Surgical anatomy of the inguinal canal in children

Comparison of Ferguson and Gross herniotomy with Mitchell Banks' herniotomy in boys older than two years

Background & Objective

In children younger than two years, most surgeons perform the inguinal herniotomy superficially through the external ring, a technique known as Mitchell-Banks' Herniotomy (MBH) while in older children, commonly Ferguson and Gross Herniotomy (FGH) is performed which involves opening of inguinal canal. Our aim was to compare the FGH and MBH in terms of recurrence in boys with inguinal hernia.

Methods

Boys with inguinal hernia presenting to Pediatric Surgery, Mayo Hospital Lahore from Dec 2016 to January 2018 were included in the study, if older than two years and younger than 14 years and without palpable deep ring (2 cm or more in width) or strangulation of inguinal hernia or malnutrition. They were randomly allocated in 2 groups after obtaining informed consent from parents, and underwent MBH (Group-A) and FGH (Group-B). Children were called for follow up after 1 week and at 6 months to assess for recurrence.

Results

Total 260 patients with inguinal hernia were enrolled (NCT: 03392636). The mean age of boys in Group-A was 5.2±3.0 years and in Group-B was 5.9±3.1 years. Mean operating time in Group-A (26.65±3.22 minutes) was longer than Group-B (15.92±4.22 minutes), and scrotal oedema was noted in 38 (29.2%) cases in Group-A, while 7 (5.4%) cases in Group-B. Testicular atrophy was noted in one patient of Group-B. Recurrence occurred in 1(0.8%) patient in Group-A, and in 8(6.2%) patients in Group-B (p-value 0.018).

Conclusion

Mitchell-Banks' herniotomy has lower recurrence rate than Ferguson and Gross Herniotomy in boys older than two years.

Outcomes of pediatric inguinal hernia repair with or without opening the external oblique muscle fascia

BACKGROUND

Considering that complications and outcome of each method of pediatric inguinal hernia repair are one of the determinants for pediatric surgeons for selection of the appropriate surgical technique, we compared the early and late complications of two inguinal repair techniques, with and without opening the external oblique muscle fascia.

MATERIALS AND METHODS

In this double-blind clinical trial study, boy children aged 1-month to 6 years with diagnosed inguinal hernia were included and randomly allocated into two groups for undergoing two types of hernia repair techniques, with and without opening the external oblique muscle fascia. Surgical complications such as fever, scrotal edema and hematoma, and wound infections classified as early complication and recurrence, testis atrophy and sensory impairment of inguinal area classified as late complications. The rates of mentioned early and late complications were compared in the two interventional groups.

RESULTS

In this study, 66 patients were selected and allocated to the two interventional groups. The prevalence of early and late complications in two studied groups were not different significantly in two interventional groups (P > 0.05). Operation time was significantly shorter in inguinal repair techniques without opening the external oblique muscle fascia than the other studied technique (P = 0.001).

CONCLUSION

The findings of our study indicated that though early and late complications of the two repair methods were similar, but the time of procedure was shorter in herniotomy without opening the external oblique muscle, which considered the superiority of this method than inguinal hernia repair with opening the external oblique muscle.

The pediatric inguinal canal: Systematic review of the embryology and surface anatomy

The inguinoscrotal region is one of the most common areas operated on in pediatric surgery. Despite this, the surface anatomy of the pediatric inguinal canal is variably defined. The aim of the current systematic review is to evaluate the development and surface anatomy of the pediatric inguinal canal. A systematic review of inguinal canal anatomy in children was conducted using the electronic databases: Medline, PubMed, Scopus, and Google Scholar. Relevant anatomical measurements and relationships were reviewed. The anatomical structures forming the walls of the inguinal canal were identified in fetuses as early as 8-10 weeks gestation. No studies addressed the developmental basis of this early defect in the lower anterior abdominal. Later gonadal development and descent has a defined role. In vivo measurements of children carried out during open surgery are inconsistent. Some studies showed rapid growth velocity of the length of the inguinal canal up to 2 years of age (with height and growth of the bony pelvis) before plateauing, while others suggested no increase in canal length prior to 10 years of age. The position of the deep inguinal ring was equally unclear; some studies suggested this was medial to the midpoint of the inguinal ligament. No studies described the position of the superficial ring, challenging the assumption that the rings are superimposed in the neonate. The dearth of studies analyzing pediatric inguinal anatomy means that changes in the position of the rings with respect to the lengthening of the canal remain unclear.

Inguinal herniotomy with the Mitchell-Banks' technique is safe in older children

PURPOSE

There is a tendency for the majority of surgeons to open the inguinal canal in children over two years old when performing inguinal hernia repair. On the other hand, in small children, most surgeons perform the herniotomy superficially to the external ring, as in Mitchell-Banks' technique (MBT). Our aim was to compare the Ferguson hernioplasty (FH) and Mitchell-Banks' technique in terms of recurrence and complication rates in older children.

METHODS

We retrospectively reviewed the office medical records of children who were at least two years old and who underwent a herniotomy procedure for inguinal hernia between 1997 and 2012.

RESULTS

The 4520 inguinal herniotomy procedures in boys who were over two years old were included in this study. Of these cases, 1607 cases (40.2%) were operated on by a FH with opening the inguinal canal, and 2388 cases (59.8%) by MBT superficially to the external ring. The median ages were 5.1 years (range, 2.0-16.2) in the FH group and 4.6 years (2.0-14.6) in the MBT group. The total complication rates were 2.3% in the FH group and 2.9% in the MBT group (P>.05). Early complications such as wound infection, scrotal edema, and hematoma were seen in 13 (0.8%), 15 (1%), and 10 (0.6%) in the FH group, and 12 (0.5%), 18 (0.7%), and 15 (0.6%) in the MBT group, respectively (P>.05). Late complications such as recurrence, trapped undescended testis, and testicular atrophy were seen in 2 (0.12%), 1 (0.06%), and 2 (0.12%) in the FH group, and 3 (0.12%), 1 (0.04%), and 2 (0.08%) in the MBT group (P>.05).

CONCLUSION

The Mitchell-Banks technique is a simple and safe procedure in older boys.