Inguinal Hernia in Children: Factors Affecting Recurrence in 62 Cases ByJay
L. Grosfeld, Kathryn Minnick, Frederick Shedd, Karen W. West, Frederick J. Rescorla, and Dennis W. Vane Indianapolis, Indiana
0 This report analyzes factors associated with 71 recurrent inguinal hernias in 62 children treated between 1976 and 1966. Cases were evaluated for sex, age, type of initial repair, interval to recurrence, the presence and type of reoperation. There were percent of patients were less than were less than 1 year of age at the Recurrence was on the right in 74%,
of comorbid conditions, 57 boys and 5 girls. Sixty 6 months old and 72% time of the initial repair. left in 24%, and bilateral
in 2%. Recurrence was noted by 6 months in 50%. by 2 years in 76%, and by 5 years in 96%. Comorbid conditions were present in 60% of cases, including increased intraabdominal pressure (ventriculoperitoneal (VP] shunts), growth failure, prematurity, chronic pulmonary disease, bladder exstrophy, connective tissue disorders, cryptorchism, seizure disorder, and malnutrftion. Incarceration was a factor in four of the 62 cases. Seven patients had multiple recurrences. Fifty-one recurrences were indirect, whereas 20 were direct inguinal hernias. Inadequate high ligation (three with chromic catgut), wound infection, and groin hematoma were other findings. The direct hernias may be related to injury to the floor of the canal during initial repair. Recurrent repair included high ligation of the sac alone (20). high ligation plus snugging of a large internal ring (11). and high ligation with repair of the iliopubic tract in patients with VP shunts, connective tissue disorder, or weak floor (20). All direct hernias had a Cooper’s ligament (McVay) repair. Two direct hernias recurred again and were successfully repaired using a preperitoneal approach. Adequate high ligation at the internal ring, snugging of a large internal ring, avoidance of injury to the canal floor, and closure of the internal ring in girls are important operative considerations in preventing indirect hernia recurrence. Selected patients with connective tissue disorders, poor nutrition, and increased intraabdominal pressure (ascites, VP shunts) associated with weak floor tissues should undergo iliopubic tract repair to prevent recurrence. Cooper’s ligament repair is usually successful in cases of direct inguinal hernia; the preperitoneal repair is advantageous in patients with multiple recurrences. Copyright o 1991 by W.B. Saunders Company INDEX WORDS:
lnguinal hernia, recurrent.
I
NGUINAL HERNIA repair remains one of the most frequentIy performed surgical procedures in childhood. Although hernia recurrence in children is less common than in adults, for whom recurrence rates as high as 5% to 10% are recorded, it still remains a clinical problem.’ The incidence of hernia recurrence in children is reported between 0.8% and 3.8%; however, the true rate of recurrence is probably unknown and may be higher than the literature suggests.24 This report analyzes those factors associated with inguinal hernia recurrence in 62 children treated at a single pediatric surgical facility.
JournalofPediatric
Surgery, Vol26, No 3 (March), 1991: pp 283-287
MATERIALS AND METHODS Seventy-onerecurrent inguinal hernias were noted in 62 infants and children treated at the James Whitcomb Riley Hospital for Children, Indiana University Medical Center from 1976 to 1988. Cases were analyzed for sex, age at diagnosis, site and type of initial repair, side of recurrence, interval to recurrence, the presence of comorbid conditions, and type of reoperation performed. Fiftyseven patients were boys and five were girls. Twenty-three of the 62 patients underwent initial repair at this hospital; 39 of the cases were initially treated at other facilities and were subsequently referred because of recurrence. Ages at initial operation are shown in Fig 1. Of the 71 recurrent hernias, 52 (73%) were on the right side, 17 (24%) on the left, and two (3%) were bilateral. The time interval between the primary repair and recurrence was skewed toward the first 6 months following repair. Fifty percent of the recurrent cases were detected within that time frame. There were three immediate recurrences noted in the recovery suite, all in patients initially repaired elsewhere. Seventysix percent of recurrent hernias presented within 2 years of the initial repair and all but three cases were detected within 5 years. The three outliers occurred at 8,10, and 14 years, respectively (Fig 2). Thirty-seven of 62 children (60%) had comorbid conditions that may contribute to hernia recurrence (Table 1). Ten of the cases had more than one comorbid condition. All eight cases of undescended testis were noted in veryyoung infants and orchiopexy had been deferred at the time of hernia repair. Seven of these patients were initially treated elsewhere. Four of 62 patients (6.5%) had incarcerated hernia prior to the initial repair, including three at Riley Hospital. Of interest is that nine of 71 recurrences presented as an incarcerated hernia. Eight of the nine patients has a comorbid condition, including connective tissue disorder (1) bladder exstrophy (1) malnutrition (1) bronchopulmonary dysplasia (l), prematurity (1) posterior urethral valves (I), seizure disorder with spastic@ (l), and growth failure (I). Postoperative complications after the initial repair that may have contributed to recurrence are shown in Fig 3. Multiple recurrences occurred in seven patients, all initially repaired at other facilities. None occurred in patients with comorbid conditions and only one was complicated by wound infection. One of the patients was a girl who had recurrences three times prior to referral and also had a family history of hernia recurrence. Although all 62 patients initially had an indirect inguinal hernia,
