Hernia sac of indirect inguinal hernia: Invagination, excision or ligation?

Hernia sac of indirect inguinal hernia: Invagination, excision or ligation?

Ibrahim Othman, MD; Hamdy Abdel Hady, MD

Department of General Surgery, Tanta University, Tanta, Egypt.

This study compares the effect of invaginating,  excision of hernia sac without ligation with the traditional method ofhigh ligation of the hernia sac on post-operative pain and recurrence.

Patients and methods: This multicenter prospective randomized study included 152 patients with 167 primary indirect inguinal hernias. In group I (54 hernias) the sac was not opened and was inverted with the finger into the peritoneal cavity.   In group E (56 hernias) the sac was excised at the neck without ligation. In group L (57 hernias) the sac was transfixed at the neck and excised in the traditional manner. The repair of the posterior wall of the inguinal canal was done according to Lichtenstein  tension free technique. Mean length of follow up was 81.50±

22.34, 79.35 ±26.76 and 77.83±21.26 months respectively.

Results: Postoperative seroma occurred in 1 patient (0.60%) in groupE and 1 patient (0.60%) in group L. Surgical site infection occurred in 2 patients (1.20%) in group I, 1 patient (0.60%) in groupE and 2 patients (1.20%) in group L. Mean postoperative  pain score was 3.04± 2.11,

3.98± 2.33 and 4.06±2.43 respectively (p: 0.049). Chronic pain occurred in 3 patients in group I (1.80%),  3 patients in groupE (1.80%)  and 5 patient in group L (3.00 %) (P: 0.749). The difference between the complications in three groups was statistically insignificant (p: 0.887). Hernia recurrence occurred in 3 patients (1.80%) in group I, 1 patient (0.60%) in groupE and

1 patient (0.60%) in group L (p: 0.429).

Conclusion: Invagination  and excision  of the hernia sac do not have adverse effects  on repair integrity.   They limit the dissection and reduce the morbidity and risk of injury to the spermatic cord and surrounded structures. They are safer and more appropriate for repair of sliding hernia. Ligation of the hernia sac in inguinal hernia surgery is not only unnecessary and time consuming but also leads to increased postoperative pain. Recurrence rates are statistically unaffected by not ligating the sac.

Key words: Hernia sac, indirect inguinal hernia, invagination,  excision, ligation

Introduction:

Hernia and its treatment have fascinated surgeons of all latitude throughout the years of recorded medical history. From the beginning of modem anatomic hernia surgery when Edoardo Bassini recommended excision and high  ligation  of  the  indirect  hernia  sac  in

1887,1 few  studies  have examined  the  best

way  to manage the  indirect  hernia  sac,  but have generated no consensus. Nevertheless, these studies showed that management of the indirect hernia sac may influence the rate of hernia recurrence and the development of postoperative pain.2-5

The  value  of  peritoneal  closure  in abdominal wounds has long been questioned. The  peritoneum   heals  rapidly   within   3-5 days leaving no adhesions in both large and small defects.6   It has also been proven that leaving the peritoneum open in closure is not associated with an increased wound failure rate.7

Recurrences  have  frustrated  surgeons  of all  ages,  experience,  skill  and  nationality. One of the cardinal causes of recurrence was thought to be failure to high ligate the sac. However, the emphasis has now shifted from the sac to the defect and hence the necessity

to ligate the sac has been questioned.  In the modem  operations  for  inguinal  hernia  like the Liechtenstein's repair and Rutkow's Mesh plug repair the sac is not ligated but simply inverted or excised without ligation.8,9

This study compares the effect of invaginating, excision of hernia sac without ligation with the traditional method of high ligation  of the  hernia  sac on post-operative pain and recurrence.

Patients and methods:

This multicenter prospective randomized study was performed in General Surgery Department, Tanta University Hospitals, and Ghodran General Hospital, Kingdom of Saudi Arabia during the period from July 2003 to December 2012 on 152 patients with primary indirect inguinal hernias (167 hernias). Only indirect,  uncomplicated  hernias  in  adult patients  were   included.   Recurrent  hernias were excluded.

Full  explanation  of  procedures,  possible

complications  and patient  consent  were assured before inclusion in the research. The study protocol was approved by the Ethics Committee of General Surgery Department, Tanta University Hospitals.

Patients  were  randomly  categorized  into

3 groups through  a computer randomization program.

All patients underwent detailed medical history, clinical examination and abdominal ultrasound examination in addition to routine hematological and biochemical investigations for preparation for anesthesia.

Patients   were   hospitalized   on  the   day

of surgery. All procedures were performed under spinal, general or local anesthesia. All patients received a single dose of Augmentin

1.2 grams (Amoxicillin and clavulinic acid, www.gsk.com) 30 minutes prior to surgery.

Inguinal canal was opened in the usual manner.  The  indirect  sac was  dissected  up to the  neck. In group I (from  Invagination) (54 hernias) the sac was not opened and was inverted with the finger into the peritoneal cavity.   In   group   E   (from   Excision)   (56 hernias)  the  sac  was  excised  at  the  neck without  ligation;  the  residual  defect  in the

parietal peritoneum was left unattended. In group L (from Ligation) (57 hernias) the sac was transfixed at the neck and excised in the traditional manner.

