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Original Article

A new, simple operative approach for bilateral inguinal hernia

repair in girls: A single transverse supra-pubic incision
Abdalla E. Zarroug, Antar M. Alkhebel1, Waleed O. Gibreel2, Mohammed Almassry1
Divisions of Pediatric Surgery, 2General Surgery, Mayo Clinic, Rochester, Minnesota, United States, 1European Gaza
Hospital, Palestinian Territories, Gaza, Palestine

Address for correspondence: Dr. Abdalla E. Zarroug, Division of Pediatric Surgery, Mayo Clinic, 200 First Street South West,
Rochester - 55905, Minnesota, United States. E-mail: abdalla.zarroug@gmail.com

ABSTRACT Access this article online

Website: www.jiaps.com
Background: Inguinal hernia repair remains one of the most common operations DOI: 10.4103/0971-9261.154649
performed by pediatric surgeons. We described a new surgical approach for treating Quick Response Code:

bilateral inguinal hernias in girls through a small single transverse supra-pubic

incision. Materials and Methods: A new approach was performed on female children
12-years-old and younger with bilateral inguinal hernias between January 2005
and April 2012. Technique: A single transverse suprapubic incision (1-1.5 cm) was
made. Using sharp and blunt dissection bilateral hernias were exposed and repaired
using a standard high ligation. Results: Ninety-nine girls with a preoperative clinical
diagnosis of bilateral inguinal hernia were included. Median age was 2 years (range:
1 month to 12 years). All patients underwent general anesthesia. Median operative
time was 12 minutes (range 5-22). There were no intra-operative complications or
misdiagnosis. Two patients had bilateral sliding hernias and the remainder had
indirect hernias. Post-operatively two patients developed non-expanding small
hematomas, both treated non-operatively without sequelae. There were zero
hernia recurrence and median follow-up was 5 years (range: 1-8 years) on 99% of
patients. Conclusion: We described a new, safe, simple, and rapid approach for
bilateral inguinal hernia repair in female pediatric population. A single transverse
suprapubic skin incision was adequate for exposing both inguinal regions with
excellent postoperative results.

KEY WORDS: Bilateral, bilateral inguinal hernia, females, herniotomy, inguinal hernia,
supra-pubic incision

INTRODUCTION Although there is variability in the way pediatric

Inguinal hernia repair remains one of the most common
operations performed by pediatric surgeons. [1,2]
The reported incidence of inguinal hernia in those
younger than 18 years old varies from 0.8-4.4%. Males
are more likely to have hernia with 3:1-10:1 ratio.[1]
Approximately 6 % of females present with bilateral
inguinal hernia.[2]
surgeons perform some of the technical aspects of
inguinal herniotomy, we know of no technique that
describes a single suprapubic incision to repair bilateral
inguinal hernia in girls. Current technical differences
from Drs. Ladd and Gross’ original description of
pediatric hernia repairs likely result from evolving
techniques, experiences, and analysis of outcomes that
suite the local community, population, or surgeon.[1-3]

Cite this article as: Zarroug AE, Alkhebel AM, Gibreel WO, Almassry M. A new, simple operative approach for bilateral inguinal hernia repair in girls:
A single transverse supra-pubic incision. J Indian Assoc Pediatr Surg 2015;20:170-3.
Source of Support: Nil, Conflicts of Interest: None declared.

