1 s2.0 S0022346817304724

Journal of Pediatric Surgery xxx (2017) xxxxxx
Contents lists available at ScienceDirect
Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg
Pediatric Surgical Images
Outcomes of laparoscopic inguinal herniorrhaphy in female pediatric

patients, particularly those with ovarian hernias
Sung Ryul Lee
Department of Surgery, Damsoyu Hospital
a r t i c l e i n f o a b s t r a c t
Article history: Purpose: Inguinal hernia in females may contain uterine adnexa. The common presentation is herniation of one
Received 14 April 2017 ovary, but involvement of both ovaries in a unilateral hernial sac and simultaneous herniation of other organs
Received in revised form 16 July 2017 are possible. Regardless, ovarian hernias have a high incarceration rate. The aim of this study was to evaluate
Accepted 9 August 2017 the outcomes of laparoscopic inguinal herniorrhaphy in female pediatric patients, particularly those with
Available online xxxx
ovarian hernias.
Methods: A retrospective study was conducted on 1185 female pediatric patients younger than 10 years who
Key words:
Female inguinal hernia
underwent laparoscopic herniorrhaphy from March 1, 2011 to November 30, 2016 at Damsoyu Hospital,
Laparoscopic herniorrhaphy Seoul, Korea. The clinical variables and characteristics of the patients were collected from the medical records.
Ovarian hernia Results: The most commonly protruding organ was the ovary in patients less than 1 year old and the omentum in
those more than 2 years old (p b 0.001). In patients who had ovarian hernia, low birth weight and preterm birth
were more frequently observed than patients without ovarian hernia (p b 0.001). Manually irreducible incarcer-
ation occurred more frequently in ovarian hernias than in bowel and omental hernias (p b 0.001). In all patients,
except one who underwent oophorectomy, the herniated organs were preserved. Unilateral inguinal hernia con-
taining multiple organs was observed in four patients who had both ovaries herniated and in 16 patients who had
the bowel and ovary herniated.
Conclusions: In the majority of female inguinal hernia patients less than 1 year old, the ovary was contained in the
hernia sac. This situation requires special precautions because of the high risk of incarceration and simultaneous
protrusion of two organs. Laparoscopic intracorporeal reduction of an incarcerated organ can be easily performed
to preserve several organs, including the ovaries, and might be a good surgical option for inguinal ovarian hernia.
2017 Elsevier Inc. All rights reserved.
Inguinal hernia is the most common pediatric disease that requires inguinal hernia and to evaluate the efcacy of the laparoscopic repair
surgical intervention. Inguinal hernias have been reported to affect six of ovarian hernias.
times more boys than girls [1]. The reported incidence of inguinal hernia
was 3%5% in term infants and 9%11% in premature infants [1]. In fe- 1. Material and methods
male patients, there are three organs that commonly herniate in the in-
guinal canalthe adnexae (i.e., ovary, fallopian tube, or uterus), the A retrospective chart review was conducted on females who
bowel, and the omentum. Most surgeons are aware of the precautions underwent laparoscopic intracorporeal high ligation of inguinal hernia
to avoid any structural damage in male inguinal hernia patients because from March 1, 2011 to November 30, 2016 (Fig. 1) at a single institution.
the gonadal vessels and spermatic cord are adjacent to the hernia sac. Of 4896 inguinal hernia patients less than 10 years of age, 1185 were fe-
Special precautions are also required during inguinal herniorrhaphy in males. In this study, male patients were excluded and only inguinal her-
female patients to avoid injury to the ovary or fallopian tube [2,3]. nias of female patients were included. The analysis for each protruded
The purposes of this study were to identify the characteristics and organ was performed and further analyzed for ovarian hernia. The af-
discuss the surgical precautions in female pediatric patients with fected organs were typically diagnosed by ultrasound and intraopera-
tive ndings. Ultrasonographic ndings of three organs were
observed: hypoechoic oval shape (ovary and fallopian tube, Fig. 2A),
hyperechoic multiple tubular shape (bowel, Fig. 2B), and homogenous
Conicts of Interest and Source of Funding: No conict of interest is declared for the
isoechoic appearance (omentum, Fig. 2C). In case of multiple organs, it