The repair of the posterior wall of the inguinal canal was done according to Lichtenstein tension free technique. A polypropylene mesh of 7.5 x 15 em (Prolene mesh, www.ecatalog.ethicon.com), was fashioned   and  placed  with  an  overlap  of the pubic bone. The mesh was fixed with a monofilament non absorbable suture. The ilioinguinal  nerve and the iliohypogastric nerve were identified and spared. The external oblique fascia was closed with absorbable sutures.

Patients  were allowed to eat and drink 3 hours after recovery. Analgesia was given in the form of 100 mg Pethedine on recovery and another  100  mg  Pethedine  intramuscularly after  12 hours  if the  patient  complained  of pain. Postoperative pain was measured for two weeks after surgery using pain visual analog scale  (VAS) on  daily  base  and collectively for the first 2 postoperative  weeks.  Patients were  discharged  from  hospital  in  the  first post-operative  morning.  Oral  non  steroidal anti-inflammatory  analgesia were prescribed (Diclofinac   potassium,                          Catafiam    50   mg tablet  TM. www.pharma.us.novartis.com) to be taken  if the  patient  complained  of pain. Patients were followed  in visits at three day interval for two weeks then every 3 months. Patients that did not come for follow up were contacted by telephone and interviewed about chronic   pain  and  recurrence.   Any  patient reporting  recurrence  in  the  operated  groin was scheduled for an outpatient clinic check. Patients were encouraged to visit the clinic at any time if they had any problem. The total follow-up time  was calculated  based on the last visit to the outpatient clinic or the contact via telephone. The mean length of follow up was 81.50 ± 22.34, 79.35 ± 26.76 and 77.83

± 21.26 months respectively.

Primary complications included infections and  formation   of  hematomas   or  seromas. A superficial infection was defined as an infection not requiring surgical treatment. A deep  infection  was  defined  as  an infection

at or near the site of hernia surgery that required surgical intervention. Hematoma and/or   seroma   formation   was   considered a primary complication even if it resorbed spontaneously. Late complications included recurrence and chronic pain.

Statistical analysis:

Quantitative    variables   were   expressed as mean ±SD. Qualitative variables were expressed as frequency and percent. Quantitative parametric variables were compared  between  the  three  groups  using the ANOVA test, quantitative non-parametric variables  were  compared  using  Mann­ Whitney test. Qualitative variables were compared  using  Chi-square  test  or  Fisher exact test when the criteria for using Chi­ square were not sufficient.  The power used was 0.80 while the level of significance was

5%.

Results:

The  demographic  characteristics  and clinical data of group I (50 patients), group E (49 patients) and group L (53 patients) are summarized in Tables  (1,2).

Postoperative seroma did not occur in group

I, occurred in 1 patient in group E (0.60%) and 1 patient in group L (0.60%). They were successfully treated conservatively.

Surgical   site   infection   occurred   in   2

patients in group I (1.20%), 1 patient in group E (0.60%) and 2 patients in group L (1.20%). Four   patients   (2.40%)   were  managed   by proper antibiotics according to culture and sensitivity result. One patient in group I (0.60%) had deep infection that needed drainage of collection and leaving the wound open until pus formation stopped. Mesh removal was not necessary.

Mean  postoperative   pain  score  for  first

2 weeks  was  3.04±  2.11 in group  I, 3.98±

2.33  in  group  E  and  4.06±2.43n  group  L (p: 0.049). Most patients improved after medical  treatment   with  oral  non  steroidal anti-inflammatory  analgesia.  Pain  persisted in 11 patients. They were considered to have chronic pain.

in group I (1.80%), 3 patients in group E (1.80%)  and 5 patient  in group  L (3.00  %) (P: 0.749). Four patients (2.40%) markedly improved after medical treatment. Others suffered from persistent low grade pain that partially  improved  (5  patients,   3.00%)  or failed to improve until the end of study (1 patient, 0.60%).

The difference between the complications m the three groups was statistically insignificant (p: 0.887).

Recurrence:

Hernia  recurrence  occurred  in 3 patients in  group  I  (1.80%),   1  patient  in  group  E (0.60%)  and  1 patient  in group  L (0.60%). In group I recurrence occurred 23, 35 and 42 months after operation, in groupE recurrence occurred  34  months  after  operation  while in group  L recurrence  occurred  24 months after  operation.   Patients   were   treated   by either Lichtenstein or TEP Laparoscopic Hernioplasty.   No   rerecurrence    happened to them until the end of this study. The difference  between  the  recurrence  rates  in the three groups was statistically insignificant (p: 0.429). Post-operative complications are summarized in Table (4).

