Variability of inguinal hernia surgical technique: A survey of North American pediatric surgeons

The tradition of learning from mentors is a unique aspect of surgical training. With this in mind, the authors sought to document our roots by analyzing the technical variability of how pediatric surgeons perform their most frequent operation, the inguinal hernia, and compare these data with the original description by Drs William Ladd and Robert Gross.

A survey compiling the operative steps of an inguinal hernia repair as well as several key clinical situations involving hernias was mailed to pediatric surgeons in North America. These results then were compared with the original inguinal hernia technique by Drs Ladd and Gross. Results are recorded as the percent who concurred with their original description.

A total of 447 of 640 (70%) surveys were returned. Geneologic data show that 81% of surgeons' hernia lineage could be traced to Drs Ladd and Gross. When compared with all respondents, Drs Ladd and Gross' hernia repair steps included incising Scarpa's fascia (61%), defining the external ring by pushing down with retractors (34%), incising the external oblique with scissors (18%), identifying the ileoinguinal nerve (81%), cleaning one underside of the external oblique (22%), bluntly spreading the cremasteric fibers (90%), elevating the sac with sharp dissection of the vessels (53%), opening the sac and inserting the forefinger into it (0%), bluntly dissecting the sac with forefinger and gauze (0%), ligating the sac with single ligature (22%) without twisting it (34%), leaving the distal sac untouched other than to drain fluid (78%), not inspecting the testicle (79%), performing a formal floor repair bringing external and internal oblique down to Poupart's ligament (10%), tightening the internal ring in both boys and girls (19% and 41%), using no local anesthetic (14%), closing Scarpa's fascia (94%), closing the skin with interrupted subcuticular sutures (49%), covering the incision with Collodion (48%), using the Stiles' dressing (0%), and only exploring the contralateral side if a hernia is suggested by history or physical examination (87% for boys, 60% for girls). The various other options surgeons use for their technique and their management decisions also are described.

There is significant variability in the way pediatric surgeons perform inguinal herniorraphy. The differences from Drs Ladd and Gross' original description likely result from evolving techniques, experiences, and analysis of outcomes.