Seminars in Pediatric Surgery (2007) 16, 50-57

Current management of hernias and hydroceles

Stanley T. Lau, MD, Yi-Horng Lee, MD, Michael G. Caty, MD

From the State University of New York at Buffalo, Women and Children’s Hospital of Buffalo, Buffalo, New York.

INDEX WORDS The repair of inguinal hernia and hydrocele is one of the most common operations in a pediatric surgery
Inguinal hernia; practice. This work reviews current concepts in the management of the inguinal hernia and hydrocele.
Hydrocele; The authors describe current concepts of anesthetic management of children undergoing repair of
Recurrent hernia; inguinal hernia. The authors also discuss current management of the contralateral hernia, hernias in
Laparoscopic hernia premature infants, and the management of an incarcerated hernia. In addition, the authors discuss the
repair; role of laparoscopy in the surgical treatment of an inguinal hernia and its application for investigation
Hernia in the of the contralateral inguinal canal.
premature infant © 2007 Elsevier Inc. All rights reserved.

The expert repair of inguinal hernias and hydroceles is the
cornerstone of the modern pediatric surgery practice. Most
pediatric surgeons perform hundreds of hernia repairs each
year. Given the low complication rate of hernia repair, any new
approach to diagnosis or treatment must meet or exceed a high
standard. In addition, novel approaches are often accompanied
by extra expense that must be justified in our cost-conscious
health care system. In this review, current concepts of the
management of inguinal hernia and hydrocele will be dis-
cussed. Rather than be an exhaustive treatise of the topic, this
review will present standard diagnosis and treatment in the
light of how newer concepts influence accepted practices. This
review will focus on current concepts of anesthesia for hernia
repair, management of the contralateral hernia, management of
hernias in the premature infant, and laparoscopic management
of inguinal hernia and hydrocele.
General considerations
Anesthesia
The vast majority of infants and children undergoing hernia
repair require general anesthesia. An exception to this rule
Address reprint requests and correspondence: Michael G. Caty,
MD, State University of New York at Buffalo, Women and Children’s
Hospital of Buffalo, 219 Bryant Street, Buffalo, NY 14222.
E-mail: caty@acsu.buffalo.edu.
would be the repair of hernias in the premature infant who
may have the procedure performed under spinal anesthesia.
The repair of hernias in premature infants will be discussed
later. General anesthesia can be accomplished in many ways
depending on the experience and preference of the anesthe-
siologist. Airway management using a mask, laryngeal
mask, or endotracheal tube are all acceptable alternatives.
Use of an endotracheal tube and rapid sequence intubation
is the safest strategy for the patient with a full stomach and
an irreducible inguinal hernia. Regional anesthesia is often
used to supplement general anesthesia and provide postop-
erative analgesia. The most common forms used are caudal
anesthesia and regional nerve blocks.
The use of regional and local anesthesia during the repair
of inguinal hernia in children is designed to provide post-
operative analgesia. It would be extremely unlikely that a
child could undergo repair of an inguinal hernia under local
or regional anesthesia. The one exception may be the older
child with cystic fibrosis and severe lung disease who might
undergo hernia repair under regional anesthesia, such as
epidural or spinal anesthesia. Regional nerve blocks are
generally performed after the induction of general anesthe-
sia. Caudal anesthesia is more commonly performed by
an anesthesiologist, whereas an ilioinguinal/iliohypogastric
block is performed by either the surgeon or anesthesiologist.
