Definitely sufficient in otherwise normal children (normal musculature). Except in abdominal wall defects and congenital anomalies such as prune belly where musculature may be weak.

Never had to do any internal ring repair in any infants or toddlers or pre-school kids.

Question may however arise in older kids / obese kids - never encounted any so far though. Any thoughts welcome

Yes, simple high ligation is the gold standart procedure in the treatment of pediatric indirect inguinal hernias. Marcy repair should be added when a huge hernia enlarges the internal inguinal ring. A laparoscopic approach, so called PIRS, described by Prof.Dr. Dariusz Patkowski from Wroclaw, is a very good alternative option to the open surgery.

yes, however in one of my female patient of sliding hernias containing the entire uterus with Fallopian tubes as content required repair of deep inguinal ring

Yes, high ligation of the sac at the level of pre peritoneal fat is sufficient for cases of congenital inguinal hernias in children. Only to add that the distal portion of the sac to the point of ligation is excised.

In our institution Marcy procedure is standard of treatment for indirect pediatric inguinal hernias, we performed more than 20 000 Marcy procedures last 15 years, and had great results, recidivism was found in only 0.03%cases. I beleave that simple high ligation of hernia sac also is sufficient.

Definitely yes. And complete section of the sac is more important than ligation. Muscle repair (Mc Vee, Bassini...) are unnecessary.

Nowadays minimal invasive procedures has showmn same results particularly in girls.

In boys, during MIS, it's important to cut the sac intraperitoneally in order to avoid post-operative hydrocele. But there are discussions!!

High ligation of the patent processus vaginalis (indirect inguinal hernia) is sufficient in the treatment of children with inguinal hernia. This can be accomplished with open and laparoscopic techniques. Here is a link that demonstrates the simple technique of laparoscopic needle assisted repair in which the hernia sac is not divided: http://www.youtube.com/watch?v=_Gc1PoPB8KI

It is important to note that in children with very large indirect inguinal hernias the internal ring and muscles/fascia transversalis are stretched and treatment may require repair of the inguinal floor. Mesh is almost never necessary.

Dear Dr Henri. I am glad you lay stress upon complete transaction of hernia sac along with high ligation. Though Laparocopy may achieve the highest ligation, it does not address transection of sac. Therefore i am personally not in favour of same. Word is out nowadays with many a consultant abandoning single side lap hernia for conventional open technique - a versatile procedure indeed.

High ligation of the sac is usually sufficient to repair most cases of indirect inguinal hernias in children. In adolescents and older kids, sometimes a floor repair may be indicated if there is a generous defect at the internal ring due to stretching of these muscles from a large and/or chronic hernia

In children, simple high ligation of the indirect sac is certainly the most popular treatment for inguinal hernia. Some also use to open the inguinal canal to get access to the spermatic cord and to reinforce the anterior wall of the inguinal canal with Mugnai-Ferrari technique. Others suggest that simple division of the hernia sac is as effective as its ligation in terms of hernia relapse. Marcy repair was suggested for large inguinal hernias in children but has gained very limited interest in the pediatric population.

In my personal experience I have used both simple ligation of the sac and the Mugnai Ferrari technique, both in newborn infants and in toddlers, with no obvious advantage of one technique over the other. I have never needed to use the Marcy repair.

Herniotomy (high ligation of the sac with excision) is enough for indirect inguinal hernia as most of other colleagues mentioned. In our department we have some indications for laparoscopy (infant, bilateral cases, female with a palpable gonad, incarcerated hernia, recurrence) according to the evidence of benefits that shown by different studies.

Herniorraphy (repair of the posterior wall of the inguinal canal e.g Marcy, Bassini...) is nearly never necessary in children with indirect inguinal hernia as the etiology is nearly the same even in teenagers (though I know that some colleagus may do it in patients over 14 years old) but we don´t have problem with herniotomy and may be we need to discuss this issue even with the general surgeons. If the internal inguinal ring is streched and very wide, I will repair it (talking about the teenagers).

Hernioplasty (to put a mesh) is never necessary in children and may be contraindicated because of its well known complications.

I have done herniorraphy only in few cases with direct inguinal hernia and usually they have other anomalies.

