Skip to main content
SpringerLink
Log in

Hernia sac of indirect inguinal hernia: invagination, excision, or ligation?

  • Original Article
  • Published:
Hernia Aims and scope Submit manuscript

Abstract

This study compares the effect of invaginating excision of hernia sac without ligation with the traditional method of high ligation of the hernia sac on postoperative pain and recurrence.

Patients and methods

This multicenter prospective randomized study included 152 patients with 167 primary indirect inguinal hernias. In group I (54 hernias), the sac was not opened and was inverted with the finger into the peritoneal cavity. In group E (56 hernias), the sac was excised at the neck without ligation. In group L (57 hernias), the sac was transfixed at the neck and excised in the traditional manner. The repair of the posterior wall of the inguinal canal was done according to Lichtenstein tension-free technique. Mean length of follow-up was 81.50 ± 22.34, 79.35 ± 26.76, and 77.83 ± 21.26 months, respectively.

Results

Postoperative seroma occurred in 1 patient (0.60 %) in group E and 1 patient (0.60 %) in group L. Surgical site infection occurred in 2 patients (1.20 %) in group I, 1 patient (0.60 %) in group E, and 2 patients (1.20 %) in group L. Mean postoperative pain score was 3.04 ± 2.11, 3.98 ± 2.33 and 4.06 ± 2.43, respectively (p: 0.049). Chronic pain occurred in 3 patients in group I (1.80 %), 3 patients in group E (1.80 %), and 5 patients in group L (3.00 %) (p: 0.749). The difference between the complications in three groups was statistically insignificant (p: 0.887). Hernia recurrence occurred in 3 patients (1.80 %) in group I, 1 patient (0.60 %) in group E, and 1 patient (0.60 %) in group L (p: 0.429).

Conclusion

Invagination and excision of the hernia sac do not have adverse effects on repair integrity. They limit the dissection and reduce the morbidity and risk of injury to the spermatic cord and surrounded structures. They are safer and more appropriate for repair of sliding hernia. Ligation of the hernia sac in inguinal hernia surgery is not only unnecessary and time consuming but also leads to increased postoperative pain. Recurrence rates are statistically unaffected by not ligating the sac.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Bassini E (1890) Ueber die Behandlung des Leistenbruches. Archiv fur Klinische Chirurgie 40:429–476

    Google Scholar 

  2. Delikoukos S, Lavant L, Hlias G, Palogos K, Gikas D (2007) The role of hernia sac ligation in postoperative pain in patients with elective tension-free indirect inguinal hernia repair: a prospective randomized study. Hernia 11(5):425–428

    Article  PubMed  CAS  Google Scholar 

  3. Gharaibeh KI, Matani YY (2000) To ligate or not to ligate the hernial sac in adults? Saudi Med J 21(11):1068–1070

    PubMed  CAS  Google Scholar 

  4. Shafik A (1980) Invagination of the hernial sac stump. technique for repair of inguinal hernia. Am J Surg 140(3):431–436

    Article  PubMed  CAS  Google Scholar 

  5. Smedberg SG, Broomé AE, Gullmo A (1984) Ligation of the hernial sac? Surg Clin North Am 64(2):299–306

    PubMed  CAS  Google Scholar 

  6. Yung S, Davies M (1998) Response of the human peritoneal mesothelial cell to injury: an in vitro model of peritoneal wound healing. Kidney Int 54(6):2160–2169

    Article  PubMed  CAS  Google Scholar 

  7. Ellis H, Heddle R (1977) Does the peritoneum need to be closed at laparotomy ? Br J Surg 64(10):733–736

    Article  PubMed  CAS  Google Scholar 

  8. Lichtenstein IL, Shulman AG, Amid PK, Montllor MM (1989) The tension free hernioplasty. Am J Surg 157(2):188–193

    Article  PubMed  CAS  Google Scholar 

  9. Rutkow IM, Robbin AW (1993) Tension-free inguinal herniorrhaphy: a preliminary report on the “mesh plug” technique. Surgery 114(1):3–8

    PubMed  CAS  Google Scholar 

  10. International Association for the Study of Pain, Subcommittee on Taxonomy (1986) Classification of chronic pain. descriptions of chronic pain syndromes and definitions of pain terms. Pain Suppl 3:S1–S226

    Google Scholar 

  11. Macrae WA, Davies HTO (1999) Chronic postsurgical pain. In: Crombie IK, Linton S, Croft P, Von Korff M, LeResche L (eds) Epidemiology of pain. IASP Press, Seattle, pp 125–142

