Variability of Inguinal Hernia Surgical Technique: A Survey of
North American Pediatric Surgeons
By M.A. Levitt, D. Ferraraccio, M.C. Arbesman, G.F. Brisseau, M.G. Caty, and P.L. Glick
Buffalo, New York
Background/Purpose: The tradition of learningfrom 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.
Methods: A survey compilingthe operative steps of an in-
guinal hernia repair as well as several key clinical situations
involvinghernias 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.
Results: 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 incisingScarpa’s fascia (61%), definingthe
external ringby pushingdown with retractors (34%), incis-
ingthe external oblique with scissors (18%), identifyingthe
ileoinguinal nerve (81%), cleaning one underside of the
external oblique (22%), bluntly spreadingthe cremasteric
fibers (90%), elevatingthe sac with sharp dissection of
the vessels (53%), openingthe sac and insertingthe fore-
finger into it (0%), bluntly dissecting the sac with forefin-
ger and gauze (0%), ligating the sac with single ligature
(22%) without twistingit (34%), leavingthe distal sac
untouched other than to drain fluid (78%), not inspecting
the testicle (79%), performinga formal floor repair bring-
ingexternal and internal oblique down to Poupart’s liga-
ment (10%), tighteningthe internal ringin both boys and
girls (19% and 41%), using no local anesthetic (14%), clos-
ingScarpa’s fascia (94%), closingthe skin with inter-
rupted subcuticular sutures (49%), coveringthe incision
with Collodion (48%), usingthe Stiles’ dressing(0%), and
only exploringthe contralateral side if a hernia is sug-
gested 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.
Conclusions: There is significant variability in the way pedi-
atric surgeons perform inguinal herniorraphy. The differ-
ences from Drs Ladd and Gross’ original description likely
result from evolvingtechniques, experiences, and analysis of
outcomes.
J Pediatr Surg 37:745-751. Copyright 2002, Elsevier Science
(USA). All rights reserved.
INDEX WORDS: Inguinal hernia, Gross, Ladd, geneology,
surgical technique.
T
HE TRADITION of learning from mentors is a
unique aspect of surgical training and is our great-
est legacy. A surgeon’s approach to a clinical problem is
the summation of the experiences and education he or
she has had managing that particular problem or a similar
problem in the past.
Elective repair of an inguinal hernia, the most com-
mon operation performed by pediatric surgeons, is ac-
cepted universally as the treatment of choice for a
healthy full-term infant.
1-4
The exact technique and steps
involved with that repair differ widely among pediatric
surgeons. Where does this variability come from? We
hypothesized that it results from a combination of train-
ing (usually from one or more surgical mentors), a
cumulative experience, from clinical practice, and from
analysis of the literature. The result is an eclectic ap-
proach by each surgeon.
To attempt to document the influence training has had
on the pediatric surgical inguinal hernia technique, we
chose to survey a large number of pediatric surgeons in
practice. We then compared these data to Drs William
Ladd and Robert Gross’ original description.
MATERIALS AND METHODS
A survey compiling the operative steps of an inguinal hernia repair,
as well as several key clinical situations involving hernias, was mailed
to 640 pediatric surgeons in North America from the APSA member-
ship directory. These results were then compared with the original
From the Department of Pediatric Surgical Services, Children’s
Hospital of Buffalo, and the Department of Surgery, Division of
Pediatric Surgery, School of Medicine and Biomedical Sciences, The
State University of New York at Buffalo, Buffalo, NY.
Address reprint requests to Philip L. Glick, MD, FACS, FAAP,
FRCS(Eng), Surgeon-in-Chief, Children’s Hospital of Buffalo, Profes-
sor of Surgery, Pediatrics and OB/GYN, State University of New York
at Buffalo, 219 Bryant St, Buffalo, NY 14222.
Copyright 2002, Elsevier Science (USA). All rights reserved.
0022-3468/02/3705-0015$35.00/0
doi:10.1053/jpsu.2002.32269
745Journal of Pediatric Surgery, Vol 37, No 5 (May), 2002: pp 745-751