From the Section of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine and the James Whitcomb Riley Hospital for Children, Indianapolis, IN. Presented at the 21st Annual Meeting of the American Pediatric SurgicalAssociation, Vancouver, British Columbia, May 19-22, 1990. Address reprint requests to Jay L. Grosfeld, MD, Surgeon-in-Chief J. W. Riley Hospital for Children, 702 Barnhill Dr (K-21). Indianapolis, IN 46202-5200. Copyright o 1991 by WB. Saunders Company 0022-3468/91/2603-0008$03.00l0
283
284
GROSFELO ET AL
4o1
Table 1. Conditions Associated With lnguinal Hernia Recurrence Condition
No. of Cases
Increased intraabdominal pressure VP
15
shunts
8
Ascites Posterior urethral valves Weight-lifting Pulmonary disease (chronic cough) Growth failure O-3mo
4-6mo
7-12mo
Z-5yr
)
Prematurity
5yr
( ll%).’ Pediatric surgical textbooks state that the rate of hernia recurrence in childhood is 0.8% to 1.0%.2*3However, most authors will agree that the true incidence of hernia recurrence is probably unknown. In the present study, 23 of 3,577 (0.6%) hernias repaired at the James Whitcomb Riley Hospital for Children recurred. Although there were 39 additional cases in the review, they were repaired at other facilities and it is impossible to accurately determine the recurrence rate other than in this center. Recent reports suggest that the recurrence rate may actually be higher. Harvey et a1,4in England, reported a 2.5% rate of recurrence, whereas Kvist et al5 and Ingimarsson and Spak6 documented a 3.7% and 3.8% rate of hernia recurrence in infants and children treated in Denmark and Sweden, respectively (Table 2). Rowe and Lloyd noted that the recurrence rate after inguinal hernia repair varied with the set of circumstances at the time of the operative procedure’ The recurrence rate after an uncomplicated elective repair was O.S%, but inound
1201
P
NOTE. Ten patients had more than one condition.
I
infection 4
100 80 60
6040
hematoma 3
/
31
201
i---
0’
t Imo
I q3mo
( &no
(
1yr
time (months,
( 2yr
( 5yr
) 6yr
years)
Fig 2. Interval to recurrence (71 recurrences in 62 patients). Note that 66% of recurrent hernias occur within 6 months and 76% within 2 years of the initial repair.
recov swelling 2
rm recur. 3
Fig 3. The postoperative complications after initial hernia repair that were related to subsequent recurrence.
RECURRENT INGUINAL HERNIA
285
Table 2. lnguinal Hernia in Childhood: Recurrence Rate Study
Rowe and Lloyd3
No. of Cases
Recurrence
2,784
0.8
Harvey et al4
392
2.5
Kvist et al5
528
3.7
lngimarsson and Spak’
118
3.8
3,577
0.6
Smith2
Present series
Rate (“lo)
1.0
creased to 2.3% in girls with sliding hernias, 6% after repair of incarcerated hernia, and 12% after repair of hernia in patients with a ventriculoperitoneal (VP) shunt placed for hydrocephalus. The percentages for incarceration and VP shunt are identical to the data observed in this study. In infants and children with an incarcerated hernia, the tissues are edematous, the sac may be friable, and the internal ring has been diIated by the trapped viscera. Furthermore, infection is more common after incarceration and may also predispose to tissue breakdown and a higher rate of hernia recurrence. Because there is a high risk of incarceration (approximately 31%) in the first year of life, early elective repair of inguinal hernias in infancy is recommended.7.9 Coran and Eraklis noted a 56% recurrence rate after high ligation of the indirect hernia sac in infants with the Hurler-Hunter syndrome.” McEntyre and Raffensperger” and Woolley et al’* similarly noted a high rate of hernia recurrence in children with connective tissue disorders (Ehlers-Danlos syndrome). McEntyre and Raffensperger recommended that infants and children with Ehlers-Danlos syndrome undergo a formal herniorrhaphy similar to those performed in adult patients.” In addition, reports by Fonkalsrud et a&l3and others”16 conceming both femoral and direct inguinal hernias in infants and children, document that recognition of these more unusual pediatric hernias often follows the performance of a previous indirect inguinal hernia repair. These observations imply that previous operative trauma may aiter the status of the tissues of the floor of the inguinal canal in the infant, and may predispose the patient to an otherwise unusual type of recurrent hernia (eg, direct, femoral). Twenty of 71 recurrences in the present report were direct. Growth failure and poor nutrition may also play a role in cases of recurrence. Four patients in the current retrospective review had documented malnutrition, whereas eight were less than the fifth percentile of weight for height on the growth grid at the time of their repair. The European reports describing a higher rate of hernia recurrence than noted in the United States reflect that these procedures are often performed at
