Inguinal Herniorrhaphy in Infants and Children

Inguinal Herniorrhaphy in Infants and Children C. EVERETT ROOP, M.D., Se.D. (MED.), F.A.C.S.*

PRELIMINARY CONSIDERATIONS

Objectives in Technique

THE technique of any operation should be planned to give the best longterm result but, when possible, such planning should also include attention to special problems attendant upon the lesion, the age and activity of the patient, as well as the cosmetic result. The technique which we use for the repair of the most common of all pediatric surgical lesions, an indirect inguinal hernia, is predicated on a clear understanding of the peculiarities of the lesion and the patient. Inguinal hernias in children are congenital defects in which spontaneous cure is not to be expected and where no alteration in strength or attenuation of surrounding muscles or ligaments need be considered in the choice of herniorrhaphy. Recurrences following herniorrhaphy in infants and children are indicative of failure to ligate the hernial sac completely and have nothing to do with variations in reconstruction of the inguinal canal. Therefore, the only objective in herniorrhaphy in infants and children is high ligation of the hernial sac. Other variations in technique are not necessarily differences in approach. Because of a number of factors, 'including cross infection in the hospital and the natural attachment of mothers for their children and vice versa, a baby is no place as safe as he is at home with his mother. Therefore, another objective becomes a technique which permits early discharge from the hospital; the sooner the better. Children dislike the removal of sutures more than almost anything connected with hospitalization and operation. Therefore, a technique which does not require removal of sutures is preferable. From the Surgical Clinic of The Children's Hospital of Philadelphia and the Harrison Department of Surgical Research, Schools of Medicine, University of Pennsylvania, Philadelphia.

* Surgeon-in-Chief, The Children's Hospital of Philadelphia; Associate Profes80r of Pediatric Surgery, School of Medicine and Graduate School of Medicine, University of Pennsylvania.

1675

1676

C. Everett Koop

Since it is impossible to keep infants dry and children inactive, techniques which require no dressing or restraint in the hospital and no limitation of activity at home are desirable. Finally, the effect of surgery on the parents of the patient may be softened by a cosmetically acceptable wound which leaves a minimal scar, as well as by a short hospitalization with no convalescent period at home. Hernias and Hydroceles

The common hydrocele in a child is a collection of ascitic fluid in the most dependent portion of the tunica vaginalis testis, visible as a swelling in the scrotum. Occasionally, the trapped fluid is above the scrotum, in which case the lesion is called a hydrocele of the cord rather than of the tunica vaginalis testis. Such hydroceles may be physiologic until the age of four months, but the presence of fluid about the testis after that age is indicative of a patent tunica vaginalis, connecting the scrotal cavity with the peritoneal cavity, or an indirect inguinal hernia. Therefore, a hydrocele after the age of four months denotes the presence of a concomitant indirect inguinal hernia. Hydroceles may indicate the presence of a hernia before the age of four months if they (1) are unusually large (especially if disproportionate in size to the contralateral side), (2) increase in size, (3) fluctuate in size. The latter sign must be a true one and not confused with a contraction and expansion of the scrotal skin which appears to alter the size of the contents of the scrotum. Diagnosis of Hernia

Hernias in children are not easily detected by the adult technique of examination which inverts the scrotal skin while attempting to palpate the internal inguinal ring. The size of the internal inguinal ring has little or nothing to do with the presence of a hernia in childhood. The diagnosis of a hernia in the pediatric age group is best made by rolling the cord beneath the palpating finger placed parallel to the cord's long axis. When the slippery peritoneal surface of the lining of the sac rubs on itself a sensation of silk rubbing on silk is diagnostic. Age of Election for Operation

Inasmuch as the hernia under discussion is congenital in origin, does not disappear spontaneously, and is a source of possible difficulty should abdominal viscera become incarcerated or strangulated therein, it should be repaired at any time it is diagnosed. Such a plan demands anesthesia as safe for the infant as for the older child, a technique free of recurrences of the hernia or damage to the blood supply of the testicle, and a staff of nurses and physicians able to meet the postoperative demands of the patient. It should be stated that the treatment of an infant's hernia at an

Inguinal Herniorrhaphy in Infants and Children

1677

elective time has many advantages over the emergency management of an incarcerated hernia. With incarceration of viscera in infantile hernias, not only is the anatomy of the hernial sac and adjacent cord not clear because of the peculiar edema associated with incarceration, but the youngster who has been vomiting and not taking fluids is a poor risk for anesthesia. Preoperative Preparation

