Omental incarceration causing hydrocele has been reported [15]. Here, the average age was 4.5 years, a little bit lower than our series. In our series, three of 18 patients had been preop‐ eratively diagnosed as hydrocele. In omental incarceration, 67% of patients had their omental tip adhered to the wall of the PPV. This might be an outcome of the role of the omentum, which moves to the damaged part of the intraperitoneal organs, for example with inflammation, wall defect or hernia. The hernial sac containing omentum closely mimicked the soft hydrocele on palpation, especially when it was not reducible due to adhesion with the bottom of the hernial sac. The groin mass was soft, not reducible without pain or tenderness.

open repair of I/SH, preoperative diagnostic imaging such as ultrasound and computed tomography have been recommended for differentiating the hernial content [14, 24, 25]. The laparoscopic approach could free patients from these preoperative examinations, because intraperitoneal inspection resolved every ambiguousness around the IIR and in the hernial

Laparoscopic Approach to Incarcerated/Sliding Indirect Inguinal Hernia in Children in Comparison with…

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67

The advantages of laparoscopic approach are that it is technically simple with short operation time, and that there is the possibility for direct inspection of incarcerated/sliding viscera before and after resolution, as well as closure of internal inguinal rings, avoiding injury to the reproductive systems. This comparative study has validated the feasibility of the laparoscopic approach, suggesting that this approach should be allowed to take the place of the gold

, Michinobu Ohno, Fumiko Yoshida, Miwako Nakano, Toshihiko Watanabe and

Department of Pediatric Surgery, Saitama City Hospital, Mimuro, Midori – ku, Saitama –

[1] Erdogan D, Karaman I, Aslan MK, Karaman A, Cavusoglu YH. Analysis of 3, 776 Pe‐ diatric Inguinal Hernia and Hydrocele Cases in a Tertiary Center. J Pediatr Surg

[2] Niedzielski J, KrlR, Gawlowska A. Could Incarceration of Inguinal Hernia in Chil‐

[3] Stylianos S, Jacir NN, Harris BH. Incarceration of Inguinal Hernia in Infants prior to

[4] Nah SA, Giacomello L, Eaton S, de Coppi P, Curry JI, Drake DP, Kiely EM, Pierro A. Surgical Repair of Incarcerated Inguinal Hernia in Children: Laparoscopic or Open?

dren be Prevented? Med Sci Monit 2003; 9(1) CR16 – 18.

Elective Repair. J Pediatr Surg 1993;28(4) 582 – 583.

Eur J Pediatr Surg 2011; 21(1) 8 – 11.

standard in treatment of children with incarcerated/sliding indirect inguinal hernia.

\*Address all correspondence to<EMAIL_ADDRESS>
sac.

**6. Conclusion**

**Author details**

Masao Endo\*

shi, Japan

**References**

2013; 48(8) 1767 – 1772.

Etsuji Ukiyama

The advantage of LH was highlighted in female infants with sliding or incarcerated ovary/ adnexa. Articles have reported that 15 – 22.4% of the inguinal hernias in female children are sliding hernias, and that the most frequently sliding organ is the ovary, followed by the Fallopian tubes [16]. Drawbacks associated with the reproductive system are a hidden but not a negligible problem. Fallopian tube obstruction or displacement of the ovary and Fallopian tube in the retroperitoneal space in a woman with a history of childhood inguinal herniorrha‐ phy has been reported as the cause of infertility [17 – 19]. We had an episode of injury to the Fallopian tube during OH for ovarian sliding hernia. OH requires the traction of the round ligament from the outside so as to obtain a good visual field and achieve high ligation [20], resulting in the remainder of the U – turned Fallopian tube in the hernial sac as acting a sliding component after reducing the ovary. Careless handling of the neck of the hernial sac can induce cutting or ligation of the Fallopian tube. Especially in female infant S/IH, the round ligament is shortened and the ovarian suspensory ligament is ventrally dislocated, facilitating the inducing of tubal occlusion as a postoperative complication [21].

Strangulation of irreducible ovaries has been reported with an incidence of 2% to 33% [22]. The incidence in our series was 28.3%. The laparoscopic findings suggested that the ovaries went into the inguinal canal through narrow IIR, twisting themselves. Uterus – containing inguinal hernia is an extremely rare condition, with 0.23% incidence [23]. The uterus may be free within the sac, adherent to the wall by adhesions or a true sliding component. [23]. In the treatment of ovary/adnexa I/SH including uterine sliding by LH, after reducing the prolapsing organs, the IIR was encircled by a suture proximal to the IIR level, placing all the surrounding viscera out of the IIR, without any special resources like OH.

In the international literature, a small number of studies have been published on laparoscopic treatment of incarcerated or sliding inguinal hernia, in particular a comparative study between laparoscopy and open surgery. Nah et al. [4] emphasized the superiority of LH in his compa‐ rative study from the viewpoint of operative complication, stating that LH presented a lower complication rate (4%) compared to OH (14%). Difficulties in identifying the correct relation of the anatomic structures, occasionally encountered in open procedures, practically almost never occur with the laparoscopic approach [6]. The advantages of the laparoscopic approach have been reported as follows: a lower incidence of complications, technically easy, all edematous tissue surgically bypassed, the cord structures not touched, reduction under direct visual control, inspection of the incarcerated organ at the end of procedure, simultaneous repair of cPPV if present [4, 5].

In our series, all the procedures with LH were completed without conversions, without serious complication and without recurrence, although all the procedures were successful also in OH, except for one Fallopian tube accident. The fact that mean operation time in the OH group exceeded the time of bilateral OH in the WC, while the time of the LH group was equal to the WC and shorter than for the OH group, indicates the technical easiness of LH. In traditional open repair of I/SH, preoperative diagnostic imaging such as ultrasound and computed tomography have been recommended for differentiating the hernial content [14, 24, 25]. The laparoscopic approach could free patients from these preoperative examinations, because intraperitoneal inspection resolved every ambiguousness around the IIR and in the hernial sac.

#### **6. Conclusion**

moves to the damaged part of the intraperitoneal organs, for example with inflammation, wall defect or hernia. The hernial sac containing omentum closely mimicked the soft hydrocele on palpation, especially when it was not reducible due to adhesion with the bottom of the hernial

The advantage of LH was highlighted in female infants with sliding or incarcerated ovary/ adnexa. Articles have reported that 15 – 22.4% of the inguinal hernias in female children are sliding hernias, and that the most frequently sliding organ is the ovary, followed by the Fallopian tubes [16]. Drawbacks associated with the reproductive system are a hidden but not a negligible problem. Fallopian tube obstruction or displacement of the ovary and Fallopian tube in the retroperitoneal space in a woman with a history of childhood inguinal herniorrha‐ phy has been reported as the cause of infertility [17 – 19]. We had an episode of injury to the Fallopian tube during OH for ovarian sliding hernia. OH requires the traction of the round ligament from the outside so as to obtain a good visual field and achieve high ligation [20], resulting in the remainder of the U – turned Fallopian tube in the hernial sac as acting a sliding component after reducing the ovary. Careless handling of the neck of the hernial sac can induce cutting or ligation of the Fallopian tube. Especially in female infant S/IH, the round ligament is shortened and the ovarian suspensory ligament is ventrally dislocated, facilitating the

Strangulation of irreducible ovaries has been reported with an incidence of 2% to 33% [22]. The incidence in our series was 28.3%. The laparoscopic findings suggested that the ovaries went into the inguinal canal through narrow IIR, twisting themselves. Uterus – containing inguinal hernia is an extremely rare condition, with 0.23% incidence [23]. The uterus may be free within the sac, adherent to the wall by adhesions or a true sliding component. [23]. In the treatment of ovary/adnexa I/SH including uterine sliding by LH, after reducing the prolapsing organs, the IIR was encircled by a suture proximal to the IIR level, placing all the surrounding

In the international literature, a small number of studies have been published on laparoscopic treatment of incarcerated or sliding inguinal hernia, in particular a comparative study between laparoscopy and open surgery. Nah et al. [4] emphasized the superiority of LH in his compa‐ rative study from the viewpoint of operative complication, stating that LH presented a lower complication rate (4%) compared to OH (14%). Difficulties in identifying the correct relation of the anatomic structures, occasionally encountered in open procedures, practically almost never occur with the laparoscopic approach [6]. The advantages of the laparoscopic approach have been reported as follows: a lower incidence of complications, technically easy, all edematous tissue surgically bypassed, the cord structures not touched, reduction under direct visual control, inspection of the incarcerated organ at the end of procedure, simultaneous

In our series, all the procedures with LH were completed without conversions, without serious complication and without recurrence, although all the procedures were successful also in OH, except for one Fallopian tube accident. The fact that mean operation time in the OH group exceeded the time of bilateral OH in the WC, while the time of the LH group was equal to the WC and shorter than for the OH group, indicates the technical easiness of LH. In traditional

sac. The groin mass was soft, not reducible without pain or tenderness.

66 Inguinal Hernia

inducing of tubal occlusion as a postoperative complication [21].

viscera out of the IIR, without any special resources like OH.

repair of cPPV if present [4, 5].

The advantages of laparoscopic approach are that it is technically simple with short operation time, and that there is the possibility for direct inspection of incarcerated/sliding viscera before and after resolution, as well as closure of internal inguinal rings, avoiding injury to the reproductive systems. This comparative study has validated the feasibility of the laparoscopic approach, suggesting that this approach should be allowed to take the place of the gold standard in treatment of children with incarcerated/sliding indirect inguinal hernia.

#### **Author details**

Masao Endo\* , Michinobu Ohno, Fumiko Yoshida, Miwako Nakano, Toshihiko Watanabe and Etsuji Ukiyama

\*Address all correspondence to<EMAIL_ADDRESS>
Department of Pediatric Surgery, Saitama City Hospital, Mimuro, Midori – ku, Saitama – shi, Japan

#### **References**

[5] Esposito C, Turial S, Alicchio F, Enders J, Castagnetti M, Krause K, Settimi A, Schier F. Laparoscopic Repair of Incarcerated Inguinal Hernia. A Safe and Effective Proce‐ dure to Adopt in Children. Hernia 2013;17(2) 235 – 239.

[19] Gueth U, Renner R, Egelhof T, Singer G, Holzgreve W, Mayr J. Retroperitoneal Dis‐ placement of Ovary and Fallopian Tube: a Complication of Surgical Management of Incarcerated Inguinal Hernia in Female Infants. J Pediatr Surg; 2007; 42(5) E33 – 35.

Laparoscopic Approach to Incarcerated/Sliding Indirect Inguinal Hernia in Children in Comparison with…

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69

[20] Endo M, Ohno M, Yoshida F, Nakano M, Watanabe T, Ukiyama E. Laparoscopic Hernia Repair and its Validation by Second – look Inspection to Internal Inguinal Rings in Children with Patent Processus Vaginalis. In: Meinhold – Heerlein I. (ed.) Laparoscopy – An Interdisciplinary Approach. Rijeka: InTech; 2011. p133 – 146.

[21] Hirabayashi T, Sakoda A, Kawano T. Ventrally Dislocated Attachment of the Ovari‐ an Suspensory Ligament, a Risk Factor for Tubal Occlusion as a Postoperative Com‐ plication of Inguinal Hernia Repair: Efficacy of Laparoscopic Inguinal Hernia Repair

[22] Boley SJ, Cahn D, Lauer T, Weinberg G, Kleinhaus S. The Irreducible Ovary: a True

[23] Akillioglu L, Kaymakci A, Akkoyun I, Guven S, Yucesan S, Hicsonmez A. Inguinal Hernias Containing the Uterus; a Case Series of 7 Female Children. J Pediatr Surg

[24] Narci A, Korkmaz M, Albyrak R, Sozubir S, Guvenc BH, Koken R, Demir T, Dogru O. Preoperative Sonography of Nonreducible Inguinal Masses in Girls. J Clin Ultra‐

[25] Akfirat M, Kazez A, Serhatilioglu S. Preoperative Sonographic Diagnosis of Sliding

Appendicial Inguinal Hernia. J Clin Ultrasound 1999; 27(3) 156 – 158.

for Preventing Tubal Damage. Pediat Surg Int 2012; 28(11) 1089 – 1094.

Available from http://www.intechopen.com

Emergency. J Pediatr Surg 1991; 26(9) 1035 – 1038.

2013; 48(10) 2157 – 2159.

sound 2008; 36(7) 409 – 412.

[19] Gueth U, Renner R, Egelhof T, Singer G, Holzgreve W, Mayr J. Retroperitoneal Dis‐ placement of Ovary and Fallopian Tube: a Complication of Surgical Management of Incarcerated Inguinal Hernia in Female Infants. J Pediatr Surg; 2007; 42(5) E33 – 35.