If the ilioinguinal/iliohypogastric nerve block is performed
before the skin incision, external landmarks are applied to
guide the introduction of the local anesthetic. The local

1055-8586/$ -see front matter © 2007 Elsevier Inc. All rights reserved.
doi:10.1053/j.sempedsurg.2006.10.007
Lau et al Hernias and Hydroceles
anesthetic is introduced at a puncture site 1 cm medial to the
anterior superior iliac spine. Because the nerves most com-
monly run below the external oblique, the needle is ad-
vanced until a “click” is felt as the needle passes through the
external oblique and the local is injected. Due to the blind
nature of the infiltration, the success rate of this block is
approximately 70% to 80%. In addition, complications such
as colon or small bowel perforation can occur. One attempt
to improve the success rate and the safety of the procedure
was the incorporation of ultrasound guidance. Willschke
and his coauthors used a 10-MHz ultrasound probe to iden-
tify the ilioinguinal and iliohypogastric nerves before infil-
tration of local anesthetic before inguinal hernia repair in
children. The anesthetic was infiltrated under ultrasound
guidance to confirm that the nerves were identified and
surrounded. This strategy resulted in the use of less anes-
thetic and improved pain relief. This offers a potential
advantage when performing the block before the incision.1
During hernia repair, the surgeon has the advantage of
placing the local in proximity to the nerves under direct
visualization. The only drawback of this approach is the
delay of onset of the block until after the incision has been
performed. Optimal pain relief is achieved by a proximal
block of both the ilioinguinal and iliohypogastric nerve at
the same time. Additional infiltration of local anesthetic
around the ilioinguinal nerve or genitofemoral nerve does
not seem to provide a measurable benefit.2,3
Contralateral hernia management
For as long as pediatric surgeons have repaired inguinal
hernias, they have debated the merits of contralateral ingui-
nal exploration. Exploration of the asymptomatic side is
designed to detect a patent processus vaginalis or nonevi-
dent clinical hernia. The goals of identifying these two
entities are to avoid a second anesthesia, minimize parental
and patient inconvenience, avoid the chance of incarcera-
tion, and reduce costs. Potential downsides to exploration of
the asymptomatic side include injury to contents of the
spermatic cord, wound infection, increased pain, increased
cost, and prolongation of the operation. For over 60 years,
a body of literature has been created that has analyzed the
natural history of the asymptomatic side. Accompanying
this body of literature has been the periodic introduction of
techniques to detect the presence of a contralateral patent
processus vaginalis. The most recent strategies for detection
are ultrasound and laparoscopy. A summary of the historical
perspective on management of the contralateral side will be
provided and the application of ultrasound and laparoscopy
will be discussed.
The decision to explore the side opposite a clinically
evident hernia has been guided by observations regarding
the presence of a contralateral processus vaginalis during
routine exploration and by the occurrence of a metachro-
nous hernia after ipsilateral repair. In addition, the influ-
ences of gender, side of initial hernia, and age at presenta-
tion have been considered as components of larger data sets.
51
Implicit in these considerations is that a patent processus
vaginalis is a common occurrence and is a precursor of a
clinical hernia.
The processus vaginalis is an extension of the perito-
neum that is thought to be created by migration of the
testicle pulling down an extension of the lower abdominal
peritoneal surface. The derivation of a processus vaginalis
in a female is less clear. If a lumen is present and a con-
nection with the abdominal cavity is maintained, then a
processus vaginalis is defined as patent. This is not a clinical
problem; however, if the processus vaginalis is patent and
enlarges to the size that intrabdominal contents are present
in the sac, then a hernia exists and repair is mandatory. The
early studies on this topic focused on the frequency of
finding a patent processus vaginalis during exploration of
the inguinal canal opposite a clinical hernia. The “natural
history” of the patent processus vaginalis was further de-
fined by the performance of unilateral inguinal hernia repair
and observation of the asymptomatic side. Additional infor-
mation has been provided by autopsy studies.
