Analysis of the efficacy of high hernia sac ligation in adolescent indirect hernia

doi:10.21203/rs.3.rs-2439466/v1

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Analysis of the efficacy of high hernia sac ligation in adolescent indirect hernia

https://doi.org/10.21203/rs.3.rs-2439466/v1

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Journal Publication

published 13 Jun, 2023

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Objective

To evaluate the efficacy of high hernia sac ligation in adolescent indirect hernia.

Methods

The data of adolescent patients underwent high hernia sac ligation in the The First People's Hospital of Foshan,China from January 2012 to December 2019 were analyzed retrospectively, mainly collecting their age, gender, weight, surgical method, the hernia ring diameter, operation time, postoperative recurrence rate and postoperative complications.

Results

A total of 71 patients were enrolled, including 62 males (87.32%) and 9 females (12.68%),all patients aged 13–18 years old (mean14.90 ± 1.57years), weighing 28-92kg (mean 53.08 ± 10.53kg), 70patients underwent laparoscopic surgery except 2 with irreducible hernias converted to laparotomy,1 patients underwent open hernia sac high ligation.the hernia ring diameter: 0.5-3cm (mean 1.39 ± 0.49cm), and the diameter of the hernia ring ≤ 2cm in 69 cases (97.18%),The operative length: 12-105min (average 25.45 ± 13.19min), There were 38(53.5%) right-sided hernias, 32 (45.1%) leftsided hernias, 1 (1.4%) performed simultaneous bilaterally.There were 68 (95.8%)reducible hernia,2(2.8%)irreducible hernias ,1(1.4%)incarcerated hernia,Hospital stay :1–5 days (mean 2.37 ± 1.04 days), Follow-up 24-119months (mean 73.56 ± 28.56months), no recurrence, one case of incision infection occured, A second operation was performed 6 months after the operation,4(5.6%)patients had complaints of intermittent pain around the ligation incision site mostly during exerciseIn .

Conclusion

High hernia sac ligation is feasible for treat indirect hernia with a diameter of the hernia ring ≤ 2cm.

indirect hernia

adolescent

high hernia sac ligation

Inguinal hernias may present at all ages，The overall incidence of inguinal hernias in childhood ranges from 0.8% to 4.4%[1]，indirect hernias of children are due to incomplete closure of the processus vaginalis[2]. The treatment of indirect inguinal hernia in children is high ligation. The incidence of adult inguinal herniorrhaphy is 27-42.5% in males and 3-5.8% in females [3-6].The pathophysiology in adults is a result of a defect in the transversalis fascia because of weakness [7]. Therefore, the standard treatment for adult inguinal hernia is posterior wall repair. Currently, tension-free repair with mesh is most commonly used. Adolescents are a unique patient population between children and adults. adolescent hernias should be treat by high ligation or mesh repair? This study retrospectively analyzed the clinical data of high hernia sac ligation in the treatment of adolescent indirect hernia to make clear its efficacy.

The general information

We retrospectively reviewed the data of adolescent patients who underwent inguinal hernia repairs from January 2012 to December 2019 in The First People's Hospital of Foshan,Guangdong,China. The inclusion criteria for this study were: age 13-18 years;primary indirect inguinal hernia; informed consent was signed by the patient’s legal guardian;no dysfunction of vital organs, including the heart, lungs, liver and kidneys. Exclusion criteria: age <13 years or >18 years;direct hernia;femoral hernia;recurrent hernia;patient who refused to sign informed consent;

heart, lung, liver and kidney failure. The patients' gender, age ,weight, hernia characteristics, operative approach, operative length,intraoperative blood loss, length of stay, postoperative recurrence rate and complications were collected.Postoperative complications were defined as surgical site infection or mesh infection, symptomatic Seroma or hematoma, symptomatic hydrocele, postoperative pain.

Surgical method:The procedures of laparoscopic high hernia sac ligation were performed with the patient in the supine position under general anesthesia. An above umbilical 5.0-mm incision was made, and a 5.0-mm trocar was used to create a CO2 pneumoperitoneum that was maintained at 10–12 mmHg. Another 5.0-mm instrument were inserted through a 5.0-mm stab incisions on the left umbilical side.

the size of the hernia diameter was measured(Figure1).A 2mm incision was made at the body surface of the deep ring, and the sled needle with a 2-0 non-absorbable suture was punctured into the preperitoneum, through the medial peritoneal membrane of the deep ring and the vascular surface, to the bottom of the deep ring,and then the needle was puncture into the abdominal cavity(Figure2), the suture was left in the abdominal cavity, and the needle was withdrawed. A crochet was inserted through the original incision , through the lateral peritoneal membrane of the deep ring, punctured into the abdomen through the original puncture hole, the suture was hooked and took out of the body surface by the crochet(Figure3),the suture was knot subcutaneously, the high ligation of the hernia sac was complete(Figure4).