Discussion of the technique of any pediatric surgical procedure would not be complete without mention of the preanesthetic medication and psychologic preparation of the patient. Atropine or scopolamine in proper dosage should be used to dry secretions even in the very young. Morphine is helpful in slowing the respiratory rate and should be used in appropriate doses to achieve this effect without depressing the patient. In older children, when sedation is helpful, one of the barbiturates such as pentobarbital should be used. Youngsters old enough to understand should be told of the coming hospitalization and surgery a short time before admission and should be thoroughly appraised of all to expect. OPERATIVE TECHNIQUE

An incision is made lU inches long in a natural skin fold some place between the anterior superior iliac spine and the pubic tubercle. There is usually at least one of these about midway between the two points mentioned. The incision should be laterally placed. If the skin is spread between the index and the third fingers of the left hand and the incision made from each end toward the center with all layers cut to the same extent, there will be no limitation of dissection through the small wound. Bleeding vessels are frequently not present and seldom exceed two. After obtaining hemostasis and exposing the shiny external oblique aponeurosis, a slit is made in that structure (Fig. 480, A) and it is then extended, with scissors, in line with its fibers both upward and downward but not more than needed to expose the cord and not through the external ring. The lateral flap of the external oblique aponeurosis grasped in a hemostat is wiped clean on its undersurface to expose Poupart's ligament but not necessarily its shelving edge (Fig. 480, B). In a large hernia the bulge may already be visible; in a smaller one, the sac may be hidden in the cord. In either instance, the cremaster muscle fibers cover the cord and must be separated. A hemostat is inserted between bundles of the cremaster fibers and spread to expose the cord (Fig. 480, C). The sac lies anteriorly and medially and can usually be grasped directly and elevated into the wound. The jaws of the hemostat should not be closed unless the sac

1678

c. Everett Koop

Fig. 480. Operative technique. A, A slit is made in the external oblique aponeurosis, after which it is extended, with scissors, in line with its fibers both upward and downward. B, The lateral flap of the external oblique aponeurosis is grasped in a hemostat and is wiped clean on its undersurface to expose Poup;trt's ligament. C, A hemostat is inserted between bundles of the cremaster fibers and spread to expose the cord. D, When the hernial sac is seen, its most anterior point is grasped with a hemostat and the third finger of the left hand placed behind the cord. The cord structures are then separated from the sac. E, The sac is now clamped and divided and, F, doubly ligated with a nonabsorbahle suture. (See Fig. 481 for continuation.)

Inguinal Herniorrhaphy in Infants and Children

1679

Fig. 481. Operative technique (continued). A, The ligated sac is now tacked beneath the internal oblique muscle. The remainder of the sac is removed and an abbreviated herniorrhaphy is performed. B, The first line of sutures approximates the medial flap of the external oblique aponeurosis to the underside of the lateral flap of the same aponeurosis without tension. A few of the conjoined muscle fibers are picked up in the same suture. Usually 4 sutures in this layer suffice. C, The lateral flap of the external oblique aponeurosis is now sutured to the anterior surface of the medial flap of the same structure by imbrication. Three or 4 sutures are usually sufficient. D, The skin edges are approximated with 4 interrupted sutures of 5--0 white silk placed subcuticularly, the stitches being taken in the actual corium in older children or in the adjacent fat of the young infant. E, Two knots only are tied in each stitch and the excess suture cut off at the knot below the skin edge. The edges are then approximated with the fingers and made to stand up slightly. F, A liquid collodion dressing is applied. (For additional details, see text.)

