Is the ligation of hernial sac necessary in herniotomy for children? A randomized controlled trial of evaluating surgical complications and duration


Department of Pediatric Surgery, Isfahan University of Medical Sciences, Isfahan, Iran


Background: Herniotomy is a common operation done by pediatric surgeons. Recent studies have shown that high ligation in herniation in adult is not necessary, but this method was not fully evaluated in children. We compared non-ligation with high-ligation sac in herniotomy in terms of surgical complications and duration.
Materials and Methods: This randomized controlled trial study was done on 104 children with inguinal hernia at Al-Zahra Hospital, Isfahan, Iran, between 2011 and 2013. Patients were equally randomized to undergo herniotomy with ligation of sac at the internal ring level or to undergo herniotomy without sac ligation. Patients were followed up just after the operation, and in the 1 st , 6 th , and 12 th weeks postoperation to discover early (scrotal hematoma, edema, wound infection, and postoperation fever) and late (adhesion and recurrence) complications. Also, duration of operation was recorded for each group.
Results: The incidence of early complications (nine cases in high-ligation and eight cases in non-ligation group) was the same in both groups (P = 0.402). No late complication was observed in any group. The mean duration of operation in high-ligation group (18.84 ± 5.47 min) was significantly shorter than non-ligation group (21.46 ± 9.03 min) (P < 0.001).
Conclusion: Complications are the same in herniotomy with or without ligation of the sac, but the duration of the non-ligation procedure is shorter than that of high-ligation. We suggest that herniotomy without sac ligation in children be the procedure of choice to save time and also to prevent any other possible complications such as nerve damage, spermatic cord injury, or peritoneal tearing.


Nyhus LM, Klein MS, Rogers FB. Inguinal hernia. Curr Probl Surg 1991;28:407-50.  Back to cited text no. 1
Othman I, Hady HA. Hernia sac of indirect inguinal hernia: Invagination, excision, or ligation? Hernia 2014;18:199-204.  Back to cited text no. 2
Grasfeld JL, Minnick K, Shedd F, West KW, Rescorla FJ, Vane DW. Inguinal hernia in children: Factors affecting recurrence in 62 cases. J Pediatr Surg 1991;26:283-7.  Back to cited text no. 3
Shulman AG, Amid PK, Lichtenstein IL. Ligation of hernial sac. A needless step in adult hernioplasty. Int Surg 1992;78:152-3.  Back to cited text no. 4
Kumari V, Biswas N, Mitra N, Konar H, Ghosh D, Das SK. Is ligation of hernial sac during orchiopexy mandatory? J Indian Assoc Pediatr Surg 2009;14:66-7.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
Mohta A, Jain N, Irniraya K, Saluja SS, Sharma S, Gupta A. Non-ligation of the hernial sac during herniotomy: A prospective study. Pediatr Surg Int 2003;19:451-2.  Back to cited text no. 6
Saghaei M. Random allocation software for parallel group randomized trials. BMC Med Res Methodol 2004;4:26.  Back to cited text no. 7
Potts WJ, Riker WL, Lewis JE. The treatment of inguinal hernia in infants and children. Ann Surg 1950;132:566-76.  Back to cited text no. 8
Rowe MI, Copelson LW, Clatworthy HW. The patent processus vaginalis and the inguinal hernia. J Pediatr Surg 1969;4:102-7.  Back to cited text no. 9
Halverson K, McVay CB. Inguinal and femoral hernioplasty: A 22-year study of the authors' methods. Arch Surg 1970;101:127-35.  Back to cited text no. 10
Weinstein M, Roberts M. Recurrent inguinal hernia: Follow-up study of 100 postoperative patients. Am J Surg 1975;129:564-9.  Back to cited text no. 11
Berliner S, Burson L, Katz P, Wise L. An anterior transversalis fascia repair for adult inguinal hernias. Am J Surg 1978;135:633-6.  Back to cited text no. 12
Fasih T, Mahapatra TK, Waddington RT. Early results of inguinal hernia repair by the 'mesh plug' technique-first 200 cases. Ann R Coll Surg Engl 2000;82:396-400.  Back to cited text no. 13
Lau H, Lee F. Lessons learned from ligation of indirect hernia sac: An alternative to reduction during endoscopic extraperitoneal inguinal hernioplasty. J Laparoendosc Adv Surg Tech A 2002;12:419-23.  Back to cited text no. 14
Vrijland WW, van Den Tol MP, Luijendijk RW, Hop WC, Busschbach JJ, de Lange DC, et al. Randomized clinical trial of non-mesh versus mesh repair of primary inguinal hernia. Br J Surg 2002;89:293-7.  Back to cited text no. 15
Sundeep VK. A Randomised Control Study of Sutureless Herniotomy/High Division of Patent Processus Vaginalis with Conventional Herniotomy/High Ligation of Patent Processus Vaginalis for Congenital Hernia/Hydrocoele in Children at Vims, Bellary. Karnataka, Bangalore: Rajiv Gandhi University of Health Sciences; 2012.  Back to cited text no. 16
Harvey MH, Johnstone MJ, Fossard DP. Inguinal herniotomy in children: A five year survey. Br J Surg 1985;72:485-7.  Back to cited text no. 17
Clausen EG, Jake RJ, Binkley FM. Contralateral inguinal exploration of unilateral hernia in infants and children. Surgery 1958;44:735-40.  Back to cited text no. 18
Goldstein IR, Potts WJ. Inguinal hernia in female infants and children. Ann Surg 1958;148:819-22.  Back to cited text no. 19
Minton JP, Clatworthy HW Jr. Incidence of patency of the processus vaginalis. A study based on six hundred bilateral operations for inguinal hernia. Ohio Med 1961;57:530-2.  Back to cited text no. 20
Moscarella AA, Stanley-Brown EG. Inguinal hernia in infants and children. Am J Surg 1962;103:453-6.  Back to cited text no. 21
Splinter WM, Reid CW, Roberts DJ, Bass J. Reducing pain after inguinal hernia repair in children: Caudal anesthesia versus ketorolac tromethamine. Anesthesiology 1997;87:542-6.  Back to cited text no. 22
Bower S, Moore BB, Weiss SM. Neuralgia after inguinal hernia repair. Am Surg 1996;62:664-7.  Back to cited text no. 23