facilities other than a Children’s Hospital by nonpediatric surgical staff.4-6Harvey et al4 also imply that all the hernia operations at their facility were performed by junior staff and that in the very small infant (66% of their cases were less than 1 year old) perhaps it would be more appropriate for more experienced personnel to be involved. The fact that many of the infants currently being treated for inguinal hernia are premature babies who required a stay in the neonatal intensive care unit and have an increased risk of hernia recurrence may support this contention.‘” In the present study, prematurity was identified as a potential comorbid factor in hernia recurrence. Smith suggested that “inexperience in dealing with diminutive structures, unfamiliarity with special anatomic variations (sliding hernia of tube and ovary in girls, bladder close to the internal ring, etc), and amplification of adult concepts” may have an adverse effect on outcome following inguinal hernia repair by the occasional infant hernia surgeon.” A number of other predisposing factors were noted during this review concerning recurrent inguinal hernia. These include increased intraabdominal pressure due to VP shunt procedures for hydrocephalus, ascites, posterior urethral valves with bladder outlet obstruction, primary closure of bladder exstrophy, weight-lifting, and respiratory conditions associated with chronic cough such as asthma and cystic fibrosis. Increased intraabdominal pressure was implicated as a predisposing factor in 24% (15/62) of recurrent cases and confirms the observations of other authors”-19 regarding this procedure and its relationship to inguinal hernia. Certain technical details during performance of indirect inguinal hernia repair are probably worth stressing. Gentle technique and minimal mobilization of the cord structures and posterior floor of the inguinal canal are important considerations. In most cases, a simple herniotomy accomplished by high ligation of the hernia sac at the level of the internal inguinal ring with an interrupted nonabsorbable suture ligature is all that will be necessary. The appearance of retroperitoneal fat attached to the base of the sac is an indication that the dissection is high enough. Careful pressure on the lower abdomen just prior to cutting the suture ligature and excising the distal hernia sac may identify leakage of peritoneal fluid from an otherwise unrecognized tear in the proximal sac. We advise the use of nonabsorbable suture for ligation of the hernia sac. Three of the infants in this review without comorbid conditions (who were initially treated elsewhere) had early indirect hernia recurrence after high ligation was accomplished with
GROSFELD ET AL
286
chromic catgut. If the internal ring is excessively large, this should be narrowed (snugged) by interrupted nonabsorbable sutures placed across the transversalis fascia inferior to the cord structures.2,3’19If the infant or young child has an associated undescended testis, a concomitant orchiopexy should be performed at the time of the hernia repair, which should obviate the need for an additional groin exploration to pex the testis and reduce the risk of hernia recurrence. Seven infants in this study treated at other institutions and one in-house case had hernia recurrence when the testis was not pexed synchronously with hernia repair. In girls, a sliding hernia of the fallopian tubes and/or ovary may be present in 15% of cases.3”9 The sac can be sutured just above the sliding component and the entire stump reduced into the abdominal cavity through the internal ring. Because there are neither vas deferens nor testicular vessels to worry about, the internal ring can then be sutured closed. This will avoid the risk of indirect hernia recurrence in girls. In cases with poor tissue turgor or a weak posterior floor of the inguinal canal, a herniorrhaphy (iliopubic tract to transversus abdominus aponeurosis repair) should be added to high ligation of the sac as definitive therapy. Examples include infants with growth failure, connective tissue disorders, selected patients with myelomeningocele and VP shunts, and chronic pulmonary disease in which a higher risk of hernia recurrence can be anticipated. In instances of direct inguinal hernia with a definite defect through the floor of the inguinal canal medial to the epigastric vessels, a Cooper’s ligament repair using strong nonabsorbable interrupted sutures should be performed. Most recurrent hernias (especially in girls)
can be repaired by using the inguinal approach a second time. However, in instances of multiple recurrences, a preperitoneal hernia repair is advised.” This is particularly useful in boys because it avoids potential injury to the vas deferens and spermatic vessels by staying out of the previously scarred tissues in the groin. In most cases, repair can be performed without insertion of prosthetic materials. Rarely, however, this may be necessary to avoid excessive tension on the repair. Goretex is the prosthetic patch we currently favor, and was used successfully in one patient with multiple recurrences in the present report. These observations and previous studies suggest that the following factors may predispose to inguinal hernia recurrence: (1) failure to ligate the sac high enough at the internal ring; (2) a large internal inguinal ring; (3) injury to the floor of the inguinal canal from operative trauma; (4) failure to close the internal inguinal ring in girls; (5) inherent weakness or friability of the tissues in patients with connective tissue disorders, poor nutrition, prematurity, and growth failure; (6) conditions associated with increased intraabdominal pressure (VP shunt, ascites, pulmonary conditions with chronic cough, urethral valves, bladder exstrophy, weight-lifting, etc); (7) incarcerated hernia requiring emergency operation; (8) postoperative wound infection and hematoma; and (9) deferred orchiopexy in infants with concomitant undescended testis. Recognition of these factors, gentle operative technique by surgeons experienced in the care of infants, modifications in the operative procedure based on selective individualization of patients at high risk for recurrence, and early elective repair prior to incarceration may prove useful in reducing the rate of recurrence.