170 Journal of Indian Association of Pediatric Surgeons / Oct-Dec 2015 / Vol 20 / Issue 4
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Zarroug, et al.: New, simple operative approach for bilateral inguinal hernia repair in girls
The specific technique described in this manuscript
was adopted to fill a need for its local community by
local surgeons in Gaza, but is applicable to the wider
pediatric surgical population. We are describing a new
approach for bilateral inguinal hernia repair in female
children through a small 1-1.5 cm transverse suprapubic
midline incision.
MATERIALS AND METHODS
Approval from the Administrative Review Board
Committee (IRB equivalent) was obtained for this
retrospective chart review. The new approach was
performed on 99 consecutive female children aged
12 years or younger with bilateral inguinal hernias
at a single institution at the European Gaza Hospital,
Gaza, Palestinian Territories between January 2005
and April 2012. Informed consent was obtained
from the parents after explaining the goals, benefits,
risks, and alternatives for this approach. All patients
had a pre-operative clinical diagnosis of bilateral
inguinal hernia based on history and physical exam.
No radiologic procedures were performed to diagnose
any hernia. Any actively incarcerated or strangulated
hernias were intentionally excluded from this new
operative approach; however a history of incarceration
or strangulation did not prevent using this approach.
The one exception is an incarcerated ovary; this did not
prevent using this approach. Sliding hernias also did
not prevent using this approach.
Description of the approach/technique
After general anesthesia, in a supine position, a
1-1.5 cm midline transverse suprapubic skin incision
is made along the skin crease [Figure 1]. Incision
is carried down through the dermis to expose the
subcutaneous fat, Camper’s fascia. Using sharp and
blunt dissection, Scarpa’s fascia is identified, grasped
and incised in the direction of the targeted hernia
Figure 1: Shows the midline transverse suprapubic incision
Journal of Indian Association of Pediatric Surgeons / Oct-Dec 2015 / Vol 20 / Issue 4
(right or left). Gentle retraction is needed laterally to
maintain excellent exposure. The sac is exposed and
elevated off the inguinal floor [Figures 2 and 3]. From
this point onwards, the steps of standard hernia repair
with a high ligation are followed according to the
surgeons’ technique. The external inguinal ring was
not opened in any of the patients. After finishing the
repair of one side, the same steps are repeated on the
contralateral side through the same skin incision. This
new modification changes the skin incision, exposure
and approach and does not alter the technical aspects
of the high ligation. Subcutaneous tissue and skin are
subsequently closed [Figure 4]. Since electricity was
intermittently available, no electrocautery was used, as
a matter of preference. Also, we neither dissected the
round ligament from the sac, nor did we tack the round
ligament to any structures.
RESULTS
Ninety-nine girls with a pre-operative clinical diagnosis
of bilateral inguinal hernia were included. Median age
was 2 years (range: 1 month-12 years). All patients
underwent general anesthesia (95% by hand-bag mask
ventilation, 5% with laryngeal mask). Median operative
time was 12 minutes (range 5-22). There were no intra-
operative complications or misdiagnosis. One patient
had an incarcerated, but viable ovary. Two patients
had bilateral sliding hernias and the remainder had
indirect hernias. One surgeon (MA) was scrubbed
for every procedure as surgeon, first assistant, or
teaching surgeon. Post-operatively 2 patients developed
non-expanding small hematomas, both treated non-
operatively without sequelae or intervention. There
were zero hernia recurrence and on follow-up was
achieved in 99% of patients. Median follow up was
5 years (range: 1-8 years).
Figure 2: Shows the exposure of the round ligament and right hernia
sac. The sac is subsequently separated from the round ligament and
ligated using a high ligation approach
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Zarroug, et al.: New, simple operative approach for bilateral inguinal hernia repair in girls
Figure 3: Shows the exposure of the round ligament and left hernia
sac. The sac is subsequently separated from the round ligament and
ligated using a high ligation approach
DISCUSSION
The idea of exposing the bilateral inguinal hernia
through a single small midline incision, to our
knowledge, has not been described previously in
pediatric surgical literature. We report 99 girls age 12
or younger that have undergone this approach with no
recurrences, few complications and a reliable, excellent
median follow-up of 5 years. We believe infant hernia
repairs are particularly suited to this approach because
the anatomy of the inguinal canal passes through a
series of changes from infancy to adulthood that favors
a single midline incision. In infants the internal and
external inguinal rings almost overlap, therefore if the
retractor exposes the external ring, it is easy to expose
the internal ring by retracting a few millimeters more.
As children grow, the internal inguinal ring becomes
more lateral in position compared to the external ring.
Thus, the midline transverse incision can easily be used
to expose both superficial and deep inguinal rings in
