Direct inguinal hernias in children

Full Text

Introduction. Inguinal hernias in children are a common pathology and account for up to 70-85% of all hernias in children [1, 2]. At the same time, the vast majority of reports are devoted to the diagnosis and treatment of various variants of oblique inguinal hernias in childhood [3, 4, 5]. Most authors use the extraperitoneal transcutaneous method of herniation under laparoscopic control [6, 7, 8]. References in publications about direct inguinal hernias in children are presented in isolated reports [9, 10]. Some of them are only descriptions of cases from practice [11, 12]. Mostly, reports about direct inguinal hernias are found in publications devoted to this pathology in adult patients [13, 14, 15]. The purpose of the study. Based on the accumulated clinical material, to show the possibilities of diagnosis and treatment of direct inguinal hernias in children. Materials and methods. The study was conducted in the surgical department of the Republican Children's Clinical Hospital in Syktyvkar. This was a study of a series of cases. The inclusion criteria were patients aged 0 to 17 years, operated on for inguinal hernias. The exclusion criterion is patients with inguinal hernias older than 17 years. During the period from 2000 to 2020, 3,221 children with inguinal hernia were treated in the surgical department. In this group, 3577 operations were performed. In 358 (10%) children, surgery was performed for a bilateral inguinal hernia. In 1492 (41.7%) patients, hernia repair according to Duhamel 1 was used. Since 2007, laparoscopic hernia repair has been used. A total of 2,087 such operations were performed (58.3%). Of these, 1194 operations were performed using the PIRS method. Of the above group of children with inguinal hernias, 7 patients (0.22%) had a direct inguinal hernia. Clinically, it was manifested by a soft-elastic protrusion of a rounded shape, localized medially and above the Pupart ligament near the projection of the outer ring of the inguinal canal, easily set into the abdominal cavity with rumbling (Fig. 1). Fig. 1. Bilateral direct inguinal hernia in a child of 7 years. Fig. 1. Bilateral direct inguinal hernia in a 7-year-old child.The above was confirmed by ultrasound examination of the hernial protrusion area, in which the intestinal loops and the large omentum were visualized as hyperechoic contents (Fig. 2). Fig. 2.Ultrasound picture of a direct inguinal hernia.Fig. 2. Ultrasound picture of a direct inguinal hernia.In laparoscopic imaging, a rectal hernia was defined as a recess of the peritoneum of a stellate or rounded shape in the projection of the medial inguinal fossa (Fig. 3 a, b). Fig.3a. Laparoscopic picture of a direct inguinal hernia of "stellate" shape.Fig. 3a. Laparoscopic picture of a direct inguinal hernia of the "stellate" shape. Fig. 3b. Laparoscopic picture of a direct inguinal hernia of a "rounded" shape.Fig. 3b. Laparoscopic picture of a straight inguinal hernia of a "rounded" shape. In this group, all children had uncomplicated direct inguinal hernia, so hernia repair was performed as planned. Two children were operated on before the introduction of the laparoscopic method of surgical intervention. They had a Bassini hernia repair. With the introduction of the laparoscopic method of herniation, it was performed in two children with intracorporeal suture of a pouch suture on a defect of the peritoneum in the medial inguinal fossa (Fig. 4). Rice.4. Laparoscopic intracorporeal herniation in direct inguinal hernia.Fig. 4. Laparoscopic intracorporeal herniation in direct inguinal hernia.In three patients, hernia repair was performed using the PIRS method. The method was performed as follows. A Tuohy needle with a monofilament thread tucked into it was used to puncture the skin in the projection of the inner edge of the medial inguinal fossa, retroperitonally bypassing it and pricking it out in the middle of the latter with a loop in the abdominal cavity (Fig. 5). Fig. 5.Hernia repair using the PIRS method for direct inguinal hernia.Fig. 5.PIRS herniation for direct inguinal hernia.The needle was removed leaving a loop in the abdominal cavity. Then, in the same way, a Tuohy needle with a twisted thread was inserted into the projection of the outer edge of the medial inguinal fossa, retroperitonally bypassing it and sticking out in the middle of the latter with the needle in the previous loop. The needle was removed and the subsequent loop was brought out by the previous loop with the tightening of the pouch suture and the formation of a subcutaneous extracorporeal node (Fig. 6). After deinsufflation, removal of the trocar and suturing of the punctures, the surgical intervention ended.Fig. 6. Sutured direct inguinal hernia.Fig. 6. Sutured direct inguinal hernia. Results. Long-term results were followed up in the period from 6 months to 15 years. There were no immediate or postoperative complications, as well as no recurrent hernia (Fig. 7a, b). Fig. 7a. 2 years after PIRS surgery for a direct inguinal hernia.Fig. 7a. 2 years after PIRS surgery for a direct inguinal hernia.Fig.7b. 15 years after Bassini hernia repair.Fig. 7b. 15 years after the Bassini herniation.Discussion. There are many scientific publications devoted to the description of inguinal hernias in children and various methods of hernia repair in them. These reports are very diverse in their coverage of the above pathology. Even in modern conditions, some authors use open herniation to achieve the goals of treatment for inguinal hernias in children [16]. However, most of the reports are devoted to various variants of laparoscopic herniation in oblique inguinal hernias in children [17, 18, 19, 20]. In the reports devoted to this pathology, there are only isolated references to the existence of direct inguinal hernias in children without a detailed description of diagnostic and treatment options [21]. There are also no reports of any additional research methods for this pathology in childhood. At the same time, the authors report that direct inguinal hernias are not so rare – 2.2% of all inguinal hernias in childhood, which is a value that deserves the attention of pediatric surgeons. Limited to the descriptive endoscopic picture of this pathology in children, the researchers do not provide data on surgical treatment options [22]. Methods of surgical treatment for direct inguinal hernias on a sufficiently large material are described by surgeons only in adult patients [23]. Our small experience has shown that direct hernias in children have their own, rather peculiar clinical picture. Ultrasound examination helps in the diagnosis of this pathology. Modern methods of surgical treatment used in the treatment of oblique inguinal hernias in children can also be successfully used in the treatment of direct inguinal hernias. When establishing the diagnosis of a direct inguinal hernia in children, the latter is clinically determined in the form of a rounded soft-elastic formation localized medially and above the Pupart ligament next to the projection of the outer ring of the inguinal canal, easily set into the abdominal cavity with rumbling, which is confirmed by the results of ultrasound examination. The most preferred method of treatment for direct inguinal hernia in children, in our opinion, is hernia repair using the PIRS method.

About the authors

Vyacheslav G. Svarich

Republican Children’s Clinical Hospital; Pitirim Sorokin Syktyvkar State University

Author for correspondence.
Email: svarich61@mail.ru
ORCID iD: 0000-0002-0126-3190
SPIN-code: 7684-9637

Dr. Sci. (Med.)

Russian Federation, Syktyvkar; 116/6 Pushkin str., Syktyvkar, 167004

Ilya M. Kagantsov

Pitirim Sorokin Syktyvkar State University; V.A. Almazov National Medical Research Center

Email: ilkagan@rambler.ru
ORCID iD: 0000-0002-3957-1615
SPIN-code: 7936-8722

Dr. Sci. (Med.), main scientific researcher

Russian Federation, Syktyvkar; Saint Petersburg

Violetta A. Svarich

Main Bureau of Medical and Social Expertise in the Republic of Komi

Email: svarich61@mail.ru
ORCID iD: 0000-0003-0858-1463

Deputy Chief Expert on Clinical Expert Work

Russian Federation, Syktyvkar

References

Supplementary files