Pediatric Infant Bilateral Open Inguinal Hernia Repair – Twin B Casey L. Meier, RN1; Lissa Henson, MD2; Domingo Alvear, MD3 1Lincoln Memorial University, DeBusk College of Osteopathic Medicine 2Philippine Society of Pediatric Surgeons 3World Surgical Foundation
Indirect inguinal hernia repair is a common procedure for premature infants because of the frequency of a patent processus vaginalis. Prompt surgical correction decreases the risk of incarceration, strangulation, and necrosis in children. There are various techniques for herniorrhaphy. This repair demonstrates an open bilateral indirect inguinal hernia repair in an infant that avoids high ligation by closing the internal inguinal ring, utilizing a purse-string method to keep the hernia sac intact. This approach limits the amount of anesthesia used and prevents excess bleeding, making it safe, effective and efficient.
An inguinal hernia (IH) is a protrusion of intra-abdominal contents through the inguinal canal that can arise at any time from infancy to adulthood. It is more common in males with a lifetime risk of 27% as compared to 3% in females. Most pediatric IHs are congenital and caused by failure of the peritoneum to close, resulting in a patent processus vaginalis (PPV). IH present as a bulge in the groin area that can become more prominent when crying, coughing, straining, or standing up, and disappears when lying down. Diagnosis is based on a thorough medical history and physical examination, but imaging tests such as ultrasound can be used when the diagnosis is not readily apparent. IHs are generally classified as indirect, direct, and femoral based on the site of herniation relative to surrounding structures. Indirect hernias protrude lateral to the inferior epigastric vessels, through the deep inguinal ring. Direct hernias protrude medial to the inferior epigastric vessels, within Hesselbach’s triangle. Femoral hernias protrude through the small and inflexible femoral ring. In infants and children, IH are always operated on to prevent incarceration.
Surgical correction in infants and children is done by high ligation of the hernia sac only, called a herniotomy. Here, we present a female infant with bilateral IH. Upon exploration, a hernia sac was found, and ligation was performed bilaterally. In female patients, it is believed that failure of the closure of the canal of Nuck alongside the round ligament of the uterus is the etiology. Oftentimes there is a “sliding hernia” where the ovary and or the fallopian tube is attached to the sac, sometimes the uterus itself is attached.
Gastrogastric fistula is a rare complication following a Roux-en-Y gastric bypass procedure wherein there is a communication between the proximal gastric pouch and the distal gastric remnant. Patients typically present with nausea and vomiting, abdominal pain, intractable marginal ulcer, bleeding, reflux, poor weight loss, and weight regain. Etiologies include postoperative Roux-en-Y gastric bypass leaks, incomplete gastric division, marginal ulcers, distal obstruction, and erosion of a foreign body. Diagnosis is made through upper gastrointestinal contrast radiography or CT scan and endoscopy. Barium contrast radiography is particularly useful and is the preferred initial study method for the detection of staple-line dehiscence, which may be small and overlooked during endoscopy.
Once identified, a gastrogastric fistula may be treated surgically with remnant gastrectomy or gastrojejunostomy revision. This article presents a case of a female patient status post Roux-en-Y gastric bypass surgery who presented with abdominal pain. Upon endoscopy, she was noted to have an inflamed gastric pouch and a gastogastric fistula. A laparoscopic gastric bypass revision was done to divide the gastrogastric fistula and to separate the gastric pouch from the gastric remnant in order to alleviate the inflamed gastric pouch and prevent further ulcer formation.
Cryptorchidism, or undescended testis, is a condition in which one or both testes fail to descend from the abdomen into the scrotum during fetal development. Phimosis, on the other hand, is a condition characterized by the inability to retract the foreskin over the glans penis.
This video serves as a step-by-step guide on orchiopexy to correct an undescended testicle and circumcision to correct phimosis. The importance of this surgical intervention lies in the preservation of testicular function, fertility potential, and the prevention of long-term complications associated with cryptorchidism. Early treatment is crucial, as it significantly reduces the risk of testicular damage and associated complications.