Follow-up: Patients were followed up in the outpatient department at 1 week, 1 month and 3 months after the operation. After 3 months post-operation, patients were followed up by telephone. If recurrence was suspected,the patient would be called back to outpatient and excluded by physical examination or imaging .No patients were lost to follow-up. The follow-up time of entire cohort was 24-119months (mean 73.56 ± 28.56months).

statistical method:All statistical analyses were performed using the spss21 statistical software .Continuous data were expressed as the mean ± standard deviation.

A total of 71 patients were enrolled, including 62 males (87.32%) and 9 females (12.68%),all patients aged 13–18 years old (mean14.90 ± 1.57years),Body weight was between 28-92kg(mean 53.08 ± 10.53kg),68 underwent elective laparoscopic high hernia sac ligation except 1 incarcerated hernia underwent emergency laparoscopic surgery.2 patients underwent laparoscopic surgery converted to laparotomy because of irreducible hernias.1patient underwent open surgery.the hernia ring diameter: 0.5-3cm (mean 1.39 ± 0.49cm), among them, the diameter of the hernia ring of 1 patient was 3cm,another patient was 2.5cm,and the other 69(97.18%) patients were ≤ 2cm ,The operative length: 12-105min (average 25.45 ± 13.19min), The amount of intraoperative bleeding was minimal and difficult to make accurate statistics.There were 38(53.5%) right-sided hernias, 32 (45.1%) leftsided hernias, 1 (1.4%) performed simultaneous bilaterally.24 patients(33.8%) performed simultaneous contralateral hernias.There were 68 (95.8%)reducible hernias,2(2.8%)irreducible hernias ,1(1.4%)incarcerated hernia,Hospital stay :1–5 days (mean 2.37 ± 1.04 days), Follow-up 24-119months (mean 73.56 ± 28.56months), no recurrence, one case of incision infection occured, a second operation was performed 6 months after the operation,4(5.6%)patients had complaints of intermittent pain around the ligation incision site mostly during exercise.There was no hydrocele ,hematoma and seroma

At present,There is no consensus on the cause and surgical treatment of adolescent indirect hernias. One opinion is that adolescent indirect hernias are considered to be the continuation of children’s indirect hernias, some of those develop symptoms early in children and are not treated until adolescents, and some are born with incomplete closure of the processus Vaginalis that do not show clinical symptoms until adolescence.Therefore, the treatment of adolescent indirect inguinal hernia is high ligation.However, the other main opinion is that postpubertal adolescents have similar anatomy to the adults with a larger internal ring diameter and variations on transverse fascia defects[7].So the indirect hernia of adolescents need to be repaired with tissue or mesh to strengthen the posterior inguinal wall.

Whether high ligation or mesh repair is more appropriate for the treatment of adolescent hernias mainly depends on the postoperative recurrence rate. Most recurrences are likely to occurred within 2 years after inguinal hernia repair, but the recurrence rate will increase with the extension of follow-up time [8–13].the recurrence rate of inguinal hernia after operation is 0-6.3%[14–16], The tension-free mesh repair is helpful to reduce the recurrence rate and has become the mainstream operation for adult hernia. However, in adolescents, the body is still developing, the insertion of the mesh may result in foreign body rejection and infection, may affect the vas deferens, and may limit the body's development. If the recurrence rate do not increase with high ligation alone, it is better not to use a mesh for adolescent hernia patients. But the real situation is not so that, a study about the treatment of adolescent hernia emphasized the likelihood that the surgical procedure was driven by the surgeon's preferences, not necessarily the course of the disease or the outcomes of the patient[17].The reason for this situation may be that there are rare studies on the treatment of adolescent hernias.

