Risk of Hernia Occurrence Where Division of an Indirect Inguinal Sac Without Ligation Is Undertaken

Abstract

We sought to ascertain the risk of inguinal hernia occurrence when division of the processus vaginalis is undertaken without ligation, in the context of laparoscopic Fowler-Stephens orchidopexy. A cohort of patients with intra-abdominal testes subjected to a two-stage Fowler-Stephens procedure was reviewed. Analysis of a 68-month period between November 2005 and August 2011 was performed. A comprehensive search of the literature was undertaken, and these data were compared with previously published studies of patients undergoing orchidopexy or herniotomy where the peritoneal defect was not closed. The procedure was undertaken as previously described, with a conventional first stage using a three-port technique. No attempt was made to approximate the peritoneal margins of the processus vaginalis/hernia or close the internal ring at the second stage. In our own experience 17 patients with undescended testes (2 with bilateral cases) underwent laparoscopically assisted, gubernaculum-sparing, Fowler-Stephens orchidopexy. Median age at first operation was 1.86 years (range, 1-9 years). All 17 patients had successful surgery with all 19 testes palpable within the scrotum at postoperative assessment at 3 and 6 months. No direct, indirect, or incisional hernias were noted at a mean follow-up of 2.7 years (standard deviation 1.71). Our experience and reports in the literature do support simple division of the indirect hernia sac as a tenable alternative to ligation. The result of this limited review would support a prospective randomized trial comparing ligation with simple division of hernia sacs.