Excision versus transfixation - ligation in herniotomy Dr.Hewa O. Ahmed CABS-Consultant SurgeonUniversity of Sulaimani-College of MedicineDr.Samira M. Salih-DCH. Sulaimani SUMMARYInguinal herniotomy is the operation most frequently performed in paediatricpatients, and open approach remains the preffered option of groin hernias ( 1 ),the aim of this study was to evaluate the efficiency of simple excision of hernialsac in comparison to classical transfixation & ligation in herniotomy.We followed up 200 patients for 3 years who underwent both procedures inparallel study, we found the result comparable, although this subject needs to beevaluated on larger number of patients & for longer periods of follow up, weconcluded that simple excision is as effective as conventional herniotomy in cureof inguinal hernias. INTRODUCTIONInguinal hernia is one of the most common surgical diseases in the paediatricage and has an over all incidence of approximately 6 % up to the age of 12 years(2).The vast majority do not require any treatment beyond high ligation of thehernial sac (3-4) . In babies, children & young atheletics straight forwardinguinal herniotomy should give a 100 % cure rate.In the present paper we tried to evaluate the results of simple excision ofthe neck of the hernial sac with out transfixation & ligation and we found theresults comparable with conventional herniotomy. METHODS & MATERIALS This is a prospective parallel study, in the period of 5 years, from Jan. 1996to Oct. 2000 in two governmental & two private hospitals in Sulaimani city,including 200 patients. Half of them ( Group A ) underwent classical herniotomy,the second half ( Group B ), underwent simple excision of the sac. All of themwere followed up to 3 years with 6 monthly assessment by the paediatrician & thesurgeon.All the patients received general anaesthesia, after incision, exploration ofthe hernial sac, the sac dissected up till the extraperitonial fat encountered,and the inferior epigastric vesseles are seen on the medial side of the hernial

sac. In group (A), the sac tranfixated as high as possible, ligated and the restexcised. In group ( B ) the sac pulled and the neck excised as high as possible.Then the wounds closed in layers. All the patients, discharged same day on thebases of the day care case, with a reporting notes, to be reported 7thpostoperative day & six monthly up to 3 years for assessment.RESULTSMajority of our patients were male children, the ratio of male / femalewas 9/1, all the females were under the age of 12 years, while most of the males(156 patients) were under the age of 12 years ( table I ) SexAgeNo. of Patients Male0 - 12 Y156 13 - 17 Y24 Male0 -12 Y20 13-17 Y---- Table I: Showing number, Age, and Sex of the Patients Most of the male patients above ( 12 ) years of age, treated by simpleherniotomy, but (6) of them (25 %) need some sort of strengthening of theposterior inguinal wall due to either weakness or over stretched deep inguinalring.After 3 years follow up, at was clear that ( 2) of the patients in group (A)and one from group (B) have recurrence of the hernia, all the recurrencesdiagnosed in the period between ( 6-12) months postoperatively, the causes of therecurrences were either severe acute cough of respiratory infection or fall on theground during sporting ( table II )No. of PatientsRecurrences 200

6 months12 months18 months2 years3 years ABABABABAB ------21------------------ Table II: Showing time of diagnosis & number of recurrences DISCUSSIONSimple excision of the sac versus classical herniotomy saves unnecessarytrauma to the vas deferens and abolishes accidental tieing of the vas deferens (5)& other components of the spermatic cord, during high transfixation & ligation inconventional. herniotomy, also it provides tension free technique. which is inless need for analgesia(6).In conventional herniotomy, the point of transfixation & ligation will remainsas a fixed point of the peritonium to the internal inguinal opening, which mayplays arole in predisposition for recurrence of the hernia (table II), while insimple excision, there is no fixed point, and the defect in the peritonium fromexcised neck will displaces away from the internal aspect of the inguinal ring andthe defect of the peritonium will reformed, in 24-48 hours by mesothelial cells ofthe peritonium.