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Key Points

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  1. High ligation of the hernia sac by either the classic open technique or more recent laparoscopic techniques remains the standard of care for pediatric indirect inguinal hernia.

  2. The issue of hernia incarceration is its frequency, especially increased in the neonatal population; the increased morbidity of operation in part related to its necessary urgency; the potential for permanent injury to the entrapped incarcerated organ; less optimal operative outcomes with potential vas and vessel injury; and treatment outcomes with greater recurrence rates.

  3. The trend toward greater application of the laparoscopic technique to hernia repair seems warranted to improve the sensitivity of diagnosis, the protection of vas, vessel, and sliding hernia sac content, and the placement using magnified vision of sac closing sutures that do not jeopardize other vital structures.

  4. Minimally invasive techniques may be particularly advantageous for the diagnosis and the treatment of both direct inguinal hernias as well as femoral hernias.

  5. Inguinal hernia repair remains one of the most common operations for children: such hernias are most common in prematures, in boys, and on the right side.

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Indirect Inguinal Hernia

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Introduction

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The management of abdominal wall hernias is a core activity of pediatric surgical practice. Salient among these is the inguinal hernia, the most frequently performed operation in the pediatric age group. Although the basic anatomy of this congenital opening has been known since antiquity, effective, sequelae-free surgical correction did not occur until the latter part of the 19th century. The advent of general anesthesia, improved equipment, aseptic surgically precise techniques, and detailed anatomical studies of the inguinal region led to the development of operations that laid the foundations of inguinal hernia repair in adults. These procedures were based on closure, with partial or total removal of the hernia sac, followed by reconstruction and reinforcement of the weakened area. It is likely that scarring resulting from these more extended dissections contributed to the decrease in recurrences.

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The recognition that pediatric inguinal hernias were almost exclusively indirect and that the abdominal wall structures were intact, led early pioneers to limit the procedure to simple ligation of the hernia sac. This was initially accomplished through the external inguinal ring, a procedure that is applicable to the very young infant because in this age group the external and internal rings are almost superimposed. A more direct approach to the internal inguinal ring, by means of incising the external oblique aponeurosis, became the next step in the evolutionary process. Despite the evidence that simple ligation of the hernia sac corrected the pathology, many surgical centers continued to add a variety of reinforcing sutures. In the mid-20th century, pediatric surgical pioneers conclusively demonstrated that high ligation of the patent processus vaginalis (PPV), without excessive mobilization of the cord structures or inguinal floor reconstruction, constitutes the most effective approach to safely correct indirect inguinal hernias.

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Advances in pediatric anesthesia, outpatient surgery, ...

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