In this study, a retrospective analysis was made to evalute the efficacy of high hernia sac ligation in the treatment of adolescent indirect hernias. After 24-119months (mean 73.56 ± 28.56months)of follow-up, the results showed the recurrence rate was 0%. some other studies have shown that the recurrence rate of high hernia sac ligation without mesh for adolescent hernias was 0.95%-3.5%, which was also relatively low[7, 18].The recurrence rate of high ligation for adolescent hernias was similar to that of mesh repair for adult hernias[19].Another study reported that the recurrence rate of patients aged 18–25 years who underwent herniectomy without mesh placement or posterior wall repair is 0%[20]. These suggests that high hernia sac ligation without mesh placement or posterior wall repair is effective enough in treating adolescent hernias.However, none of these studies showed the size of the deep ring of the indirect hernia, as the size of the internal ring may affect the choice of the surgeon[17, 21].The internal ring is small, the surgeon chooses the hernia sac high ligation more, the internal ring is large, and the surgeon chooses the mesh repair or tissue repair more.So how large the internal ring should the surgeon select mesh repair or tissue repair?How small select a simple high hernia sac ligation?

S. R. Lee. et al[18] have done a comparative study of the high ligation of the laparoscopic hernia sac and the posterior wall repair in the adolescent indirect hernia. The size of the internal ring diameter in the two groups was 2.37 ± 0.52 (1.60–3.62) cm VS 2.41 ± 0.58 (1.59–3.65) cm (p = 0.592).The results showed that the recurrence rate in high ligation group(4/115,3.48%) was higher than that in posterior wall suture repair group (0/129,0%) (p = 0.048).Shen Yingmo et al [22]have done a prospective comparative study between high ligation and Lichtenstein hernioplasty using acellular tissue matrix (ACTM) grafts in adolescent patients. the diameter of the two groups was 2.2 ± 0.5cm vs2.3 ± 0.5cm(p = 0.499) ,The results showed that the recurrence rate no difference between the two groups6% (3/50) vs0% (0 / 50) (p = 0.079), but subgroup (the patients with Gilbert type 3 hernias)analysis found that the recurrence rate of high ligation group was higher than mesh repair group. The results indicated that indirect hernia repair in adolescents with a internal ring diameter greater than 3cm and severe transverse fascia defect,mesh repair may be a more suitable surgical method.

From the current literature[18, 22],the conclusion seems to be drawn. the diameter of internal ring more than 3cm or severe transverse fascia defect of adolescent indirect hernias were recommended to use mesh repair, when the diameter of internal ring between 2-3cm ,the efficacy of high hernia sac ligation was controversial, these patients can be considered laparoscopic posterior wall suture repair or open muscle repair. in our study, 97% of adolescent indirect hernia patients with a internal ring diameter ≤ 2cm ,these patients were treat with high hernia sac ligation,the reccurence was 0. Therefore, we believe that the ligation of high hernia sac in adolescents with a internal ring diameter ≤ 2cm is effective.But we should also note that in our study, the number of cases were small; no comparative study was done; the follow-up time of some patients was short, patients with recent surgery must be followed for a longer period of time to observe the true recurrence rate

The main complication after inguinal hernia repair is seroma, the high ligation of the hernia sac does not require the separation of the preperitoneal space and hernia sac, the incidence of seroma is low. No seroma occurred in this study.one case of incision infection occured in this study, the patient underwent laparoscopy converted to laparotomy because of irreducible hernia, 6 months after the operation, the wound was infected due to the non-absorbable suture knot which was removed by a second operation.4patients (4/71,5.63%)had complaints of intermittent pain around the ligation incision site mostly during exercise,This was similar to previous research[7, 23].the patient’s pain degree was mild, so no treatment was needed. No hydrocele occurred after surgery.

In summary, high hernia sac ligation in the treatment of adolescent indirect hernias with the diameter of internal ring ≤ 2cm is effective, The rate of recurrence and complications is low. Therefore, this study suggests that high hernia sac ligation is effective enough for the treatment of adolescent indirect hernias with the diameter of internal ring ≤ 2cm and no need to worry about the adverse effects of using the mesh.However, this study is a retrospective study with a small number of participants. Further prospective comparative study is required.

Ethics approval and consent to participate

Subjects and their legal guardians have given their written informed consent and the First People's Hospital of Foshan institutional review board has approved the study protocol . All methods were carried out in accordance with relevant guidelines and regulations or Declaration of Helsinki.

Consent to publish

Not applicable.

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests

Funding

No funding was used for this study.

Authors’ contributions

GYF made substantial contributions to the conception of the study and the design of the work,

acquisition and interpretation of data and drafted the manuscript. GY made substantial contributions to

the conception of the study, acquisition and interpretation of data and revisions of the manuscript. All

authors have read and approved the manuscript.