[5] Esposito C, Turial S, Alicchio F, Enders J, Castagnetti M, Krause K, Settimi A, Schier F. Laparoscopic Repair of Incarcerated Inguinal Hernia. A Safe and Effective Proce‐

[6] Kaya M, Huckstedt T, Schier F. Laparoscopic Approach to Incarcerated Inguinal Her‐

[7] Endo M, Watanabe T, Nakano M, Yoshida F, Ukiyama E. Laparoscopic Completely Extraperitoneal Repair of Inguinal Hernia in Children: A Single Institute Experience with 1, 257 Repairs Compared with Cut – down Herniorrhaphy. Surg Endosc

[8] Endo M, Ukiyama E. Laparoscopic Closure of Patent Processus Vaginalis in Girls with Inguinal Hernia Using a Specially Devised Suture Needle. Ped Endosurg Innov

[9] Rowe MI, Lloyd DA. Inguinal Hernia. In: Welch KJ, Randolph JG, Ravitch MM, O'Neil JA Jr, Rowe MI. (eds.) Pediatric Surgery 4thED. Chicago, London: Year Book

[10] Woolley MM. Inguinal hernia. In: Pediatric Surgery 3rdED. Chicago: Year Book Med‐

[11] Rowe MI, Clatworthy HW. Incarcerated and Strangulated Hernias in Children. A

[12] Lombardo V, Pavone G. Intraoperative Finding of Amyand's Hernia in a Recurrent

[13] Okur MH, Karacay S, Uygun I, Topcu K, Ozturk H. Amyand's Hernias in Childhood (a Report on 21 Patients): a Single – center Experience. Pediatr Surg Int 2013; 29(6)

[14] Michalinos A, Moris D, Vernadakis S. Amyand's Hernia: a Review. Am J Surg 2013, pii: S0002 – 9610(13)00646 – 6. Doi: 10.1016/j.amjsurg.2013.07043. [Epub ahead of

[15] Kapisiz A, Karabulut R, Turkyilmaz Z, Sonmez K, Basaklar AC. Omental Incarcera‐ tion may Cause Hydrocele and this Hydrocele Confused Simple or Scrotal Hydro‐

[16] Turk E, Fescekoglu OR, Acari C, Karaca F, Bilen CM, Edirne Y, Karakaya E. Sliding

[17] Swanson JA, Chapler FK. Infertility as a Consequence of Bilateral Inguinal Hernior‐

[18] Cam C, Celik C, Sancak A, Iskender C, Karateke A. Inguinal Herniorrhaphy in Child‐ hood may Result in Tubal Damage and Future Infertility. Arch Gynecol Obstet 2009;

Hernia in Female Children. Acta Chir Belg 2013; 113(4) 281 – 284.

Statistical Study of High – risk Factors. Arch Surg 1970;101: 136 – 139.

Inguinal Hernia. Report of a Case. Ann Ital Chir 2013; 84: 583 – 584.

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print]

Medical Publishers; 1986. p779 – 793.

**Chapter 5**

**Laparoscopic Inguinal Preperitoneal Injection (LIPI) —**

Inguinal hernia repair is the most common procedure in pediatric surgery. Suture techniques for laparoscopic inguinal hernia repair in children are easy to perform and popular with a low recurrence rate. The aim of this study was to evaluate the effect of laparoscopic preperitoneal injection of 3-dimensional gel on closing of the inguinal hernia sac (IHS) in laboratory animals. We performed peritoneoscopy by 12 male Chinchilla rabbits weighing 1200 to 1400 g. Endo‐ scope was introduced in abdominal cavity and bilateral deep inguinal rings were identified. The needle Tuohy with the injectable polymeric bulking agent DAM+ (3-Dimensional Polya‐ crylamide gel with Ions of Silver "Argiform", Bioform®) was introduced preperitoneally. The implant was then injected across the entire orifice of the deep inguinal rings and draped over the cord structures. After completion of bilateral repairs, the rabbits were extubated and observed in animal laboratory. Then the second laparoscopy was performed 6 months after and the deep inguinal rings were inspected. At second laparoscopy no reopening to the entire orifice of the deep inguinal rings were noted. Accurate placement the polymeric agent and adequate coverage of the vas deferens was accomplished in all animals. This scientific report demonstrates that the biopolymeric implant gives good postoperative results and a stable trend of closing IHS in long-term follow-up. We hope that the injectable polymeric bulking agents can be used for treatment of inguinal hernias at pediatric patients after additional

Inguinal hernia is the most frequent diagnosis in pediatric surgery. Familiarity with embry‐ ology is necessary to understand the inguinal abnormalities. During fetal life, the descent of

> © 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**Novel Experimental Technique for Inguinal Hernia**

**Repair in Children**

http://dx.doi.org/10.5772/57159

animal and human researches.

**1. Introduction**

Yury Kozlov, Vladimir Novozhilov, Vitaly Kovalev and Pavel Krasnov

Additional information is available at the end of the chapter

## **Laparoscopic Inguinal Preperitoneal Injection (LIPI) — Novel Experimental Technique for Inguinal Hernia Repair in Children**

Yury Kozlov, Vladimir Novozhilov, Vitaly Kovalev and Pavel Krasnov

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/57159

#### **1. Introduction**

Inguinal hernia repair is the most common procedure in pediatric surgery. Suture techniques for laparoscopic inguinal hernia repair in children are easy to perform and popular with a low recurrence rate. The aim of this study was to evaluate the effect of laparoscopic preperitoneal injection of 3-dimensional gel on closing of the inguinal hernia sac (IHS) in laboratory animals. We performed peritoneoscopy by 12 male Chinchilla rabbits weighing 1200 to 1400 g. Endo‐ scope was introduced in abdominal cavity and bilateral deep inguinal rings were identified. The needle Tuohy with the injectable polymeric bulking agent DAM+ (3-Dimensional Polya‐ crylamide gel with Ions of Silver "Argiform", Bioform®) was introduced preperitoneally. The implant was then injected across the entire orifice of the deep inguinal rings and draped over the cord structures. After completion of bilateral repairs, the rabbits were extubated and observed in animal laboratory. Then the second laparoscopy was performed 6 months after and the deep inguinal rings were inspected. At second laparoscopy no reopening to the entire orifice of the deep inguinal rings were noted. Accurate placement the polymeric agent and adequate coverage of the vas deferens was accomplished in all animals. This scientific report demonstrates that the biopolymeric implant gives good postoperative results and a stable trend of closing IHS in long-term follow-up. We hope that the injectable polymeric bulking agents can be used for treatment of inguinal hernias at pediatric patients after additional animal and human researches.

Inguinal hernia is the most frequent diagnosis in pediatric surgery. Familiarity with embry‐ ology is necessary to understand the inguinal abnormalities. During fetal life, the descent of

© 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

the testis into the inguinal canal and scrotum brings a small pouch of peritoneum alongside. This peritoneal extension is the processus vaginalis. In females, the formation of the labia has the same peritoneal remnant, referred to as the canal of Nuck. The peritoneal canals are obliterated in up to 95–98% of fetuses before birth. Failure of this peritoneal fusion results in a spectrum of abnormalities. The degree of fusion failure results in either a hydrocele or a hernia [1, 2]. There are two types of inguinal hernia: direct, where the abdominal musculature is weak and visceral contents protrude through the wall of the inguinal canal and exit via the superficial inguinal ring, and indirect inguinal hernia, where visceral contents pass into the patent processus vaginalis (PPV) via an open deep inguinal ring and exit via the superficial inguinal rings. The latter is the most common finding in children.

Since the description of extraperitoneally ligation of the internal inguinal ring by Takehara [4] and Ozdegiz [5], the treatment of inguinal hernias at children was transformed to «story of needles and hooks». A small hook or Tuohy needle, loaded with a suture, is passed around the deep ring after making a small inguinal skin incision. The passage of the suture is observed via an endoscope at the umbilicus (Fig.2). The ligature is then brought extracorporally and tied, thus closing the hernial orifice. The transabdominal extraperitoneal repair has some support for a lower recurrence rate, when compared to the traditional open procedure. A slightly higher recurrence rate appears to exist when comparing the transperitoneal to the extraperitoneal and open repair. The advantages of a reduced injury to the vas and vessels, a reduction in testicular atrophy, and improved cosmesis are not supported by current levels of

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73

evidence.

**Figure 2.** Preperitoneal ligation of the internal inguinal ring by Ozdegiz

with preoperative incarceration.

Complications are rare following surgery for hernia or hydrocele. Injury to the vas deferens during inguinal or hydrocele repair is a potential risk [6] with treatment requiring microsur‐ gical repair. Visceral injury during laparoscopic repair is very rare and can be treated either by open or laparoscopic surgery. Injury to the genitofemoral nerve, resulting in chronic pain, is a rare occurrence [7]. Testicular ascent following inguinal tissue contracture is another possible long-term problem as well as testicular atrophy, though the latter is associated usually

The surgical principal in laparoscopic repair in children is to close the inguinal hernia sac (IHS) at its neck as in the open repair. Different techniques of laparoscopic hernia repair have been developed, but there are two basic approaches – a purely intracorporeal [8-11] ligation and

Inguinal hernia in children can be repaired through either an open or laparoscopic technique. In 1995, Shcheben'kov [3] first reported on laparoscopic inguinal hernia repair in pediatric patients. Since that time, laparoscopic ligation of inguinal hernias has been performed in many institutions with a variety of methods of suturing of open inguinal rings.

The laparoscopic approach can be performed either transperitoneally or through a preperito‐ neal approach with transperitoneal visualization. The transperitoneal method incorporates a telescope through an umbilical port, allowing direct visualization of the deep inguinal rings, followed by the controlled passage of instruments either with or without the assistance of trocars. The deep ring is then closed with either an absorbable or nonabsorbable suture either as purse string or similar (Fig.1).

**Figure 1.** Transperitoneal ligation of the internal inguinal ring by Schier (Z-suture)

Since the description of extraperitoneally ligation of the internal inguinal ring by Takehara [4] and Ozdegiz [5], the treatment of inguinal hernias at children was transformed to «story of needles and hooks». A small hook or Tuohy needle, loaded with a suture, is passed around the deep ring after making a small inguinal skin incision. The passage of the suture is observed via an endoscope at the umbilicus (Fig.2). The ligature is then brought extracorporally and tied, thus closing the hernial orifice. The transabdominal extraperitoneal repair has some support for a lower recurrence rate, when compared to the traditional open procedure. A slightly higher recurrence rate appears to exist when comparing the transperitoneal to the extraperitoneal and open repair. The advantages of a reduced injury to the vas and vessels, a reduction in testicular atrophy, and improved cosmesis are not supported by current levels of evidence.

**Figure 2.** Preperitoneal ligation of the internal inguinal ring by Ozdegiz

the testis into the inguinal canal and scrotum brings a small pouch of peritoneum alongside. This peritoneal extension is the processus vaginalis. In females, the formation of the labia has the same peritoneal remnant, referred to as the canal of Nuck. The peritoneal canals are obliterated in up to 95–98% of fetuses before birth. Failure of this peritoneal fusion results in a spectrum of abnormalities. The degree of fusion failure results in either a hydrocele or a hernia [1, 2]. There are two types of inguinal hernia: direct, where the abdominal musculature is weak and visceral contents protrude through the wall of the inguinal canal and exit via the superficial inguinal ring, and indirect inguinal hernia, where visceral contents pass into the patent processus vaginalis (PPV) via an open deep inguinal ring and exit via the superficial

Inguinal hernia in children can be repaired through either an open or laparoscopic technique. In 1995, Shcheben'kov [3] first reported on laparoscopic inguinal hernia repair in pediatric patients. Since that time, laparoscopic ligation of inguinal hernias has been performed in many

The laparoscopic approach can be performed either transperitoneally or through a preperito‐ neal approach with transperitoneal visualization. The transperitoneal method incorporates a telescope through an umbilical port, allowing direct visualization of the deep inguinal rings, followed by the controlled passage of instruments either with or without the assistance of trocars. The deep ring is then closed with either an absorbable or nonabsorbable suture either

inguinal rings. The latter is the most common finding in children.

**Figure 1.** Transperitoneal ligation of the internal inguinal ring by Schier (Z-suture)

as purse string or similar (Fig.1).

72 Inguinal Hernia

institutions with a variety of methods of suturing of open inguinal rings.

Complications are rare following surgery for hernia or hydrocele. Injury to the vas deferens during inguinal or hydrocele repair is a potential risk [6] with treatment requiring microsur‐ gical repair. Visceral injury during laparoscopic repair is very rare and can be treated either by open or laparoscopic surgery. Injury to the genitofemoral nerve, resulting in chronic pain, is a rare occurrence [7]. Testicular ascent following inguinal tissue contracture is another possible long-term problem as well as testicular atrophy, though the latter is associated usually with preoperative incarceration.

The surgical principal in laparoscopic repair in children is to close the inguinal hernia sac (IHS) at its neck as in the open repair. Different techniques of laparoscopic hernia repair have been developed, but there are two basic approaches – a purely intracorporeal [8-11] ligation and laparoscopic-assisted extracorporeal ligation [4, 5]. Therefore, further development in minimal access surgery for pediatric inguinal hernia is to decrease the number and size of skin incisions. With a trend toward increasing use of extracorporeal knotting and decreasing use of working ports and endoscopic instruments, single-port endoscopy-assisted percutaneous extraperito‐ neal closure with variable devices is the attainment.

high efficiency of Dermabond® for closing IHS. Explanation of this efficiency is that this tissue agent is not absorbable. The other tissue adhesives are all absorbable, and may have become ineffective within months. Comparing different tissue adhesives Kato Y. et al. have shown that laparoscopic injection of 2-octyl-cyanoacrylate (Dermabond®) was highly effective for closing the orifice of the IHS [16]. Following study [17] demonstrates that fibrin glue and cyanoacrylate are better tolerated than sutures by patients, and that the glues lead to better results during initial follow-up and a better trend in long-term data. The glues were recommended for use

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Injectable soft tissue fillers play an important role in cosmetic and reconstructive surgery. Since the acceptance of collagen as a filler, new reabsorbable and non-absorbable implants have appeared with varying degrees of success. Today, as we know more about products and their potential complications, a more accurate treatment plan can be arranged for the patient. The ideal desired characteristics for a soft tissue filler are that they must be safe, biocompatible, easy to inject, long lasting effect, and not provoke any complications.  The advantage of these products is longevity. One of these products is polyacrylamide. The chemical properties of polyacrylamide gel with a high proportion of water cause fewer foreign body reactions. The capsule gets thicker with fibroblasts and macrophage accumulation. This product is the first choice for facial soft tissue augmentation, such a cheek, chin, or mandibular augmentation. Polyacrylamide adds volume to the subcutaneous tissue, thereby restoring of augmentic facial and body contours. It is also used for lip augmentation, nasolabial folds, perioral wrinkles, glabellar frown lines, and depressed mouth corners. This product must be injected deeply in the subcutaneous tissues. Polyacrylamide implantation is considered permanent. It cannot be reabsorbed into the body. Hydrophilic polyacrylamide gels are non-toxic, non-sensitizing, non-mutagenic, biocompati‐ ble and chemically stable. After injection the water content is absorbed by the body whilst the

gel becomes encapsulated. It remains soft and pliable like the body's own tissue.