author and no funding was received for this study.
Central tower 5 ~ 9F, Bongeunsa-ro 213, Gangnam-gu, Seoul, Republic of Korea.
was difcult to differentiate from the ultrasonography (Fig. 2D, E).
Tel.: +82 10 2718 3195; fax: +82 2 542 0099. Twenty patients with unilateral hernias and two or more protruding or-
E-mail address: kingsoss@naver.com. gans were diagnosed during surgery because the ultrasound ndings
http://dx.doi.org/10.1016/j.jpedsurg.2017.08.008
0022-3468/ 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Lee SR, Outcomes of laparoscopic inguinal herniorrhaphy in female pediatric patients, particularly those with ovarian
hernias, J Pediatr Surg (2017), http://dx.doi.org/10.1016/j.jpedsurg.2017.08.008
Downloaded for Ryan Juliansyah Zein (ryan.naturalis@gmail.com) at Universitas Tarumanagara from ClinicalKey.com by Elsevier on December 12, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
2 S.R. Lee / Journal of Pediatric Surgery xxx (2017) xxxxxx
Fig. 1. Patient enrollment.
were inaccurate. In 34 patients, the protruding organs were not seen on view. The patients were categorized and compared based on the herni-
ultrasound, and the organ status was determined during surgery by vi- ated organs.
sual inspection around the inguinal ring (Fig. 3). Organs near the deep
inguinal ring were identied. In the case of the ovary, the uterine ad- 1.1. Technique of laparoscopic herniorrhaphy
nexa deviated from the pelvic cavity toward the deep inguinal ring
(Fig. 3C). In the cases of the bowel and omentum, the uterine adnexa The surgical procedures were performed in the supine position
were correctly positioned in the pelvic cavity (Fig. 3F). In a total of 54 under general anesthesia. The laparoscopic system comprised a 2.9-
patients (4.6%), the organ status was conrmed during surgery. The mm camera with 2.7-mm instruments. A transumbilical incision using
organ was determined through location and state of organ such as a No.15 scalpel was made for insertion of a trocar, through which pneu-
edema or congestion. When the organs were identied on ultrasonogra- moperitoneum was induced and maintained by carbon dioxide insufa-
phy prior to surgery, all of them were consistent with the laparoscopic tion at 58 mmHg. Two other instruments were inserted without a
Fig. 2. Ultrasonographic and laparoscopic ndings in female pediatric patients with inguinal hernia. Inguinal hernia containing the (A) bowel, (B) omentum, (C) ovary, (D) uterus and both
ovaries, and (E) bowel and ovary.
S.R. Lee / Journal of Pediatric Surgery xxx (2017) xxxxxx 3
Fig. 3. Ultrasonographic and laparoscopic ndings in female pediatric patients with inguinal hernia whose organs were not conrmed with ultrasonography. (A) No protruding organs
were observed on ultrasonography, but the canal of Nuck (arrow) was observed. (B) Organ status was determined during surgery by visual inspection of the ovary (arrow) near the
inguinal ring. (C) Uterine adnexa (arrow) were deviated from the pelvic cavity toward the deep inguinal ring. (D) Organs were not observed on ultrasonography, but the canal of Nuck
(arrow) was observed. (E) Organ status was determined during surgery by visual inspection of the bowel (arrow) near the inguinal ring. (F) Uterine adnexa were correctly positioned
in the pelvic cavity.
trocar through separate 3.0-mm stab incisions in the lateral abdomen. 1.2. Diet protocol and follow-up
After removal of the hernial sac, intracorporeal high ligation using a
nonabsorbable, multilament, 3.0 4.0 silk suture was performed Postoperatively, oral food intake was permitted after 1 h of observa-
(Fig. 4). The high ligation suture method was a linear suture, and not a tion and patients were able to go home on the same day. Telephone in-
purse-string suture. The contralateral canal of Nuck was examined for terviews were conducted to check the postoperative status on day 7, at
patency and underwent simultaneous suturing, as necessary. 6 months, and annually thereafter.
Fig. 4. High ligation procedures. (A) Ovarian incarceration. (B) Intracorporeal reduction. (C) Internal ring after the reduction. (D) Hernia sac removal. (E) Intracorporeal linear suture.
(F) Correction of the abnormal uterine adnexa position.
Table 1 Table 3
Demographic characteristics of all female patients with inguinal hernia. Characteristics of patients with inguinal hernia containing the ovary (Patient
number = 328).
Total
(Patient number = 1185) Values
Age (months) 39.5 29.4 (0.5120) Hernia, N (%)

