Original Article

Authors

S. A. Nah*, L. Giacomello*, S. Eaton, P. de Coppi, J. I. Curry, D. P. Drake, E. M. Kiely, A. Pierro

Aliation

UCL Institute of Child Health & Great Ormond Street Hospital for Children, Unit of Paediatric Surgery, London,
United Kingdom

Key words
incarcerated inguinal hernia

laparoscopic hernia repair

open hernia repair

Abstract

received
May 18, 2010
accepted after revision
June 18, 2010
Bibliography
DOI http://dx.doi.org/
10.1055/s-0030-1262793
Published ahead of print
Eur J Pediatr Surg
Georg Thieme
Verlag KG Stuttgart New York
ISSN 0939-7248
Correspondence
Prof. Agostino Pierro
UCL Institute of Child Health &
Great Ormond Street
Hospital for Children
Unit of Paediatric Surgery
London
United Kingdom
Tel.: + 44 2079 052 641
Fax: + 44 2074 046 181
pierro.sec@ich.ucl.ac.uk

Purpose: The management of Incarcerated

Inguinal Hernia (IIH) in children is challenging
and may be associated with complications. We
aimed to compare the outcomes of laparoscopic
vs. open repair of IIH.
Methods: With institutional ethical approval
(09SG13), we reviewed the notes of 63 consecutive children who were admitted to a single
hospital with the diagnosis of IIH between 2000
and 2008. Data are reported as median (range).
Groups were compared by chi-squared or t-tests
as appropriate.
Results: Open repair (n = 35): There were 21
children with right and 14 with left IIH. 2 patients
also had contralateral reducible inguinal hernia.
Small bowel resection was required in 2 children. Laparoscopic repair (n = 28): All children
had unilateral IIH (19 right sided, 9 left sided). 15
children (54 %) with no clinical evidence of contralateral hernia, had contralateral patent processus vaginalis at laparoscopy, which was also

Introduction

Inguinal hernia is the most common condition in

childhood requiring surgery. Repair in an elective
setting carries a low risk and has good results
with minimal complications. However, while
waiting for elective repair, the child is at risk of
developing incarceration, transforming a safe
elective procedure into a more emergent one,
requiring manual reduction and urgent repair
[1, 2]. Incarceration is also associated with other
significant morbidities, including testicular or
ovarian infarction and atrophy, bowel obstruction and strangulation, wound infection and
recurrence [3, 4]

repaired. The groups were similar with regard

to gender, age at surgery, history of prematurity,
interval between admission and surgery, and
proportion of patients with successful preoperative manual reduction. However, the duration of
operation was longer in the laparoscopy group
(p = 0.01). Time to full feeds and length of hospital stay were similar in both groups. Postoperative follow-up was 3.5 months (136), which was
similar in both groups. 5 patients in the group
undergoing open repair had serious complications: 1 vas transaction, 1 acquired undescended
testis, 2 testicular atrophy and 1 recurrence. The
laparoscopic group had a single recurrence.
Conclusion: Open repair of incarcerated
inguinal hernia is associated with serious complications. The laparoscopic technique appears
safe, avoids the dicult dissection of an oedematous sac in the groin, allows inspection of the
reduced hernia content and permits the repair
of a contralateral patent processus vaginalis if
present.

For many years, open surgery has been the procedure of choice for the treatment of Incarcerated
Inguinal Hernia (IIH). Recently, minimal access
surgery has gained a firm foothold in elective
inguinal hernia repairs, with paediatric surgeons
also using it to repair IIH [5, 6]. Our study aims to
compare the outcome after laparoscopic repair of
IIH vs. open surgery.

Materials and Methods

63 consecutive children with the diagnosis of IIH

were admitted to our institution between 2000
and 2008. With institutional ethical approval, we
reviewed the medical records of all the patients.
The diagnosis was confirmed in all cases after

* equally contributed.
Nah SA et al. Surgical Repair of Incarcerated Inguinal Hernia Eur J Pediatr Surg

Downloaded by: Agostino Pierro. Copyrighted material.

Surgical Repair of Incarcerated Inguinal Hernia in

Children: Laparoscopic or Open?