In our experimental study we proposed the laparoscopic preperitoneal injection of 3-Dimen‐ sional gel (DAM+™) on closing the orifice of the IHS in laboratory animals. This polymer is injectable hydrophilic polyacrylamide gel with 0.03% residual unpolymerized acrylamide monomer. It is manufactured by Bioform in Russia. This product is the second generation polyacrylamide gel comprised of 95% polyacrylamide and 5% water, it is also manufactured using a silver ion process to help repel bacteria. It comes in sterile syringe with a needle of 25Gx1½ (Fig.3). Prepacked and tested for microbiological cleanness the gel DAM+ is then sterilized in an autoclave chamber and tested for sterility. The 3-D polymeric gel is the most physiological and the safest implant out of the rest existing implants. Its structure and properties respond in the best way to the inner space of the human body. It contains silver, which creates unfavorable medium against bacterial invasion and development of pathogenic microbiological flora. This filling agent is inert, does not react to the previously injected gels, admits possibility of its multiple injections into the same anatomical region in the case it has

in adults for mesh fixation of tension-free inguinal repair.

**3. Polyacrylamides in surgery**

Laparoscopic approach to inguinal hernia in children has become an alternative to the conventional open procedure. Advantages of endoscopic repairs include the ability to evaluate the contralateral side, avoidance of access trauma to the vas deferens and gonadal vessels, iatrogenic cryptorchidism, shorter operative time, less postoperative pain and length of hospital stay. According to the literature, open herniorhaphy in children has been reported to have recurrence rate of 0.8% to 3.8% and postoperative contralateral hernia rates up to 30% [12, 17]. Recurrence rates in laparoscopic approach has ranged from 0.7% to 4.3% [13, 14].

There are some technical limitations, although modifications on laparoscopic surgery continue to be refined. The known limitations of the laparoscopic surgery are as follows - the necessity for intra-abdominal skills, such as intracorporeal suturing, knot tying, and manipulation of the suture on a needle, high operating costs and cardiorespiratory changes by pneumoperito‐ neum. In fact, compared with open herniotomy, laparoscopic approach did not take any superiority in cosmesis. Conversely, the procedure was thought not to be a minimally invasive surgery because of the necessity of multiple skin incisions and pneumoperitoneum during operation.

#### **2. Polymers in inguinal surgery**

Laparoscopic inguinal hernia repair involves less dissection of the abdominal wall and spermatic cord structures, so the risk for complications may be lower, but some kind of suture (ie, z-suture, n-suture, purse string suture, and extraperitoneal closure) must be used. Placing his sutures correctly is difficult, and there is a considerable learning curve involved, especially in premature, because of the extremely limited operative field. In contrast, deep inguinal ring does not require surgical ligation, and can be closed using injected tissue adhesive.

Laparoscopic hernia surgery continues to evolve with new polymeric products allowing surgeons multiple choices in treating their patients. In 2004 Miyano G. et al. [15], published experimental work with injection of 2-octyl-cyanoacrylate (Dermabond®) into right IHS under laparoscopic control. Herniography results showed no flow of gastrografin solution into treated inguinal hernia sac in rats. Histologic examination in the treated HIS demonstrated localized mild inflammation, and foreign body giant cells were observed around the Derma‐ bond®. The spermatic vessels, vas deferens, and testes were normal. All testes had large numbers of normal sperm. This technique is innovative concept for the treatment of inguinal hernia because it uses tissue adhesives to close hernia sac. This approach eliminates dissection of the spermatic cord and ligation of the IHS, thus virtually completely lowering the risks of injuries. Later, in 2005, the same group of authors published paper comparing several types of tissue adhesives in the treatment of inguinal hernia [16]. This experimental work has shown high efficiency of Dermabond® for closing IHS. Explanation of this efficiency is that this tissue agent is not absorbable. The other tissue adhesives are all absorbable, and may have become ineffective within months. Comparing different tissue adhesives Kato Y. et al. have shown that laparoscopic injection of 2-octyl-cyanoacrylate (Dermabond®) was highly effective for closing the orifice of the IHS [16]. Following study [17] demonstrates that fibrin glue and cyanoacrylate are better tolerated than sutures by patients, and that the glues lead to better results during initial follow-up and a better trend in long-term data. The glues were recommended for use in adults for mesh fixation of tension-free inguinal repair.

#### **3. Polyacrylamides in surgery**

laparoscopic-assisted extracorporeal ligation [4, 5]. Therefore, further development in minimal access surgery for pediatric inguinal hernia is to decrease the number and size of skin incisions. With a trend toward increasing use of extracorporeal knotting and decreasing use of working ports and endoscopic instruments, single-port endoscopy-assisted percutaneous extraperito‐

Laparoscopic approach to inguinal hernia in children has become an alternative to the conventional open procedure. Advantages of endoscopic repairs include the ability to evaluate the contralateral side, avoidance of access trauma to the vas deferens and gonadal vessels, iatrogenic cryptorchidism, shorter operative time, less postoperative pain and length of hospital stay. According to the literature, open herniorhaphy in children has been reported to have recurrence rate of 0.8% to 3.8% and postoperative contralateral hernia rates up to 30% [12,

There are some technical limitations, although modifications on laparoscopic surgery continue to be refined. The known limitations of the laparoscopic surgery are as follows - the necessity for intra-abdominal skills, such as intracorporeal suturing, knot tying, and manipulation of the suture on a needle, high operating costs and cardiorespiratory changes by pneumoperito‐ neum. In fact, compared with open herniotomy, laparoscopic approach did not take any superiority in cosmesis. Conversely, the procedure was thought not to be a minimally invasive surgery because of the necessity of multiple skin incisions and pneumoperitoneum during

Laparoscopic inguinal hernia repair involves less dissection of the abdominal wall and spermatic cord structures, so the risk for complications may be lower, but some kind of suture (ie, z-suture, n-suture, purse string suture, and extraperitoneal closure) must be used. Placing his sutures correctly is difficult, and there is a considerable learning curve involved, especially in premature, because of the extremely limited operative field. In contrast, deep inguinal ring

Laparoscopic hernia surgery continues to evolve with new polymeric products allowing surgeons multiple choices in treating their patients. In 2004 Miyano G. et al. [15], published experimental work with injection of 2-octyl-cyanoacrylate (Dermabond®) into right IHS under laparoscopic control. Herniography results showed no flow of gastrografin solution into treated inguinal hernia sac in rats. Histologic examination in the treated HIS demonstrated localized mild inflammation, and foreign body giant cells were observed around the Derma‐ bond®. The spermatic vessels, vas deferens, and testes were normal. All testes had large numbers of normal sperm. This technique is innovative concept for the treatment of inguinal hernia because it uses tissue adhesives to close hernia sac. This approach eliminates dissection of the spermatic cord and ligation of the IHS, thus virtually completely lowering the risks of injuries. Later, in 2005, the same group of authors published paper comparing several types of tissue adhesives in the treatment of inguinal hernia [16]. This experimental work has shown

does not require surgical ligation, and can be closed using injected tissue adhesive.

17]. Recurrence rates in laparoscopic approach has ranged from 0.7% to 4.3% [13, 14].

neal closure with variable devices is the attainment.

operation.

74 Inguinal Hernia

**2. Polymers in inguinal surgery**

Injectable soft tissue fillers play an important role in cosmetic and reconstructive surgery. Since the acceptance of collagen as a filler, new reabsorbable and non-absorbable implants have appeared with varying degrees of success. Today, as we know more about products and their potential complications, a more accurate treatment plan can be arranged for the patient. The ideal desired characteristics for a soft tissue filler are that they must be safe, biocompatible, easy to inject, long lasting effect, and not provoke any complications.  The advantage of these products is longevity. One of these products is polyacrylamide. The chemical properties of polyacrylamide gel with a high proportion of water cause fewer foreign body reactions. The capsule gets thicker with fibroblasts and macrophage accumulation. This product is the first choice for facial soft tissue augmentation, such a cheek, chin, or mandibular augmentation. Polyacrylamide adds volume to the subcutaneous tissue, thereby restoring of augmentic facial and body contours. It is also used for lip augmentation, nasolabial folds, perioral wrinkles, glabellar frown lines, and depressed mouth corners. This product must be injected deeply in the subcutaneous tissues. Polyacrylamide implantation is considered permanent. It cannot be reabsorbed into the body. Hydrophilic polyacrylamide gels are non-toxic, non-sensitizing, non-mutagenic, biocompati‐ ble and chemically stable. After injection the water content is absorbed by the body whilst the gel becomes encapsulated. It remains soft and pliable like the body's own tissue.

In our experimental study we proposed the laparoscopic preperitoneal injection of 3-Dimen‐ sional gel (DAM+™) on closing the orifice of the IHS in laboratory animals. This polymer is injectable hydrophilic polyacrylamide gel with 0.03% residual unpolymerized acrylamide monomer. It is manufactured by Bioform in Russia. This product is the second generation polyacrylamide gel comprised of 95% polyacrylamide and 5% water, it is also manufactured using a silver ion process to help repel bacteria. It comes in sterile syringe with a needle of 25Gx1½ (Fig.3). Prepacked and tested for microbiological cleanness the gel DAM+ is then sterilized in an autoclave chamber and tested for sterility. The 3-D polymeric gel is the most physiological and the safest implant out of the rest existing implants. Its structure and properties respond in the best way to the inner space of the human body. It contains silver, which creates unfavorable medium against bacterial invasion and development of pathogenic microbiological flora. This filling agent is inert, does not react to the previously injected gels, admits possibility of its multiple injections into the same anatomical region in the case it has been not enough injected or applied in stage-by-stage corrections. DAM+ can be injected through thin needles, hence it causes minimal traumas. It is very important that it does not cause an inflammation, nor any allergy or non-compatibility with the tissues thanks to absence in it of initiators of immune reactions. During long-term localization within the injection zone, DAM+ does not exert any inflammatory reactions. When injected correctly, it does not migrate from the injection zone.

low reactivity and reduce the risks of local inflammation. The histological examination has shown development of good capsule with macrophageal infiltration, marked vascularity and absence of any signs of local inflammation. In microscopic research 1 month after the operation, the implanted material remained located in the subcutaneous cellular tissue in the form of grid structures of fibrous character. There was a round cell reaction observed with excess of macrophage elements. Three months after the implantation, the histopathologic feature got changed. Thin polymer taenias penetrating into the tissue had developed in all directions from the main conglomerate of the implanted material. That phenomenon was explained by the fact that a conjunctive capsule began its formation. Within the connective tissue, not far from the implanted material, vessels were seen enlarged plethoric blood vessels. After six months, around the implanted material revealed a connective tissue infiltrated with macrophages and other round cell elements and marked the development of the capsule. In some areas around the implanted material observed a mature connective capsule isolating the polymer from the surrounding tissues. The main components of that capsule were collagen fibers and mature fusiform fibroblasts between them. Reaction of the blood system remained expressive, some

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**4. Experimental technique of laparoscopic inguinal preperitoneal injection**

Minimally invasive surgery has become more frequent in children in the last decade. These techniques require special training because of the low incidence of many surgical diseases in children, and the skills needed are difficult to acquire. For this purpose, several training models have been used, including endotraining boxes, animals, and, more recently, virtual reality. The smaller size of pediatric patients requires not only adequate endoscopic instruments but also an appropriate animal model for teaching and training pediatric minimally invasive surgery. The most commonly used animals are pigs, which are good models only for big children and adolescents; furthermore, they are expensive and hard to obtain. Rabbits are commonly used in experimental medicine, easy to obtain, very similar in weight to a newborn, and less expensive than pigs. Reports of laparoscopy performed for experimental laparoscopic surgical procedures in rabbits, including the gasless model [22], and other procedures, mainly in gynecology [23-26], prompted us to choose the adult rabbit as our training model for treatment of inguinal hernia. The naturally opened inguinal duct in rabbits resembles the human inguinal hernia with peritoneal fold. Because of inguinal canal of rabbits remains open and patent throughout life and the internal inguinal ring is also open and wide, they are chosen for laboratory study. Simple cohort of twelve male Chinchilla rabbits weighing 1200 to 1400 g was used as subjects. All animals had unrestricted access to food and water pre- and postopera‐ tively. Experimental work was done according to the "Hospital experimental work state" and

This work was developed at the Experimental Surgery Center of the Institute of Surgery Irkutsk, Russia. A 5-mm 30-degree endoscope without additional laparoscopic instruments

vessels were enlarged and plethoric.

was approved by hospital ethical committee.