Surgical repair should be considered in all symptomatic paraesophageal hernias. Laparoscopic repair is considered the gold standard with a quicker recovery and lower morbidity and mortality compared to open repairs. The patient in this case presented with worsening dysphagia to solids and dyspnea in the setting of an enlarging paraesophageal hernia with a component of organoaxial volvulus. She underwent a laparoscopic paraesophageal hernia repair with a Toupet fundoplication and posterior gastropexy. The patient exhibited subjective improvement in her dysphagia to solids and dyspnea with exertion as well as an objective improvement in her pulmonary function tests postoperatively.
This video demonstrates a case involving an open parastomal hernia repair with retromuscular KeyBaker mesh placement. The case involves an obese patient with a large symptomatic parastomal hernia repair after a laparoscopic end sigmoid colostomy. The CT scan shows an intact linea alba with a 7-cm parastomal defect involving the small bowel and sigmoid colon. The use of a retromuscular KeyBaker mesh placement provides the advantages of offsetting the fascial and peritoneal defects afforded by a standard Sugarbaker repair with the added benefit of reinforcing the lateral abdominal wall by performing a keyhole slit in the mesh.
Intraperitoneal Mesh Repair for Incisional Hernia William B. Hogan1; Yoko Young Sang, MD2; Shabir S. Abadin, MD, MPH3 1Warren Alpert Medical School of Brown University 2Louisiana State University Shreveport 3World Surgical Foundation
Incisional hernias remain an important postoperative complication of any procedure involving a laparotomy incision. Although most incisional hernias remain asymptomatic, incarceration and strangulation are emergent complications requiring prompt diagnosis and intervention. Mesh repair has become widely favored over simple suture repair of abdominal fascial defects in recent decades, though recurrence of incisional hernias remains high. Despite the advent of laparoscopic approaches to hernia repair, open approaches are utilized when numerous adhesions are encountered, laparoscopic access is unsafe, or when laparoscopy is not readily available. We present an open surgical repair of a large incisional hernia involving the abdominal midline and parastomal site in a woman with a history of laparotomy and colostomy with a subsequent reversal for a perforated colon.
A left lower quadrant partial-thickness Spigelian-type incisional hernia resulting from wound complications after deep inferior epigastric perforator (DIEP) flap harvest is repaired in a minimally-invasive, robotic-assisted, transabdominal preperitoneal (TAPP) fashion. Utilizing robotic assistance, a large preperitoneal flap is created, fascial closure is achieved using barbed suture, and the hernia defect is reinforced widely with medium-weight polypropylene mesh. In this patient, this approach also allows for areas that had previously had mesh placed to be avoided, and for repair of a fat-containing indirect left inguinal hernia. Similar approaches can address primary or lateral incisional hernias. This patient had an uncomplicated postoperative course without early wound morbidity.
This video demonstrates the surgical technique for a laparoscopic totally extraperitoneal (TEP) left inguinal hernia repair with mesh. This is a technically challenging operation with a steep learning curve; however, it is one useful option for patients with bilateral hernias, recurrent hernias, or when a minimally-invasive approach is desired. It provides tension-free repair and allows exposure to the entire groin area to evaluate and repair indirect, direct, and femoral hernias. The only absolute contraindication to laparoscopic TEP repairs is the inability to undergo general anesthesia due to significant cardiopulmonary disease or other factors.
A diaphragmatic hernia (DH) is characterized by protrusion of abdominal organs into the chest cavity through an opening in the diaphragm. A sliding or paraesophageal hernia is the most prevalent type, characterized by its occurrence near the esophageal hiatus. Typically present since birth, it can also develop later in life, occasionally arising as a result of severe trauma or iatrogenic injury. Less often, congenital DHs protrude through posterolateral or substernal diaphragmatic defects, referred to as Bochdalek and Morgagni hernias, respectively.
DH can remain asymptomatic and is commonly detected as an incidental finding during evaluation for other medical issues. Hiatal hernias differ from abdominal wall hernias in that they are influenced by the constant motion of the diaphragm, which exerts continuous friction and pressure changes on the esophagus and the stomach. As a result, hiatal hernias have a higher likelihood of recurrence following surgical correction in comparison to abdominal hernias.
This is the case of an exploratory laparotomy for bowel obstruction and primary pledgeted repair of two diaphragmatic hernias.
