Pediatric (this article refers to children younger than 6 years old) inguinal hernia is the most common disease in pediatric surgery and is a common ventral hernia, accounting for 75% to 90% of all ventral hernias. Inguinal hernia occurs mostly in males, with a male to female incidence ratio of approximately 15:1, and is more common on the right side than on the left side, probably due to a later descent of the right testicle in males. The etiology is the same as for all ventral hernias: 1.
1. reduced strength of the abdominal wall, most commonly in pediatric patients the spermatic cord or uterine round ligament crossing the inguinal canal leading to reduced strength of the abdominal wall, biological studies have shown that the reduced strength of the abdominal wall may be due to disturbances in collagen metabolism in the tendon membrane, mainly due to reduced hydroxyproline amino acid content, which affects the strength of the abdominal wall.
2, increased intra-abdominal pressure, frequent crying in children is a common cause of increased intra-abdominal pressure. The latter mostly contributes to the entry of hernia contents into the hernia sac. Pediatric inguinal hernia is considered to be a congenital disease, and except for a few that heal on their own within a few months after birth, the vast majority of children grow older with age and the hernia must be treated surgically to heal.
The inguinal hernia in pediatric patients is due to congenital non-closure or incomplete closure of the peritoneal sheath rather than to muscular weakness, and generally a simple high ligation of the hernia sac can achieve satisfactory results without repair. Therefore, the principle of treatment for pediatric inguinal hernia is to perform a high ligation of the hernia sac. Currently, it is believed that laparoscopic treatment of pediatric inguinal hernia is gradually replacing traditional open surgery as the main procedure, but preoperative analysis should be specific to the case characteristics, and some children still need to undergo traditional open surgery.
The laparoscopic high ligation of the hernia sac includes
1. transabdominal intraperitoneal loop suture ligation. A small incision of 0.3 cm is made at 3 cm next to the left and right umbilicus, respectively, and two operating forceps are placed. 2 to 3 Z-shaped sutures are intermittently made in the abdominal cavity with a needle with thread to close the inner ring opening starting from the medial side of the hernia ring, and the intra-abdominal suture is tied. The suture is reliable, but the operation is tedious due to the intra-abdominal suture and knotting, and there is a risk of damaging the intestinal canal, vas deferens and spermatic vessels, so not much is carried out in China at present.
2.Extracorporeal knotting of the hernia sac and suturing. A small 0.3 cm incision is made 3 cm to the left of the umbilicus and a manipulation forceps is placed. A small 0.15 cm incision is made at the projection of the body surface of the inner ring opening on the affected side, a hernia needle is inserted, and under laparoscopic surveillance, the thread is wrapped around the peritoneum below the inner ring opening through the hernia needle, the residual gas of the hernia sac is squeezed, the looped thread is tightened and knotted to close the inner ring opening, and the thread is buried under the skin of the incision of the needle eye. This procedure is safe and easy to operate, in accordance with traditional surgical habits, easy to retrieve materials and low cost, and is now the main mode of laparoscopic surgery in children.
Traditional open hernia bursa high ligation: an incision of about 1.5 cm is made at the transverse skin line of the lower abdomen, the skin and subcutaneous tissues are incised layer by layer, the spermatic cord and the hernia bursa are separated, and a simple hernia bursa high ligation is routinely performed, and if there is a defect in the inguinal canal wall (such as a large internal ring opening), additional repair can be performed.
Features of laparoscopic versus traditional open surgery for inguinal hernia.
1. Laparoscopic procedure.
(1) small laparoscopic wound, little injury, almost no scar, with minimally invasive and aesthetic features.
(2) Operating in the abdominal cavity without dissecting the inguinal canal, it can avoid local tissue adhesions and injuries to the levator muscle, spermatic cord arteries and veins, vas deferens and nerves, maintaining the normal anatomical structure of the inguinal canal, with little local trauma and fast recovery.
(3) laparoscopic ligation of the hernia sac at the intra-abdominal ring opening to achieve a true high ligation, which is in accordance with surgical principles.
(4) Some pediatric inguinal hernias are bilateral and only exist in a potentially occult form, with up to 26% to 32% reported in the literature. There may be no clinical manifestations at the time of surgery, but when the abdominal pressure increases, especially after healing of the inguinal hernia on the contralateral side (the side of the first lesion), an inguinal mass may develop. During laparoscopic surgery, it is easy to detect the presence of occult hernia on the contralateral side by exploring the abdominal cavity, which can be treated together with surgery, avoiding reoperation.
(5) The laparoscopy is operated in the abdominal cavity, and it is not easy to have postoperative complications such as scrotal hematoma, edema, testicular atrophy and medically-derived cryptorchidism.
(6) Laparoscopic surgery requires the establishment of an artificial pneumoperitoneum, and smaller infants (<6 months old) are still immature due to the development of various organs, and their respiratory and circulatory systems are significantly disturbed by the pressure of the pneumoperitoneum, which makes anesthesia medication and management difficult.
2, traditional open surgery: open surgery for pediatric inguinal hernia is a traditional surgical method in the past, which can treat almost all types of pediatric inguinal hernia, regardless of age, and can be supplemented with repair if necessary. However, because intraoperative dissection of the inguinal canal may be required, there is a risk of injury or incorrect ligation of the vas deferens, which affects the child’s reproductive function. Complications such as scrotal hematoma are more frequent due to the large intraoperative separation trauma.
The choice between laparoscopic and traditional surgery: laparoscopic high hernial sac ligation has the advantages of minimally invasive, aesthetic, simultaneous detection of bilateral occult hernia, short operation time, fast postoperative recovery, low recurrence rate and few complications, so laparoscopic surgery is generally recommended as the first choice at present, but traditional open surgery can be considered in cases where
(1) The child is young, <6 months old.
(2) Those with inguinal canal wall defects, such as giant hernias or large preoperative findings of the affected external ring opening, requiring repair.
(3) Preoperative consideration of the presence of severe lower abdominal adhesions, such as those with a history of lower abdominal surgery
(4) those with preoperative symptoms and signs highly suspicious of sliding hernia
(5) those who need emergency surgery for incarcerated hernia.
The treatment of pediatric inguinal hernia should also be selected according to the specific situation of the child and the medical level of the hospital, so that the treatment can be individualized and the best results can be achieved.