I tottaly agree with Hussein. I would like to add that we dosac excision without disturbing the posterior wall.No repair unless there is awide ring or a concomitant direct hernia which i rarely faced

In pediatric hernias simple high ligation of the indirect sac is the standard treatment. In girls less than 1 year old with sliding hernias some add the barker technique. It is almost never necessary to repair the inguinal floor and never indicated to use mesh.

The use of the open or the laparoscopic technique remains a personal choice but seems less indicated in boys ( needs complete section of the sac).

In our Institution, high ligation of the sac has proved to be an efficient and way in inguinal hernia repair in children, so that is the practice that we have been following for many years now and our results are very satisfactory.. best regards from Department of Pediatric Surgery of Kosova

Medical University of Vienna, Pediatric surgical division

We do only high ligature and only open procedure since at least (to my knowledge) 1980. The results are fairly good depending on the experience of the surgeon and the fraction of premature infants/less than 2000g body weight.

In mature infants our recurrence rate is less than 1% overall and less than 0.8% in hands of experienced surgeons. We know this are not the best results but the laparoscopic way was tried and left due to the much more complicated technical circumstances and troubles and also higher costs. So actually we do not know if the minimally invasive approach will provide better results or not.

We never use mesh because we do not see the benefit on the one hand and we do not know the long term effects of the mesh implantation to an infant who will live with this maybe 60-90 years - there are obviously no longterm studies , not even predictive studies dealing with this problem.

Rare cases of direct hernias get an differentiated always adjusted to the case approach, most of the colleagues prefer the Bassini procedure, but do not perform it correctly because they are no longer General Surgeons also and therefore are not trained with Shouldice which I prefer to do if it makes sense.

This seems to be a problem in the education and training due to the new separation of ped surgeons from the general surgery...The elder surgeons among us will know what I mean.

However this discussion is really worth to be continued from many aspects, thank you Dr.Aanning

I concur with the above contributors who advocate a high ligation only. Even if the internal ring has been stretched wide, I have not experience any recurrence when there had been no repair. Presumably when the fundamental problem has been dealt with, muscular tone will close the defect.

This would be in keeping with the concept that peadiatric hernia is a developmental problem of the processus vaginalis rather than a degenerative weakness of the inguinal canal.

Simple high ligation In majority of cases

Neck closure if it is wide with 1-2 sutures

Additional component of herniorapphy (no mesh) in children with abd wall defects, EDS So far great results in personal and institutional experience

Simple high ligation of the indirect sac is certainly the most usual treatment for inguinal hernia.

High ‘ligation’ is the standard treatment for Pediatric Inguinal Hernia.

The exemptions are;

1. Sliding inguinal hernia in females with fallopian tube in the sac (it is more common than one can guess) – Purse-string suturing.

2. Large or Massive Inguinal Hernia – if the internal ring remains wide after the sac is ligated, one or two interrupted sutures to close the internal ring.

3. Laparoscopic double ligation/purse-string of sac – in females with bilateral inguinal hernia

Not Excision rather INCISION along with HIGH LIGATION is the standard treament. Distal sac need not be EXCISED. In males it may be detrimental to excise distal sac. However the communication with distal sac must be dealt with. The recurrence rates are substantial in laparoscopy while deal only with high ligation - Hence incsion along with high ligation. This is the preferred method and has stood test of time. Its an absolutely extra-peritoneal approach; surface surgery; safe under any aneshesia; the scar is minimal.

If direct hernia is excluded, no need for mesh or Bassini procedure in addition to high ligation even in pts older than 14 yrs or suffering from connective tissue disorders. Best regards

I am grateful for all your contributions.

Question: is the final result from open high ligation the same as from laparoscopic high ligation in repair of indirect inguinal hernias in the pediatric population?

Dr Lars

You ought to ask the opposite: If lap high ligation results are at par with open procedure..

The verdict was out long time ago.. so much so that lap herniotomy is to be condemned altogether. Could give you ref from established doyens of paed laparocopists..

Appreciate your response and I do need to do a literature search.

Do you think that pneumoperitoneum alters how one is able to effect high ligation? - or is there another factor(s)?

Open high ligation of the sac with narrowing if the ring is wide gives excellent results in

in pediatric population.

High ligation of the persistant PVD is more than enough for most children with inguinal hernia. Rarely, in huge direct and indirect hernias (mostly with former premature or VLBW babies), internal ring narrowing.