REFERENCES 1. Greenburg AG: Revisiting the recurrent groin hernia. Am J Surg 154:35-40,1987 2. Smith CD: The abdominal parietes, in Welch KJ (ed): Complications of Pediatric Surgery. Philadelphia, PA, Saunders, 1982, pp 216-220 3. Rowe MI, Lloyd DA: Inguinal hernia, in Welch KJ, Randolph JG, Ravitch MM, et al (eds): Pediatric Surgery (ed 4). Chicago, IL, Year Book, 1986, pp 779-793 4. Harvey MH, Johnstone MJ, Fossard DP: Inguinal herniotomy in children: A five year survey. Br J Surg 72:485-487,198s 5. Kvist E, Gyrtrup JH, Mejdahl S, et al: Outpatient orchiopexy and herniotomy in children. Acta Paediatr Stand 78:754-758, 1989 6. Ingimarsson 0, Spak I: Inguinal and femoral hernias: Longterm results in a community hospital. Acta Chir Stand 149:291-297, 1983 7. Rescorla FJ, Grosfeld JL: Inguinal hernia repair in the perinatal period and early infancy: Clinical considerations. J Pediatr Surg 19:832-837,1984 8. Harper RG, Garcia A, Sia C: Inguinal hernia: A common problem of premature infants weighing 1000 grams or less at birth. Pediatrics 56:112-115, 1975
9. Puri P, Guiney EJ, O’Donnell B: Inguinal hernia in infants: The fate of the testis following incarceration. J Pediatr Surg 19:44-46, 1984 10. Coran AG, Eraklis AH: Inguinal hernia in the HurlerHunter syndrome. Surgery 61:302-304,1967 11. McEntyre RL, Raffensperger JG: Surgical complications of Ehlers-Danlos syndrome in children. J Pediatr Surg 12:531-535, 1977 12. Woolley MM, Morgan S, Hays DM: Heritable disorders of connective tissue: Surgical and anesthetic problems. J Pediatr Surg 2:325-331, 1967 13. Fonkalsrud EW, de Lorimier AA, Clahvorthy HW Jr: Femoral and direct hernias in infants and children. JAMA 192:597599,1965 14. Viidik T, Marshall DG: Direct inguinal hernias in infancy and childhood. J Pediatr Surg 15:646-647, 1980 15. Schulz S, Schmidt PF: Femoral hernia in children. Z Kinderchir 40:287-288,1985 16. Anderas P, Jona JZ, Glichlich M, et al: Femoral hernias in children: An infrequent problem. Arch Surg 122:950-951,1987
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17. Gross K, DeSanto A, Grosfeld JL, et al: Intra-abdominal complications of cystic fibrosis. J Pediatr Surg 20:431-435,1985 18. Grosfeld JL, Cooney DR: Inguinal hernia after ventriculoperitoneal shunt for hydrocephalus. J Pediatr Surg 9:311-315, 1974
19. Grosfeld JL: Current concepts in inguinal hernia in infants and children. World J Surg 13:506-515,1989 20. Boley SJ, Kleihaus S: A place for the Cheatle-Henry approach in pediatric surgery. J Pediatr Surg 1:394-397, 1966
Discussion H.B. Othersen (Charleston, SC): As was pointed out, this is the bread and butter of pediatric surgeons and if things are going wrong we need to find out what’s happening and why and how they can be corrected. The thing that was most interesting to me about this paper is that 51 of these hernias were indirect in their recurrence. I think a lot of these never had the sac ligated in the first place. I concede the direct hernias occurring as a result of comorbid conditions, such as cystic fibrosis, etc, but it seems to me that there are only three conditions in which you would have an indirect so-called recurrence, and one is that the sac was never ligated; it was missed. We all know that with a big hernia in a small child sometimes you can ligate only part of the sac or even get a tear in the sac and the sac may not have been ligated high enough, and a remnant of the sac was left. I would like to ask you, when you reviewed these at the recurrence operation, could you tell where the suture had been placed, because most of them except the three you mentioned used nonabsorbable sutures. The second question is whether herniograms would be of any use in evaluating these children preoperatively? N.R. Feins (Boston, MA): Did you find any femoral hernias in your series of recurrences? I have seen some children in whom the femoral hernia was missed at the time of exploration for what was thought to be an indirect inguinal hernia. The patient appears with an inguinal scar and a bulge. hf. Schwartz (Sacramento, CA): Dr Grosfeld, in your review 20 of the 71 recurrent hernias were the direct type. You have suggested that the cause was
trauma to the inguinal floor at the time of the initial procedure. Although this may be the cause in some, I am wondering if in many of these patients there was a preexisting direct defect. In fact, some infants may have had a complex hernia, and high ligation of the sac at the internal ring might pull the peritoneum from the direct space, but this obviously will not correct the defect. J. Grosfeld (response): Dr Otherson asked about operative findings. The recurrent indirect hernias were due to an unrecognized hole in the base of the sac, a missed sac, inadequate dissection of the sac to the level of the internal ring resulting in a persistent sac remnant, failure to snug a very large internal ring, and in three cases, the use of absorbable suture for ligation of the sac. We did not use herniography. Dr Feins, we have seen a few femoral hernias each year in children; however, none were noted in this group. In response to Dr Schwartz’s question, we could not determine if the direct hernias were present at the time of initial repair in cases performed elsewhere. However, none were noted at this institution. When repairing an indirect inguinal hernia, the dissection should be kept within the confines of the cremasteric. The floor of the canal should not be disturbed and the vas should never be grasped by a forceps (to avoid crush injury). The dissection must be taken up to the level of the internal ring, where one can usually see some preperitoneal fat prior to attempting suture ligation. Gentle pressure on the lower abdomen will indicate whether there is a “missed hole in the peritoneum” by producing a rush of peritoneal fluid.