Several studies in the 1960s used large patient databases
to frame this question. Sparkman reviewed 918 children
who had undergone hernia repair and contralateral explora-
tion and found a 57% rate of patency of the processus
vaginalis.4 Rowe and his coauthors reviewed 2764 patients
and identified a patency rate of 48%. When patients were
stratified by age, patency was seen to decline with older age
at the time of exploration. Infants who were operated on at
2 months or less had a 63% patency rate. At age 2 years, the
rate of patency declined to an average of 41% and did not
decline significantly in teenagers.5 Additional information
regarding the outcome of the asymptomatic side has re-
sulted from observing the asymptomatic side following uni-
lateral repair. Kiesewetter reviewed a group of 237 infants
who underwent unilateral repair and found a metachronous
hernia rate of 31%.6 This is the highest figure noted in the
literature. Sparkman reviewed a group of children in his
previously noted study and followed 1944 children who
underwent unilateral repair. Contralateral hernias were
noted in 15.8% patients in follow up.4 Contemporary stud-
ies have suggested a lower rate of metachronous hernia.
Tackett and her colleagues followed 656 patients prospec-
tively and found a metachronous hernia rate of 8.8%.7
Autopsy data suggest that adults who expire without a
clinical hernia will demonstrate a patent processus vaginalis
in 15% to 30%.8
A synthesis of these publications suggests that approxi-
mately half of children under 2 years of age will have a
patent processus vaginalis. Approximately 40% of children
over the age of 2 until adulthood will have a patent proces-
sus vaginalis. If patients are observed after ipsilateral hernia
repair, a metachronous hernia will appear on the contralat-
eral side from 8% to 31% of the time. Combining these data
leads to the conclusion that if a patent processus vaginalis is
observed, it will only become clinically significant in 25%
to 50% of the time.
52
Multiple strategies have been introduced to avoid a neg-
ative contralateral exploration. Herniography was designed
as an outpatient preoperative study to detect either the
occult hernia or a contralateral processus vaginalis. It has
several drawbacks: it is painful, involves fluoroscopy, and
has been known to be associated with visceral perforation.
The technique of herniography has largely been abandoned
in the modern children’s hospital. Another strategy involves
the placement of a Bakkes dilator through the hernia sac to
attempt to probe the contralateral hernia or processus vagi-
nalis. Several techniques of pneumoperitoneum have been
used to attempt to insufflate the contralateral side. The
Goldstein test involved attempted insufflation of the con-
tralateral side by introducing air through a catheter placed in
the hernia sac. Other investigators have used a laparoscopic
insufflator to inflate the abdomen. Holcomb and his col-
leagues evaluated insufflation by following up with imme-
diate laparoscopy and found this technique to be unreliable.9
Several authors have suggested the use of preoperative
ultrasonography for the investigation of the contralateral
side. Chen used a criterion of 4 mm of the internal ring to
define a hernia or processus vaginalis. When this criteria
was applied, the diagnostic accuracy of ultrasound was
97.9%.10 Hata evaluated 348 patients and demonstrated an
accuracy rate of 95%.11 The advantages of ultrasound in-
clude being noninvasive, dynamic, and not involving pneu-
moperitoneum.
Laparoscopy to detect presence of a hernia in children
was introduced in 1992. The contralateral side may be
examined either by direct evaluation through an umbilical
port or by passing a 70-degree laparoscope through the
hernia sac. Findings that suggest a patent processus vagina-
lis or hernia include the continuation of the peritoneum
through the internal ring, and retrograde fluid passage dur-
ing compression of the inguinal canal (Figure 1A–D). Ob-
servational studies using laparoscopy reveal the incidence
of a patent processus vaginalis to be similar to historical
studies using open exploration. Intraoperative laparoscopy
for the detection of a contralateral hernia or patent processus
vaginalis is highly sensitive. A meta-analysis of 964 pa-
tients revealed a sensitivity of 99.4% and a specificity of
99.5%.12 Given the fact that a patent processus vaginalis is
not clinically significant in the majority of patients, we do
not routinely perform a contralateral exploration, either
laparoscopically or open.