**(LIPI)**

**Figure 3.** Polyacrylamide gel DAM+ in packing

This agent is used in clinical practice for endoprothesis of the soft tissues by increases of their volume. Polyacrylamide in fact has been used for decades in the preparation of soft contact lenses. Besides, the toxicity of polyacrylamide has been studied for more than 30 years. Research indicates that polyacrylamide is non toxic and practically non biodegradable. DAM + is absolutely safe because of the presence of silver ions, known for their antibacterial properties. There are also no allergy issues with this gel. There are some articles with good results of using this gel in bronchial surgery for endoscopic treatment of bronchial fistulas and prophylaxis, treatment of primary insufficiency of bronchial stump after pneumonectomy [18, 19] and in endoscopic treatment of vesico-ureteral reflux in children [20]. Safety of the hydrophilic gel DAM+ has been repeatedly confirmed by its pre-clinical tests on animals, also by its experimental clinical application [21]. In this experimental study it was shown that polyacrylamide gel had low reactivity with surrounding tissue. Ions of silver contribute to this low reactivity and reduce the risks of local inflammation. The histological examination has shown development of good capsule with macrophageal infiltration, marked vascularity and absence of any signs of local inflammation. In microscopic research 1 month after the operation, the implanted material remained located in the subcutaneous cellular tissue in the form of grid structures of fibrous character. There was a round cell reaction observed with excess of macrophage elements. Three months after the implantation, the histopathologic feature got changed. Thin polymer taenias penetrating into the tissue had developed in all directions from the main conglomerate of the implanted material. That phenomenon was explained by the fact that a conjunctive capsule began its formation. Within the connective tissue, not far from the implanted material, vessels were seen enlarged plethoric blood vessels. After six months, around the implanted material revealed a connective tissue infiltrated with macrophages and other round cell elements and marked the development of the capsule. In some areas around the implanted material observed a mature connective capsule isolating the polymer from the surrounding tissues. The main components of that capsule were collagen fibers and mature fusiform fibroblasts between them. Reaction of the blood system remained expressive, some vessels were enlarged and plethoric.

been not enough injected or applied in stage-by-stage corrections. DAM+ can be injected through thin needles, hence it causes minimal traumas. It is very important that it does not cause an inflammation, nor any allergy or non-compatibility with the tissues thanks to absence in it of initiators of immune reactions. During long-term localization within the injection zone, DAM+ does not exert any inflammatory reactions. When injected correctly, it does not migrate

This agent is used in clinical practice for endoprothesis of the soft tissues by increases of their volume. Polyacrylamide in fact has been used for decades in the preparation of soft contact lenses. Besides, the toxicity of polyacrylamide has been studied for more than 30 years. Research indicates that polyacrylamide is non toxic and practically non biodegradable. DAM + is absolutely safe because of the presence of silver ions, known for their antibacterial properties. There are also no allergy issues with this gel. There are some articles with good results of using this gel in bronchial surgery for endoscopic treatment of bronchial fistulas and prophylaxis, treatment of primary insufficiency of bronchial stump after pneumonectomy [18, 19] and in endoscopic treatment of vesico-ureteral reflux in children [20]. Safety of the hydrophilic gel DAM+ has been repeatedly confirmed by its pre-clinical tests on animals, also by its experimental clinical application [21]. In this experimental study it was shown that polyacrylamide gel had low reactivity with surrounding tissue. Ions of silver contribute to this

from the injection zone.

76 Inguinal Hernia

**Figure 3.** Polyacrylamide gel DAM+ in packing

### **4. Experimental technique of laparoscopic inguinal preperitoneal injection (LIPI)**

Minimally invasive surgery has become more frequent in children in the last decade. These techniques require special training because of the low incidence of many surgical diseases in children, and the skills needed are difficult to acquire. For this purpose, several training models have been used, including endotraining boxes, animals, and, more recently, virtual reality. The smaller size of pediatric patients requires not only adequate endoscopic instruments but also an appropriate animal model for teaching and training pediatric minimally invasive surgery.

The most commonly used animals are pigs, which are good models only for big children and adolescents; furthermore, they are expensive and hard to obtain. Rabbits are commonly used in experimental medicine, easy to obtain, very similar in weight to a newborn, and less expensive than pigs. Reports of laparoscopy performed for experimental laparoscopic surgical procedures in rabbits, including the gasless model [22], and other procedures, mainly in gynecology [23-26], prompted us to choose the adult rabbit as our training model for treatment of inguinal hernia. The naturally opened inguinal duct in rabbits resembles the human inguinal hernia with peritoneal fold. Because of inguinal canal of rabbits remains open and patent throughout life and the internal inguinal ring is also open and wide, they are chosen for laboratory study. Simple cohort of twelve male Chinchilla rabbits weighing 1200 to 1400 g was used as subjects. All animals had unrestricted access to food and water pre- and postopera‐ tively. Experimental work was done according to the "Hospital experimental work state" and was approved by hospital ethical committee.

This work was developed at the Experimental Surgery Center of the Institute of Surgery Irkutsk, Russia. A 5-mm 30-degree endoscope without additional laparoscopic instruments was used. All procedures were recorded on hard disk of the videohub. All animals were placed supine and laparoscopy was done under general anesthesia. Acepromazine (0,25 mg/kg), midazolam (1 mg/kg) and meperidine (5 mg/kg) were administrated intramuscularly as premedication. The induction to general anesthesia was performed with Isoflurane 5%, using a tracheal tube, and maintained with Isoflurane 3-4% under manual ventilation. The animals were positioned supine over a surgical table and kept in place with elastic bands. The abdomen had previously been shaved. All needle movements are performed from outside the body cavity under camera control. To choose the location for the needle puncture, the position of the internal inguinal ring is assessed by pressing the inguinal region from the outside with the tip of a Pean forceps (Fig.4).

**Figure 5.** Laparoscopic view on the orifice of the inguinal hernia sac (IHS), the spermatic cord and vas deferens in rab‐

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After injection of the bulking agent and closing of the orifice of the IHS, the rabbits were extubated and observed in animal laboratory. Second laparoscopy was performed six month later using the same technique. At the second procedure the integrity of the closed internal inguinal rings and the presence of ring abscess, peritonitis and adhesions were recorded. At second laparoscopy integrity of the closed internal inguinal ring was present. No opening of the rings was observed. Accurate placement of the polymeric agent and adequate coverage of

**Figure 6.** Tip of the Tuohy needle (a) before the gels implantation

bit

**Figure 4.** Position telescope and Tuohy needle during laparoscopic inguinal preperitoneal injection (LIPI)

At the beginning of procedure was performed the inspection of deep inguinal rings and cord structures (Fig.5). The Tuohy needle with injectable polymeric bulking agent DAM+™ (3- Dimensional polyacrylamide gel with ions of silver "Argiform", Bioform®) was introduced preperitoneally (Fig.6). The 2.0 ml of implant was then injected across the entire orifice of the internal inguinal rings (Fig.7) and draped over the cord structures (Fig.8). Mean operative time ranged from 10 to 12 minutes for bilateral hernia repair. Time required to inject the DAM+™ was less than 1 minute Postoperative recovery was rapid and all animals returned to their normal activity after the procedure.

Laparoscopic Inguinal Preperitoneal Injection (LIPI) — Novel Experimental Technique for Inguinal Hernia... http://dx.doi.org/10.5772/57159 79

**Figure 5.** Laparoscopic view on the orifice of the inguinal hernia sac (IHS), the spermatic cord and vas deferens in rab‐ bit

**Figure 6.** Tip of the Tuohy needle (a) before the gels implantation

was used. All procedures were recorded on hard disk of the videohub. All animals were placed supine and laparoscopy was done under general anesthesia. Acepromazine (0,25 mg/kg), midazolam (1 mg/kg) and meperidine (5 mg/kg) were administrated intramuscularly as premedication. The induction to general anesthesia was performed with Isoflurane 5%, using a tracheal tube, and maintained with Isoflurane 3-4% under manual ventilation. The animals were positioned supine over a surgical table and kept in place with elastic bands. The abdomen had previously been shaved. All needle movements are performed from outside the body cavity under camera control. To choose the location for the needle puncture, the position of the internal inguinal ring is assessed by pressing the inguinal region from the outside with the

**Figure 4.** Position telescope and Tuohy needle during laparoscopic inguinal preperitoneal injection (LIPI)

At the beginning of procedure was performed the inspection of deep inguinal rings and cord structures (Fig.5). The Tuohy needle with injectable polymeric bulking agent DAM+™ (3- Dimensional polyacrylamide gel with ions of silver "Argiform", Bioform®) was introduced preperitoneally (Fig.6). The 2.0 ml of implant was then injected across the entire orifice of the internal inguinal rings (Fig.7) and draped over the cord structures (Fig.8). Mean operative time ranged from 10 to 12 minutes for bilateral hernia repair. Time required to inject the DAM+™ was less than 1 minute Postoperative recovery was rapid and all animals returned to their

tip of a Pean forceps (Fig.4).

78 Inguinal Hernia

normal activity after the procedure.

After injection of the bulking agent and closing of the orifice of the IHS, the rabbits were extubated and observed in animal laboratory. Second laparoscopy was performed six month later using the same technique. At the second procedure the integrity of the closed internal inguinal rings and the presence of ring abscess, peritonitis and adhesions were recorded. At second laparoscopy integrity of the closed internal inguinal ring was present. No opening of the rings was observed. Accurate placement of the polymeric agent and adequate coverage of

in all cases. This technique is simple, safe, and does not require any laparoscopic skills. Our method is highly successful, but in preparation for its use clinically, we must perform a particular studies requiring investigation local tissue reaction and long-term follow-up after the gel injection. In addition, we have concerns about hernia recurrence because polyacryla‐ mide gel may lose its volume effect. Such research will confirm if there are any detrimental

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Progress in pediatric surgery and anesthesia has reduced the risk of the procedure of the hernioraphy so that in most centers it is performed as a day surgery. Further develop‐ ment in minimal access surgery for pediatric inguinal hernia is to decrease the number and size of skin incisions. With a trend toward increasing use of extracorporeal knotting and decreasing use of working ports and endoscopic instruments, laparoscopic inguinal preperitoneal injection (LIPI) of 3-D gel may be the attainment. We develop a modified technique of non-operative treatment of the inguinal hernia in children and we assume that gel injection in preperitoneale space can be performed under ultrasound visualization

A technology of ultrasound guided nerve block in infants undergoing inguinal hernioraphy gained special popularity in pediatric anesthesia recently. The ilioinguinal/iliohypogastric nerve block is a popular regional anesthetic technique for postoperative pain relief after inguinal surgery in children [27, 28]. It is not easily to perform because the peritoneal cavity is just millimeters from the ilioinguinal and iliohypogastric nerves in small children. Needle placement and spread of local anesthetic is easily seen with high-resolution ultrasonography. Using ultrasound guidance, greater success can be achieved by more accurate placement of

We can transfer this technique and make similar procedure for a gel injection at pediatric patients with inguinal hernia. The idea consists in the following. Before placement of the 3-D polyacrylamide gel an initial ultrasound exploration of the area of the proposed injection site is performed by an experienced ultrasonographer using a stationary or transportable ultra‐ sound unit and a 5–10 MHz linear probe with an active area of 20-30 mm. Inguinal masses in children must be carefully evaluated. The proposed site of injection will be then prepared with

The position of the needle tip in a particular anatomical structure (transverse abdominal muscle, internal oblique abdominal muscle, external oblique abdominal muscle; within the peritoneal cavity or subcutaneous) will be recorded. After that gel injection will be made. The injection of the gel will be performed by surgeon with experience of performing inguinal hernia repair. However this technique demands approbation on animal (rabbits) and then can be

reduced volumes of local anesthetics closer to the targeted nerves.

sequelae associated with this technique.

**5. Application in the future**

without laparoscopic control.

chlorhexidine.

transfered on the humans.

**Figure 7.** Tip of the Tuohy needle (a) after the gels implantation (b – spermatic cord)

**Figure 8.** View of the inguinal hernia sac after LIPI procedure with preperitoneal placement of the polymeric agent (a)

the vas deferens were accomplished in all animals. Adhesions between the closed orifice of the IHS and the small bowel were absent in all rabbits. There were no signs of peritonitis and abscess formation.

In the current study, histologic examination clearly showed that mild inflammation was localized within the IHS only adjacent to the gel and there were no histopathologic changes detected around the vas deferens and spermatic vessels. Our results has shown that after six months of DAM+™ injection closing of internal inguinal ring was observed with no reopening in all cases. This technique is simple, safe, and does not require any laparoscopic skills. Our method is highly successful, but in preparation for its use clinically, we must perform a particular studies requiring investigation local tissue reaction and long-term follow-up after the gel injection. In addition, we have concerns about hernia recurrence because polyacryla‐ mide gel may lose its volume effect. Such research will confirm if there are any detrimental sequelae associated with this technique.

#### **5. Application in the future**

the vas deferens were accomplished in all animals. Adhesions between the closed orifice of the IHS and the small bowel were absent in all rabbits. There were no signs of peritonitis and

**Figure 8.** View of the inguinal hernia sac after LIPI procedure with preperitoneal placement of the polymeric agent (a)

**Figure 7.** Tip of the Tuohy needle (a) after the gels implantation (b – spermatic cord)

In the current study, histologic examination clearly showed that mild inflammation was localized within the IHS only adjacent to the gel and there were no histopathologic changes detected around the vas deferens and spermatic vessels. Our results has shown that after six months of DAM+™ injection closing of internal inguinal ring was observed with no reopening

abscess formation.

80 Inguinal Hernia

Progress in pediatric surgery and anesthesia has reduced the risk of the procedure of the hernioraphy so that in most centers it is performed as a day surgery. Further develop‐ ment in minimal access surgery for pediatric inguinal hernia is to decrease the number and size of skin incisions. With a trend toward increasing use of extracorporeal knotting and decreasing use of working ports and endoscopic instruments, laparoscopic inguinal preperitoneal injection (LIPI) of 3-D gel may be the attainment. We develop a modified technique of non-operative treatment of the inguinal hernia in children and we assume that gel injection in preperitoneale space can be performed under ultrasound visualization without laparoscopic control.