Follow-up period (months) 31.7 15.1 (672) Unilateral hernia 305
Symptom location, N (%) One ovary 285 (93.5%)
Right 540 (45.6%) Both ovaries 4 (1.3%)
Left 581 (49.0%) Ovary and bowel 16 (5.2%)
Bilateral 64 (5.4%) Bilateral hernia 23
Asymptomatic contralateral 472 (42.1%) One ovary on each side 20 (87.0%)
open canal of Nuck, N (%)a Ovary and bowel on each side 3 (13.0%)
(In unilateral symptom patients) Reduction method, N (%)
Organs, N (%) Manual reduction 257 (78.4%)
Bowel 87 (7.3%) Intracorporeal reduction 71 (21.6%)
Omentum 770 (65.0%) Oophorectomy 1 (0.3%)
Ovary 309 (26.1%) Torsion or congestion, N (%) 46 (14.0%)
Ovary and bowel 19 (1.6%)
Pre-term birth (b37 weeks), N (%) 56 (4.7%)
Low birth weight (b2.5 kg), N (%) 35 (3.0%)
Manually irreducible 77(6.5%) 2. Results
incarceration, N (%)
Complications, N (%) 2.1. Patient demographics
Hematoma 2 (0.17%)
Seroma 0 (0%)
Table 1 shows the demographic characteristics of the 1185 patients;
Wound infection 1 (0.1%)
Organ resection Oophorectomy 1(0.1%) the average age was 39.5 29.4 (0.5120) months, and the average
Recurrence, N (%) 2 (0.17%) follow-up period was 31.7 15.1 (672) months. The laterality of the
Metachronous contralateral 0 hernia was right in 45.6%, left in 49.0%, and bilateral in 5.4%. The herni-
inguinal hernia, N (%)
ated organs included the bowel in 7.3% of patients, the omentum in
a
Percentage calculated except bilateral symptom patients in denominator. 65.0%, and the ovary in 26.1%; ovary and bowel were herniated in 1.6%
of patients. The number of patients with manually irreducible incarcer-
ated organ was 77; ovary was 52, bowel was 5, omentum was 1, and
two or more organs (including ovary) were 19. They underwent suc-
1.3. Statistical analysis cessful laparoscopic intracorporeal reduction. An oophorectomy was
performed in one female patient with an unrecovered ischemic ovary.
All statistical analyses were performed using SPSS software, version There was no conversion to open surgery. Postoperative complications
23.0 for Windows (SPSS Inc.; Chicago, Illinois, USA). Continuous vari- included two inguinal hematoma and one umbilical wound infection.
ables were presented as mean and standard deviation, whereas categor- During the follow-up period, two recurrences have been observed.
ical variables were presented as frequency and percentage. The
ShapiroWilk's test was used to check for the normality of the continu- 2.2. Clinical characteristics of the patients according to the herniated organs
ous variables. Because not all continuous variables were normally dis- (Table 2)
tributed, our choice of statistical test was the KruskalWallis test. For
categorical variables, Fisher's exact test or 2 test was used. A univariate Hernias containing multiple organs in a unilateral (16 patients,
p-value of 0.05 was considered statistically signicant. ovary and bowel) and bilateral (3 patients, ovary and bowel on each
Table 2
Comparison of clinical characteristics according to herniated organs [1166 patients, exclusion of 19 hernia patients (16 patients with unilateral multiple organs, ovary and bowel and 3
patients with bilateral multiple organs, ovary and bowel on each side)].
Ovary (n = 309) Bowel (n = 87) Omentum (n = 770) p-valueb