Current management of hernias in the
premature infant
Inguinal hernias occur more commonly in premature infants
compared with the general population, with a reported in-
cidence of up to 30%13,14 and incarceration rates of up to
31%.14,15 The timing of surgical repair in these neonates is
controversial.14,16-22 In a small premature infant, the oper-
ation is technically more difficult and associated with a
Seminars in Pediatric Surgery, Vol 16, No 1, February 2007
higher morbidity. Furthermore, the anesthetic risk is higher
in a premature infant. Some debate exists about the optimal
time to repair the asymptomatic hernia found in a premature
infant in the neonatal intensive care unit.
Timing of inpatient repair
The factors that must be considered in making the decision
when to operate include the technical difficulties of a fragile
hernia sac and higher risk of injury to the vas deferens or the
testicular vessels, the presence of comorbid conditions as-
sociated with prematurity, and the anesthetic risks in a
premature infant. The morbidity associated with an inguinal
herniorrhaphy is higher in premature infants, with an increased
incidence of testicular atrophy and recurrent hernias.23
Because of the risks of herniorrhaphy in the premature
infant, many surgeons used to discharge patients home from
the neonatal intensive care unit (NICU) and repair their hernia
once they reached a certain age or weight. With recent ad-
vances in anesthesiology and neonatal care, many surgeons
have moved toward performing an early hernia repair before
discharge from the NICU.14,19,21,22,24-27 Others prefer to per-
form an even earlier repair to minimize the risk of incarcera-
tion. In a survey of 599 members of the Surgical Section of the
American Academy of Pediatrics, 63% of the 395 responders
indicated that they repair reducible hernias in former preterm
infants before their discharge from the NICU. Ten percent
operate at 50 weeks postconceptual age and 3.0 kg in weight,
and 5% repair the hernia at 60 weeks postconceptual age and
3.5 kg in weight. Five percent indicated that they repair the
hernia when convenient, regardless of either postconceptual
age or weight.28 Compared with a previous survey taken in
1993,26 there are more surgeons repairing the hernias in pre-
mature infants earlier.
Proponents of immediate repair29 justify the risk of an
early operation based on an increased risk of incarceration
with a longer waiting period before surgical repair. Others
advocate waiting until an arbitrary weight or age criteria has
been met, thereby optimizing some of the associated mor-
bidities.14 Still others recommend waiting until the infant is
ready for discharge from the NICU.19,24,25,27 In our practice,
we typically repair neonatal inguinal hernias before dis-
charge from the NICU. If the family is reliable, however,
and we cannot easily schedule the repair without prolonging
the hospital stay, we may make an exception and perform
the operation soon after discharge.
Uemura and coworkers22 suggest that a lengthy delay
before repair can lead to the adhesion of the thickened
hernia sac to the spermatic cord, complicating the operation
and leading to longer operative times with an increased risk
of cord damage. A more difficult dissection could also lead
to damage to the testicular vessels and subsequent testicular
atrophy. These authors retrospectively reviewed 40 prema-
ture infants from the neonatal intensive care unit of a single
institution who underwent inguinal herniorrhaphy. They
found that a group of 21 very low birth weight infants (less
than 1000 g) had a longer waiting period, likely due to their
Lau et al Hernias and Hydroceles 53

Figure 1 (A) The cannula is inserted through the ipsilateral hernia sac, and the abdomen insufflated. A 70-degree scope is inserted for
contralateral evaluation. (B) Laparoscopic evaluation of the contralateral processus through a right inguinal hernia sac, demonstrating a
closed processus. The inverted “V” of the vas and vessels is seen. (C) Laparoscopic evaluation of the contralateral processus through a left
inguinal hernia sac, demonstrating a patent processus (note the air bubbles emanating from the site. (D) Laparoscopic evaluation of the
contralateral processus through a left inguinal hernia sac, demonstrating an obvious patent processus. (Courtesy of Dr. George W. Holcomb
III, MD, MBA, Children’s Mercy Hospital, Kansas City, MO.) (Color version of figure is available online.)