Acknowledgement

Not applicable

Brandt, M. L.(2008)Pediatric Hernias. Surgical Clinics of North America, 88(1)：27–43.
Arnold G，Coran MD．（2012） Pediatric Surgery［M］． 7th Edition． UK: Mosby: 985-1001．
Primatesta P, Goldacre MJ (1996) Inguinal hernia repair: incidence of elective and emergency surgery, readmission and mortality. Int J Epidemiol 25(4):835–839
Herna´ndez-Irizarry R, Zendejas B, Ramirez T et al. (2012) Trends in emergent inguinal hernia surgery in Olmsted County, MN: a population-based study. Hernia 16(4):397–403.
Burcharth J, Pedersen M, Bisgaard T, et al.(2013) Nationwide prevalence of groin hernia repair. PLoS One 8(1):e54367.
Ohene-Yeboah M, Abantanga F, Oppong J, et al. (2009) Some aspects of the epidemiology of external hernias in kumasi, Ghana. Hernia 13(5):529–532.
Gasior AC,Knott EM,Kanters A,et al.(2015)Two-center Analysis of Long-term Outcomes after High Ligation Inguinal Hernia Repair in Adolescents.The American Surgeon, (81):1260-1262
Shehata SM, El Batarny AM, Attia MA, et al. (2015) Laparoscopic interrupted muscular arch repair in recurrent unilateral inguinal hernia among children. J Laparoendosc Adv Surg Tech A 25:675–680
Collaboration EUHT. (2002) Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials. Ann Surg 235:322–332
Shalaby R, Ismail M, Gouda S, et al.(2015) Laparoscopic management of recurrent inguinal hernia in childhood. J Pediatr Surg 50:1903–1908
Lee SR, Choi SB. (2017) The efficacy of laparoscopic intracorporeal linear suture technique as a strategy for reducing recurrences in pediatric inguinal hernia. Hernia 21:425–433
Sevonius D, Gunnarsson U, Nordin P, et al. (2011) Recurrent groin hernia surgery. Br J Surg 98(10):1489–1494.
Köckerling F, Koch A, Lorenz R, et al. (2015)How long do we need to follow-up our hernia patients to find the real recurrence rate? Front Surg2(24):1-5.
Pokorny H, Klingler A, Schmid T, et al. (2008) Recurrence and complications after laparoscopic versus open inguinal hernia repair: results of a prospective randomized multicenter trial. Hernia 12:385–389.
Burcharth J, Andresen K, Pommergaard H-C, et al.(2014) Recurrence patterns of direct and indirect inguinal hernias in a nationwide population in Denmark. Surgery 155(1):173–177.
Kantor N, Travis N, Wayne C, et al.(2014) Laparoscopic versus open inguinal hernia repair in children: which is the true gold-standard? A systematic review and meta-analysis.Pediatr. Surg. Int. 35(9):1013–1026
Nicholas E. Bruns,Ian C. Glenn, Neil L. McNinch,et al.(2017)Treatment of routine adolescent inguinal hernia vastly differs between pediatric surgeons and general surgeons.Surg Endosc31:912-916.
S. R. Lee.(2018)Benefits of laparoscopic posterior wall suture repair in treating adolescent indirect inguinalhernias.Hernia,22(4):653–659.
Criss CN, Gish N, Gish J, et al. (2018)Outcomes of Adolescent and Young Adults Receiving High Ligation and Mesh Repairs: A 16-Year Experience.J Laparoendosc Adv Surg Tech A 28(2)：223-228.
van Kerckhoven G, Toonen L, Draaisma WA, et al. (2016)Herniotomy in young adults as an alternative to mesh repair: A retrospective cohort study. Hernia 20:675–679.
T E Lobe ,F M Bianco.(2022)Adolescent inguinal hernia repair: a review of the literature and recommendations for selective management.Hernia 26:831–837 .
Ying-mo Shen , Jie Chen ,Mao-lin Tian, et al.(2014)Lichtenstein repair of indirect inguinal hernias with acellular tissue matrix grafts in adolescent patients: a prospective, randomized, controlled trial.Surg Today 44:429–435
Kristensen AD, Ahiburg P, Lauridsen MC, et al. (2012) Chronic pain after inguinal hernia repair in children. Br J Anaesth 109:603-8.

No competing interests reported.

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Journal Publication

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You are reading this latest preprint version

Analysis of the efficacy of high hernia sac ligation in adolescent indirect hernia

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Abstract

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Methods

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Introduction

Materials And Methods

Results

Discussion

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