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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 1  |  Page : 33-36

Comparison of Inguinal Herniotomies with and Without Opening the External Oblique Aponeurosis in Children Above the Age of Two


1 Department of Pediatric Surgery, Süleyman Demirel University Medical Faculty, Isparta, Turkey
2 Kartal Dr. Lütfi Kırdar City Hospital, Clinics of Pediatric Surgery, İstanbul, Turkey

Date of Submission16-Feb-2021
Date of Acceptance22-Jun-2021
Date of Web Publication19-Jan-2022

Correspondence Address:
Dr. Y Kart
S.D.Ü. Araştırma ve Uygulama Hastanesi, 32260 Çünür, ISPARTA
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_82_21

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   Abstract 


Background: Mitchell-Banks technique (MBT), in which inguinal canal is not opened, usually used in inguinal hernia repair in children under 2 years of age. The majority of pediatric surgeons tend to open the inguinal canal while performing inguinal hernia surgery in children over 2 years of age, called as modified Ferguson herniotomy (FH). Aims: This study aimed to compare early and late complications of the MBT and FH in over 2 years of age patients who underwent inguinal hernia surgery. Patients and Methods: We retrospectively reviewed the medical records of all children between 2 and 16 years old who underwent inguinal herniotomy procedure using the MBT and FH between January 2013 and December 2019. Patients were evaluated in terms of demographic data, early and late complications. Results: This study included 834 children. Of these, 379 (44.8%) were operated on by an FH with opening the inguinal canal (Group 1), and 455 (55.2%) by MBT superficially to the external ring (Group 2). There were 68 (17.9%) females and 311 (82.1%) males in group 1, while there were 151 (33.2%) females and 304 (66.8%) males in group 2. Early complications were wound infection (1.1% in the group 1 vs. 1.3% in the group 2, P = 1.00) and scrotal hematoma (1.3% vs. 1.8%, P = 0.89). Late complications included recurrence (1.6% in the group 1 vs. 1.8% in the group 2, P = 0.12), undescended testis (2.1% vs. 0.7%, P = 0.71), testicular atrophy (1.5% vs. 0.4%, P = 0.79), and hydrocele (1.9% vs. 1.8%, P = 0.87). There was no statistically significant difference in terms of early and late complications ratio between two groups. Conclusion: This study showed that inguinal hernia repair performed without opening the inguinal canal in children older than 2 years do not lead to an increase in complications. In this respect, MBT can be used as a simple and safe procedure in older children.

Keywords: Children, complication, inguinal hernia, Mitchell-Banks technique


How to cite this article:
Kart Y, Ozturk C. Comparison of Inguinal Herniotomies with and Without Opening the External Oblique Aponeurosis in Children Above the Age of Two. Niger J Clin Pract 2022;25:33-6

How to cite this URL:
Kart Y, Ozturk C. Comparison of Inguinal Herniotomies with and Without Opening the External Oblique Aponeurosis in Children Above the Age of Two. Niger J Clin Pract [serial online] 2022 [cited 2022 Dec 3];25:33-6. Available from: https://www.njcponline.com/text.asp?2022/25/1/33/335996




   Introduction Top


Inguinal hernia is seen at a rate of 3.5%–5% in term babies and approximately 18% in premature babies.[1],[2] Consequently, the most common surgical procedure performed in children is inguinal hernia surgery. The basic principle in the repair of inguinal hernia in infants and children is high ligation of the hernia sac.[3] Elective pediatric inguinal hernia repair stages are different between surgeons. But all of them believe that the main point of surgery is based on accurate anatomy understanding, minor manipulation of vas deferens and vessels during dissection of sac and closing it on the highest point.[4],[5]

There are two methods frequently used by pediatric surgeons to perform inguinal hernia repair. First method is modified Ferguson herniotomy (FH), in which the external oblique aponeurosis is opened to identify the internal ring. Second method is Mitchell-Banks technique (MBT). This technique is performed without opening external oblique aponeurosis, and hernia sac is closed outside of the inguinal canal. Children under two years of age have very short inguinal canal, where the internal and external rings are overlapping. Therefore, pediatric surgeons generally prefer MBT for patients under age of 2. On the other hand, FH is used in older children, in whom inguinal canal is longer. However, the inguinal canal is shorter and the tissues are more flexible in older children than adults. Recent studies showed that MBT can be performed safely in older children.[4],[5] Advantages of the MBT technique; shortening the operation time, decreasing the risk of ilioinguinal nerve damage, and not having the risk of weakening the posterior inguinal wall.[3] MBT has been also used safely in children aged up to 11 years to make use of its advantages and with a recurrence rate similar to FH in previous studies,[3],[5] but the two techniques have not been compared in terms of early and late results.