comorbid conditions. These patients also had a longer op-
erative time, which these authors felt was due to a thicken-
ing of the cord from the long-standing hernia resulting in a
more difficult operation. They recommended repairing a
hernia within 14 days of making the diagnosis.
Rajput and coworkers21 suggested that rather than choosing
an arbitrary weight or age, an individualized approach is nec-
essary, particularly in very low birth weight premature infants
under 1500 g at birth. These authors suggest that one should
use an individualized approach to account for multiple factors
such as the pulmonary status and history of incarceration to
determine the optimal time for surgical repair.
Anesthetic risks
Premature infants are at a higher risk for developing post-
operative respiratory complications compared with full-
54 Seminars in Pediatric Surgery, Vol 16, No 1, February 2007

term and even older premature infants. Steward reported It is our practice, like many pediatric surgeons, to post-
that 33% of premature infants undergoing herniorrhaphy operatively monitor in the hospital all ex-premature infants
developed respiratory complications, most commonly ap- who are less than 60 weeks postconceptual age. We do not
nea.30 All of the infants with apnea weighed less than 3 kg have a minimum weight or gestational age before repairing
at the time of surgery and were under 10 weeks of age. asymptomatic hernias because of the risk of incarceration,
Allen and coworkers reported an association with the use of and recommend elective repair in a timely fashion. If a
intraoperative narcotics and muscle relaxants and the inci- neonate has significant bronchopulmonary disease and has
dence of postoperative apnea– bradycardia episodes in ex- bilateral inguinal hernias, we may stage the repair to mini-
premature infants with a postconceptual age of ⬍60 mize postoperative respiratory difficulties due to a loss of
weeks.31 Warner and coworkers found that a history of abdominal domain with the reduction of the hernias.
apnea or respiratory distress syndrome significantly in-
creased the chance of a postoperative respiratory event in Current management of hydroceles
premature infants undergoing herniorrhaphy.32 A history of
bradycardia or ventilatory support for 24 hours or more after When examining a child with an inguinal hernia, a hydro-
birth were also significant risk factors. cele must be considered in the differential diagnosis. This
The anesthetic risk for former preterm infants is in- determination can typically be made by clinical examina-
versely proportional to the postconceptual age. However, tion. By palpation, one can feel the narrowing of the hy-
drocele neck at the external inguinal ring without extension
there is still some controversy about the minimum postcon-
into the inguinal canal. Ultrasound can also be helpful in
ceptual age that reduces the chance of a postoperative an-
making this distinction.
esthetic event. Several studies have attempted to address
The patent processus vaginalis will spontaneously close
this question, leading to recommendations ranging from 40
over a period of 1 to 2 years in most instances. Therefore,
to 60 weeks postconceptual age.31-37 Although the postcon-
ceptual age has been shown to be the major risk factor, the
presence or absence of a history of preoperative apnea or the
need for ventilatory support also influences the safety of
performing an outpatient procedure. Some studies also
show that the presence of anemia is an independent risk
factor for a postoperative apneic event.32,38
Cote and coworkers performed a meta-analysis of former
preterm infants undergoing an inguinal herniorrhaphy with
general anesthesia.38 Their analysis included 255 patients
from 8 studies at 4 institutions. They found a strong rela-
tionship between the incidence of postoperative apnea and
the postconceptual and gestational ages. The authors re-
ported the incidence of postoperative apnea to be less than
5% once a child with a gestational age of 35 weeks reached
a postconceptual age of 48 weeks. This incidence drops to
less than 1% once the child reaches a postconceptual age of
54 weeks. A lower gestational age resulted in a slightly
higher risk for postoperative apnea even with the same
postconceptual age. For example, they predicted that, in a
child with a gestational age of 32 weeks, the incidence of
apnea would be less than 1% at a postconceptual age of 56
weeks. This analysis also showed that infants who were
small for gestational age appeared to have a lower incidence
of apnea compared with larger children. After controlling
for gestational and postconceptual ages, however, the only
independent risk factor was anemia.
