Is routine contralateral exploration advisable for children with unilateral inguinal hernias?

Abstract

A lthough early surgical repair of clinically recognized unilateral indirect inguinal hernias in infants and children is almost universally recommended, controversy has persisted for 4 decades regarding the advisability of performing contralateral exploration in the absence of an identifiable hernia. Discussions on this subject have become even more active during recent years as more sophisticated technology has become available to demonstrate the presence of a clinically undetectable contralateral hernia. Since inguinal hemiorrhaphy is the most common operation performed by surgeons on patients in the pediatric age group, an estimated 6% to 8% of the male population, this decision must be made frequently. Few subjects currently arouse such intense expression of personal divergent views between pediatric surgeons. Consequent to the report by Rothenberg and Barnett’ in 1955, which proposed that contralateral exploration be performed routinely for children undergoing inguinal hemiorrhaphy, many published reports have made the same recommendation, based on the high incidence of patent hernia sacs found after a large number of bilateral operations. 2*3 The reported incidence of bilateral hernias in children has ranged from 6% to more than 80%, with the highest frequency observed in the youngest patients. Many surgeons have therefore recommended that contralateral repair be performed in patients under 2 years of age-before the hernia may close spontaneously. The controversy regarding contralateral exploration is largely centered on the definition of what constitutes a patent processus vaginalis and when does it become a hernia.4 Since it is widely recognized that the majority of patent processes close spontaneously, surgical repair of a patent processus at an early age is likely to have rninimal benefit for most patients. Furthermore, up to 20% of adult men coming to autopsy have a patent processus without any previous clinical history of hemia.5 Most surgeons recognize that hemiorrhaphy is somewhat more technically demanding and is associated with a higher risk of spermatic cord injury in infants than in older children. Exploration may even occasionally cause damage to the intact floor of the inguinal canal, placing the patient at risk for the development of a direct inguinal hernia in later years.