L. Grosfeld, Kathryn Minnick, Frederick Shedd, Karen W. West, Frederick J. Rescorla, and Dennis W. Vane Indianapolis, Indiana
0 This report analyzes factors associated with 71 recurrent inguinal hernias in 62 children treated between 1976 and 1966. Cases were evaluated for sex, age, type of initial repair, interval to recurrence, the presence and type of reoperation. There were percent of patients were less than were less than 1 year of age at the Recurrence was on the right in 74%,
of comorbid conditions, 57 boys and 5 girls. Sixty 6 months old and 72% time of the initial repair. left in 24%, and bilateral
in 2%. Recurrence was noted by 6 months in 50%. by 2 years in 76%, and by 5 years in 96%. Comorbid conditions were present in 60% of cases, including increased intraabdominal pressure (ventriculoperitoneal (VP] shunts), growth failure, prematurity, chronic pulmonary disease, bladder exstrophy, connective tissue disorders, cryptorchism, seizure disorder, and malnutrftion. Incarceration was a factor in four of the 62 cases. Seven patients had multiple recurrences. Fifty-one recurrences were indirect, whereas 20 were direct inguinal hernias. Inadequate high ligation (three with chromic catgut), wound infection, and groin hematoma were other findings. The direct hernias may be related to injury to the floor of the canal during initial repair. Recurrent repair included high ligation of the sac alone (20). high ligation plus snugging of a large internal ring (11). and high ligation with repair of the iliopubic tract in patients with VP shunts, connective tissue disorder, or weak floor (20). All direct hernias had a Cooper’s ligament (McVay) repair. Two direct hernias recurred again and were successfully repaired using a preperitoneal approach. Adequate high ligation at the internal ring, snugging of a large internal ring, avoidance of injury to the canal floor, and closure of the internal ring in girls are important operative considerations in preventing indirect hernia recurrence. Selected patients with connective tissue disorders, poor nutrition, and increased intraabdominal pressure (ascites, VP shunts) associated with weak floor tissues should undergo iliopubic tract repair to prevent recurrence. Cooper’s ligament repair is usually successful in cases of direct inguinal hernia; the preperitoneal repair is advantageous in patients with multiple recurrences. Copyright o 1991 by W.B. Saunders Company INDEX WORDS:
lnguinal hernia, recurrent.
I
NGUINAL HERNIA repair remains one of the most frequentIy performed surgical procedures in childhood. Although hernia recurrence in children is less common than in adults, for whom recurrence rates as high as 5% to 10% are recorded, it still remains a clinical problem.’ The incidence of hernia recurrence in children is reported between 0.8% and 3.8%; however, the true rate of recurrence is probably unknown and may be higher than the literature suggests.24 This report analyzes those factors associated with inguinal hernia recurrence in 62 children treated at a single pediatric surgical facility.
JournalofPediatric
Surgery, Vol26, No 3 (March), 1991: pp 283-287
MATERIALS AND METHODS Seventy-onerecurrent inguinal hernias were noted in 62 infants and children treated at the James Whitcomb Riley Hospital for Children, Indiana University Medical Center from 1976 to 1988. Cases were analyzed for sex, age at diagnosis, site and type of initial repair, side of recurrence, interval to recurrence, the presence of comorbid conditions, and type of reoperation performed. Fiftyseven patients were boys and five were girls. Twenty-three of the 62 patients underwent initial repair at this hospital; 39 of the cases were initially treated at other facilities and were subsequently referred because of recurrence. Ages at initial operation are shown in Fig 1. Of the 71 recurrent hernias, 52 (73%) were on the right side, 17 (24%) on the left, and two (3%) were bilateral. The time interval between the primary repair and recurrence was skewed toward the first 6 months following repair. Fifty percent of the recurrent cases were detected within that time frame. There were three immediate recurrences noted in the recovery suite, all in patients initially repaired elsewhere. Seventysix percent of recurrent hernias presented within 2 years of the initial repair and all but three cases were detected within 5 years. The three outliers occurred at 8,10, and 14 years, respectively (Fig 2). Thirty-seven of 62 children (60%) had comorbid conditions that may contribute to hernia recurrence (Table 1). Ten of the cases had more than one comorbid condition. All eight cases of undescended testis were noted in veryyoung infants and orchiopexy had been deferred at the time of hernia repair. Seven of these patients were initially treated elsewhere. Four of 62 patients (6.5%) had incarcerated hernia prior to the initial repair, including three at Riley Hospital. Of interest is that nine of 71 recurrences presented as an incarcerated hernia. Eight of the nine patients has a comorbid condition, including connective tissue disorder (1) bladder exstrophy (1) malnutrition (1) bronchopulmonary dysplasia (l), prematurity (1) posterior urethral valves (I), seizure disorder with spastic@ (l), and growth failure (I). Postoperative complications after the initial repair that may have contributed to recurrence are shown in Fig 3. Multiple recurrences occurred in seven patients, all initially repaired at other facilities. None occurred in patients with comorbid conditions and only one was complicated by wound infection. One of the patients was a girl who had recurrences three times prior to referral and also had a family history of hernia recurrence. Although all 62 patients initially had an indirect inguinal hernia,
