–9. 2. Shah A, Gandhi H, Shah AV. Laparoscopic approach to treatment of congenital inguinal hernia in children (a study of 45 cases). J Indian Assoc Pediatr Surg 2002;7:59–63. 3. Geisler DP, Jegathesan S, Parmley MC, et al. Laparoscopic exploration for the clinically undetected hernia in infancy and childhood. Am J Surg 2001;182:693–6. 4. Wolf SA, Hopkins JW. Laparoscopic incidence of contralateral patent processus vaginalis in boys with clinical unilateral inguinal hernias. J Pediatr Surg 1994;29:1118–20.
ASIAN JOURNAL OF SURGERY VOL 29 • NO 1 • JANUARY 2006
070/20
Incidental Inguinal Hernias on Laparoscopy Rakesh Handa, Ravi Kale and Manmohan Harjai, Department of Paediatric Surgery, Army Hospital (Research & Referral), New Delhi, India.
OBJECTIVE: Laparoscopic examination of the contralateral inguinal ring has been advocated to exclude contralateral hernia in young children. We used the size of the open internal ring and the depth of the patent processus vaginalis as a parameter to decide whether laparoscopic herniotomy was indicated. METHODS: Records of all laparoscopic procedures in children performed in a large tertiary care hospital over a 2.5-year period were retrospectively analysed. RESULTS: Laparoscopy in 346 children revealed the presence of an incidental asymptomatic patent processus vaginalis in 47 cases. Of these, 38 were present as a contralateral hernia among 171 laparoscopies for inguinal hernias. CONCLUSION: The presence of an incidentally detected, asymptomatic but significant-sized open internal ring is not uncommon. The authors recommend that a 1-cm diameter and a 2-cm depth of open internal ring be taken as a significant indication for herniotomy. The authors also emphasize that a reported incidence of contralateral patent processus vaginalis of up to 56.2% justifies the procedure of laparoscopic herniotomy in all children. [Asian J Surg 2006;29(1):28–30] Key Words: contralateral patent processus vaginalis, incidental, inguinal hernia, laparoscopy
Introduction The presence of an asymptomatic patent processus vaginalis has always been an enigma that proponents of routine contralateral inguinal exploration have tried to unravel. The use of laparoscopy has made its detection easier. Observation of an open internal ring was routinely recorded in all laparoscopies performed and the size of the open internal ring and the depth of the patent processus vaginalis was used as a parameter to decide whether laparoscopic herniotomy was indicated. Laparoscopic detection of a contralateral patent processus vaginalis has very high sensitivity and specificity.1
November 2001 to May 2004 were retrospectively analysed. The presence of an asymptomatic patent processus vaginalis recorded during any laparoscopic procedure was noted. The dimensions of the open internal ring, both the diameter and depth, were recorded from markings made on the side of the laparoscopic needle holder. These markings were in the form of scratches on the metallic needle holder at every 0.5 cm, which permitted easy measurement of the diameter by holding the needle holder against the open internal ring and the depth by passing the needle holder into the inguinal canal.
Results Patients and methods Records of all laparoscopic procedures in children performed in a large tertiary care hospital over a 2.5-year period from
The total number of cases undergoing laparoscopy was 346, and an incidental asymptomatic patent processus vaginalis was observed in 47 cases. The age of the patients in this study
Address correspondence and reprint requests to Dr. Rakesh Handa, A-49 New Friends Colony, New Delhi-110065, India. E-mail: [email protected] • Date of acceptance: 22 June 2005 © 2006 Elsevier. All rights reserved.
28
ASIAN JOURNAL OF SURGERY VOL 29 • NO 1 • JANUARY 2006
070/2001
■ INCIDENTAL INGUINAL HERNIA ■
was between 2 months and 12 years. An asymptomatic patent processus vaginalis was present in 38 of 171 laparoscopies for inguinal hernias, six of 128 laparoscopies for impalpable testes, one of 10 laparoscopic appendectomies and two of 37 laparoscopies for various procedures (Table 1). Of the 171 patients undergoing laparoscopic herniotomy, there were 12 girls and a male-to-female ratio of 12:1. An open internal ring of 1 cm or more in diameter and 2 cm or more in depth was treated using laparoscopic herniotomy in 41 cases. The remaining six cases, who were not subjected to laparoscopic herniotomy because they did not meet the above criteria, have not developed a clinically evident inguinal hernia on that side in a follow-up of 1 year. The demographics of the patients with a contralateral patent processus vaginalis are detailed in Table 2. The additional operative time required to perform laparoscopic herniotomy in those with an incidental contralateral inguinal hernia did not exceed 8 minutes.