a
Age (months) 5.45 6.70(0.548) 12.8 9.77(155) 56.9 20.7(14120) b0.001
b 12 (311) 267 (86.4%) 44 (50.6%) 0 (0.0%) b0.001
1324 (91) 37 (12.0%) 38 (43.7%) 16 (2.1%)
2560 (456) 5 (1.6%) 5 (5.7%) 446 (57.9%)
61120 (308) 0 (0.0%) 0 (0.0%) 308 (40.0%)
Weight (kg)a 6.33 2.60 (2.818.0) 8.91 2.82 (3.819.0) 17.5 4.44 (5.042.0) b0.001
Pre-term birth (b37 weeks), N (%) 35 (11.3%) 4 (4.6%) 15 (1.9%) b0.001
Low birth weight (b2.5 kg), N (%) 23 (7.4%) 4 (4.6%) 6 (0.8%) b0.001
Organ identify
Sonography 274 (88.7%) 84 (96.6%) 770 (100%) b0.001
Laparoscopic view 35 (11.3%) 3 (3.4%) 0 (0.0%)
Symptom location, N (%)
Right 115 (37.2%) 33 (37.9%) 389 (50.5%) 0.001
Left 174 (56.3%) 48 (55.2%) 346 (44.9%)
Both 20 (6.5%) 6 (6.9%) 35 (4.6%)
Asymptomatic contralateral open canal of Nuck (except bilateral), N (%)c 113 (39.1%) 35 (43.2%) 324 (42.1%) 0.642
Manually irreducible incarceration, N (%) 52 (16.8%) 5 (5.7%) 1 (0.1%) b0.001
Operation timea, min 17.8 7.20 (545) 16.9 7.14 (540) 15.1 6.27 (545) b0.001
Recurrence, N (%) 2 (0.6%) 0 (0%) 0 (0%) 0.115
a
Continuous variables were tested using KruskalWallis test.
b
Categorical variables were tested using 2 test or Fisher's exact test.
c
Percentage calculated except bilateral symptom patients in denominator.
S.R. Lee / Journal of Pediatric Surgery xxx (2017) xxxxxx 5
Fig. 5. Left inguinal hernia with ovarian torsion in the hernia sac. (A) Incarceration of the left ovary. (B) Ovarian congestion after intracorporeal reduction. (C) Improvement in color.
(D) Incarceration of the left ovary. (E) Ovarian Torsion after intracorporeal reduction. (F) Improvement in color after detorsion.
side) sacs were excluded from the analyses. Patients who had ovarian incarceration was signicantly higher in the ovarian hernia group
hernia represented the youngest group, with an average age of [16.8% (52/309)] than in the bowel [5.7% (5/87)] or omental hernia
5.45 6.70 months, whereas those who had omental hernia were the group [0.1% (1/770)] (p b 0.001). The recurrence rate was not signi-
oldest group (56.9 20.7 months of age); this difference in age be- cantly different among the groups.
tween both groups was signicant (p b 0.001). There were 311 female
inguinal hernia patients less than 1 year of age. Female patients less 2.3. Clinical characteristics of inguinal ovarian hernia
than 1 year of age had a signicantly higher incidence of ovarian hernia
than bowel hernia [85.9% (267/311) vs. 14.5% (44/311); p b 0.001]. In As shown in Table 3, the unilateral inguinal hernias contained one
preterm babies, ovarian hernia was signicantly more frequent than ovary in 285 patients, both ovaries and the uterus in four unilateral her-
bowel or omental hernia (p b 0.001). The rate of irreducible nia patients, and one ovary and the bowel in 16 unilateral hernia
Fig. 6. Intracorporeal reduction of multiple organs. (A) Both ovarian and uterine incarceration. (B) First, intracorporeal reduction of the contralateral ovary (arrow). (C) Second,
intracorporeal reduction of the uterus (arrow). (D) Final, intracorporeal reduction of the ipsilateral ovary (arrow). (E) Ovarian and bowel incarceration. First, intracorporeal reduction
of the bowel (arrow). (F) Incarceration of the ovary in the internal ring after bowel reduction (G) Second, intracorporeal reduction of the ovary (arrow). (H) Final, reduction of the
fallopian tube (arrow).
patients. Twenty patients had bilateral hernia containing one ovary on ine adnexa toward the internal ring of the hernia side (Fig. 4). Although
each side. Three patients had bilateral ovarian and bowel hernia on this anatomic position was a challenge, high ligation after pulling the
each side. Intracorporeal reduction was successful in the majority of round ligament enabled an intracorporeal correction of this abnormality
cases with manually irreducible incarcerated ovarian hernia (Fig. 5). in the uterine adnexal position.
Ovarian torsion and congestion in the manually irreducible incarcerated In inguinal hernia patients, one organ usually herniates into the in-
hernias were found in 46 patients, one of whom underwent oophorec- guinal canal. Multiple organ incarceration in unilateral inguinal hernia