From the Section of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine and the James Whitcomb Riley Hospital for Children, Indianapolis, IN. Presented at the 21st Annual Meeting of the American Pediatric SurgicalAssociation, Vancouver, British Columbia, May 19-22, 1990. Address reprint requests to Jay L. Grosfeld, MD, Surgeon-in-Chief J. W. Riley Hospital for Children, 702 Barnhill Dr (K-21). Indianapolis, IN 46202-5200. Copyright o 1991 by WB. Saunders Company 0022-3468/91/2603-0008$03.00l0
283
284
GROSFELO ET AL
4o1
Table 1. Conditions Associated With lnguinal Hernia Recurrence Condition
No. of Cases
Increased intraabdominal pressure VP
15
shunts
8
Ascites Posterior urethral valves Weight-lifting Pulmonary disease (chronic cough) Growth failure O-3mo
4-6mo
7-12mo
Z-5yr
)
Prematurity
5yr
( ll%).’ Pediatric surgical textbooks state that the rate of hernia recurrence in childhood is 0.8% to 1.0%.2*3However, most authors will agree that the true incidence of hernia recurrence is probably unknown. In the present study, 23 of 3,577 (0.6%) hernias repaired at the James Whitcomb Riley Hospital for Children recurred. Although there were 39 additional cases in the review, they were repaired at other facilities and it is impossible to accurately determine the recurrence rate other than in this center. Recent reports suggest that the recurrence rate may actually be higher. Harvey et a1,4in England, reported a 2.5% rate of recurrence, whereas Kvist et al5 and Ingimarsson and Spak6 documented a 3.7% and 3.8% rate of hernia recurrence in infants and children treated in Denmark and Sweden, respectively (Table 2). Rowe and Lloyd noted that the recurrence rate after inguinal hernia repair varied with the set of circumstances at the time of the operative procedure’ The recurrence rate after an uncomplicated elective repair was O.S%, but inound
1201
P
NOTE. Ten patients had more than one condition.
I
infection 4
100 80 60
6040
hematoma 3
/
31
201
i---
0’
t Imo
I q3mo
( &no
(
1yr
time (months,
( 2yr
( 5yr
) 6yr
years)
Fig 2. Interval to recurrence (71 recurrences in 62 patients). Note that 66% of recurrent hernias occur within 6 months and 76% within 2 years of the initial repair.
recov swelling 2
rm recur. 3
Fig 3. The postoperative complications after initial hernia repair that were related to subsequent recurrence.
RECURRENT INGUINAL HERNIA
285
Table 2. lnguinal Hernia in Childhood: Recurrence Rate Study
Rowe and Lloyd3
No. of Cases
Recurrence
2,784
0.8
Harvey et al4
392
2.5
Kvist et al5
528
3.7
lngimarsson and Spak’
118
3.8
3,577
0.6
Smith2
Present series
Rate (“lo)
1.0
creased to 2.3% in girls with sliding hernias, 6% after repair of incarcerated hernia, and 12% after repair of hernia in patients with a ventriculoperitoneal (VP) shunt placed for hydrocephalus. The percentages for incarceration and VP shunt are identical to the data observed in this study. In infants and children with an incarcerated hernia, the tissues are edematous, the sac may be friable, and the internal ring has been diIated by the trapped viscera. Furthermore, infection is more common after incarceration and may also predispose to tissue breakdown and a higher rate of hernia recurrence. Because there is a high risk of incarceration (approximately 31%) in the first year of life, early elective repair of inguinal hernias in infancy is recommended.7.9 Coran and Eraklis noted a 56% recurrence rate after high ligation of the indirect hernia sac in infants with the Hurler-Hunter syndrome.” McEntyre and Raffensperger” and Woolley et al’* similarly noted a high rate of hernia recurrence in children with connective tissue disorders (Ehlers-Danlos syndrome). McEntyre and Raffensperger recommended that infants and children with Ehlers-Danlos syndrome undergo a formal herniorrhaphy similar to those performed in adult patients.” In addition, reports by Fonkalsrud et a&l3and others”16 conceming both femoral and direct inguinal hernias in infants and children, document that recognition of these more unusual pediatric hernias often follows the performance of a previous indirect inguinal hernia repair. These observations imply that previous operative trauma may aiter the status of the tissues of the floor of the inguinal canal in the infant, and may predispose the patient to an otherwise unusual type of recurrent hernia (eg, direct, femoral). Twenty of 71 recurrences in the present report were direct. Growth failure and poor nutrition may also play a role in cases of recurrence. Four patients in the current retrospective review had documented malnutrition, whereas eight were less than the fifth percentile of weight for height on the growth grid at the time of their repair. The European reports describing a higher rate of hernia recurrence than noted in the United States reflect that these procedures are often performed at