The aim of this study is to compare postoperative early and late results in children aged 2–16 years who were operated with MBT and FH for indirect inguinal hernia.


   Material and Methods Top


Study groups

The medical records of all children between 2 and 16 years old who underwent inguinal herniotomy using MBT and FH between January 2013 and December 2019 were retrospectively reviewed. Patients with recurrent inguinal hernia, strangulated hernia, accompanying undescended testis and connective tissue disease were excluded from the study. All patients were operated by the same two surgeons and surgeons performed all operations together. Patients were categorized in two groups. The first underwent herniotomy without incising external oblique aponeurosis (group 1) and the second underwent herniotomy with incising external oblique aponeurosis and canal, and closing the sac in inner ring (group 2). The study was approved by Institutional Review Board (2020/514/186/3).

Patients who had all controls for one year were included in the study. The controls of the patients were performed at the first week, first month, sixth month, and first year after the operation by outpatient clinic examination. Scrotal edema, hematoma and wound infection in the early period, and recurrence, iatrogenic undescended testis, hydrocele, and atrophic testis in the late period during the follow-up. The study was approved by Institutional Review Board (2020/514/186/3).

Statistical analysis

The statistical analyses were performed using SPSS software Statistics for Windows, Version 22.0 (Chicago: SPSS Inc, Chicago, Illinois, USA). Chi-square test was used to compare nominal variables. P values lower than 0.05 were considered significant.


   Results Top


This study included 834 children. Group 1 consisted of 379 (44.8%) patients and group 2 consisted of 455 (55.2%) patients. There were 68 (17.9%) females and 311 (82.1%) males in group 1, while there were 151 (33.2%) females and 304 (66.8%) males in group 2 [Table 1]. The inguinal hernia was right sided in 196 (51.7%) patients, left sided in 108 (28.4%) patients, and bilateral in 75 (19.9%) patients in group 1. On the other hand, the inguinal hernia was right sided in 246 (54.1%) patients, left sided in 153 (33.6%) patients, and bilateral in 56 (12.3%) patients in group 2 [Table 2].
Table 1: Demographic characteristics of the patients

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Table 2: Side of inguinal hernia

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Early complications were wound infection (1.1% in the group 1 vs. 1.3% in the group 2, P = 1.00) and scrotal hematoma (1.3% vs. 1.8%, P = 0.89). Late complications included recurrence (1.6% in the group 1 vs. 1.8% in the group 2, P = 0.12), undescended testis (2.1% vs. 0.7%, P = 0.71), testicular atrophy (1.5% vs. 0.4%, P = 0.79), and hydrocele (1.9% vs. 1.8%, P = 0.87) [Table 3]. There was no statistically significant difference in terms of early and late complications ratio between two groups. No mortality was seen in both groups.
Table 3: Early and late complications seen in the groups

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   Discussion Top


Inguinal hernia surgery is the most common surgery performed by pediatric surgeons and has a signature feature for them. Over the years, it has evolved into various forms with the training, experience, and analysis of the results of each surgeon. The exact technique and steps involved with that repair differ widely among the surgeons. The success of hernia repair in infants and children is based on the principle that closure of hernia sac neck and division of the sac is the single most important step in repairing an indirect inguinal hernia.[3]

Many pediatric surgeons open the roof of the inguinal canal while preserving the external ring or by including the ring as described by Ferguson and Gross. This repair is known as FH.[4] But some pediatric surgeons prefer MBT, which is high ligation and removal of the hernia sac through the external inguinal ring.[2],[4] The MBT does not deviate from this principle, if the hernia sac can be isolated and dissected at the external ring without opening the external oblique fascia, the chance of injuring the ilioinguinal nerve is minimized and weakening of the posterior wall of the inguinal canal is avoided.[3] Another advantage of the MBT is reduction of the operative and anesthesia time since fewer tissue planes are incised.[3]

