Excision versus transfixation - ligation in herniotomy

Dr.Hewa O. Ahmed CABS-Consultant Surgeon

University of Sulaimani-College of Medicine

Dr.Samira M. Salih-DCH. Sulaimani

SUMMARY

Inguinal herniotomy is the operation most frequently performed in paediatric

patients, and open approach remains the preffered option of groin hernias ( 1 ),
the aim of this study was to evaluate the efficiency of simple excision of hernial
sac in comparison to classical transfixation & ligation in herniotomy.

We followed up 200 patients for 3 years who underwent both procedures in

parallel study, we found the result comparable, although this subject needs to be
evaluated on larger number of patients & for longer periods of follow up, we
concluded that simple excision is as effective as conventional herniotomy in cure
of inguinal hernias.

INTRODUCTION

Inguinal hernia is one of the most common surgical diseases in the paediatric
age and has an over all incidence of approximately 6 % up to the age of 12 years
(2).The vast majority do not require any treatment beyond high ligation of the
hernial sac (3-4) . In babies, children & young atheletics straight forward
inguinal herniotomy should give a 100 % cure rate.

In the present paper we tried to evaluate the results of simple excision of

the neck of the hernial sac with out transfixation & ligation and we found the
results comparable with conventional herniotomy.

METHODS & MATERIALS

This is a prospective parallel study, in the period of 5 years, from Jan. 1996
to Oct. 2000 in two governmental & two private hospitals in Sulaimani city,
including 200 patients. Half of them ( Group A ) underwent classical herniotomy,
the second half ( Group B ), underwent simple excision of the sac. All of them
were followed up to 3 years with 6 monthly assessment by the paediatrician & the
surgeon.

All the patients received general anaesthesia, after incision, exploration of

the hernial sac, the sac dissected up till the extraperitonial fat encountered,
and the inferior epigastric vesseles are seen on the medial side of the hernial
sac. In group (A), the sac tranfixated as high as possible, ligated and the rest
excised. In group ( B ) the sac pulled and the neck excised as high as possible.
Then the wounds closed in layers. All the patients, discharged same day on the
bases of the day care case, with a reporting notes, to be reported 7th
postoperative day & six monthly up to 3 years for assessment.

RESULTS

Majority of our patients were male children, the ratio of male / female
was 9/1, all the females were under the age of 12 years, while most of the males
(156 patients) were under the age of 12 years ( table I )

Sex
Age
No. of Patients

Male
0 - 12 Y
156

13 - 17 Y
24

Male
0 -12 Y
20

13-17 Y
----

Table I: Showing number, Age, and Sex of the Patients

Most of the male patients above ( 12 ) years of age, treated by simple

herniotomy, but (6) of them (25 %) need some sort of strengthening of the
posterior inguinal wall due to either weakness or over stretched deep inguinal
ring.

After 3 years follow up, at was clear that ( 2) of the patients in group (A)
and one from group (B) have recurrence of the hernia, all the recurrences
diagnosed in the period between ( 6-12) months postoperatively, the causes of the
recurrences were either severe acute cough of respiratory infection or fall on the
ground during sporting ( table II )

No. of Patients
Recurrences

200
 6 months
12 months
18 months
2 years
3 years

A
B
A
B
A
B
A
B
A
B

---
---
2
1
---
---
---
---
---
---

Table II: Showing time of diagnosis & number of recurrences

DISCUSSION

Simple excision of the sac versus classical herniotomy saves unnecessary

trauma to the vas deferens and abolishes accidental tieing of the vas deferens (5)
& other components of the spermatic cord, during high transfixation & ligation in
conventional. herniotomy, also it provides tension free technique. which is in
less need for analgesia(6).

In conventional herniotomy, the point of transfixation & ligation will remains

as a fixed point of the peritonium to the internal inguinal opening, which may
plays arole in predisposition for recurrence of the hernia (table II), while in
simple excision, there is no fixed point, and the defect in the peritonium from
excised neck will displaces away from the internal aspect of the inguinal ring and
the defect of the peritonium will reformed, in 24-48 hours by mesothelial cells of
the peritonium.
CONCLUSION

The result of this paper suggest that simple excision may be superior to
conventional herniotomy but needs to be evaluated on wider groups of patients and
it is a cause for concern & requires farther study.

