Two hundred infants with PIH were operated upon using a skin incision overlying the spermatic cord as it crossed the pectineal line. Their ages ranged from 1 week to 14 months, with an average of 4.5 months. Their mean body weight was 5 kg. We operated upon 107 infants with right PIH, 74 with left side hernia, and 19 with bilateral hernias. The mean volume of testis on the affected side in unilateral cases was 704.5 on the right side and 724 mm3 on the left side, and the mean volume of testis in bilateral cases was 700 mm3 (Table 1).
The mean length of incision was 1 cm. Ten cases required extensions of incision up to 2 cm and this occurred during the early period of study. The mean operative time for unilateral cases was 20 min, whereas that for bilateral cases was 32 min. As regards the postoperative period 30 cases had scrotal edema, which improved with time and completely disappeared by the first postoperative follow-up visit. No cases had wound infection. Three cases had recurrence. These cases were operated upon laparoscopically once detected. Follow-up was carried out at the third postoperative month using inguinoscrotal ultrasound. We found no obvious change in testicular size in relation to its size before the operation. On the sixth postoperative month, the mean size of the testis on the affected side was 715.24 mm3 in the right cases and 727 mm3 in the left cases, and 710 mm3 in bilateral cases. This means no cases of testicular atrophy were recorded. Parents were satisfied with the cosmetic appearance of the incision (Tables 2–4).
Conventional open repair of PIH is considered a common surgical practice in infants and is considered the standard for repair 6.
However, it sometimes requires extensive hernia sac dissection from other spermatic cord structures including testicular vessels and vas deferens, which may focus light on the impact of these manipulations on the vascularity of the testis and structural changes in the vas while approaching the sac 7,8.
There are multiple studies using Doppler scanning of the testis to detect any impairment of vascularity in adults after inguinal hernia repair. Some authors have reported affection of vascularity in the immediate postoperative period that returned to normal values in the late postoperative period, whereas other authors have stated that there is no change in the early postoperative period 9,10.
This motivated us to modify the conventional technique so that it was a fine balance between the MIA and traditional approach.
In this respect we were in agreement with Ikeda et al. 6, who also pursued this minimal approach with satisfactory surgical and cosmetic results.
To achieve this minimal invasive strategy during our work we needed to be closest to the cord. This occurred only when the skin incision was made overlying the thickened cord as it crossed the pectineal line so that we could selectively extract the sac and repair the hernia.
In the traditional conventional approach the incision for inguinal hernia repair was made within the lowest abdominal crease at the inguinal region, which was above our incision by a few centimeters and necessitated adequate dissection to reach the cord and hence the sac 11.
Although our main aim was to avoid stretching or extraction of the cord during repair of the PIH, thus avoiding unnecessary manipulation of vas or vessels, this seemed to be the second goal for Ikeda et al. 6, whose main goal was the final cosmetic results.
Palabiyik et al. 12 studied the effect of manipulation of the cord structures in the conventional approach on the vascularization of the testis. They performed their study on kids aged 2–14 years using duplex scanning before, immediately after, and 30 days after the operation and found only changes in the early postoperative period, which returned to normal values at the end of the late postoperative period; thus, these changes were transient. They excluded children younger than 2 years because of the inability to assess the vascularity of the testis 12.
We believe that depending on the size of the testis instead of on a duplex study during follow-up with ultrasound scanning allowed us to detect any changes in the size of the testis especially in infants below 2 years of age, a group excluded by Palabiyik et al. 12. During our study no cases had postoperative testicular atrophy.
Oyen 8 showed that the traditional approach may be associated with a very low incidence of vas or testicular vessel injuries but they are far more disastrous.
From the experimental point of view Choi et al. 13 showed that the dissection of the cord and high ligation of the sac, which may not directly affect the vas, may affect testicular growth.
As regards MIA, Schier et al.14 were the first to evaluate testicular vascularization in PIH repair in children following the laparoscopic approach and concluded that laparoscopic repair did not impair testicular perfusion and also avoided injury to the vas. As in our study they depended on the testicular size as well as on duplex scanning.
In the same context, Çelebi et al.7 stated that open and laparoscopic hernia repair techniques did not impair the testicular vascularization. But they did not study the vas structural changes.
On revision of their technique Ikeda et al. 6 recorded no cases of testicular atrophy during follow-up but they depended mainly on clinical examination and comparison with the contralateral side or, if bilateral, compared testicular size with that of normal children of the same age group. From our point this was more subjective than if they had depended on ultrasound examination, which was more objective, especially when compared with preoperative results 15.