1680

c. Everett Koop

is identified for fear of injuring the vas deferens or blood vessels in the cord. If the sac is not identified, a curved hemostat may be inserted beneath the cord and that structure elevated into the wound. When the sac is seen, its most anterior point is grasped with a hemostat and the third finger of the left hand placed behind the cord (Fig. 480, D). The cord structures are then separated from the sac at this one point of circumference of the cord by never actually pinching the cord structures with forceps, rather using the latter instrument to pick and tease the vessels and vas deferens from the sac. As soon as the sac is clear of the cord structures, it is doubly clamped and divided (Fig. 480, E). Dissection is then carried toward the internal ring using the same principle of never pinching the cord structures. When the ring is reached, we believe twisting the sac makes it stronger and prevents proximal rents when a needle passes through the sac. It also pushes sac contents back into the peritoneal cavity. If one watches the twisting, the cord structures will not become snared in the process. The sac is then doubly ligated (Fig. 480, F) with a nonabsorbable suture and the ligated sac tacked beneath the internal oblique muscle (Fig. 481, A). This is done because some of the sacs are so flimsy that we feel safer with the abdominal wall instead of the ligated end of the sac taking up the force of intra-abdominal pressure. The hernia is now cured and the remainder of the operation could consist of skin closure alone without fear of recurrence of the hernia. The fluid in the hydrocele, if present, will slowly be absorbed. However, we prefer to remove the remainder of the sac and to do an abbreviated herniorrhaphy. Attention is then turned to the lower part of the sac and it is dissected as was the upper portion. If the hydrocele will not come up to the internal ring, the fluid is let out by taking off the hemostat or by puncturing the sac under direct vision as the hydrocele is pushed from the scrotal side toward the external ring. If and when the dissection of the sac gets close to the blood supply intimately adherent to the cord, the sac is cut away from it and the remainder is left attached to the cord. The bottle operation in which the hydrocele sac is everted arid is sewn to itself ill carried out only in large hydroceles with unusually heavy walls. The cord is buried in our repair and the first line of sutures approximates the medial flap of the external oblique aponeurosis to the underside (not the shelving edge of Poupart's ligament) of the lateral flap of the same aponeurosis without tension. In so doing a few of the conjoined muscle fibers (there is usually no tendon in children) are picked up in the same suture (Fig. 481, B). Usually four sutures in this layer suffice. The lateral flap of the external oblique aponeurosis is then sutured to the anterior surface of the medial flap of the same structure by imbrication (Fig. 481, C). Three or four sutures are sufficient to do this. The subcutaneous fascia is then approximated and the skin is ready for clo-

.1

Inguinal Herniorrhaphy in Infants and Children

1681

sure. This last step is important because it has to do with early activity, trauma to the wound, and cosmetic appearance as well. The skin edges are approximated with four interrupted sutures of 5-0 white silk placed subcuticularly. These stitches must be placed the same distance from the end of the wound on each side as well as the same distance back from the edge of the wound. The stitch should be taken in the actual corium (Fig. 481, D) in older children or in the adjacent fat of the young infant whose skin is usually very thin. Two knots only are tied in each .stitch and the excess suture cut off at the knot below the skin edge (Fig.481, E). The edges are then approximated with the fingers and made to stand up slightly before applying a liquid collodion dressing (Fig. 418, F). It is preferable that the collodion be quite liquid and that it be evaporated rapidly by fanning so that the surface does not dry, leaving ether beneath the film to blister the skin. The child is returned to his bed without restraint, fed ad lib, and discharged on full activity the morning after operation. INGUINAL HERNIAS IN FEMALES

In female pediatric patients, inguinal hernias are usually sliding hernias with the mesosalpinx being adherent to one wall of the sac. The viscus contained in the sac is frequently fallopian tube and/or ovary. Repair of this congenital defect is undertaken as described previously for the male except that one need not protect the cord structures and the round ligament may be grasped, twisted and ligated with the proximal sac. It is important not to ligate the sac high enough to damage the fallopian tube or its blood supply. Ligation and fixation are carried out as described above. COMMENT

The repair of the hernia associated with an undescended testicle is similar but some variation in technique makes the handling of these specially delicate sacs somewhat easier.! Bilateral hernias in children are common; much more so when the left side is the side of complaint because it is the left tunica vaginalis testis which closes first in utero. The presence of a hernia on the contralateral side should always be looked for. If found, bilateral herniorrhaphy may be carried out without fear of jeopardizing the repair of one side by doing the other. The technique presented here is not a new one. It, or variations of it, have been used for years by surgeons dealing frequently with the surgical problems of children. In our own hands, for more than a decade, it has served well in the management of about 6000 lesions. We have used the same technique in children of any age up to 14 years, altering it only for the extremely rare child who has a defect in Hesselbach's triangle and a

c.

1682

Everett Koop

direct hernia in conjunction with this indirect hernia. In these infants, an adult type of Ferguson herniorrhaphy is carried out. REFERENCE Koop, C. E. and Minor, C. L.: Observations on Undescended Testes. II. The Technique of Surgical Management. Arch. Surg. To be published. 1740 Bainbridge Street Philadelphia 46, Pennsylvania