Discussion The presence of an incidentally detected, asymptomatic but significant-sized open internal ring is not uncommon. Various authors have reported an incidence of 18–52.6% for contralateral inguinal hernias on laparoscopy,2–4 which sug-
gests the routine performance of laparoscopic herniotomy in children to avoid a second operation at a later date. In a meta-analysis of paediatric inguinal hernia, use of laparoscopy for detection of a contralateral patent processus vaginalis showed a sensitivity of 99.4% and a specificity of 99.5%.1 This effectively relegates the use of open contralateral exploration into the realms of history. This study also silences the critics of laparoscopic herniotomy, since it shows no significant increase in the operating time compared to an open herniotomy.1 In our study, an incidental patent processus vaginalis was seen in 13.6% of laparoscopies (47/346) for a variety of conditions including inguinal hernia, impalpable testis, acute appendicitis, recurrent painful abdomen, ambiguous genitalia and laparoscopy-assisted Hirschsprung’s pull-through. However, the incidence of an asymptomatic contralateral patent processus vaginalis was 22.2% (38/171) of herniotomies for symptomatic inguinal hernia. This incidence of a contralateral patent processus vaginalis is in consonance with numerous published studies.2–4 At laparoscopy, a patent processus vaginalis can be of various configurations. A small depression in the internal ring can appear as a patent processus vaginalis to the uninitiated. However, such internal rings do not require laparoscopic
Table 1. Incidence of patent inguinal ring Laparoscopic procedure Inguinal hernia Impalpable testis (unilateral) Appendicitis Recurrent pain abdomen Ambiguous genitalia Others*
n
Patent inguinal ring
Internal ring < 1 cm wide, < 2 cm deep No herniotomy
1710 1280 10 16 09 12
38 (contralateral) 06 (contralateral) 1 1 1 0
3 2 – 1 – –
*Blunt abdominal trauma, cholecystectomy, laparoscopic-assisted Hirschsprung’s pull-through.
Table 2. Demographics of patients with contralateral patent processus vaginalis Age (yr)
Patent internal ring + laparoscopic herniotomy
Patent internal ring < 1 cm wide, < 2 cm deep No herniotomy
<1 1–2 > 2–5 > 5–10 > 10
8 120 160 4 1
– – 3 2 1
ASIAN JOURNAL OF SURGERY VOL 29 • NO 1 • JANUARY 2006
070/2001
29
■ HANDA et al ■
herniotomy. No literature exists as to what dimensions of open internal ring require treatment. In our study, we used the criteria of 1 cm diameter and 2 cm depth for herniotomy. Six cases of the 47 with a patent processus vaginalis did not undergo surgery, as they did not match these criteria. These six patients were closely followed for 1 year and have not shown development of a clinical inguinal hernia on that side. We hypothesize that an open internal ring of less than 1 cm in diameter and 2 cm in depth does not require a formal herniotomy. We recommend that examination of the complete peritoneal cavity should be routinely performed in all laparoscopies in children. An open internal ring of 1 cm diameter and 2 cm depth is a significant indication for herniotomy. We are of the opinion that the presence of a 22% incidence of contralateral patent processus vaginalis in our series, and a reported inci-
30
dence of up to 52.6%,4 justifies laparoscopic herniotomy in all cases of inguinal hernia, as it is a simple, safe and quick procedure.
References 1. Miltenburg DM, Nuchtern JG, Jaksic T, et al. Laparoscopic evaluation of the pediatric inguinal hernia—a meta-analysis. J Pediatr Surg 1998;33:874–9. 2. Shah A, Gandhi H, Shah AV. Laparoscopic approach to treatment of congenital inguinal hernia in children (a study of 45 cases). J Indian Assoc Pediatr Surg 2002;7:59–63. 3. Geisler DP, Jegathesan S, Parmley MC, et al. Laparoscopic exploration for the clinically undetected hernia in infancy and childhood. Am J Surg 2001;182:693–6. 4. Wolf SA, Hopkins JW. Laparoscopic incidence of contralateral patent processus vaginalis in boys with clinical unilateral inguinal hernias. J Pediatr Surg 1994;29:1118–20.
ASIAN JOURNAL OF SURGERY VOL 29 • NO 1 • JANUARY 2006
070/20