Excision versus transfixation - ligation in herniotomy

Dr.Hewa O. Ahmed CABS-Consultant Surgeon University of Sulaimani-College of Medicine Dr.Samira M. Salih-DCH. Sulaimani

SUMMARY Inguinal herniotomy is the operation most frequently performed in paediatric patients, 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 hernial sac in comparison to classical transfixation & ligation in herniotomy. We followed up 200 patients for 3 years who underwent both procedures in parallel study, we found the result comparable, although this subject needs to be evaluated on larger number of patients & for longer periods of follow up, we concluded that simple excision is as effective as conventional herniotomy in cure of inguinal hernias.


Inguinal hernia is one of the most common surgical diseases in the paediatric age 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 the hernial sac (3-4) . In babies, children & young atheletics straight forward inguinal herniotomy should give a 100 % cure rate. In the present paper we tried to evaluate the results of simple excision of the neck of the hernial sac with out transfixation & ligation and we found the results comparable with conventional herniotomy.


This is a prospective parallel study, in the period of 5 years, from Jan. 1996 to 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 them were followed up to 3 years with 6 monthly assessment by the paediatrician & the surgeon. All the patients received general anaesthesia, after incision, exploration of the 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 rest excised. 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 the bases of the day care case, with a reporting notes, to be reported 7th postoperative day & six monthly up to 3 years for assessment.

RESULTS Majority of our patients were male children, the ratio of male / female was 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 )

Sex Age No. of Patients Male 0 - 12 Y 156 13 - 17 Y 24 Male 0 -12 Y 20 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 simple herniotomy, but (6) of them (25 %) need some sort of strengthening of the posterior inguinal wall due to either weakness or over stretched deep inguinal ring. 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 recurrences diagnosed in the period between ( 6-12) months postoperatively, the causes of the recurrences were either severe acute cough of respiratory infection or fall on the ground during sporting ( table II )

No. of Patients Recurrences 200

6 months 12 months 18 months 2 years 3 years A B A B A B A B A B ----2 1 -------------

Table II: Showing time of diagnosis & number of recurrences


Simple excision of the sac versus classical herniotomy saves unnecessary trauma to the vas deferens and abolishes accidental tieing of the vas deferens (5) & other components of the spermatic cord, during high transfixation & ligation in conventional. herniotomy, also it provides tension free technique. which is in less need for analgesia(6).

In conventional herniotomy, the point of transfixation & ligation will remains as a fixed point of the peritonium to the internal inguinal opening, which may plays arole in predisposition for recurrence of the hernia (table II), while in simple excision, there is no fixed point, and the defect in the peritonium from excised neck will displaces away from the internal aspect of the inguinal ring and the defect of the peritonium will reformed, in 24-48 hours by mesothelial cells of the peritonium.


The result of this paper suggest that simple excision may be superior to conventional herniotomy but needs to be evaluated on wider groups of patients and it is a cause for concern & requires farther study.


The authors of this work like to express their thanks to all the workers in 16th surgical unite for their kind technical help.


1Page 57.

Annals of the RC of S of England, Jan. 1999, Vol. 81, No.1,

‫‪2-H. Brendan Devlin, Management of abdominal hernias, page 76 Butter worths, First‬‬ ‫.8891 ,‪edition‬‬

‫& ‪3-Charles V. Mann, Bailey & Love's short practice of surgery, page 890.Chapman‬‬ ‫‪Hall Medical . 22nd‬‬ ‫7991. ‪edition‬‬

‫.9991 ,‪4-Schwartz et al, Principles of surgery, page 1743, Mc Grawhill 7th edition‬‬

‫8001:)01( 25 ;8991 ,‪5-Lemelle-JL; Schmitt-M, Inguinal hernia in infant, Ann-chir‬‬‫.61‬

‫‪6-Koninger-JS; Oster-M;Butters -M, Management of inguinal hernia - a comparison of‬‬ ‫,‪current methods‬‬ ‫.4-0431:)21(96 ;‪chirurg. 1998 Dec‬‬

‫تةنيا بِين بةبةراورد لةطةَ تةقةَ، بةست، ثاشان بِين تورةكةى قؤِى‬ ‫ر‬ ‫ر‬ ‫ل‬ ‫ل‬ ‫ر‬

‫د.هيوا عمر احد - نةشتةرطةرى ثسثؤِ-زانكؤى سلَمان - كؤليجى ثزيشكى‬ ‫ي‬ ‫ر‬ ‫د.سية ممد صال -دبلؤمى نةخؤشى مناَن - سلَمان‬ ‫ي‬ ‫ل‬

‫نةشتةرطةرى قؤِى لموسةَن، يةكَكة لةو نةشتةرطةريانةى كة لةناو مناَندا بَوة،‬ ‫ل‬ ‫ل‬ ‫ي‬ ‫ل‬ ‫ر‬ ‫نةشتةركارى بةَِطة ضارةيةكى ثةسةندكراو ماوةتةوة بؤ ضارةسةر. ئامانى ئةم لَكؤَينةوةية‬ ‫ي ل‬ ‫ري‬ ‫بريتىية لة هةَسةنطاندن كاريطةرى تةنيا بِين بةبةراورد لةطةَ تةقةَ، بةست ثاشان بِين‬ ‫ر‬ ‫ل‬ ‫ل‬ ‫ر‬ ‫ل‬ ‫.تورةكةى قؤِى‬ ‫ر‬ ‫002 ) نةخؤش كةوتي كة لة لَكؤَينةوةيةكى‬ ‫ي ل‬ ‫بؤ ئةم مةبةستةش سَساَ ثاش (‬ ‫ً ل‬ ‫ى‬

‫هاوتةريبدا، هةردوو جؤر نةشتةرطةرىيةكةيان بؤ كرا. ئةنامةكان لةيةكةوة نزيك بوون ،‬ ‫طةرضى ثَويستة ئةم بابةتة لة ذمارةيةكى زؤرترى نةخؤش و بؤماوةيةكى درَذتر بكؤَرَتةوة،‬ ‫ل ي‬ ‫ي‬ ‫ي‬ ‫لة دةرئةنام دا ئةتواني بََي، تةنيا بِين تورةكةى قؤِى بةَِطةيةكى بةكارى ضارةسةرى‬ ‫ري‬ ‫ر‬ ‫ر‬ ‫لي‬ ‫.قؤرى لموسةلن دائةنرَت‬ ‫ي‬

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