In children aged 0–12 years; the internal and external inguinal rings are nearly superimposed, so the inguinal canal is poorly developed and some studies indicate a canal length of 4-23 mm and around 40 mm in adolescent.[5] Because the shorter inguinal canal in children and the flexible fascia enable the inner and outer rings to move closer to each other with traction applied on the hernia sac toward the caudal axis, this allows better visualization of the inner ring.[5] The inguinal canal is different in young children from adults and older children in several respects, as it is shorter, obviously lies in a less oblique plane in a more anterioposterior direction, and the tissues involved are more elastic.[1] All these factors provide some freedom to the surgeon for moving the spermatic cord and visualizing the inguinal canal. In children under the age of 2 years, the majority of surgeons perform the operation superficial to the external inguinal ring. In older patients, the tendency to open the inguinal canal or divide the external ring is much greater. However, we believe that in children, due to the characteristics of the inguinal canal, herniotomy can be performed up to the age of 16 without opening the inguinal canal. At least during the operation, if the length and elasticity of the inguinal canal allow sufficient dissection of the hernia sac, the operation can be completed without opening the inguinal canal.

The Mitchell Banks procedure cannot be employed in all cases of pediatric inguinal hernia. With an undescended testis and associated hernia, the external oblique fascia should be incised. In cases of incarcerated hernia, incising the external oblique fascia will facilitate the operation.[3],[6] Therefore patients with recurrent inguinal hernia, strangulated hernia, and accompanying undescended testis were excluded from our study.

The complication rate in children after inguinal hernia repair is usually 2% or less.[4] Surgeon training, experience and less manipulation are the most important factors for reducing the complications. Huges et al.[7] reported, recurrence rate was 2.2%. In our study, recurrence rate was (1,6% in group 1 and 1,8% in group 2). Askarpour et al.[4] reported, hydrocele incidence after surgery was without incision group 15.9% vs. 7.36% with incision group. In our study, hydrocele incidence was (1,9% in group 1 and 1,8% in group 2). The undescended testis incidence after herniotomy varied from 0.034 to 0.29% in the literature.[8],[9] In our study undescended testis rate after surgery (2,1% in group 1 and 0,7% in group 2). The complication rate in both groups of patients was found to be consistent with the literature in our study. In this study, no significant difference was found when short-term and long-term complications were compared in children who underwent inguinal hernia surgery using MBT and FH. We did not find a decrease in the effect of MBT technique and an increase in complication rates with increasing age in children.

The MBT has been also used safely in children aged up to 11 years to make use of its advantages and with a recurrence rate similar to FH in previous studies.[4],[5] In this study, we have shown that inguinal hernia operations can be performed safely using MBT in children up to the age of 16.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Vogels HD, Bruijnen CJ, Beasley SW. Predictors of recurrence after inguinal herniotomy in boys. Pediatr Surg Int 2009;25:235-8.  Back to cited text no. 1
    
2.
Ravi K, Hamer DB. Surgical treatment of inguinal herniae in children. Hernia 2003;7:137-40.  Back to cited text no. 2
    
3.
Kurlan MZ, Wels PB, Piedad OH. Inguinal herniorrhaphy by the Mitchell Banks technique. J Pediatr Surg 1972;7:427-9.  Back to cited text no. 3
    
4.
Askarpour S, Peyvasteh M, Sherafatmand S. Comparison between inguinal herniotomies with and without incising external oblique aponeurosis: A randomized clinical trial. Arq Bras Cir Dig 2017;30:187-9.  Back to cited text no. 4
    
5.
Türk E, Memetoglu ME, Edirne Y, Karaca F, Saday C, Güven A. Inguinal herniotomy with the Mitchell-Banks' technique is safe in older children. J Pediatr Surg 2014;49:1159-60.  Back to cited text no. 5
    
6.
Levitt MA, Ferraraccio D, Arbesman MC, Brisseau GF, Caty MG, Glick PL. Variability of inguinal hernia surgical technique: A survey of North American pediatric surgeons. J Pediatr Surg 2002;37:745-51.  Back to cited text no. 6
    
7.
Hughes K, Horwood JF, Clements C, Leyland D, Corbett HJ. Complications of inguinal herniotomy are comparable in term and premature infants. Hernia 2016;20:565-9.  Back to cited text no. 7
    
8.
Erdogan D, Karaman I, Aslan MK, Karaman A, Cavusoğlu YH. Analysis of 3,776 pediatric inguinal hernia and hydrocele cases in a tertiary center. J Pediatr Surg 2013;48:1767-72.  Back to cited text no. 8
    
9.
Miyake H, Fukumoto K, Yamoto M, Nouso H, Kaneshiro M, Nakajima H, et al. Comparison of percutaneous extraperitoneal closure (LPEC) and open repair for pediatric inguinal hernia: Experience of a single institution with over 1000 cases. Surg Endosc 2016;30:1466-72.  Back to cited text no. 9
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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