In children under one year age,herniotomy is done without opening the inguinal canal.simple sac ligation is enough. In elderly children the inguinal canal is opened,so after ligation of the sac ,anatomic repair of the inguinal canal is required.

pl read my article-Vincent PJ, Joshi CS, Pujahari AK. Recent trends in dealing with the inguinal hernial sac.MJAFI;2003,59:108-110

Dr Lars: AT laparosocpy herniotomy our observation had been that if one were to INCISE THE sac and suture - the chances recurrence were much less as compared to just picking up the peritoneum and placing a tie around same. However incising was tedious; chances of injury to Vas very high; and results were not reproducible. hope this helps

Dr Aswini: Fine article, but I am afraid yours is an adult patient population and not paediatric. I accept that in adults Dissection may be sufficient without ligation. I would beg to differ in children. "Child is not a small Adult". Anyone who has seen an immediate postoperative recurence of hernia (bowel loops of large enterocele) - rarest of rare cases would think umpteen times before leaving the hernia sac without ligation. Furthermore once a surgeon has done the tedious dissection and sac with all its four walls are free I see no reason not to ligate. Pain / parasthesis is NOT / SELDOM due to ligation rather due to entrapment of ilioinguinal nerve.

I completely agree with dr Patankar. The article cited above has been put out of the context as the study groups are definitely not of pediatric age group. Further the assumption that postoperative pain is because of ligation is again far fetched. The notion that peritoneum heals within hours is theoritcally ok but does it have the strength to withstand the increased intra-abdominal pressure that occurs during extubation of a child from GA?. I had to manage this case which recurred immediately at postoperative period and at re-exploration the ligature had given way [see attachment]. My limited experience endorses High ligation as the choice [open or laparoscopic] for pediatric hernias.

I completely agree with the points projected by Dr Patankar. in addition I wud like to say that although theoretically the peritoneum heals within hours or days what about its strength to withstand high intra-abdominal pressure that often occurs when a child is extubated from GA? I had a case which recurred immediately in postop and at re-exploration the ligature had given way.[ It is just a personal observation and I am open to correction] In the article's conclusion it is mentioned that ligation makes the procedure "time consuming" is also far fetched as it takes less time, even less than prepping and draping the patient to transfix the neck. In my limited experience I would endorse High ligation as the procedure of choice [open or Lap] so far as pediatric hernia is concerned.

I also do herniotomy without opening the inguinal canal. Simple sac ligation is enough through superficial opening of inguinal canal

Dear Dr Nexhmi: Your technique of not opening the inguinal canal is well accepted for neonates and smaller infants - Michel Blank Technique. what do you do for bigger children and larger sacs / Incomplete hernias and congenital hydrocele. Esp in Congenital hydroceles in not so big kids?

Tightening of the internal ring (Marcy repair) or inguinal floor reconstruction is appropriate when these structures have been stretched/obliterated by a large, chronic indirect hernia. The ring caliber and inguinal floor integrity can be assessed after high ligation. In children, floor reconstruction can be carried with autologous tissue using a modified-Bassini repair, and prosthetic material is usually not necessary.

Dr Frazier - I agree floor recons is seldom required in congenital hernia unless associated with morbid condition such as defects of abdominal wall musculature / prune belly syndrome etc

Yes! Inguinal ernia in children is an indirect hernia consequent to the patency of the processus vaginalis (PPV). So, once the hernia content is reduced, the ligation of the the hernia sac (PPV) at the internal inguinal ring represents the treatment of inguinal hernias in children. Normally in the classic open repair the hernia sac is not only ligated but also interrupted. In laparoscopic procedures the sac is ligated only (or cauterized and ligated to better close it).

I think high ligation of the sac is very important in hernia repair for children because in almost all cases of hernia in children is congenital.

I perform needle assisted laparascopic hernia repair at my institute. We use a 3mm or 5mm port for our telescope (through the umbilicus) and perform a percutaneous closure of the external ring, using an anjiocath needle to place a loop around the open internal ring. The suture is tied and placed subcutaneously. Cosmetic results are excellent. The process is minimally invasive and only requires 3-5mmH2O pneumoperitonium. Patients are sent home the same day.