    Google Scholar 

  12. Schug S. Pogatzki-Zahn E (2011) Chronic Pain after Surgery or Injury. International Association for the Study of Pain (IASP) Pain Clinical Updates XIX(1):1–6

  13. Abrahamson J (1998) Etiology and pathophysiology of primary and recurrent groin hernia formation. Surg Clin North Am 78(6):953–972

    Article  PubMed  CAS  Google Scholar 

  14. Postlethwait RW (1985) Recurrent inguinal hernia. Ann Surg 202(6):777–779

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  15. Pietri P, Gabrielli F (1986) Recurrent inguinal hernia. Int Surg 71(3):164–168

    PubMed  CAS  Google Scholar 

  16. Griffith CA (1984) The Marcy repair revisited. Surg Clin North Am 64(2):215–227

    PubMed  CAS  Google Scholar 

  17. Weinstein M, Roberts M (1975) Recurrent inguinal hernia. follow-up study of 100 postoperative patients. Am J Surg 129(5):564–569

    Article  PubMed  CAS  Google Scholar 

  18. Callesen T, Bech K, Andersen J, Nielsen R, Roikjaer O, Kehlet H (1999) Pain after primary inguinal herniorraphy: influence of surgical technique. J Am Coll Surg 188:355–359

    Article  PubMed  CAS  Google Scholar 

  19. Panos RG, Beck DE, Maresh JE, Harford FJ (1992) Preliminary results of a prospective randomized study of Cooper’s ligament versus Shouldice herniorrhaphy technique. Surg Gynecol Obstet 175(4):315–319

    PubMed  CAS  Google Scholar 

  20. Amid PK, Shulman AG, Lichtenstein IL (1996) Open ‘tension-free’ repair of inguinal hernias: the Lichtenstein technique. Eur J Surg 162(6):447–453

    PubMed  CAS  Google Scholar 

  21. Lichtenstein IL, Shulman AG, Amid PK (1991) Twenty questions about hernioplasty. Am Surg 57(11):730–733

    PubMed  CAS  Google Scholar 

  22. Shulman AG, Amid PK, Lichtenstein IL (1993) Ligation of hernial sac. a needless step in adult hernioplasty. Int Surg 78(2):152–153

    PubMed  CAS  Google Scholar 

  23. Lichtenstein IL (1987) Herniorrhaphy. a personal experience with 6,321 cases. Am J Surg 153(6):553–559

    Article  PubMed  CAS  Google Scholar 

  24. Abrahamson J (1990) Hernias. In: Schwarts SI, Ellis H (eds) Maginot’s abdominal operations, 9th edn. Prentice-Hall International, Conneticut, pp 215–296

    Google Scholar 

  25. Wantz GE (1999) Abdominal wall hernias. In: Schwartz SI, Shires GT, Spencer FC, Daly GM, Fischer JE, Galloway AC (eds) Priciples of surgery, vol 2, 17th edn. McGraw-Hil, USA, pp 1585–1611

    Google Scholar 

  26. Haapaniemi S, Nilsson E (2002) Recurrence and pain three years after groin hernia repair. validation of postal questionnaire and selective physical examination as a method of follow-up. Eur J Surg 168(1):22–28

    Article  PubMed  Google Scholar 

  27. Bendavid R (2001) The Shouldice repair. In: Bendavid R, Arregui M, Flament JB, Phillips EH (eds) Abdominal Wall Hernias: principles and management. Springer, New York, pp 370–375

    Chapter  Google Scholar 

  28. Gilbert AI, Graham MF (1997) Sutureless technique: second version. Can J Surg 40(3):209–212

    PubMed  CAS  PubMed Central  Google Scholar 

  29. McCormack K, Wake BL, Fraser C, Vale L, Perez J, Grant A (2005) Transabdominal pre-peritoneal [TAPP] versus totally extraperitoneal [TEP] laparoscopic techniques for inguinal hernia repair: a systematic review. Hernia 9(2):109–114

    Article  PubMed  CAS  Google Scholar 

Download references

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Department of General Surgery, Tanta University, Tanta, Egypt

    I. Othman & H. A. Hady

  2. Ghodran General Hospital, P O Box 14, Baljrashi, 22888, KSA

    I. Othman

Authors
  1. I. Othman
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. H. A. Hady
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to I. Othman.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Othman, I., Hady, H.A. Hernia sac of indirect inguinal hernia: invagination, excision, or ligation?. Hernia 18, 199–204 (2014). https://doi.org/10.1007/s10029-013-1081-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10029-013-1081-z

Keywords

Search

Navigation