facilities other than a Children’s Hospital by nonpediatric surgical staff.4-6Harvey et al4 also imply that all the hernia operations at their facility were performed by junior staff and that in the very small infant (66% of their cases were less than 1 year old) perhaps it would be more appropriate for more experienced personnel to be involved. The fact that many of the infants currently being treated for inguinal hernia are premature babies who required a stay in the neonatal intensive care unit and have an increased risk of hernia recurrence may support this contention.‘” In the present study, prematurity was identified as a potential comorbid factor in hernia recurrence. Smith suggested that “inexperience in dealing with diminutive structures, unfamiliarity with special anatomic variations (sliding hernia of tube and ovary in girls, bladder close to the internal ring, etc), and amplification of adult concepts” may have an adverse effect on outcome following inguinal hernia repair by the occasional infant hernia surgeon.” A number of other predisposing factors were noted during this review concerning recurrent inguinal hernia. These include increased intraabdominal pressure due to VP shunt procedures for hydrocephalus, ascites, posterior urethral valves with bladder outlet obstruction, primary closure of bladder exstrophy, weight-lifting, and respiratory conditions associated with chronic cough such as asthma and cystic fibrosis. Increased intraabdominal pressure was implicated as a predisposing factor in 24% (15/62) of recurrent cases and confirms the observations of other authors”-19 regarding this procedure and its relationship to inguinal hernia. Certain technical details during performance of indirect inguinal hernia repair are probably worth stressing. Gentle technique and minimal mobilization of the cord structures and posterior floor of the inguinal canal are important considerations. In most cases, a simple herniotomy accomplished by high ligation of the hernia sac at the level of the internal inguinal ring with an interrupted nonabsorbable suture ligature is all that will be necessary. The appearance of retroperitoneal fat attached to the base of the sac is an indication that the dissection is high enough. Careful pressure on the lower abdomen just prior to cutting the suture ligature and excising the distal hernia sac may identify leakage of peritoneal fluid from an otherwise unrecognized tear in the proximal sac. We advise the use of nonabsorbable suture for ligation of the hernia sac. Three of the infants in this review without comorbid conditions (who were initially treated elsewhere) had early indirect hernia recurrence after high ligation was accomplished with
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chromic catgut. If the internal ring is excessively large, this should be narrowed (snugged) by interrupted nonabsorbable sutures placed across the transversalis fascia inferior to the cord structures.2,3’19If the infant or young child has an associated undescended testis, a concomitant orchiopexy should be performed at the time of the hernia repair, which should obviate the need for an additional groin exploration to pex the testis and reduce the risk of hernia recurrence. Seven infants in this study treated at other institutions and one in-house case had hernia recurrence when the testis was not pexed synchronously with hernia repair. In girls, a sliding hernia of the fallopian tubes and/or ovary may be present in 15% of cases.3”9 The sac can be sutured just above the sliding component and the entire stump reduced into the abdominal cavity through the internal ring. Because there are neither vas deferens nor testicular vessels to worry about, the internal ring can then be sutured closed. This will avoid the risk of indirect hernia recurrence in girls. In cases with poor tissue turgor or a weak posterior floor of the inguinal canal, a herniorrhaphy (iliopubic tract to transversus abdominus aponeurosis repair) should be added to high ligation of the sac as definitive therapy. Examples include infants with growth failure, connective tissue disorders, selected patients with myelomeningocele and VP shunts, and chronic pulmonary disease in which a higher risk of hernia recurrence can be anticipated. In instances of direct inguinal hernia with a definite defect through the floor of the inguinal canal medial to the epigastric vessels, a Cooper’s ligament repair using strong nonabsorbable interrupted sutures should be performed. Most recurrent hernias (especially in girls)
can be repaired by using the inguinal approach a second time. However, in instances of multiple recurrences, a preperitoneal hernia repair is advised.” This is particularly useful in boys because it avoids potential injury to the vas deferens and spermatic vessels by staying out of the previously scarred tissues in the groin. In most cases, repair can be performed without insertion of prosthetic materials. Rarely, however, this may be necessary to avoid excessive tension on the repair. Goretex is the prosthetic patch we currently favor, and was used successfully in one patient with multiple recurrences in the present report. These observations and previous studies suggest that the following factors may predispose to inguinal hernia recurrence: (1) failure to ligate the sac high enough at the internal ring; (2) a large internal inguinal ring; (3) injury to the floor of the inguinal canal from operative trauma; (4) failure to close the internal inguinal ring in girls; (5) inherent weakness or friability of the tissues in patients with connective tissue disorders, poor nutrition, prematurity, and growth failure; (6) conditions associated with increased intraabdominal pressure (VP shunt, ascites, pulmonary conditions with chronic cough, urethral valves, bladder exstrophy, weight-lifting, etc); (7) incarcerated hernia requiring emergency operation; (8) postoperative wound infection and hematoma; and (9) deferred orchiopexy in infants with concomitant undescended testis. Recognition of these factors, gentle operative technique by surgeons experienced in the care of infants, modifications in the operative procedure based on selective individualization of patients at high risk for recurrence, and early elective repair prior to incarceration may prove useful in reducing the rate of recurrence.