A technology of ultrasound guided nerve block in infants undergoing inguinal hernioraphy gained special popularity in pediatric anesthesia recently. The ilioinguinal/iliohypogastric nerve block is a popular regional anesthetic technique for postoperative pain relief after inguinal surgery in children [27, 28]. It is not easily to perform because the peritoneal cavity is just millimeters from the ilioinguinal and iliohypogastric nerves in small children. Needle placement and spread of local anesthetic is easily seen with high-resolution ultrasonography. Using ultrasound guidance, greater success can be achieved by more accurate placement of reduced volumes of local anesthetics closer to the targeted nerves.

We can transfer this technique and make similar procedure for a gel injection at pediatric patients with inguinal hernia. The idea consists in the following. Before placement of the 3-D polyacrylamide gel an initial ultrasound exploration of the area of the proposed injection site is performed by an experienced ultrasonographer using a stationary or transportable ultra‐ sound unit and a 5–10 MHz linear probe with an active area of 20-30 mm. Inguinal masses in children must be carefully evaluated. The proposed site of injection will be then prepared with chlorhexidine.

The position of the needle tip in a particular anatomical structure (transverse abdominal muscle, internal oblique abdominal muscle, external oblique abdominal muscle; within the peritoneal cavity or subcutaneous) will be recorded. After that gel injection will be made. The injection of the gel will be performed by surgeon with experience of performing inguinal hernia repair. However this technique demands approbation on animal (rabbits) and then can be transfered on the humans.

#### **6. Conclusion**

Inguinal hernia repair is one of the most common pediatric surgical procedure worldwide. During the last 10 years, laparoscopic surgery has rapidly invaved the pediatric surgical practice. The hopes associated with introduction of a laparoscopy in treatment of pediatric inguinal hernias didn't come true. Unexpectedly, but the randomized, single-blinded, pro‐ spective repair between elective laparoscopic and open repair of unilateral inguinal hernia in children showed that recovery and surgical outcome were similar [28]. Besides, laparoscopic repair significantly increased the postoperative time and operative room time.

[3] Shcheben'kov M.V. Laparoscopic hernioraphy. Endoscopic surgery (Mosk). 1995; 4:

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[4] Takehara H, Yakabe S, Kameoka K. Laparoscopic percutaneous extraperitoneal clo‐ sure for inguinal hernia in children: clinical outcome of 972 repairs done in 3 pedia‐

[5] Ozgediz D, Roayaie K, Lee H, et al., Subcutaneous endoscopically assisted ligation (SEAL) of the internal ring for repair of inguinal hernias in children: report of a new

[6] Steigman CK, Sotelo-Avila C, Weber TR. The incidence of spermatic cord structures in inguinal hernia sacs from male children. Am J Surg Pathol 1999;23:880–885.

[7] Chen LE, Zamakhshary M, Foglia RP, et al. Impact of wait time on outcome for in‐

[8] Schier F. Laparoscopic surgery of inguinal hernias in children: initial experience. J

[9] Schier F. Laparoscopic inguinal hernia repair: a prospective personal series of 542

[10] Montupet P, Esposito C. Laparoscopic treatment of congenital inguinal hernia in

[11] Prasad R, Lovvorn HN, Wadie GM, et al. Early experience with needlescopic ingui‐

[12] Endo M, Watanabe T, Nakano M, et al. Laparoscopic completely extraperitoneal re‐ pair of inguinal hernia in children: a single-institute experience with 1257 repairs

[13] Shalaby R, Shams AM, Mohamed S, et al. Two-trocar needlescopic approach to incar‐

[14] Chan KL, Tam PK. Technical refinements in laparoscopic repair of childhood ingui‐

[15] Miyano G, Yamataka A, Kato Y, et al. Laparoscopic injection of Dermabond tissue adhesive for the repair of inguinal hernia: short- and long-term follow-up. J Pediatr

[16] Kato Y, Yamataka A, Miyano G. Tissue adhesives for repairing inguinal hernia: a

[17] Testini M, Lissidini G, Poli E, et al. A single-surgeon randomized trial comparing su‐ tures, N-butyl-2-cyanoacrylate and human fibrin glue for mesh fixation during pri‐

compared with cut-down herniorrhaphy. Surg Endosc. 2009;23:1706–1712.

cerated inguinal hernia in children. J Pediatr Surg. 2007;42:1259–1262.

preliminary study. J Laparoendosc Adv Surg Tech A. 2005;15:424-428.

tric surgical institutions. J Pediatr Surg. 2006;41:1999-2003.

technique and early results. Surg Endosc. 2007;21:1327-1331.

guinal hernia repair in infants. Pediatr Surg Int 2009;25:223–227.

nal herniorrhaphy in children. J Pediatr Surg. 2003;38:1055–1058.

7-9. [Article in Russian]

Pediatr Surg 2000;35:1331–1335.

children. J Pediatr Surg 2006;41:1081–1084.

children. J Pediatr Surg. 1999;34:420–423.

nal hernias. Surg Endosc. 2004;18:957–960.

mary inguinal hernia repair. Can J Surg;53:155-160.

Surg. 2004;39:1867-1870.

Injection implants can be regarded as a self-sufficient non-surgical alternative for correction of inguinal hernia in children. No doubt, materials of such kind must be safe and effective, and respond to a number of requirements: biocompatibility, non-toxicity, long-term effect, absence of antigenic properties and pyrogenic reactions. The injection method is excellent alternative to open and laparoscopic methods of treatment of inguinal hernia in children which use an anesthesia and an incision for operation performance. The advantages of this technique are that there is no dissection of the spermatic cord and there is no ligation of the IHS. The near future will show viability of this method.

#### **Author details**

Yury Kozlov1\*, Vladimir Novozhilov2 , Vitaly Kovalev3 and Pavel Krasnov2

\*Address all correspondence to<EMAIL_ADDRESS>
1 Department of Newborn Surgery, Pediatric Hospital Irkutsk, Irkutsk State Medical Acade‐ my of Continuing Education, Russia

2 Department of Newborn Surgery, Pediatric Hospital Irkutsk, Irkutsk State Medical Acade‐ my of Continuing Education, Russia

3 Department of Newborn Surgery, Pediatric Hospital Irkutsk, Russia

#### **References**

[3] Shcheben'kov M.V. Laparoscopic hernioraphy. Endoscopic surgery (Mosk). 1995; 4: 7-9. [Article in Russian]

**6. Conclusion**

82 Inguinal Hernia

**Author details**

**References**

future will show viability of this method.

Yury Kozlov1\*, Vladimir Novozhilov2

my of Continuing Education, Russia

my of Continuing Education, Russia

1993;40:1121–1131.

1993;73:799–836.

\*Address all correspondence to<EMAIL_ADDRESS>
3 Department of Newborn Surgery, Pediatric Hospital Irkutsk, Russia

Inguinal hernia repair is one of the most common pediatric surgical procedure worldwide. During the last 10 years, laparoscopic surgery has rapidly invaved the pediatric surgical practice. The hopes associated with introduction of a laparoscopy in treatment of pediatric inguinal hernias didn't come true. Unexpectedly, but the randomized, single-blinded, pro‐ spective repair between elective laparoscopic and open repair of unilateral inguinal hernia in children showed that recovery and surgical outcome were similar [28]. Besides, laparoscopic

Injection implants can be regarded as a self-sufficient non-surgical alternative for correction of inguinal hernia in children. No doubt, materials of such kind must be safe and effective, and respond to a number of requirements: biocompatibility, non-toxicity, long-term effect, absence of antigenic properties and pyrogenic reactions. The injection method is excellent alternative to open and laparoscopic methods of treatment of inguinal hernia in children which use an anesthesia and an incision for operation performance. The advantages of this technique are that there is no dissection of the spermatic cord and there is no ligation of the IHS. The near

, Vitaly Kovalev3

1 Department of Newborn Surgery, Pediatric Hospital Irkutsk, Irkutsk State Medical Acade‐

2 Department of Newborn Surgery, Pediatric Hospital Irkutsk, Irkutsk State Medical Acade‐

[1] Sherer LR, Grosfeld JL. Inguinal hernia and umbilical anomalies. Ped Clin North Am

[2] Skandalakis JE, Colborn GL, Androulakis JA, Skandalakis LJ, Pemberton LB. Em‐ bryologic and anatomic basis of in- guinal herniorrhaphy. Surg Clin North Am

and Pavel Krasnov2

repair significantly increased the postoperative time and operative room time.

[18] Bisenkov L.N., Bikhodzhin R.Sh. The endoscopic treatment of bronchial fistulas by submucosal injections. Vestn Khir Im I I Grek. 2005;164:38-41. [Article in Russian]

**Section 3**

**Special Types of Groin Hernias**

**Special Types of Groin Hernias**

[18] Bisenkov L.N., Bikhodzhin R.Sh. The endoscopic treatment of bronchial fistulas by submucosal injections. Vestn Khir Im I I Grek. 2005;164:38-41. [Article in Russian] [19] Bisenkov L.N., Bikhodzhin R.Sh. Prophylaxis and treatment of primary insufficiency of bronchial stump after pneumonectomy. Khirurgiia (Mosk). 2007;1:59-65. [Article

[20] Osipov I, Lebedev D, Sosnin E, et al. Our experience in endoscopic treatment of vesi‐

[21] Fedorova V.N., Dirsh A.V., Borchunova E.N. Tissue reactivity to the injection of dif‐ ferent types of polyacrylamide gels. Regenerative surgery. 2004; № 2. Electronic jour‐

[22] Luks FI. Gasless laparoscopy in infants. The rabbit model. J Pediatr Surg

[23] Marana R, Luciano AA, Muzii L, et al. Laparoscopy versus laparotomy for ovarian conservative surgery. A randomized trial in the rabbit model. Am J Obstet Gynecol

[24] Hurd W. A comparison of the relative risk of vessel injury with conical versus pyra‐ midal laparoscopic trocars in a rabbit model. Am J Obstet Gynecol 1995;173:1731–

[25] Ordoñez JL, Domínguez J, Evrard V, et al. The effect of training and duration of sur‐ gery on adhesion formation in the rabbit model. Hum Reprod 1997;12:2654–2657. [26] Molinas CR, Cabral CR, Koninckx PR. Effect of the diameter of the endoscope and of surgeon training on the duration and quality of laparoscopic surgery in a rabbit

[27] Willschke H, Marhofer P, Bosenberg A, Johnston S, Wanzel O, Cox SG, Sitzwohl C, Kapral S. Ultrasonography for ilioinguinal/iliohypogastric nerve blocks in children.

[28] Denny NM, Harrop-Griffith W. Location, location, location! Ultrasound in regional

[29] Koivusalo AI, Korpela R, Wirtavuori K, et al. A single-blinded, randomized compari‐

co-ureteral reflux in children. Arch Ital Urol Androl. 2005;77:146-148.

nal: http://www.reg-surgery.ru/home.html. [Article in Russian].

model. J Am Assoc Gynecol Laparosc 1999;6:447–452.

son of laparoscopic versus open hernia repair in children.

in Russian]

84 Inguinal Hernia

1995;30:1206–1208.

1994;171:861–864.

Br J Anaesth 2005;95:226–30

Pediatrics 2009;123:332–337.

anaesthesia. Br J Anaesth 2005;95:1–2

1733.

**Chapter 6**

**Strangulated Inguinal Hernia**

Evangelos P. Misiakos, George Bagias, Nickolaos Zavras, Panagiotis Tzanetis, Paul Patapis and Anastasios Machairas

http://dx.doi.org/10.5772/57379

techniques of cautery or caustics [1].

**1. Introduction**

Additional information is available at the end of the chapter

An inguinal hernia is an abnormal protrusion of intra-abdominal tissue through a fascial defect in the groin. When a part of bowel which is inside the hernia sac becomes obstructed, there may initially be no interference with blood supply. This case results in a strangulated inguinal hernia, in which gangrene of the contents of the sac has been occurred. Strangulated inguinal hernia is a life-threatening condition which requires urgent surgical intervention. Historically, the prominence of "adhesive bands" as a cause of intestinal obstruction was already known, and was also the main historical cause of small intestinal obstruction before the advent of anesthesia. The descriptive history of hernias can be traced back through the centuries to Hippocrates and the knowledge of the catastrophic effects of incarceration of a hernia dates back to immemorial times. Celsus had referred many interesting historical incidences and he was also the first to describe the surgical techniques for the correction of recurring hernias. Of course, these procedures were very brutal compared to modern techniques, involving various

The modern era of thoughtful anatomical and surgical approach to hernia restoration dates back to the beginning of the nineteenth century with Sir Ashley Cooper's and Antonio Scarpa's illustrated monographs in England and in Italy respectively. It is interesting that the life threatening problem of strangulated inguinal hernia was occasionally successfully managed by the simple process of resecting the ischemic part of the bowel, leaving what amounted to a double-barreled enterostomy. Undoubtedly, few patients survived the debilitating effects of small bowel fistula but occasionally intestinal continuity was spontaneously re-established by retraction of the open ends of the bowel and gradual closing of the external fistula. Some of the well-known surgeons of the nineteenth century, such as Gimbernat (1793), Richter (1778),

> © 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **Chapter 6**

## **Strangulated Inguinal Hernia**

Evangelos P. Misiakos, George Bagias, Nickolaos Zavras, Panagiotis Tzanetis, Paul Patapis and Anastasios Machairas

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/57379

#### **1. Introduction**

An inguinal hernia is an abnormal protrusion of intra-abdominal tissue through a fascial defect in the groin. When a part of bowel which is inside the hernia sac becomes obstructed, there may initially be no interference with blood supply. This case results in a strangulated inguinal hernia, in which gangrene of the contents of the sac has been occurred. Strangulated inguinal hernia is a life-threatening condition which requires urgent surgical intervention. Historically, the prominence of "adhesive bands" as a cause of intestinal obstruction was already known, and was also the main historical cause of small intestinal obstruction before the advent of anesthesia. The descriptive history of hernias can be traced back through the centuries to Hippocrates and the knowledge of the catastrophic effects of incarceration of a hernia dates back to immemorial times. Celsus had referred many interesting historical incidences and he was also the first to describe the surgical techniques for the correction of recurring hernias. Of course, these procedures were very brutal compared to modern techniques, involving various techniques of cautery or caustics [1].

