Risk of Hernia Occurrence Where Division of an Indirect Inguinal Sac Without Ligation Is Undertaken

Abstract

We sought to ascertain the risk of inguinal hernia occurrence when division of the processus vaginalis is undertaken without ligation, in the context of laparoscopic Fowler–Stephens orchidopexy. A cohort of patients with intra-abdominal testes subjected to a two-stage Fowler–Stephens procedure was reviewed. Analysis of a 68-month period between November 2005 and August 2011 was performed. A comprehensive search of the literature was undertaken, and these data were compared with previously published studies of patients undergoing orchidopexy or herniotomy where the peritoneal defect was not closed. The procedure was undertaken as previously described, with a conventional first stage using a three-port technique. No attempt was made to approximate the peritoneal margins of the processus vaginalis/hernia or close the internal ring at the second stage. In our own experience 17 patients with undescended testes (2 with bilateral cases) underwent laparoscopically assisted, gubernaculum-sparing, Fowler–Stephens orchidopexy. Median age at first operation was 1.86 years (range, 1–9 years). All 17 patients had successful surgery with all 19 testes palpable within the scrotum at postoperative assessment at 3 and 6 months. No direct, indirect, or incisional hernias were noted at a mean follow-up of 2.7 years (standard deviation 1.71). Our experience and reports in the literature do support simple division of the indirect hernia sac as a tenable alternative to ligation. The result of this limited review would support a prospective randomized trial comparing ligation with simple division of hernia sacs.

Introduction

The technique of open inguinal herniotomy and single-stage orchidopexy is well established. Surgeons worldwide dissect the patent processus vaginalis (PPV) from the vas deferens and testicular vessels, before ligating it at the deep ring. This practice has led to high rates of success with minimal recurrence rate.¹ While reviewing our technique of gubernacular-sparing second-stage Fowler–Stephens orchidopexy, however, we noted that no hernias developed in our patients following a groin dissection in which the PPV was not ligated. We therefore documented the findings from our small number of patients and performed a literature search to look for similar experience.

Subjects and Methods

Our cohort of patients who had undergone a two-stage Fowler–Stephens procedure was reviewed. Data were prospectively collected in a Microsoft^® (Redmond, WA) Excel database. The period from November 2005 to August 2011 was analyzed.

Procedure

The procedure was undertaken as previously described,² with a conventional first stage using a three-port technique. At the second stage the testis is mobilized laparoscopically on a peritoneal pedicle using sharp dissection, without division of the gubernaculum. Dissection is continued via a groin incision, and the testis is delivered into a subdartos pouch. No attempt is made to approximate the peritoneal margins of the PPV or close the internal ring; the processus vaginalis is simply divided at the level of the deep ring.

A detailed literature search was then undertaken using HMIC, UpToDate, BMJ best practice, CINAHL, Medline, BMJ case reports, and EMbase. In addition, the Cochrane database, TRIP database, Google Scholar, international guidelines, and National Health Service evidence were searched. The search terms were Orchidopex*, Orchiopex*, Cryporchi*, “inguinal hernia,” “herniot,” “ligation,” and “hernia sac.” Original research articles describing the rate of recurrent hernias were then subjected to analysis.

Results

In our own experience 17 patients with undescended testes (2 with bilateral cases) underwent laparoscopically assisted, gubernaculum-sparing, Fowler–Stephens orchidopexy. Median age at first operation was 1.86 years (range, 1–9 years).

All 17 patients had successful surgery with all 19 testes palpable within the scrotum at postoperative assessment at 3 and 6 months. A careful history and physical examination did not reveal evidence of a direct, indirect, or incisional hernia in any patient at a mean follow-up of 2.7 years (standard deviation 1.71).

A literature search returned 12 studies, of which 5 reported the results of nonligation of processus vaginalis in children.^3–7 Of these, 2 were laparoscopic, and the rest were open procedures. The total number of patients reported by these authors is 674, with 753 procedures described in total. None of these articles reported a hernia following surgery. The results of these studies are summarized in Table 1.

Table 1.

Results of Literature Search

Study	Operation	Number of patients (number of cases)	Hernias	Length of follow-up
Mohta et al.³ (2003)	Open orchidopexy/herniotomy	25(25)	None	1 year
Handa et al.⁴ (2005)	Lap orchidopexy	58 (71)	None	1.5–6.5 years
Kumari et al.⁵ (2009)	Open orchidopexy	50 (62)	None	1 year
Riquelme et al.⁶ (2010)	Lap herniotomy	91 (91)	None	4 months–4 years
Jain et al.⁷ (2011)	Open orchidopexy	450 (504)	None	9–243 months
Our series	Lap second-stage F-S	17 (19)	None	2.6 years

F-S, Fowler-Stephens orchidopexy; Lap, laparoscopic.

Of the five studies reviewed, only one has a control group.³ The remaining studies represent large case series. Follow-up reported by these authors ranges from 4 months to 4 years, with the majority of authors reporting a mean follow-up of 1 year.

Discussion

Our own results and review of the limited literature available would support division of the processus vaginalis at the internal ring as a tenable alternative to ligation. It is possible that peritoneal division at the internal ring, leaving raw margins, results in rapid apposition and sealing of the defect averting progression to a hernia. The evidence presented, however, must be interpreted with caution. The literature reviewed and presented simply relates to case series, only one of which had a randomized control group. The level of evidence presented by these studies is, therefore, low. In addition, the patient populations studied are somewhat different. The literature reports deal principally with the PPV in the context of open orchidopexy, with a small number of open herniotomies and laparoscopic procedures. Although wide at the point of the internal ring, the PPV encountered during orchidopexy does not normally lead to a hernia preoperatively, and the occurrence of a hernia following orchidopexy is an extremely rare event. The fact that a hernia does not occur after an orchidopexy in which the processus is not ligated may be the consequence of the narrow nature of the inguinal canal or of cicatrization of the processus as the consequence of manipulation. Of more interest is the question of what might happen if the PPV is not ligated in the context of a herniotomy with a hernia as the presenting symptom. With limited evidence to support nonligation of a PPV, these data are not yet robust enough to enable conclusions to be drawn about this question.

Conclusions

Our experience and review of the current literature tentatively support the nonligation of the processus vaginalis in the context of an inguinal or laparoscopic orchidopexy. This evidence reinforces some limited published data supporting nonligation of a hernia sac at herniotomy.

We believe that these data would justify a multicenter study to further investigate this question.

Footnotes

Disclosure Statement

No competing financial interests exist.

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