AKNOWLEDGEMENTS

The authors of this work like to express their thanks to all the workers in 16th
surgical unite for their kind technical help.

REFERNCES

1- Annals of the RC of S of England, Jan. 1999, Vol. 81, No.1,

Page 57.
‫‪2-H. Brendan Devlin, Management of abdominal hernias, page 76 Butter worths, First‬‬
‫‪edition, 1988.‬‬

‫& ‪3-Charles V. Mann, Bailey & Love's short practice of surgery, page 890.Chapman‬‬
‫‪Hall Medical . 22nd‬‬

‫‪edition .1997‬‬

‫‪4-Schwartz et al, Principles of surgery, page 1743, Mc Grawhill 7th edition, 1999.‬‬

‫‪5-Lemelle-JL; Schmitt-M, Inguinal hernia in infant, Ann-chir, 1998; 52 (10):1008-‬‬

‫‪16.‬‬

‫‪6-Koninger-JS; Oster-M;Butters -M, Management of inguinal hernia - a comparison of‬‬

‫‪current methods,‬‬

‫‪chirurg. 1998 Dec; 69(12):1340-4.‬‬

‫ِى‬
‫ِين تورةكةى قؤر‬
‫َ‪ ،‬بةست‪ ،‬ثاشان بر‬
‫َ تةقةل‬
‫ِين بةبةراورد لةطةل‬
‫تةنيا بر‬

‫َمان ‪ -‬كؤليجى ثزيشكى‬

‫ِ‪-‬زانكؤى سلي‬
‫د‪.‬هيوا عمر احد ‪ -‬نةشتةرطةرى ثسثؤر‬

‫َن ‪ -‬سلي‬
‫َمان‬ ‫د‪.‬سية ممد صال ‪-‬دبلؤمى نةخؤشى منال‬

‫َوة‪،‬‬
‫َندا بل‬
‫َكة لةو نةشتةرطةريانةى كة لةناو منال‬
‫َن‪ ،‬يةكي‬
‫ِى لموسةل‬
‫نةشتةرطةرى قؤر‬

‫َينةوةية‬ ‫َطة ضارةيةكى ثةسةندكراو ماوةتةوة بؤ ضارةسةر‪ .‬ئامانى ئةم لي‬

‫َكؤل‬ ‫ِي‬‫نةشتةركارى بةر‬

‫ِين‬
‫َ‪ ،‬بةست ثاشان بر‬
‫َ تةقةل‬
‫ِين بةبةراورد لةطةل‬
‫َسةنطاندن كاريطةرى تةنيا بر‬
‫بريتىية لة هةل‬

‫ِى‬
‫‪.‬تورةكةى قؤر‬

‫َينةوةيةكى‬ ‫‪ ) 200‬نةخؤش كةوتي كة لة لي‬

‫َكؤل‬ ‫َ ثاش (‬
‫َسال‬
‫بؤ ئةم مةبةستةش سى‬
‫ً‬
‫هاوتةريبدا‪ ،‬هةردوو جؤر نةشتةرطةرىيةكةيان بؤ كرا‪ .‬ئةنامةكان لةيةكةوة نزيك بوون ‪،‬‬

‫َتةوة‪،‬‬
‫َري‬
‫َذتر بكؤل‬
‫َويستة ئةم بابةتة لة ذمارةيةكى زؤرترى نةخؤش و بؤماوةيةكى دري‬
‫طةرضى ثي‬

‫َطةيةكى بةكارى ضارةسةرى‬

‫ِي‬‫ِى بةر‬
‫ِين تورةكةى قؤر‬
‫َي‪ ،‬تةنيا بر‬
‫َي‬‫لة دةرئةنام دا ئةتواني بل‬

‫َت‬
‫‪.‬قؤرى لموسةلن دائةنري‬