For repair of inguinal hernia in infants and children, what age is appropriate for opening the external oblique muscle before herniotomy?
I believe you are referring to the in-folding of the external oblique aponeurosis that makes up the inguinal canal. I open it for all ages when I do open herniotomy. The ilioinguinal nerve can be seen in here and needs to be preserved. Separating the cremasteric muscles through this approach allows identification of the hernia sac as well as delivering the sac out with ease. If you enter through the external oblique muscle, your plane is too medial and you will have problem finding and bringing the hernia sac out of the wound. It is important to remember that the inguinal canal is short in neonates, what more in premature babies hence this technique may be challenging when doing them. Hope this helps.
Above 12 months. Before 1 year of age there is no need to open the external oblique aponeurosis provided you do dissect the sac high enough to avoid residual patent processus vaginalis that would end up with a recurrency in a 2 to 3 years
I try to stay outside the canal upto 2 yrs or so (no hard and fast rule), but I suppose one has to take the size of child as well. Weights / heights differ in various parts of the world.
I open the external oblique when is necessary. I don't think it depends on the age only, but on the anatomy. In neonate and sometimes in girls, it is not necessary to enter the inguinal canal. Also in very large hernias the external ring could be so distorted that you only need so separate the cremaster to access the sac and to complete the operation. Saludos, JC.
I always try to do it without opening the canal. The oldest i have done was 10 y old
There is no clear evidence based answer for this question. The classical experience view of the seniors varies. Most of the authors say that no need to open the canal before 12 months which I agree with; but I open the external oblique when it is necessary even before 12 months. Thanks for the question and the nice discussion.
Opening the canal would help to achieve more length - the cremastric muscles could be adequately excised; also dealing with the Patent processus vaginalis (herniotomy) - both would easily give an additional cm to an cm and half. But I guess laparoscopy surgeons (esp adults) have forgotten about how to achieve the extra centimeters of length!!
The classic Michel Blank approach for neonatal hernia if upto one month. After one month its best to open the aporneurosis to reach the neck of the sac at the deep ring - it does not add much to morbidity or duration of surgery. The incision varies according to age beyond one month. It is very helpful to avoid residual ppv that may lead to a residual swelling - not a recurrence in the true sense.
I perform a herniotomy without opening the external oblique muscle only in girls up to 6 months of age. For the same procedure in boys you have to deal with the fragile and sometimes shortened spermatic cord.
Actually, I didn’t find any information about “the classic Michel Blank approach for neonatal hernia…” Could you please give me a tip?
What concerns laparoscopic herniotomy. I’m convinced that this procedure is a very burden and unnecessary procedure for babies and very small children.
Ognya Brankov, In adition to factors already mentioned by Zahoor Patankar, it could be opened and content inspected to determine if normal internal female genitalia are present, once the sac is freed up to internal ring. If testicle is found in male, the gonads should be inspected for apêndix testis or epididymis and excised if either or both vestigial structures are found, then testicle is accurately returned to the scrotum pulling on gubernaculum.
Must prevent secondary ascent of testes - the incidence is very small nonetheless there. Hence herniotomy at the neck - after carefully dissecting the sac - which is possible only upon opening of aponeurosis.
Every standard surgical procedures for inguinal hernia repair in children are high successful and the recurrences are very rare. Incision of external oblique muscle does not change it. It is performed to make the resection of hernial sac at the level of its neck easily. The incision is not necessary if you can do it through the external ring, mostly during the first year of life. However, if you do it, there are not consequences at any age.
The inguinal canal is completely lengthened by about 5 years. Till that there is no need to open ext. oblique aponeurosis.Can check earlier editions of Bailey and Loves text book of surgery!
The classic Michel Blank approach for neonatal hernia if upto one month of NOT OPENING OF External Ring can be adopted. Thereafter its better to open external ring for completeness of herniotomy at neck lest a bulge remains.
Over my 22 year experience as the only Physician Assistant to a changing cadre of pediatric surgeons (three Chiefs of Service, 10 attending surgeons) personal preference reigns. I have one surgeon who NEVER opens the external oblique aponeurosis in any pt at any age , male or female. He asserts a high ligation obtained by emptying sac of contents with "twisting and doubly ligating the sac" is sufficient. He claims to have no recurrences. Other surgeons have used 6 months, 12 months or the size of the hernia sac to decide when to open the external aponeurosis.
I create an external oblique window in all neonates and children. Also no need to close afterwards.
Dr Roy Would not the external and internal ring superimposed in youngest of neonates?
Yes, the rings are closer the younger the child, but the sac can always be exposed through an external oblique window. I have used both techniques many times, but I find the Mitchell Banks herniotomy not as neat to perform as there are more facial layers to dissect.