Recent literature has suggested that the use of regional
anesthesia (spinal, epidural, or caudal) has a role in decreas-
ing the risk of a postoperative respiratory complication as
compared with general anesthesia.39-43 Perhaps this de-
creased risk may lead to a decreased need for inpatient
postoperative monitoring in the ex-premature infant after an Figure 2 Hydrocele of the canal of Nuck in a female term infant,
inguinal herniorrhaphy. with meconium staining. (Color version of figure is available online.)
Lau et al Hernias and Hydroceles
most pediatric surgeons will avoid operation within the first
1 to 2 years of life unless a hernia cannot be excluded. After
the age of 2 years, the hydrocele will be unlikely to resolve,
and an operation will be required. A high ligation of the
patent processus vaginalis should be performed, and the
distal fluid collection should be emptied.
If the hydrocele shows signs of communication (fre-
quently changing in size), then there is a significant ex-
change of fluid between the peritoneal cavity and the hy-
drocele sac (Figure 2). Many pediatric surgeons will choose
to repair a communicating hydrocele earlier.
In 1993, a survey of the Section on Surgery of the
American Academy of Pediatrics26 showed that 43% of
responders would perform a repair in an infant with a scrotal
hydrocele since early infancy only if the hydrocele is still
present at 1 year of age. Almost 20% would perform a repair
only if there were signs of communication. If the hydrocele
was communicating, and there was no definite hernia, then
two-thirds of the responders would schedule an elective
herniorrhaphy and one-third would wait until the child was
6 to 12 months of age.
A second survey of the Section on Surgery of the Amer-
ican Academy of Pediatrics28 taken in 2003 showed similar
results to the prior survey. Forty-two percent of responders
indicated that they would repair a hydrocele that had been
present since early infancy if it was still present at 1 year of
age. Fourteen percent would perform a repair only with
communicating hydroceles. Five percent would operate at
2 years old.
In our practice, we recommend a groin exploration for all
patients with hydroceles who are over 2 years of age. We
would recommend a formal repair, even in the young ado-
lescent, to exclude the presence of a hernia or a patent
processus vaginalis. We do not routinely perform a tran-
scrotal hydrocelectomy.
In patients with a recurrent hydrocele after a groin ex-
ploration, we may perform an ultrasound to rule out a
recurrent hernia and continue observation of the hydrocele
for up to 1 year. If the hydrocele is still present at that time,
then we recommend a transcrotal aspiration. If the hydro-
cele recurs again, then we would recommend a repeat as-
piration.
Current management of incarcerated
inguinal hernias
Whereas the contents of an incarcerated hernia cannot easily
be reduced into the abdominal cavity, the contents of a
strangulated hernia are tightly constricted and likely to be
gangrenous. The incidence of incarceration has been re-
ported in the general pediatric population to be between 6%
and 18%. However, the risk of incarceration is higher in
infancy, with a reported incidence of approximately 30%.44
A nonreducible hernia in children requires operative explo-
ration. These hernias, unless treated, are likely to progress to
strangulation and infarction.
55
The initial management of an incarcerated inguinal her-
nia without strangulation should be nonoperative.44 Anal-
gesia or sedation can also be used to aid the reduction of an
incarcerated hernia. Gentle compression is usually success-
ful in 70% to 85% of patients,44-46 and an elective repair can
be performed in 24 to 48 hours. This time allows some
resolution of the edema, minimizing the difficulty of the
dissection and the risk of complications. However, failure to
reduce the hernia, even with sedation, is an indication for an
immediate operation.
The operative management is determined by the viability
of the intestine. If the incarcerated intestine is viable, the
surgeon can simply reduce the hernia and perform a high
ligation of the sac. If the intestine is no longer viable, it
should be resected, either through the sac or through a
separate abdominal incision. An incarcerated hernia in an
infant is more technically difficult and has a higher compli-
cation rate since the hernia sac is typically edematous and
fragile. The testicular vessels and the vas are particularly
susceptible to injury because of the edema and often diffi-
cult dissection.