The modern era of thoughtful anatomical and surgical approach to hernia restoration dates back to the beginning of the nineteenth century with Sir Ashley Cooper's and Antonio Scarpa's illustrated monographs in England and in Italy respectively. It is interesting that the life threatening problem of strangulated inguinal hernia was occasionally successfully managed by the simple process of resecting the ischemic part of the bowel, leaving what amounted to a double-barreled enterostomy. Undoubtedly, few patients survived the debilitating effects of small bowel fistula but occasionally intestinal continuity was spontaneously re-established by retraction of the open ends of the bowel and gradual closing of the external fistula. Some of the well-known surgeons of the nineteenth century, such as Gimbernat (1793), Richter (1778),

© 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Camper (1801), Hesselbach (1806) and Scarborough (1809), contributed to the anatomy and clinical findings associated with hernias. There was a limit, however, to what could be accomplished surgically until the introduction of antisepsis, and anesthesia techniques, so subsequent surgeons such as Bassini, Halsted, Billroth, Marcy and others defined the various types of surgical approach to abdominal wall hernias, up to 1880.

internal ring and displace or attenuate the inguinal floor. Then the peritoneum may protrude on either side of epigastric vessels, to form a combined direct and indirect hernia, which is called "*pantaloon hernia*". Contents of this hernia can be part of small intestine, omentum,

Strangulated Inguinal Hernia http://dx.doi.org/10.5772/57379 89

The appearance and progression of a hernia is caused by the increase of intra-abdominal pressure. Many conditions are responsible for this increase. Marked obesity, abdominal strain from heavy exercise, cough, constipation with straining at stool and prostatism with straining on mictutition are some of the common reasons of intra-abdominal pressure's increase. Cirrhosis with ascites, chronic ambulatory peritoneal dialysis and chronically enlarged pelvic orgaans can also contribute. Last but not least, advanced age and chronic debilitating disease can result to transversalis fascia (which forms the floor of Hesselbach

The *strangulation of inguinal hernia* implies interference with the blood supply associated with an obstruction, which may not necessarily be complete. In most cases, it occurs as a compli‐ cation of intussusception, torsion, volvulus, or any other form of closed-loop obstruction. Interference with the blood supply may occur either from twisting of the bowel on the mesentery or from distension of an obstructed closed loop. It has been pointed out that there is a distinction between long, medium (8±20 inches), and short loop strangulated obstruction. Medium strangulated loops usually result to toxic shock syndrome by the formation of exotoxins of Clostridium welchii, and short loops tend to perforate and cause peritonitis. The contents of the hernia sac can be only ileum, only omentum, ileum with omentum, and rarely only colon, ileum with colon, colon with omentum, testicle, appendix, urinary bladder,

The incidence rate of strangulated inguinal hernia varies between 0.29 and 2.9 %. The mortality rate also ranges between 2.6 to 9 %, but Tanaka et al[3] have shown that a delay of 12 h increased significantly intestinal resection rate. Needless to say, the delay in diagnosis can also affect the length of hospital stay and hospital costs. Moreover, mortality risk is seven times higher in cases after emergency strangulated inguinal hernia surgery and 20 times higher if bowel resection was undertaken. Strangulated hernias are more frequently seen in elderly patients, and their prevalence in the over-60-year-old population has been reported to be 9.8 % com‐ pared with 1.8 % for younger patients; morbidity and mortality rates are 55 and 15 %, respec‐ tively, for patients over 65 years in case of herniorrhaphy in emergency. In addition, it has been reported that advanced age in the patients with strangulated inguinal hernia is considered as a prognostic factor of surgical or medical postoperative complications. The relation between mortality and age is understandable, poor risk being related to both intestinal necrosis and

systemic complications of more dubious control in emergency circumstances.

peritoneum, bladder, and part of colon.

Meckel's diverticulum, and preperitoneal tissue.

triangle) debilitation.

**4. Epidemiology**

#### **2. Anatomy**

In the groin, an indirect inguinal hernia is caused when obliteration of the processus vaginalis (the peritoneal extension which accompanies the testicle in its descent into its final position, the scrotum) fails to occur. The hernia sac which has been formed passes through the internal inguinal ring, a defect in the transversalis fascia, between the anterior iliac spine and the pubic tubercle. The sac may extend partway along the inguinal canal, or it can pass through the external inguinal ring, a defect medially in the external oblique muscle, above the pubic tubercle. When the hernia sac reaches fully into the scrotum is called *complete hernia*. The hernia sac and the spermatic cord are invested by the cremaster muscle which is just an extension of internal oblique muscle's fibers [2].

A direct inguinal hernia however, is caused by a weaknes or defect in the floor of Hesselbach triangle. The Hesselbach triangle is defined inferiorly by the inguinal ligament, laterally by the inferior epigastric arteries, and medially by the conjoined tendon. Usually, the transversalis fascia, which forms the floor of Hesselbach triangle, is weakened, though a discrete defect in the fascia may occasionally occur. This type of direct inguinal hernia has distinct borders, thus it is more possible to incarcerate [2].

At this point, we need to mention some anatomic structures, which are important, not only for understanding the pathophysiologgy of hernias, but also for understanding the surgical techniques being used. The conjoined tendon is a fusion of the medial aponeurosis of trans‐ versus abdominis and internal oblique muscles, that passes along the inferolateral edge of the rectus abdominis muscle and attaches to the pubic tubercle. The inguinal ligament is formed by the lowermost border of the external oblique aponeurosis, and it passes between the pubic tubercle and the anterior iliac spine. The Cooper ligament is a strong, fibrous band that extends laterally for about 2.5 cm along the iliopectineal line on the superior aspect of the superior pubic ramus. Finally, the iliopubic tract, parallel to inguinal ligament, is a band of connective tissue that starts form the iliopsoas fascia, crosses below the internal inguinal ring, and inserts into the superior pubic ramus, in order to form the Gimbernat ligament.

#### **3. Pathophysiology**

The majority of inguinal hernias are indirect hernias. As we mentioned above, an inguinal hernia is formed when the processus vaginalis cannot obliterate, and a direct inguinal hernia is caused when the floor of Hesselbach triangle is weakened. An indirect hernia may dilate the internal ring and displace or attenuate the inguinal floor. Then the peritoneum may protrude on either side of epigastric vessels, to form a combined direct and indirect hernia, which is called "*pantaloon hernia*". Contents of this hernia can be part of small intestine, omentum, peritoneum, bladder, and part of colon.

The appearance and progression of a hernia is caused by the increase of intra-abdominal pressure. Many conditions are responsible for this increase. Marked obesity, abdominal strain from heavy exercise, cough, constipation with straining at stool and prostatism with straining on mictutition are some of the common reasons of intra-abdominal pressure's increase. Cirrhosis with ascites, chronic ambulatory peritoneal dialysis and chronically enlarged pelvic orgaans can also contribute. Last but not least, advanced age and chronic debilitating disease can result to transversalis fascia (which forms the floor of Hesselbach triangle) debilitation.

The *strangulation of inguinal hernia* implies interference with the blood supply associated with an obstruction, which may not necessarily be complete. In most cases, it occurs as a compli‐ cation of intussusception, torsion, volvulus, or any other form of closed-loop obstruction. Interference with the blood supply may occur either from twisting of the bowel on the mesentery or from distension of an obstructed closed loop. It has been pointed out that there is a distinction between long, medium (8±20 inches), and short loop strangulated obstruction. Medium strangulated loops usually result to toxic shock syndrome by the formation of exotoxins of Clostridium welchii, and short loops tend to perforate and cause peritonitis. The contents of the hernia sac can be only ileum, only omentum, ileum with omentum, and rarely only colon, ileum with colon, colon with omentum, testicle, appendix, urinary bladder, Meckel's diverticulum, and preperitoneal tissue.

#### **4. Epidemiology**

Camper (1801), Hesselbach (1806) and Scarborough (1809), contributed to the anatomy and clinical findings associated with hernias. There was a limit, however, to what could be accomplished surgically until the introduction of antisepsis, and anesthesia techniques, so subsequent surgeons such as Bassini, Halsted, Billroth, Marcy and others defined the various

In the groin, an indirect inguinal hernia is caused when obliteration of the processus vaginalis (the peritoneal extension which accompanies the testicle in its descent into its final position, the scrotum) fails to occur. The hernia sac which has been formed passes through the internal inguinal ring, a defect in the transversalis fascia, between the anterior iliac spine and the pubic tubercle. The sac may extend partway along the inguinal canal, or it can pass through the external inguinal ring, a defect medially in the external oblique muscle, above the pubic tubercle. When the hernia sac reaches fully into the scrotum is called *complete hernia*. The hernia sac and the spermatic cord are invested by the cremaster muscle which is just an extension of

A direct inguinal hernia however, is caused by a weaknes or defect in the floor of Hesselbach triangle. The Hesselbach triangle is defined inferiorly by the inguinal ligament, laterally by the inferior epigastric arteries, and medially by the conjoined tendon. Usually, the transversalis fascia, which forms the floor of Hesselbach triangle, is weakened, though a discrete defect in the fascia may occasionally occur. This type of direct inguinal hernia has distinct borders, thus

At this point, we need to mention some anatomic structures, which are important, not only for understanding the pathophysiologgy of hernias, but also for understanding the surgical techniques being used. The conjoined tendon is a fusion of the medial aponeurosis of trans‐ versus abdominis and internal oblique muscles, that passes along the inferolateral edge of the rectus abdominis muscle and attaches to the pubic tubercle. The inguinal ligament is formed by the lowermost border of the external oblique aponeurosis, and it passes between the pubic tubercle and the anterior iliac spine. The Cooper ligament is a strong, fibrous band that extends laterally for about 2.5 cm along the iliopectineal line on the superior aspect of the superior pubic ramus. Finally, the iliopubic tract, parallel to inguinal ligament, is a band of connective tissue that starts form the iliopsoas fascia, crosses below the internal inguinal ring, and inserts

The majority of inguinal hernias are indirect hernias. As we mentioned above, an inguinal hernia is formed when the processus vaginalis cannot obliterate, and a direct inguinal hernia is caused when the floor of Hesselbach triangle is weakened. An indirect hernia may dilate the

into the superior pubic ramus, in order to form the Gimbernat ligament.

types of surgical approach to abdominal wall hernias, up to 1880.

**2. Anatomy**

88 Inguinal Hernia

internal oblique muscle's fibers [2].

it is more possible to incarcerate [2].

**3. Pathophysiology**

The incidence rate of strangulated inguinal hernia varies between 0.29 and 2.9 %. The mortality rate also ranges between 2.6 to 9 %, but Tanaka et al[3] have shown that a delay of 12 h increased significantly intestinal resection rate. Needless to say, the delay in diagnosis can also affect the length of hospital stay and hospital costs. Moreover, mortality risk is seven times higher in cases after emergency strangulated inguinal hernia surgery and 20 times higher if bowel resection was undertaken. Strangulated hernias are more frequently seen in elderly patients, and their prevalence in the over-60-year-old population has been reported to be 9.8 % com‐ pared with 1.8 % for younger patients; morbidity and mortality rates are 55 and 15 %, respec‐ tively, for patients over 65 years in case of herniorrhaphy in emergency. In addition, it has been reported that advanced age in the patients with strangulated inguinal hernia is considered as a prognostic factor of surgical or medical postoperative complications. The relation between mortality and age is understandable, poor risk being related to both intestinal necrosis and systemic complications of more dubious control in emergency circumstances.

#### **5. Diagnosis**

#### **5.1. Risk factors**

Many habits, conditions and diseases have been accused of development of an inguinal hernia. Patients with abnormal collagen metabolism have an increased risk, due to transversalis fascia debilitation. This fact is substantiated by the higher incidence of inguinal hernias in patients with aortic aneurysm. Abnormality in collagen metabolism can be familial, and studies have revealed families with increased incidence rates of hernias. Smokers have also an abnormal collagen metabolism, as a result smoking is almost certainly considered as a risk factor. Another risk factor is a patent processus vaginalis. Chronic coughing in patients with chronic obstructive pulmonary disease (COPD) seems to be a risk factor, as it contributes to an increase of intraabdominal pressure. Ascites in terms of hepatic cirrhosis and peritoneal dialysis can increase the risk of inguinal hernia or a recurrent hernia. Although physical work is not a risk factor, some studies revealed that long-term and heavy work does increase the risk of hernias [3]. Needless to say that, the patient should be questioned, if it is possible, about these factors. This would help a lot to an early and a safer diagnosis.