Original Article

Table 1 Clinical characteristics of 63 children who underwent open or laparoscopic repair of incarcerated inguinal hernia.
Open (n = 35)

Laparoscopic (n = 28)

p-value

1.8 (0.581.7)
3.3 (1.021.4)
31:4
16 (46 %)
left 13, right 20, bilateral 2
30 (86 %)
36.2 (1.3215)
13 (37 %)
35 (18150)
7 (20 %)
9 (2144)
66 (16240)
4 (136)

3.1 (0.739.8)
4.7 (1.910.0)
23:5
6 (21 %)
left 9, right 19, bilateral 0
26 (93 %)
35.9 (1.4112.2)
21 (75 %)
50 (3097)
15 (54 %)
9 (260)
59 (6191)
3 (224)

N.S.
0.01*
N. S.
N. S.
N. S.
N. S.
N. S.
0.001*
0.01*
0.005*
N. S.
N. S.
N. S.

physical examination by a consultant paediatric surgeon. Data

collected included weight, age, gender, history of prematurity,
unilaterality or bilaterality of the hernia, type of repair (open or
laparoscopic), duration of operation, operator level (consultant
or trainee), presence of contralateral Patent Processus Vaginalis
(PPV), time to full feeds, length of hospital stay, and postoperative complications.
After confirmation of the diagnosis, manual reduction was
attempted. This was done under sedation according to the preference of the assessor. After reduction, all the children underwent surgical repair of the hernia using either laparoscopic or
open methods. The type of operation depended on the surgeons
preference. The practice was to wait at least 24 h after manual
reduction before undertaking surgery. In the cases where manual reduction was not successful, the hernia was repaired
urgently.

Open inguinal hernia repair

A skin crease is made above and lateral to the pubic tubercle. The
external oblique fascia is opened in the direction of the fibres.
The hernial sac is freed from the vas and testicular vessels in
males, or from the round ligament in females. The sac is opened
to inspect and reduce content not successfully reduced preoperatively. The sac is twisted, ligated at the level of the internal
inguinal ring with 1 or 2 stitches, and divided. The contralateral
side is explored if there is evidence of a contralateral hernia or
hydrocoele. 1 surgeon had a preference for routine exploration
of the contralateral side in IIH.

Laparoscopic inguinal hernia repair

A Hasson cannula is inserted peri-umbilically using an open
technique. Pneumoperitoneum is created. A 3 mm telescope is
introduced; 3 mm instruments (needle driver, atraumatic forceps) are inserted in the right and left flanks without insertion
of ports. The hernial orifice is inspected and any content reduced.
The previously incarcerated viscera are inspected. The open
internal ring on the same side of the hernia is closed with a
purse-string or Z-type suture of non-absorbable material. The
forceps elevate the peritoneum so the stitch is applied carefully,
avoiding the vas and the vessels. The contralateral ring is
inspected and considered patent when it is wider than the tip of
the 3 mm forceps. A patent ring is closed as above.
Statistical analysis was done using SPSS 16.0 software and
GraphPad Prism 4. Data are reported as median and range.
Groups were compared by chi-squared, t-test, or Mann-Whitney

Nah SA et al. Surgical Repair of Incarcerated Inguinal Hernia Eur J Pediatr Surg

tests as appropriate. A p-value of less than 0.05 was considered

significant.

Results

A total of 63 consecutive children were reviewed. Their clinical

Table 1. 35 children had open hernia
data are displayed in
repair and 28 had laparoscopic repair. All repairs prior to 2005
were done using the open technique. Between 2005 and 2008,
both methods (open 19, laparoscopic 28) were used.
The groups were similar with regard to gender distribution and
age at operation. However, the childrens weight in the open
group (3.3 kg, range: 1.021.4) was less than in the laparoscopic
group (4.7 kg, range: 1.910.0) (p = 0.01). There were more children with a history of prematurity in the open group (n = 17,
46 %) compared to the laparoscopic group (n = 6, 21 %), although
this did not reach statistical significance (p = 0.06). 2 patients in
the open group had bilateral inguinal hernia at presentation,
while none in the laparoscopic group did (p = N. S.). Manual
reduction was unsuccessful in 5 patients in the open group and
in 2 in the laparoscopic group (p = N. S.). There was no dierence
in the time interval between admission and surgery between
the 2 groups.

Operative procedure
There were no conversions to an open procedure from laparoscopic hernia repair. Fewer contralateral PPVs were found in the
open group (n = 7, 20 %) compared to the laparoscopic group
(n = 15, 54 %) (p = 0.005). More consultants were the primary surgeons in the laparoscopic group (n = 21, 75 %) than in the open
group (n = 13, 37 %) (p = 0.001) and the duration of operation was
longer in the laparoscopic group (50 min, range: 3097) compared to the open group (35 min, range: 18150) (p = 0.01). 2
children in the open group required small bowel resection for
strangulated bowel; none in the laparoscopic group did.