Ceylan et al.16 proved that there was progressive thinning of the smooth muscle layer of the vas deferens and testicular atrophy in their experimental work due to temporary stretching of the cord during the conventional approach to hernia repair.
The estimated values for the injury of the vas deferens during conventional open repair were 0.8–2% 17.
Through our technique we did not record any incidence of vas deferens injury because of selective sac extraction in which the vas and vessels were located at the base of the field away from the dissection.
The final cosmetic results were as satisfactory to the parents in our study as in the study of Ikeda et al. 6.
In conclusion, we believed that our technique aided in considerably reducing unnecessary stretching, extraction, and dissection of the cord structures and in avoiding any testicular atrophy or vas injury. Therefore, we believe that it is a step midway between the conventional inguinal open approach and the laparoscopic approach for PIH repair.
Conflicts of interest
There are no conflicts of interest.
1. Kumar A, Ramakrishnan TS. Single port laparoscopic repair of pediatric inguinal hernias: our experience at a secondary care center. J Minim Access Surg 2013; 9:7–12.
2. 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; 37:745–751.
3. Ein SH, Njere I, Ein A. Six thousand three hundred sixty-one pediatric inguinal hernias: a 35-year review. J Pediatr Surg 2006; 41:980–986.
4. Schier F. Laparoscopic inguinal hernia repair a prospective personal series of 542 children. J Pediatr Surg 2006; 41:1081–1084.
5. Bharathi RS, Arora M, Baskaran V. Minimal access surgery of pediatric inguinal hernias: a review. Surg Endosc 2008; 22:1751–1762.
6. Ikeda H, Hatanaka M, Suzuki M, Fujino J, Tahara K, Ishimaru Y. A selective sac extraction method: another minimally invasive procedure for inguinal hernia repair in children: a technical innovation with satisfactory surgical and cosmetic results. J Pediatr Surg 2009; 44:1666–1671.
7. Çelebi S, Yildiz A, Üçgül A, Karadağ ÇA, Sever N, Akin M, Dokucu Aİ. Do open repair and different laparoscopic techniques in pediatric inguinal hernia repairs affect the vascularization of testes? J Pediatr Surg 2012; 47:1706–1710.
8. Oyen RH. Scrotal ultrasound. Eur Radiol 2002; 12:19–34.
9. Aydede H, Erhan Y, Sakarya A, Kara E, Ilkgül O, Can M. Effect of mesh and its localisation on testicular flow and spermatogenesis in patients with groin hernia. Acta Chir Belg 2003; 103:607–610.
10. Dilek ON, Yucel A, Akbulut G, Degirmenci B. Are there adverse effects of herniorrhaphy techniques on testicular perfusion? Evaluation by color Doppler ultrasonography. Urol Int 2005; 75:167–169.
11. Glick PL, Boulanger SC. Grosfeld JL, O’Neill JA, Fonkalsrud EW, Coran AG. Inguinal hernia and hydroceles. Pediatric surgery, 6th ed. Philadelphia, PA: Mosby; 2006. 1172–1192.
12. Palabiyik FB, Cimilli T, Kayhan A, Toksoy N. Do the manipulations in pediatric inguinal hernia operations affect the vascularization of testes? J Pediatr Surg 2009; 44:788–790.
13. Choi SE, Kook MC, Kim CJ, Lee SC, Park KW, Jung SE, Kim WK. Effects of compression/stretching of the spermatic cord and blunt dissection on testicular growth and fertility. J Pediatr Surg 2009; 44:2163–2167.
14. Schier F, Turial S, Huckstadt TH, Klein KU, Wannik T. Laparoscopic inguinal hernia repair does not impair testicular perfusion. J Pediatr Surg 2008; 43:131–135.
15. Suzuki M, Hatanaka M, Fujino J, Igarashi A, Hasegawa M, Tahara K, et al.. Safety and efficacy of selective sac extraction method of inguinal hernia repair in children: results of a prospective study. Pediatr Surg Int 2014; 30:499–502.
16. Ceylan H, Karakök M, Güldür E, Cengiz B, Bağci C, Mir E. Temporary stretch of the testicular pedicle may damage the vas deferens and the testis. J Pediatr Surg 2003; 38:1530–1533.
© 2016 Annals of Pediatric Surgery
17. Benge BN, Jordan GH. Prepubertal vassal injury: its effect on postpubertal vas deferens. J Urol 1993; 149:906–909.