REFERENCES 1. Greenburg AG: Revisiting the recurrent groin hernia. Am J Surg 154:35-40,1987 2. Smith CD: The abdominal parietes, in Welch KJ (ed): Complications of Pediatric Surgery. Philadelphia, PA, Saunders, 1982, pp 216-220 3. Rowe MI, Lloyd DA: Inguinal hernia, in Welch KJ, Randolph JG, Ravitch MM, et al (eds): Pediatric Surgery (ed 4). Chicago, IL, Year Book, 1986, pp 779-793 4. Harvey MH, Johnstone MJ, Fossard DP: Inguinal herniotomy in children: A five year survey. Br J Surg 72:485-487,198s 5. Kvist E, Gyrtrup JH, Mejdahl S, et al: Outpatient orchiopexy and herniotomy in children. Acta Paediatr Stand 78:754-758, 1989 6. Ingimarsson 0, Spak I: Inguinal and femoral hernias: Longterm results in a community hospital. Acta Chir Stand 149:291-297, 1983 7. Rescorla FJ, Grosfeld JL: Inguinal hernia repair in the perinatal period and early infancy: Clinical considerations. J Pediatr Surg 19:832-837,1984 8. Harper RG, Garcia A, Sia C: Inguinal hernia: A common problem of premature infants weighing 1000 grams or less at birth. Pediatrics 56:112-115, 1975
9. Puri P, Guiney EJ, O’Donnell B: Inguinal hernia in infants: The fate of the testis following incarceration. J Pediatr Surg 19:44-46, 1984 10. Coran AG, Eraklis AH: Inguinal hernia in the HurlerHunter syndrome. Surgery 61:302-304,1967 11. McEntyre RL, Raffensperger JG: Surgical complications of Ehlers-Danlos syndrome in children. J Pediatr Surg 12:531-535, 1977 12. Woolley MM, Morgan S, Hays DM: Heritable disorders of connective tissue: Surgical and anesthetic problems. J Pediatr Surg 2:325-331, 1967 13. Fonkalsrud EW, de Lorimier AA, Clahvorthy HW Jr: Femoral and direct hernias in infants and children. JAMA 192:597599,1965 14. Viidik T, Marshall DG: Direct inguinal hernias in infancy and childhood. J Pediatr Surg 15:646-647, 1980 15. Schulz S, Schmidt PF: Femoral hernia in children. Z Kinderchir 40:287-288,1985 16. Anderas P, Jona JZ, Glichlich M, et al: Femoral hernias in children: An infrequent problem. Arch Surg 122:950-951,1987
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17. Gross K, DeSanto A, Grosfeld JL, et al: Intra-abdominal complications of cystic fibrosis. J Pediatr Surg 20:431-435,1985 18. Grosfeld JL, Cooney DR: Inguinal hernia after ventriculoperitoneal shunt for hydrocephalus. J Pediatr Surg 9:311-315, 1974
19. Grosfeld JL: Current concepts in inguinal hernia in infants and children. World J Surg 13:506-515,1989 20. Boley SJ, Kleihaus S: A place for the Cheatle-Henry approach in pediatric surgery. J Pediatr Surg 1:394-397, 1966
Discussion H.B. Othersen (Charleston, SC): As was pointed out, this is the bread and butter of pediatric surgeons and if things are going wrong we need to find out what’s happening and why and how they can be corrected. The thing that was most interesting to me about this paper is that 51 of these hernias were indirect in their recurrence. I think a lot of these never had the sac ligated in the first place. I concede the direct hernias occurring as a result of comorbid conditions, such as cystic fibrosis, etc, but it seems to me that there are only three conditions in which you would have an indirect so-called recurrence, and one is that the sac was never ligated; it was missed. We all know that with a big hernia in a small child sometimes you can ligate only part of the sac or even get a tear in the sac and the sac may not have been ligated high enough, and a remnant of the sac was left. I would like to ask you, when you reviewed these at the recurrence operation, could you tell where the suture had been placed, because most of them except the three you mentioned used nonabsorbable sutures. The second question is whether herniograms would be of any use in evaluating these children preoperatively? N.R. Feins (Boston, MA): Did you find any femoral hernias in your series of recurrences? I have seen some children in whom the femoral hernia was missed at the time of exploration for what was thought to be an indirect inguinal hernia. The patient appears with an inguinal scar and a bulge. hf. Schwartz (Sacramento, CA): Dr Grosfeld, in your review 20 of the 71 recurrent hernias were the direct type. You have suggested that the cause was
trauma to the inguinal floor at the time of the initial procedure. Although this may be the cause in some, I am wondering if in many of these patients there was a preexisting direct defect. In fact, some infants may have had a complex hernia, and high ligation of the sac at the internal ring might pull the peritoneum from the direct space, but this obviously will not correct the defect. J. Grosfeld (response): Dr Otherson asked about operative findings. The recurrent indirect hernias were due to an unrecognized hole in the base of the sac, a missed sac, inadequate dissection of the sac to the level of the internal ring resulting in a persistent sac remnant, failure to snug a very large internal ring, and in three cases, the use of absorbable suture for ligation of the sac. We did not use herniography. Dr Feins, we have seen a few femoral hernias each year in children; however, none were noted in this group. In response to Dr Schwartz’s question, we could not determine if the direct hernias were present at the time of initial repair in cases performed elsewhere. However, none were noted at this institution. When repairing an indirect inguinal hernia, the dissection should be kept within the confines of the cremasteric. The floor of the canal should not be disturbed and the vas should never be grasped by a forceps (to avoid crush injury). The dissection must be taken up to the level of the internal ring, where one can usually see some preperitoneal fat prior to attempting suture ligation. Gentle pressure on the lower abdomen will indicate whether there is a “missed hole in the peritoneum” by producing a rush of peritoneal fluid.