Outcome
Postoperative follow-up was similar in both groups (open procedure: 4 months, range: 136; laparoscopic procedure: 3 months,
range 224) (p = N.S). In both groups, the time to achieving full
feeds and the length of hospital stay was similar.
5 patients (14 %) in the group undergoing open repair had seri Table 2). 1 patient had a transected vas
ous complications (
deferens which was repaired immediately during the same
anaesthesia. The other serious complications were observed

Downloaded by: Agostino Pierro. Copyrighted material.

age at surgery (months)

weight (kg)
gender (M:F)
history of prematurity
side of hernia
successful preoperative manual reduction
interval between admission and surgery (hours)
consultant as primary surgeon
duration of operation (min)
contralateral patent processus vaginalis
interval between surgery and full feeds (hours)
length of hospital stay (hours)
duration of follow-up (months)

Table 2 Postoperative complications.

complications (total number

of patients)
vas transection
acquired undescended testis
testicular atrophy
inguinal hernia recurrence

Open

Laparoscopic

(n = 35)

(n = 28)

1
1
2
1

0
0
0
1

p-value
N. S.

during outpatient follow-up: 2 patients had testicular atrophy, 1

patient had an acquired high testis for which an orchiopexy was
done 6 months after the initial hernia repair, and 1 patient had a
recurrence on the same side as the incarceration 4 months after
repair. In the laparoscopic group, there was only 1 (4 %) serious
complication, an inguinal hernia recurrence. This presented 5
months postoperatively and was repaired laparoscopically.
There were no wound infections seen in either group.

Discussion

This study indicates that incarcerated hernia can be repaired

using both open and laparoscopic procedures. The laparoscopic
technique appears to oer more advantages compared to the
open technique and should be considered, provided that the surgeon is experienced in operative laparoscopy.
Incarceration of an inguinal hernia poses unique challenges for
the management of a common condition that is otherwise
straightforward and low risk. The presence of an oedematous
sac with ill-defined tissue planes can be a pitfall for even the
most experienced of surgeons. IIH have notoriously been associated with an array of morbidities including vas and vascular
injury, small bowel strangulation and testicular atrophy.
Laparoscopic hernia repair is now being adopted in many centres. Schier et al. reported a multicentre series that concluded
that laparoscopic repair is safe with a recurrence rate of 3 % [7].
Chan et al. compared laparoscopic and open paediatric inguinal
hernia repair in a prospective randomised single-blind trial [8].
They concluded that patients who had laparoscopic repair had
less pain, a faster recovery and a better wound cosmesis. However, the duration of procedure was longer with laparoscopic
repair of unilateral inguinal hernias. This eect was lost in bilateral repairs.
As surgeons gained experience with laparoscopic hernia repair,
it became inevitable that this technique would be employed in
the management of IIH. A small number of studies have advocated its use [5, 6].
In our study, both the open and laparoscopic groups were similar in age, gender distribution and history of prematurity. However, the weight of patients in the open group was lower, possibly
reflecting a greater reluctance among surgeons to employ the
relatively newer laparoscopic technique in smaller patients who
were anticipated to have more dicult procedures. We did
notice a distinct shift in trend during the duration of the study,
with more open procedures done in the earlier part of the study
period and more laparoscopic repairs in the later period.
More than half of the patients in the laparoscopic group (n = 15,
54 %) were found to have a contralateral PPV, which was repaired
at the same time. This is a distinct and oft-cited advantage of
laparoscopic hernia repair [9, 10]. It allows inspection of the