Although the complication rate from the repair of an
incarcerated inguinal hernia is higher than that of an elective
herniorrhaphy, many cases of incarceration can be pre-
vented with a timely elective operation. Stylianos and co-
workers reviewed the experience of incarcerated inguinal
hernias at The Boston Floating Hospital between 1984 and
1991.46 The authors found a 9% incidence of incarceration
out of 908 consecutive cases of inguinal hernias. Out of the
patients with an incarcerated hernia, 30 (35%) were known
to have an inguinal hernia before incarceration. In fact, 25
out of the 30 patients with a known hernia were already
scheduled for an elective repair. They reported that median
time from surgical office visit to planned elective repair was
22 days (with a range of 14 to 42 days) and a mean interval
from office visit to incarceration was 8.3 days (range 0.5 to
28 days). Furthermore, 47 (85%) of the children with incar-
cerated hernias were under 1 year of age. These authors
suggested that an earlier repair of elective hernias would
prevent a significant percentage of incarcerated hernias and
a decrease in subsequent complications.
Laparoscopic repair of inguinal hernias
Recently, minimally invasive techniques using laparoscopy
have provided an alternative method for surgical repair of
pediatric inguinal hernias. Early results using laparoscopy
had a higher recurrence rate and a longer operative time, but
refinements in the techniques used and continued experi-
ence have lowered these risks. Proponents of the laparo-
scopic approach cite a comparable operative time compared
with open surgery and a similar complication rate.47-51
The laparoscopic approach also offers the surgeon the
ability to easily examine the contralateral groin and to repair
any hernia found. This advantage, of course, assumes that
the surgeon is a supporter of performing a contralateral
groin exploration. If the surgeon would normally perform a
56
contralateral exploration, either using laparoscopic or open
techniques, then performing a laparoscopic hernia repair
easily provides this option. However, as previously dis-
cussed, not all pediatric surgeons support contralateral groin
explorations.
Another proposed advantage of the laparoscopic tech-
nique is an improvement in the cosmetic outcome. The
incisions required with the minimally invasive techniques
are smaller (3-5 mm) than the standard open incision. Op-
ponents of the laparoscopic approach would argue that the
small groin incision of the open technique is more easily
hidden by clothing than the trochar sites required in the mid
abdomen.
Other advantages of the laparoscopic approach may be in
cases of recurrent inguinal hernias50,52 or in cases of incar-
cerated hernias.53 In the case of recurrent hernias that were
previously repaired using open techniques, the laparoscopic
approach allows the surgeon to avoid previously operated
tissue planes and potentially lowers the risks of injury to the
vas or testicular atrophy.
The standard initial approach to an incarcerated hernia is
manual reduction. This maneuver, although usually success-
ful, is associated with some risk since the incarcerated
intestine cannot be inspected due to the lack of visualiza-
tion. Once the hernia is reduced, most pediatric surgeons
will admit the patient to the hospital and repair the hernia in
1 to 2 days. As previously discussed, the operation carries a
higher risk of recurrence, injury to the vas, or testicular
atrophy due to the edema and fragility of the tissues.
The laparoscopic approach to an incarcerated inguinal
hernia offers several advantages. The reduction of the in-
carcerated bowel can be facilitated using both laparoscopic
reduction (pulling the intestine laparoscopically) and with
external manual reduction. The pneumoperitoneum may
also help to widen the internal ring, allowing an easier
reduction.53 Immediate inspection of the incarcerated bowel
is possible, allowing resection if necessary. Furthermore,
the hernia could be immediately repaired, perhaps avoiding
the edematous tissues and decreasing the higher complica-
tion rate associated with incarcerated hernias.53
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