Inguinal hernia is a known complication after radical retropubic prostatectomy, whether if it is open or laparoscopic, and has been reported to occur in 7–21% of patients. Other types of lower midline incision surgery as well could promote the development of postoperative inguinal hernia, such as a low (cosmetic) incision for appendectomy, which can disrupt the shutter mechanism and increase the risk of an inguinal hernia. Surgeons should be aware of this important postoperative complication and prophylactic surgical procedures must be evaluated to address the problem.

**Figure 1.** Strangulated recurrent hernia 2 years after a mesh repair. Local swelling, redness, edema and tenderness are

Strangulated Inguinal Hernia http://dx.doi.org/10.5772/57379 91

Although they are considered to be rare, there are some cases in which the hernia is occulted, particularly in obese patients, where a small part of the small intestine is strangulated. In these cases, the physical examination cannot establish the diagnosis of strangulated inguinal hernia by itself, and further imaging examinations are carried out. An ultrasonography of the lower abdomen can be performed, after patient's metabolic stabilization, but its sensitivity is low. A computed tomography is another diagnostic tool, with low specificity, but it is useful in the rare case of involvement of the urinary bladder. MRI can also be performed, and is capable for revealing the inflammatory site, and the bowel obstruction, which occurs in strangulated hernias. MRI's sensitivity is 94.5% and specificity is 96.3%. Herniography is also safe, sensitive (100%) and specific (98–100%) imaging examination [4]. Imaging findings are taken into account in combination with physical examination's findings and the general condition of the

Although laboratory findings are remarkable, they cannot be used for diagnosis of strangu‐ lated inguinal hernia. Hemoconcentration and leucocytosis (especially when is not accounted

the main local signs.

**5.3. Imaging examinations**

patient, and the diagnosis is established.

**5.4. Laboratory examinations**

#### **5.2. Signs and symptoms**

As we mentioned above, it has been reported that a delay in diagnosis of 12 h or more, increases significantly morbidity and mortality [4]. This fact points out the importance of the early diagnosis. Strangulated hernia should be regarded as a possible diagnosis in cases of acute small bowel obstruction, especially when no previous laparotomy has been carried out. The first diagnostic tool is the physical examination of the patient. The most common presenting clinical findings for emergency admission are an irreducible mass in the abdominal wall and localized pain (Fig. 1). Patients may have also signs and symptoms of mechanical bowel obstruction, as well as metabolic disorders, such as breath odor, constipation, diarrhea, vomiting and inability for gas exit. Duration of symptoms prior to admission can be from a few hours, up to several days. Significant concomitant medical illnesses can also be found in some cases, though essential hypertension and cardiovascular disorders are considered to be the commonest problems seen. The palpation of the infected area can provide additional information. A punctilious palpation of the inguinal area is needed, in order to locate the hernia site. In the majority of cases, the physical examination establishes the diagnosis of strangulated hernia, and no further examination is needed. The diagnosis of inguinal hernia can be established by physical examination with a sensitivity of 74.5–92% and a specificity of 93%.

**Figure 1.** Strangulated recurrent hernia 2 years after a mesh repair. Local swelling, redness, edema and tenderness are the main local signs.

#### **5.3. Imaging examinations**

**5. Diagnosis**

90 Inguinal Hernia

**5.1. Risk factors**

Many habits, conditions and diseases have been accused of development of an inguinal hernia. Patients with abnormal collagen metabolism have an increased risk, due to transversalis fascia debilitation. This fact is substantiated by the higher incidence of inguinal hernias in patients with aortic aneurysm. Abnormality in collagen metabolism can be familial, and studies have revealed families with increased incidence rates of hernias. Smokers have also an abnormal collagen metabolism, as a result smoking is almost certainly considered as a risk factor. Another risk factor is a patent processus vaginalis. Chronic coughing in patients with chronic obstructive pulmonary disease (COPD) seems to be a risk factor, as it contributes to an increase of intraabdominal pressure. Ascites in terms of hepatic cirrhosis and peritoneal dialysis can increase the risk of inguinal hernia or a recurrent hernia. Although physical work is not a risk factor, some studies revealed that long-term and heavy work does increase the risk of hernias [3]. Needless to say that, the patient should be questioned, if it is possible, about these factors.

Inguinal hernia is a known complication after radical retropubic prostatectomy, whether if it is open or laparoscopic, and has been reported to occur in 7–21% of patients. Other types of lower midline incision surgery as well could promote the development of postoperative inguinal hernia, such as a low (cosmetic) incision for appendectomy, which can disrupt the shutter mechanism and increase the risk of an inguinal hernia. Surgeons should be aware of this important postoperative complication and prophylactic surgical procedures must be

As we mentioned above, it has been reported that a delay in diagnosis of 12 h or more, increases significantly morbidity and mortality [4]. This fact points out the importance of the early diagnosis. Strangulated hernia should be regarded as a possible diagnosis in cases of acute small bowel obstruction, especially when no previous laparotomy has been carried out. The first diagnostic tool is the physical examination of the patient. The most common presenting clinical findings for emergency admission are an irreducible mass in the abdominal wall and localized pain (Fig. 1). Patients may have also signs and symptoms of mechanical bowel obstruction, as well as metabolic disorders, such as breath odor, constipation, diarrhea, vomiting and inability for gas exit. Duration of symptoms prior to admission can be from a few hours, up to several days. Significant concomitant medical illnesses can also be found in some cases, though essential hypertension and cardiovascular disorders are considered to be the commonest problems seen. The palpation of the infected area can provide additional information. A punctilious palpation of the inguinal area is needed, in order to locate the hernia site. In the majority of cases, the physical examination establishes the diagnosis of strangulated hernia, and no further examination is needed. The diagnosis of inguinal hernia can be established by physical examination with a sensitivity of 74.5–92% and a specificity of 93%.

This would help a lot to an early and a safer diagnosis.

evaluated to address the problem.

**5.2. Signs and symptoms**

Although they are considered to be rare, there are some cases in which the hernia is occulted, particularly in obese patients, where a small part of the small intestine is strangulated. In these cases, the physical examination cannot establish the diagnosis of strangulated inguinal hernia by itself, and further imaging examinations are carried out. An ultrasonography of the lower abdomen can be performed, after patient's metabolic stabilization, but its sensitivity is low. A computed tomography is another diagnostic tool, with low specificity, but it is useful in the rare case of involvement of the urinary bladder. MRI can also be performed, and is capable for revealing the inflammatory site, and the bowel obstruction, which occurs in strangulated hernias. MRI's sensitivity is 94.5% and specificity is 96.3%. Herniography is also safe, sensitive (100%) and specific (98–100%) imaging examination [4]. Imaging findings are taken into account in combination with physical examination's findings and the general condition of the patient, and the diagnosis is established.

#### **5.4. Laboratory examinations**

Although laboratory findings are remarkable, they cannot be used for diagnosis of strangu‐ lated inguinal hernia. Hemoconcentration and leucocytosis (especially when is not accounted for by hemoconcentration) can indicate bowel obstruction and strangulation, and so do lactic acidosis, when it does not resolve with volume resuscitation. When the strangulation of small intestine is diagnosed, however, the reason (in this case strangulated inguinal hernia) is not pointed out.

anesthesia allows for quick recovery time and, thus, is safe for early discharge in today's increasingly ambulatory surgery era. For patients with increased age or with elevated American Society of Anesthesiologists (ASA) classification (depending on co-existing cardio‐ vascular and/or pulmonary disease), local anesthesia causes much less hemodynamic disor‐ ders and it is believed that it is being better tolerated than general anesthesia. Large randomized control studies have shown decrease in overall anesthesia time, urinary retention, and postoperative pain following use of local anesthesia compared to regional and general anesthesia. It has also been indicated that local anesthesia is associated with recurrence rates, but it doubtful whether this increased recurrence rate is a result of local anesthesia, or the use

Strangulated Inguinal Hernia http://dx.doi.org/10.5772/57379 93

Needles to say, when herniorrhaphy is performed under local anesthesia, patients still feel the pressure and little pain. These effects can be minimized with the addition of anxiolytic agents. Additionally, the patient must always give consent for the possibility of conversion to general anesthesia, should he or she develop difficulty tolerating the procedure because of anxiety or

Commonly used local anesthetics are 0.5-1% lidocaine with epinephrine, or 0.25% bupivacaine, or a combination of these 2 agents in 50:50 mixtures. A field block is applied by injecting along the site of incision, superficial to deep, and lateral to the pubic tubercle, to provide anesthesia to the deeper structures. In order to block the ilioinguinal nerve, an injection is placed just medial to the anterior superior iliac spine. Additional local anesthetic can be injected through‐ out the procedure. For example, the administration below the fibers of the external oblique aponeurosis, as described by Lichtenstein's group, anesthetizes its 3 major nerves by flooding the enclosed inguinal canal and serves to hydrodissect the underlying ilioinguinal nerve (making it less prone to injury when the aponeurosis is incised). Other techniques, such as epidural anesthesia, have been widely reported, but results depend largely on local expertise. Elective inguinal hernia repair is considered an aseptic procedure as there is only a <2% surgical site infection rate. Although current data remain controversial, it is suggested (by numerous recent meta-analysis) to use antibiotic prophylaxis when performing a mesh-based repair. Cephalosporins (eg, cefazolin) are commonly administered by the anesthesiologist as a single dose prior to the skin incision. However, a properly funded, prospectively randomized study

Traditional surgical repairs, like Bassini and Shouldice techniques are not used very common in elective inguinal hernia repair. However, in an emergency surgery, as in cases of strangu‐ lated inguinal hernias, these techniques are preferred from contemporary tension-free techniques, due to high possibility of mesh infection, in tension free techniques. Regardless the choice between traditional and tension-free techniques, the operation begins with an oblique skin incision (or along the Langer lines) approximately 2 centimeter superior to and parallel to the thigh crease, and then the incision is being extended 5 cm toward the anterior superior iliac spine, starting from just lateral to the pubic tubercle. In thin patients, the external ring can actually be palpated just lateral and slightly above the pubic tubercle and should be

is still needed to definitively reveal the safest choice of anesthesia.

of Lichtenstein repair technique [6].

**6.2. Traditional techniques**

discomfort.

#### **5.5. Surgical diagnostics**

A definitive diagnosis of strangulation of the intestine can only be made through surgical exploration. Very little data have been published regarding the laparoscopy and exploratory laparotomy in comparison as a first approach in cases of strangulated groin hernia, when intestinal ischemia is suspected. Although midline laparotomies increase morbidity, due to possible intestinal resection, in some studies, almost the half of overall of midline laparotomies were performed without any intestinal resection [5]. When the patient is older, and there is a big possibility to have a lot of co-morbidities, the laparoscopy or hernioscopy could be of most benefit, avoiding the alternative of a laparotomy. Laparoscopy could help to diagnose bowel ischemia thus decreasing both negative and nontherapeutic laparotomy rates. Once the diagnosis of bowel ischemia is established, laparotomy could be performed. Evisceration, which is a rare occurrence of any incision, is more possible when the patient is old and he/she undergoes an emergency surgery. This complication could be avoided in emergency cases in this advanced aged population by using laparoscopy. Moreover, the decision to perform a bowel resection can be reliably made only by using laparoscopy.

#### **5.6. Differential diagnosis**

Strangulated hernia should be distinguished from other conditions which include swelling in the groin. First of all, a differential diagnosis should be made between strangulated inguinal and other types of hernias, such as femoral and incisional hernias. Other cases, in which the patient has groin swelling mass are lymhadenopathy, varicocele, aneurysm, soft-tissue tumor and an abscess, which can be a result of many pathological conditions in the inguinal area. Other relatively rare conditions are endometriosis and several genital anomalies (for example, ectopic testis). Cases that include pain in the inguinal area, but not the typical swelling are adductor tendinitis, pubic osteitis, hip artrosis and bursitis ileopectinea [4].

#### **6. Treatment**

A strangulated inguinal hernia, as an incident of acute abdomen, needs emergency surgery. As we mentioned above, the incidence rate of strangulated inguinal hernias is relatively low, because of the high acceptance of the value of elective hernia repair, but it is still a frequent incident of acute abdomen, especially in the elderly patients, in whom the hernia is not always diagnosed until strangulation.

#### **6.1. Anesthesia**

The choice between different anesthesia types for inguinal hernia repair is currently under discussion, and it is influenced by patient preferences and his/her medical history. Local anesthesia allows for quick recovery time and, thus, is safe for early discharge in today's increasingly ambulatory surgery era. For patients with increased age or with elevated American Society of Anesthesiologists (ASA) classification (depending on co-existing cardio‐ vascular and/or pulmonary disease), local anesthesia causes much less hemodynamic disor‐ ders and it is believed that it is being better tolerated than general anesthesia. Large randomized control studies have shown decrease in overall anesthesia time, urinary retention, and postoperative pain following use of local anesthesia compared to regional and general anesthesia. It has also been indicated that local anesthesia is associated with recurrence rates, but it doubtful whether this increased recurrence rate is a result of local anesthesia, or the use of Lichtenstein repair technique [6].

Needles to say, when herniorrhaphy is performed under local anesthesia, patients still feel the pressure and little pain. These effects can be minimized with the addition of anxiolytic agents. Additionally, the patient must always give consent for the possibility of conversion to general anesthesia, should he or she develop difficulty tolerating the procedure because of anxiety or discomfort.

