Do Infants and Children have Measurable Inguinal Canals?

Abstract

Introduction: Herniotomy is a common procedure performed by Paediatric Surgeons. However, opinions differ as to whether to open the inguinal canal when performing this procedure or not. Those who advocate performing herniotomy without opening the inguinal canal believe that in early childhood, the superficial inguinal ring is directly superimposed on the deep inguinal ring, there being no appreciable inguinal canal in this age group. Our study was planned to open the inguinal canal and simply measure the distance between the pubic tubercle medially and the inferior epigastric vessels laterally. Finding a measurable inguinal canal in all cases studies debunks the belief that the superficial inguinal ring frequently overlaps the deep inguinal ring. the inguinal canals of 75 children from 1 day to 2 years old were measured during herniotomies and orchidopexies. Premature babies were excluded from this study. The inguinal canals were all opened. Using a simple sterilized metallic ruler, the distance between the ipsilateral inferior epigastric vessels and the ipsilateral pubic tubercle was measured. Results: The lengths of the inguinal canals ranged from 1cm to 4.5 cm (mean 2.88cm+/-.71cm SD). The shortest inguinal canal length was 1 cm while the longest inguinal canal was 4.5 cm. Conclusion: Children with inguinal hernia up to the age of 2 years have a measurable inguinal canal and we suggest the excision of the hearnial sac superficial to the external inguinal ring runs the risk of leaving substantial sac behind proximal to the transfixing suture, even when some traction is applied to the sac before applying the transfixing suture.

Age‐related changes in inguinal region anatomy from 0 to 19 years of age

“…The inguinal region is one of the most commonly accessed by pediatric surgeons and urologists to treat conditions such as indirect inguinal hernia, congenital hydrocele, and cryptorchidism (Singal and Shukla ; Osuoji and Bankole ; Taghavi et al ). The incidence of these congenital abnormalities is particularly high in babies who are premature, therefore this group is more likely to require surgery (Davenport ; Singal and Shukla ; Williamson et al ).…”

“…Difference in surgical approach within the inguinoscrotal region may be based on several factors including individual surgeon preference (Ravi and Hamer ; Osuoji and Bankole ) or commonly held beliefs about anatomical differences in children of different age groups. For example, two different approaches are used for inguinal herniotomy depending on age; Mitchell‐Bank, for subjects from 0 to 2 years of age, is performed via the superficial inguinal ring and avoids cutting external oblique or the superficial inguinal ring; Ladd and Gross, for subjects from 2 to 10 years of age, incises the external oblique and dissects the inguinal hernial sac to reveal its contents (Ravi and Hamer ; Singal and Shukla ).…”

“…Indeed, there is a belief that there is no measurable inguinal canal to dissect in the younger age group (Hale et al ; Standring ). Intraoperative observational studies have, however, pointed toward the consistent presence of an inguinal canal within all age groups, even the very young (Parnis et al ; Ravi and Hamer ; Osuoji and Bankole ) and as such the Ladd and Gross technique might therefore be a viable approach to most pediatric inguinal canals. This is advantageous to both the patient and institution because the approach is associated with a reduced risk of hernia recurrence (Osuoji and Bankole ).…”

“…The adult inguinal canal is an oblique inferomedially oriented passageway through the inferomedial part of the anterior abdominal wall through which a range of structure pass; including the spermatic cord in males and the round ligament of the uterus in females (Standring ). It is accessed by the deep (located internally) and superficial (located externally) inguinal rings and has a length of 3–6 cm in the adult (Osuoji and Bankole ; Standring ; Taghavi et al ). The deep inguinal ring in adults is commonly located in the region between the midpoint of the inguinal ligament and a point midway between the anterior superior iliac spine and the pubic symphysis (midinguinal point) (Campbell ; Andrews et al ; Parnis et al ; Koliyadan et al ; Hale et al ; Tunstall and Shah ).…”

“…Despite this, inadvertent femoral artery puncture with subsequent hematoma still occurs suggesting an improved knowledge of its position is required (Grier and Hartnell ; Irani et al ). In adults, the femoral artery most commonly sits at the mid‐inguinal point ±1.5 cm (Hunt and Harris ; Hale et al ; Tunstall and Shah ; Osuoji and Bankole ), whereas in neonates and children, the age‐dependent position of the femoral artery is less clear.…”