contralateral side and concomitant repair, avoids the need for

repeated anaesthesia, and prevents a potentially hazardous
incarceration of the contralateral side without creating an additional surgical wound [11]. 7 patients (including 2 patients with
clinical bilateral inguinal hernia) in the open group had a contralateral PPV which was also repaired. These were done by a
consultant whose preferred practice was routine open exploration of the contralateral side.
In our study, we also noticed that more laparoscopic procedures
were done by consultants compared to open procedures which
were more likely to be done by trainees. This was probably a
reflection of the diculty that was anticipated in carrying out a
laparoscopic procedure for IIH.
The duration of the operation was longer in the laparoscopic
group. This is consistent with other reports [6, 8]. There were
some other theoretical advantages of laparoscopic surgery that
were not observed in our patients. While Koivusalo et al.
reported a shorter waiting time for surgery after manual reduction for laparoscopic repair compared to open procedures, we
did not observe any dierence between the groups [6]. Similarly
there was no dierence in the postoperative recovery as assessed
by time to full feeds and length of hospital stay, and the reported
benefits of quicker recovery and shorter hospital stay in patients
undergoing laparoscopic surgery were not seen [5, 8].
When we looked at serious complications post repair, there were
5 (14 %) in the open group and only 1 (4 %) in the laparoscopic
group. Although this did not reach statistical significance, these
results seem to indicate a trend towards more severe morbidities after open surgery. We might expect that avoiding a dicult
dissection in the groin, and operating under the superior magnification of a laparoscope, would greatly reduce the incidence of
vas and vascular injury. Testicular atrophy and acquired high
testis would also be avoided. However, these advantages should
be carefully balanced against the theoretical risk of visceral
injury during port and instrument insertion in laparoscopy.
A critical confounding factor is that more laparoscopic repairs
were done by consultants compared to the open procedures
group. To eliminate this bias which is inevitable in a retrospective
study, a prospective randomised controlled trial should be performed comparing laparoscopic vs. open repair of IIH. Weighted
minimisation for treatment allocation will be performed so that
the experience of the operating surgeon will be equally distributed among the 2 study groups as previously done in other trials
comparing open and laparoscopic surgery in children [12].
In conclusion, laparoscopic repair of incarcerated inguinal hernia appears safe. It may be associated with fewer serious complications compared to open hernia repair. It avoids the dicult
dissection of an oedematous sac in the groin, allows inspection
of reduced hernia content and permits the repair of a contralateral patent processus vaginalis if present.

Conflict of Interest: None

References
1 Chen LE, Zamakhshary M, Foglia RP et al. Impact of wait time on outcome for inguinal hernia repair in infants. Pediatr Surg Int 2009; 25:
223227
2 Stylianos S, Jacir NN, Harris BH. Incarceration of inguinal hernia in
infants prior to elective repair. J Pediatr Surg 1993; 28: 582583
3 Puri P, Guiney EJ, ODonnell B. Inguinal hernia in infants: The fate of
the testis following incarceration. J Pediatr Surg 1984; 19: 4446
4 Palmer BV. Incarcerated inguinal hernia in children. Ann R Coll Surg
Eng 1978; 60: 121124

Nah SA et al. Surgical Repair of Incarcerated Inguinal Hernia Eur J Pediatr Surg

Downloaded by: Agostino Pierro. Copyrighted material.

Original Article

Original Article

10 Lau ST, Lee YH, Caty MG. Current management of hernias and hydroceles. Sem Pediatr Surg 2007; 16: 5057
11 Ron O, Eaton S, Pierro A. Systematic review of the risk of developing
a metachronous contralateral inguinal hernia in children. Br J Surg
2007; 94: 804811
12 Hall NJ, Pacilli M, Eaton S et al. Recovery after open vs. laparoscopic
pyloromyotomy for pyloric stenosis: a double-blind multicentre randomised controlled trial. Lancet 2009; 373 (9661): 390398

Downloaded by: Agostino Pierro. Copyrighted material.

5 Kaya M, Huckstedt T, Schier F. Laparoscopic approach to incarcerated

inguinal hernia in children. J Pediatr Surg 2006; 41: 567569
6 Koivusalo A, Pakarinen MP, Rintala RJ. Laparoscopic herniorraphy after
manual reduction of incarcerated inguinal hernia. Surg Endosc 2007;
21: 21472149
7 Schier F. Laparoscopic surgery of inguinal hernias in children initial
experience. J Pediatr Surg 2000; 35: 13311335
8 Chan KL, Hui WC, Tam PKH. Prospective, randomized, single-center,
single-blind comparison of laparoscopic vs. open repair of pediatric
inguinal hernia. Surg Endosc 2005; 19: 927932
9 Miltenburg DM, Nuchtern JG, Jaksic T et al. Laparoscopic evaluation of
the pediatric inguinal hernia a meta-analysis. J Pediatr Surg 1998;
33: 874879

Nah SA et al. Surgical Repair of Incarcerated Inguinal Hernia Eur J Pediatr Surg