Commonly used local anesthetics are 0.5-1% lidocaine with epinephrine, or 0.25% bupivacaine, or a combination of these 2 agents in 50:50 mixtures. A field block is applied by injecting along the site of incision, superficial to deep, and lateral to the pubic tubercle, to provide anesthesia to the deeper structures. In order to block the ilioinguinal nerve, an injection is placed just medial to the anterior superior iliac spine. Additional local anesthetic can be injected through‐ out the procedure. For example, the administration below the fibers of the external oblique aponeurosis, as described by Lichtenstein's group, anesthetizes its 3 major nerves by flooding the enclosed inguinal canal and serves to hydrodissect the underlying ilioinguinal nerve (making it less prone to injury when the aponeurosis is incised). Other techniques, such as epidural anesthesia, have been widely reported, but results depend largely on local expertise.

Elective inguinal hernia repair is considered an aseptic procedure as there is only a <2% surgical site infection rate. Although current data remain controversial, it is suggested (by numerous recent meta-analysis) to use antibiotic prophylaxis when performing a mesh-based repair. Cephalosporins (eg, cefazolin) are commonly administered by the anesthesiologist as a single dose prior to the skin incision. However, a properly funded, prospectively randomized study is still needed to definitively reveal the safest choice of anesthesia.

#### **6.2. Traditional techniques**

for by hemoconcentration) can indicate bowel obstruction and strangulation, and so do lactic acidosis, when it does not resolve with volume resuscitation. When the strangulation of small intestine is diagnosed, however, the reason (in this case strangulated inguinal hernia) is not

A definitive diagnosis of strangulation of the intestine can only be made through surgical exploration. Very little data have been published regarding the laparoscopy and exploratory laparotomy in comparison as a first approach in cases of strangulated groin hernia, when intestinal ischemia is suspected. Although midline laparotomies increase morbidity, due to possible intestinal resection, in some studies, almost the half of overall of midline laparotomies were performed without any intestinal resection [5]. When the patient is older, and there is a big possibility to have a lot of co-morbidities, the laparoscopy or hernioscopy could be of most benefit, avoiding the alternative of a laparotomy. Laparoscopy could help to diagnose bowel ischemia thus decreasing both negative and nontherapeutic laparotomy rates. Once the diagnosis of bowel ischemia is established, laparotomy could be performed. Evisceration, which is a rare occurrence of any incision, is more possible when the patient is old and he/she undergoes an emergency surgery. This complication could be avoided in emergency cases in this advanced aged population by using laparoscopy. Moreover, the decision to perform a

Strangulated hernia should be distinguished from other conditions which include swelling in the groin. First of all, a differential diagnosis should be made between strangulated inguinal and other types of hernias, such as femoral and incisional hernias. Other cases, in which the patient has groin swelling mass are lymhadenopathy, varicocele, aneurysm, soft-tissue tumor and an abscess, which can be a result of many pathological conditions in the inguinal area. Other relatively rare conditions are endometriosis and several genital anomalies (for example, ectopic testis). Cases that include pain in the inguinal area, but not the typical swelling are

A strangulated inguinal hernia, as an incident of acute abdomen, needs emergency surgery. As we mentioned above, the incidence rate of strangulated inguinal hernias is relatively low, because of the high acceptance of the value of elective hernia repair, but it is still a frequent incident of acute abdomen, especially in the elderly patients, in whom the hernia is not always

The choice between different anesthesia types for inguinal hernia repair is currently under discussion, and it is influenced by patient preferences and his/her medical history. Local

bowel resection can be reliably made only by using laparoscopy.

adductor tendinitis, pubic osteitis, hip artrosis and bursitis ileopectinea [4].

pointed out.

92 Inguinal Hernia

**5.5. Surgical diagnostics**

**5.6. Differential diagnosis**

**6. Treatment**

**6.1. Anesthesia**

diagnosed until strangulation.

Traditional surgical repairs, like Bassini and Shouldice techniques are not used very common in elective inguinal hernia repair. However, in an emergency surgery, as in cases of strangu‐ lated inguinal hernias, these techniques are preferred from contemporary tension-free techniques, due to high possibility of mesh infection, in tension free techniques. Regardless the choice between traditional and tension-free techniques, the operation begins with an oblique skin incision (or along the Langer lines) approximately 2 centimeter superior to and parallel to the thigh crease, and then the incision is being extended 5 cm toward the anterior superior iliac spine, starting from just lateral to the pubic tubercle. In thin patients, the external ring can actually be palpated just lateral and slightly above the pubic tubercle and should be the medial starting point of incision. Then the dissection is going deeper through the subcu‐ taneous tissue until the aponeurosis of the external oblique is identified. In strangulated hernia the tissues maybe inflamed and edematous, therefore careful dissection of the anatomic structures is mandatory. Along with external oblique aponeurosis, the apex of the inguinal canal and also the external inguinal ring must be identified, before incising the external oblique muscle. The inguinal canal should be entered at its apex. For a correct identification of the apex of the canal, the lower wall of the canal, which is where the external oblique aponeurosis disappears into the fat of the thigh, should be pointed out. Approximately one finger breadth above this point is a good entry site into the canal. The external inguinal ring is also important because the external ring is ultimately the end point of the division to be made in the external oblique aponeurosis and defines the orientation of this cut [6].

Once the external oblique aponeurosis is identified, is thoroughly exposed and a gentle stab incision in its mid-portion along the orientation of its fibers is made. This incision is extended superiorly, and medially downward, through the superficial ring, thus exposing the inguinal canal and the cord structures. Afterwards comes the circumferentially mobilization of the cord structures off the floor of the canal by working on the pubic tubercle as a fulcrum. With blunt dissection of the index finger in a sweeping and medially encircling fashion, the cord is sufficiently freed, so that the cord structures can be surrounded by a Penrose drain for convenient retraction. This allows exposure of the inguinal floor and protects the cord structures. Then, an examination of the anteromedial aspect of the cord should be made, for an indirect component of the hernia. Separating the cremasteric muscle along its fibers often facilitates this. The cremasteric muscle fibers must be dissected carefully with slow electro‐ cautery coagulation, as the cut muscle fibers tend to bleed. If an indirect hernia is present, the sac is dissected off the cord structures, down toward its base at the internal inguinal ring, until it is comfortably invaginated into the preperitoneal space. This is preferably achieved without division of the sac. However, if necessary, as with certain large hernias, the sac can be entered carefully and examined for visceral contents, and then divided with a high ligation. The peritoneal fluid within the sac should be sucked and sent for culture. If there is ischemic bowel inside the sac it should be resected promptly and anastomosed with an end-to-end manner. Occasionally there may be only strangulation of a portion of the greater omentum or stran‐ gulation of a portion of the sac itself, which maybe the cause of local discomfort and pain (Fig. 2). Direct hernias, which protrude through the inguinal floor at the Hesselbach triangle, are similarly dissected away from the cord structures toward their base and then are inverted below the transversalis fascia.

speedy stitch that allows for surgery to be complete in approximately one hour. Bassini's original technique yielded outstanding results for a pure tissue technique; however, problems occurred when surgeons failed to open the posterior wall. So, a new operation, known as the "modified" or "North American" Bassini was introduced. By not opening the posterior wall, the wall tissue was damaged in its most medial portion by sutures placed under tension, and recurrences resulted, primarily in the pubic tubercle area. Thus, the failure of this operation in its first year was more likely due to an overlooked second hernia or to poor surgical technique, rather than a metabolic or tissue defect that might predispose to recurrent hernia.

**Figure 2.** After opening of the subcutaneous tissue, a gangrenous portion of the sac and the adjacent preperitoneal

Strangulated Inguinal Hernia http://dx.doi.org/10.5772/57379 95

tissue was revealed, which was resected.

The Shouldice technique (it is also known as ilio-inguinal incision) begins with the ligation of superficial veins. Afterwards, comes the same procedure as described above. The reconstruc‐ tion in Schouldice technique is achieved by continuous suturing using 2.0 or 3.0 polypropro‐ pylene sutures; starting medially, not through the periosteum of the pubic tubercle. Suturation of the inferior edge of the fascia transversalis (Thomson's ligament) to a fold of the anterior side of the conjoined tendon ('white line') is being made, until the internal ring is constricted (in order to allow passage for the spermatic cord and point of tweezers). Then comes the second layer after including cremaster stump with the same thread to the iliopubic tract (inferior edge of the inguinal ligament). The third layer begins laterally, with the closure of the conjoined tendon to inguinal ligament. Original Shouldice has a fourth layer in the same plane. Finally,

Closure of the defect and buttressing of the inguinal canal floor can now be performed. The Bassini technique is widely used, but the Shouldice technique is considered to be better, in terms of recurrence, is not usually used, because of the more extensive dissection, and a belief that the skill of surgeons is important as well. The Bassini repair is a technique in which the surgeon sutures the conjoined tendon to the inguinal ligament, which slides the patient's own muscles together to cover the hole in the abdominal wall and repair the hernia. The spermatic cord remains in its normal anatomic position under the external oblique aponeurosis. The surgeon closes the incision with a stitch known as the simple interrupted suture pattern, a

the medial starting point of incision. Then the dissection is going deeper through the subcu‐ taneous tissue until the aponeurosis of the external oblique is identified. In strangulated hernia the tissues maybe inflamed and edematous, therefore careful dissection of the anatomic structures is mandatory. Along with external oblique aponeurosis, the apex of the inguinal canal and also the external inguinal ring must be identified, before incising the external oblique muscle. The inguinal canal should be entered at its apex. For a correct identification of the apex of the canal, the lower wall of the canal, which is where the external oblique aponeurosis disappears into the fat of the thigh, should be pointed out. Approximately one finger breadth above this point is a good entry site into the canal. The external inguinal ring is also important because the external ring is ultimately the end point of the division to be made in the external

Once the external oblique aponeurosis is identified, is thoroughly exposed and a gentle stab incision in its mid-portion along the orientation of its fibers is made. This incision is extended superiorly, and medially downward, through the superficial ring, thus exposing the inguinal canal and the cord structures. Afterwards comes the circumferentially mobilization of the cord structures off the floor of the canal by working on the pubic tubercle as a fulcrum. With blunt dissection of the index finger in a sweeping and medially encircling fashion, the cord is sufficiently freed, so that the cord structures can be surrounded by a Penrose drain for convenient retraction. This allows exposure of the inguinal floor and protects the cord structures. Then, an examination of the anteromedial aspect of the cord should be made, for an indirect component of the hernia. Separating the cremasteric muscle along its fibers often facilitates this. The cremasteric muscle fibers must be dissected carefully with slow electro‐ cautery coagulation, as the cut muscle fibers tend to bleed. If an indirect hernia is present, the sac is dissected off the cord structures, down toward its base at the internal inguinal ring, until it is comfortably invaginated into the preperitoneal space. This is preferably achieved without division of the sac. However, if necessary, as with certain large hernias, the sac can be entered carefully and examined for visceral contents, and then divided with a high ligation. The peritoneal fluid within the sac should be sucked and sent for culture. If there is ischemic bowel inside the sac it should be resected promptly and anastomosed with an end-to-end manner. Occasionally there may be only strangulation of a portion of the greater omentum or stran‐ gulation of a portion of the sac itself, which maybe the cause of local discomfort and pain (Fig. 2). Direct hernias, which protrude through the inguinal floor at the Hesselbach triangle, are similarly dissected away from the cord structures toward their base and then are inverted

Closure of the defect and buttressing of the inguinal canal floor can now be performed. The Bassini technique is widely used, but the Shouldice technique is considered to be better, in terms of recurrence, is not usually used, because of the more extensive dissection, and a belief that the skill of surgeons is important as well. The Bassini repair is a technique in which the surgeon sutures the conjoined tendon to the inguinal ligament, which slides the patient's own muscles together to cover the hole in the abdominal wall and repair the hernia. The spermatic cord remains in its normal anatomic position under the external oblique aponeurosis. The surgeon closes the incision with a stitch known as the simple interrupted suture pattern, a

oblique aponeurosis and defines the orientation of this cut [6].

below the transversalis fascia.

94 Inguinal Hernia

**Figure 2.** After opening of the subcutaneous tissue, a gangrenous portion of the sac and the adjacent preperitoneal tissue was revealed, which was resected.

speedy stitch that allows for surgery to be complete in approximately one hour. Bassini's original technique yielded outstanding results for a pure tissue technique; however, problems occurred when surgeons failed to open the posterior wall. So, a new operation, known as the "modified" or "North American" Bassini was introduced. By not opening the posterior wall, the wall tissue was damaged in its most medial portion by sutures placed under tension, and recurrences resulted, primarily in the pubic tubercle area. Thus, the failure of this operation in its first year was more likely due to an overlooked second hernia or to poor surgical technique, rather than a metabolic or tissue defect that might predispose to recurrent hernia.

The Shouldice technique (it is also known as ilio-inguinal incision) begins with the ligation of superficial veins. Afterwards, comes the same procedure as described above. The reconstruc‐ tion in Schouldice technique is achieved by continuous suturing using 2.0 or 3.0 polypropro‐ pylene sutures; starting medially, not through the periosteum of the pubic tubercle. Suturation of the inferior edge of the fascia transversalis (Thomson's ligament) to a fold of the anterior side of the conjoined tendon ('white line') is being made, until the internal ring is constricted (in order to allow passage for the spermatic cord and point of tweezers). Then comes the second layer after including cremaster stump with the same thread to the iliopubic tract (inferior edge of the inguinal ligament). The third layer begins laterally, with the closure of the conjoined tendon to inguinal ligament. Original Shouldice has a fourth layer in the same plane. Finally, the reapproximation of the external oblique aponeurosis is achieved with a running 3-0 polyglactin suture; at that stage the surgeon must be careful for the underlying ilioinguinal nerve. Reapproximation of the Scarpa fascia is followed with interrupted 3-0 polyglactin suture and then a running subcuticular closure of the skin with 3-0 poliglecaprone suture. The operative site is cleaned and sterile dressings are applied