younger patients. Furthermore, exposing both inguinal
canals through a transverse midline incision allows
for simultaneous correction of the bilateral hernia
through one incision. Although not the only reason,
this approach was initially considered as a mean of
shortening the anesthetic time. When considering
operating room scheduling, time is of the essence in
Gaza as trauma often can disrupt an elective schedule.
Thereafter, the cosmetic result was considered superior
to standard bilateral standard incisions, although we did
not tabulate data to test this latter hypothesis.
We intentionally performed this technique on girls
and not boys because the technical repair in girls is
much easier than male inguinal hernia repair where
the vas deferens and testicular vessels need to be
spared, whereas there is no need to save the round
172 Journal of Indian Association of Pediatric Surgeons / Oct-Dec 2015 / Vol 20 / Issue 4
Figure 4: Shows the midline incision closure at the completion of the
procedure
ligament in girls. Another selection we made was
to limit this approach to bilateral hernias; there is
probably no advantage to this approach in older
children with unilateral hernias. Having stated that,
from our experience, it would not be difficult to repair a
unilateral hernia using a midline suprapubic transverse
incision approach with a laparoscopic contralateral
exploration as described by Bhatia et al.,[4] and thereafter
repair the contralateral side through the same incision
if needed. However, this approach probably makes
sense for younger children such as infants (2-years-
old or younger) where there is relatively high risk of
a contralateral patent processus vaginalis. We did not
perform any unilateral hernia (with a contralateral
laparoscopic groin exploration) through our approach
since there were no 3-5mm laparoscopic scopes in
Gaza at the time of this manuscript. Therefore we
recommend this approach to be used in female patients
with a confirmed clinical diagnosis of bilateral inguinal
hernia. Although an argument can be made that a
laparoscopic approach could achieve superior cosmetic
results through several 2-3 cm incisions, it can also
be argued that remaining outside the peritoneum is
the ideal method of hernia repair. Furthermore, even
in 2014 most pediatric surgeons across the world has
neither developed the skill to perform a laparoscopic
hernia repair nor do they have the mini-laparoscopic
equipment to perform laparoscopic inguinal hernia
repairs.
As children grow, the internal ring becomes more lateral
in position compared to the external ring. This anatomic
relationship should be considered when repairing the
hernia in older children. In this situation, more lateral
retraction or making a bigger incision may be needed
based on individual surgeon’s preference. In our series,
a 1.5 cm provided an excellent exposure that allowed
adequate hernia repair in children 12 years and younger.
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Zarroug, et al.: New, simple operative approach for bilateral inguinal hernia repair in girls
Our follow-up of 5 years compares very favorably to
other reports who have published new techniques for
inguinal hernia repairs, in particular the laparoscopic
approaches.[5] We believe our follow up is excellent for
two reasons. First, Gaza has strict travel restrictions
in place since 2005 (beginning of this study) and
most patients therefore literally have little option to
go elsewhere. Second, there is a single payer system
in Gaza and patients are referred back to the initial
surgeon if a complication occurs as a matter of practice
patterns, therefore all but one patient had excellent
follow-up.
This is a retrospective paper with its inherit bias.
Clearly there is a selection bias, as this was a
retrospective study that selected excellent candidates.
However, our paper adds to the literature a small,
but significant technical modification that reduces
two small incisions to one small incision in well-
selected patients, which should reduce surgical time.
Although a Pfannenstiel incision has been described
as a single case, they entered the peritoneum and had
an entirely different approach.[6] Ideally, the next step
is to perform a randomized controlled study comparing
our approach to the standard bilateral incision to
determine any differences.
Journal of Indian Association of Pediatric Surgeons / Oct-Dec 2015 / Vol 20 / Issue 4
CONCLUSION
We describe a new, safe, simple, and rapid approach
for bilateral inguinal hernia in female pediatric
population. A midline suprapubic transverse skin
incision was adequate for exposing both inguinal
regions with excellent postoperative results. Median
patient follow-up of 5 years was excellent and reliable.
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1. Bronsther B, Abrams MW, Elboim C. Inguinal hernias in
children — A study of 1,000 cases and a review of the literature.
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2. Levitt MA, Ferraraccio D, Arbesman MC, Brisseau GF, Caty MG,
Glick PL. Variability of inguinal hernia surgical technique:
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3. Ladd WE, Gross RE. Abdominal Surgery of Infancy and Childhood,
Philadelphia, W. B. Saunders Company, 1941.
4. Bhatia AM, Gow KW, Heiss KF, Barr G, Wulkan ML. Is the use
of laparoscopy to determine presence of contralateral patent
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