tomy. When two organs were incarcerated at the same time, reduction had been reported by few studies and was demonstrated in 20 patients
of one organ at a time facilitated the process. In the case of unilateral (16 patients with ovary and bowel and 4 patients with both ovaries) in
hernia containing both ovaries and the uterus, intracorporeal reduction this study. In all of our patients with multiple organ inguinal herniation,
could be performed without difculty particularly when the organs at least one ovary was involved. In cases with simultaneous protrusion
were reduced in the order of ovary-uterus-ovary (Fig. 6A to D). In the of the ovary and fallopian tube into the hernial sac, the fallopian tube
case of unilateral hernia containing the bowel and the ovary, is released rst into the abdominal cavity to allow easy reduction of
intracorporeal reduction was performed in the order of bowel- the ovary. When two or more organs were incarcerated in unilateral in-
fallopian tube-ovary (Fig. 6E to H). guinal hernia at the same time, reduction of organs one at a time facili-
tated an easy process. There were two recurrences of ovarian hernia and
3. Discussion none in the other hernias; this difference was not statistically signi-
cant. A longer follow-up period is probably required to obtain a signi-
Inguinal hernia is relatively less common in females compared with cant difference in recurrence rates among the hernia groups.
that in males [4]. An abnormal open pouch of the peritoneum extending This study was not a comparison of surgical methods but a report on
into the female labia majora is called the canal of Nuck, which was rst de- the outcomes of laparoscopic herniorrhaphy in female pediatric pa-
scribed by Anton Nuck in 1691 [5]. The canal of Nuck is a homologue of tients with inguinal hernia. Based on the lower incidence of inguinal
the processus vaginalis in males and can cause inguinal hernia in females. hernia in females than in males, our results might not be applicable to
The inguinal hernia sac may contain the bowel and omentum in the entire population of pediatric inguinal hernia.
males but may also contain uterine adnexa in females. Inguinal hernia
containing the ovary is common in female infants and can present 4. Conclusions
with incarceration in many cases [6]. Uterine adnexa have been found
in up to 31% (15%20%) of female pediatric inguinal hernia patients. Ovarian inguinal hernia was common in female patients less than
This predilection was age-related because 70% of female pediatric ingui- 1 year of age. Ovarian hernia patients had a higher rate of incarceration,
nal hernia patients were younger than 5 years [79]. This study con- and there were a higher number of patients with multiple organ in-
rmed that the organs herniated can signicantly change before and volvement. In addition, ovarian congestion owing to torsion occurs fre-
after the age of 1 year. Specically, the incidence of ovarian hernia in pe- quently in the manually irreducible incarcerated ovarian hernia. In
diatric female patients was signicantly higher before the age of 1 year. these cases, laparoscopic surgery enabled easy reduction and preserva-
Moreover, most of the patients more than 2 years of age had omental in- tion of incarcerated organs.
guinal hernia. In this study, the incidence of ovarian hernia in patients
less than the age of 2 years was higher than that in other published data. Declaration of conict of interest
Incarcerated ovaries can undergo torsion that leads to lymphatic and
venous obstruction, which increases the risk for strangulation. A Dr. SR Lee declares no conict of interest.
prolonged duration of incarceration causes arterial obstruction and in-
creases the chances of requiring oophorectomy. According to one report References
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Journal of Pediatric Surgery xxx (2017) xxxxxx

Contents lists available at ScienceDirect

Journal of Pediatric Surgery

Pediatric Surgical Images

Outcomes of laparoscopic inguinal herniorrhaphy in female pediatric

Fig. 1. Patient enrollment.

Age (months) 39.5 29.4 (0.5120) Hernia, N (%)

Ovary (n = 309) Bowel (n = 87) Omentum (n = 770) p-valueb

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