Discussion:

Surgeons have long undertaken the burden ofthe  'sac' in inguinal hernia repair. Thus the sac got pride of place in hernia surgery at the expense of the 'defect'. It is a long held belief that ligating the sac is an important adjunct to groin hernia operations.9,10

Various reports discussing recurrence considered excision and high ligation of the indirect inguinal hernia sac an essential  part of the repair, and if not performed properly recurrence is more common.ll-14 Studies reporting on open hernia technique still describe  ligating  the  sac.l5,16 In  all  of  the above references the sac ligation was either quoted in passing or it was over emphasized as an essential part of the repair. There was, however, very little support for this step and no further clinical or experimental analysis provided.

repair, invagination and excision of the hernia sac were associated with a similar statistical risk  of   hernia  recurrence   surgery   as  sac ligation.

Recurrence rates have fallen markedly following   the   introduction   of   mesh   and its current widespread use. In the original description ofthe Lichtenstein technique, the indirect hernia sac is dissected from the cord to a point beyond the neck of the sac, opened and   then   returned   into  the   preperitoneal cavity  without  excision.l 7-19 The  sheet  of mesh  should  protect  against  and  hold  back any indirect inguinal hernia bulge.

It has been shown that, during abdominal

surgery, the peritoneum  heals rapidly within

2-3  days,  leaving  no  adhesions,  regardless of the size of the defect2 and leaving the peritoneum open was not associated  with an increased incidence of wound failure.6,7

The  place  of  non-ligation2°-21 was  well

documented  by  Smedberg  et  al,5  who presented the only prospective and controlled study  of either  ligation  and excision  of the sac or excising the sac as deep as possible, then leaving it open without ligation or transfixation. They used both clinical and radiological   methods  to  define  recurrence. The study showed that leaving the sac open does not compromise the repair and results in less post-operative pain. Their study has been quoted in some surgical textbooks.21,22

In the Shouldice technique the indirect hernia  sac  is  opened,  inspected,  and  then either    excised   or   simply   returned    into the preperitoneal space. High ligation is considered unnecessary. Thorough dissection and  reconstruction   of  the  internal  inguinal ring is performed routinely during Shouldice repair, giving recurrence rates of around 1% in specialized  centers but as high  as 10-15

% 3 years after surgery in non-specialized units.23,24

The   sac   is   not   ligated   in   Rutkow's Mesh Plug repair but inverted. Rutkow recommended   that  hernia  sacs  should  not be opened for visual inspection because it simply involutes without any problem in few days.  He thinks that  because  peritoneum  is a highly  sensitive  structure  ligating  the  sac

does nothing more than produce miniature "peritonitis".  This  iatrogenic   peritonitis   is one of the factors contributing to the post­ operative    discomfort,    pain    and   malaise that accompany suture hernia repairs. The reported  recurrence  rate  in Rutkow's  Mesh Plug repair is 0.2%.6

High  dissection  of the  sac and  not  high

ligation  is the  critical  factor.  High  ligation does not  influence recurrence  rate and  may be a cause of increased post-operative pain.l O However, high dissection of the sac well up into the  retroperitoneum  and the freeing  of the sac from the edges ofthe internal ring are important  for  the  prevention  of  recurrence and  allow  good   exposure   of  the  ring  to facilitate the repair. The sac is not ligated in Gilbert's sutureless repair and laparoscopic hernia repairs.25,26

Outcomes other than recurrence such as long-term  postoperative  pain and discomfort are now of greater clinical importance. Recurrence rates are so low after mesh repair that chronic pain is currently the issue of greatest importance following groin hernia repa1r.

In      our      series      post-operative       pam

was significantly less when the sac was invaginated or excised than when ligated. Following excision of the hernia sac, pain during convalescence  may increase if the peritoneal opening is ligated in open sutured repair.5 Similarly, in open mesh repair early postoperative   pain  has  been  found   to  be greater after excision than after invagination ofthe hernia sac.l9

Neither of those studies5,19 nor the present study  showed  an  important  risk  of  chronic pain after invagination,  excision  or ligation of  the  sac.  Chronic  pain  in  the  inguinal region was reported during follow up after inguinal  hernioplasty.  The  reason  for  this is the failure to identify and preserve nerve structures  during  surgery. A recent  reviews on  nerve  management  during  open  hernia repair suggested that nerves should probably be identified to prevent damage caused by sutures placed near the nerves. 27,28 The mesh frequently  causes  temporary  discomfort during the first year after surgery independent

Table 1: The demographic characteristics of patients (percentage to patient number).

Table 2: The clinical data of patients (percentage to patient number).

Table 3: Post operative pain.

ofthe surgical method used. This discomfort at the  inguinal  region  then  subsides  when the mesh integrates permanently with the abdominal wa11.29,30

Conclusion :

Invagination and excision of the hernia sac do not have adverse effects on repair integrity. They limit the dissection and reduce the morbidity and risk of injury to the spermatic cord and surrounded structures. They are safer

Table 4 Postoperative complications in both groups (percentage to hernia number).

and  more  appropriate for  repair  of  sliding hernia.  Ligation  of the hernia sac in inguinal hernia  surgery  is  not  only  unnecessary  and time  consuming but  also  leads  to  increased postoperative   pain.    Recurrence   rates   are statistically unaffected by not ligating the sac.

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