Inguinal hernia repair in children: Surgical technique

Inguinal hernia repair in children: Surgical technique

+Model ARTICLE IN PRESS JVS-557; No. of Pages 5 Journal of Visceral Surgery (2016) xxx, xxx—xxx Available online at ScienceDirect www.sciencedire...

2MB Sizes 1 Downloads 224 Views

+Model

ARTICLE IN PRESS

JVS-557; No. of Pages 5

Journal of Visceral Surgery (2016) xxx, xxx—xxx

Available online at

ScienceDirect www.sciencedirect.com

SURGICAL TECHNIQUE

Inguinal hernia repair in children: Surgical technique F. Le Roux a,∗, A. Lipsker b, S. Mesureur c, E. Haraux c a

Service de chirurgie digestive et métabolique, CHU d’Amiens, université Picardie Jules-Verne, 80000 Amiens, France b Service de chirurgie urologique et transplantation, CHU d’Amiens, université Picardie Jules-Verne, 80000 Amiens, France c Service de chirurgie infantile, CHU d’Amiens, université Picardie Jules-Verne, 80000 Amiens, France

Introduction Inguinal hernia in children, occurring more often in boys, is the result of imperfect closure of the processus vaginalis (PV), whose incidence is increased by premature birth and/or low birth weight [1]. In the male, incomplete closure of the PV results in hydrocele, whereas complete funicular closure leads to cysts of the spermatic cord. Neither cysts nor hydroceles require operation before the age of 2 [2]. In the female, inguinal hernia is defined as failure of closure of Nuck’s canal that runs in parallel with the round ligament. Before one year of age, the ovary usually occupies the hernia sac, and it is important to avoid any ovarian trauma. After one year, the hernia sac can also contain herniated intestine, just as for boys. Inguinal hernia in children, just like adult hernia, can result in strangulation. Therefore, noncomplicated inguinal hernia should undergo elective surgical repair, whereas incarceration calls for an emergency procedure. We describe a right-sided inguinal hernia repair first in males, then in females of pediatric age.



Corresponding author. E-mail address: [email protected] (F. Le Roux).

http://dx.doi.org/10.1016/j.jviscsurg.2015.12.006 1878-7886/© 2016 Published by Elsevier Masson SAS.

Please cite this article in press as: Le Roux F, et al. Inguinal hernia repair in children: Surgical technique. Journal of Visceral Surgery (2016), http://dx.doi.org/10.1016/j.jviscsurg.2015.12.006

+Model JVS-557; No. of Pages 5

ARTICLE IN PRESS

2

F. Le Roux et al.

Positioning of patient and surgical 1 approach

The operation can be performed under general anesthesia or caudal block with associated local anesthesia. The child is positioned supine. A 2 cm incision is made along the lower abdominal skin crease, just in front of the external inguinal ring, 1 cm lateral to the pubic spine.

2

Dissection of the hernia sac

3

Identification of the spermatic cord

The underlying fatty tissue is dissected with electrocautery down to the superficial fascia, which is then opened with scissors. Small Farabeuf type retractors expose the external inguinal ring where the hernia sac protrudes. Exposure of the sac can be facilitated by splitting the muscular fibers of the external oblique abdominal muscle, thus widening the orifice of the external ring. Caution should be exercised to avoid injury to the genital branch of the genitofemoral nerve. Christophe forceps are used to peel off the sac bordering the internal aspect of the inguinal ligament under the superficial inguinal ring and the superior aspect of the conjoined tendon. This should be done just below the level of the external ring, because should the sac be opened inadvertently, it is easier to restart the dissection just above.

As the hernia sac is dissected free, the elements of the spermatic cord appear. Once it has been sufficiently separated from the sac, the spermatic cord is encircled either by a vascular tape or held by an atraumatic grasper.

Please cite this article in press as: Le Roux F, et al. Inguinal hernia repair in children: Surgical technique. Journal of Visceral Surgery (2016), http://dx.doi.org/10.1016/j.jviscsurg.2015.12.006

+Model JVS-557; No. of Pages 5

ARTICLE IN PRESS

Inguinal hernia repair in children: Surgical technique

Dissection of the elements of the 4 spermatic cord and sac

Dissection of the sac is continued, freeing it from the cord. Caution should be exercised during this dissection to avoid injury to any of the elements of the cord or opening of the sac. Along the superior aspect of the cord, the cremasteric fibers that envelope the sac can be split along their longitudinal axis, helping to expose the sac, so that it can be grasped with dissection forceps. Electrocautery should not be used during this step in order to avoid any thermal injury to the elements of the spermatic cord. The lateral aspect of the sac is held on slight traction allowing to expose and sweep the elements downwards with another dissection forceps.

Please cite this article in press as: Le Roux F, et al. Inguinal hernia repair in children: Surgical technique. Journal of Visceral Surgery (2016), http://dx.doi.org/10.1016/j.jviscsurg.2015.12.006

3

+Model JVS-557; No. of Pages 5

ARTICLE IN PRESS

4

F. Le Roux et al.

5

Closure of the processus vaginalis

6

Abdominal wall closure

Caution must be exercised during this step in order to avoid injury to any of the elements of the spermatic cord. Once the sac is isolated, it can be clamped with a hemostat after checking that it does not contain any intestinal element. An absorbable constrictor knot is placed at the neck of the sac, close to the internal ring, in order to prevent recurrence. We use a slowly absorbable 4.0 monofilament, the same we use to close the abdominal wall layers later on. The hernia sac can then be divided distal to the knot. The distal part is left open. The opening can be widened in case of associated hydrocele, taking care to avoid any injury to the spermatic cord.

If the external ring was opened during incision of the external oblique fascia, it should be closed with a running absorbable suture, once again taking care to avoid injury to the genital branch of the genitofemoral nerve and the spermatic cord. The superficial fascia is closed with interrupted sutures using the same material. Lastly, the skin is closed with an intradermal absorbable 5.0 suture. The wound can be dressed with a dry dressing or impermeable film. At the end of the procedure, it is important to check the position of the testicle within the scrotum.

Please cite this article in press as: Le Roux F, et al. Inguinal hernia repair in children: Surgical technique. Journal of Visceral Surgery (2016), http://dx.doi.org/10.1016/j.jviscsurg.2015.12.006

+Model JVS-557; No. of Pages 5

ARTICLE IN PRESS

Inguinal hernia repair in children: Surgical technique

7

Particularities in the young female

The surgical approach is identical to that for hernia repair in the boy. The hernia sac is freed, and once the surgeon is sure that the sac does not contain any ovarian or intestinal contents, it is closed and divided. The distal end of the sac is left open. Classically, the neck of the sac within the round ligament is fixed to the conjoined tendon with a suture also closing the internal ring, the so-called Barker artifice, which is supposed to preclude the need to modify the fixation of the uterus and prevent dyspareunia in the future. Lastly, the abdominal wall is closed similar to the procedure described above for boys.

Disclosure of interest The authors declare that they have no competing interest.

References [1] Galinier P1, Bouali O, Juricic M, Smail N. Focusing of inguinal hernia in children. Arch Pediatr 2007;14(4):399—403. [2] Lau ST1, Lee YH, Caty MG. Current management of hernias and hydroceles. Semin Pediatr Surg 2007;16(1):50—7.

Please cite this article in press as: Le Roux F, et al. Inguinal hernia repair in children: Surgical technique. Journal of Visceral Surgery (2016), http://dx.doi.org/10.1016/j.jviscsurg.2015.12.006

5