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Inguinal herniotomy with the Mitchell-Banks'

technique is safe in older children.
DATASET OCTOBER 2014

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Journal of Pediatric Surgery 49 (2014) 11591160

Contents lists available at ScienceDirect

Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Inguinal herniotomy with the MitchellBanks technique is safe in

older children
Erdal Trk a,, Mehmet Erdal Memetoglu b, Yesim Edirne b, Fahri Karaca b, Cezmi Saday c, Ahmet Gven d
a

Department of Pediatric Surgery, Izmir University, Faculty of Medicine, Izmir, Turkey

Denizli State Hospital, Clinics of Pediatric Surgery, 20100, Denizli, Turkey
Aydin State Hospital, Clinics of Pediatric Surgery, 09000, Aydin, Turkey
d
Department of Pediatric Surgery, Gulhane Military Medical Faculty, Etlik, 06018, Ankara, Turkey
b
c

a r t i c l e

i n f o

Article history:
Received 1 July 2013
Received in revised form 18 September 2013
Accepted 18 September 2013
Key words:
Indirect inguinal hernia
Mitchell-Banks technique
High ligation
Complication

a b s t r a c t
Purpose: There is a tendency for the majority of surgeons to open the inguinal canal in children over two years
old when performing inguinal hernia repair. On the other hand, in small children, most surgeons perform the
herniotomy supercially to the external ring, as in Mitchell-Banks technique (MBT). Our aim was to compare
the Ferguson hernioplasty (FH) and Mitchell-Banks technique in terms of recurrence and complication rates
in older children.
Methods: We retrospectively reviewed the ofce medical records of children who were at least two years old
and who underwent a herniotomy procedure for inguinal hernia between 1997 and 2012.
Results: The 4520 inguinal herniotomy procedures in boys who were over two years old were included in
this study. Of these cases, 1607 cases (40.2%) were operated on by a FH with opening the inguinal canal, and
2388 cases (59.8%) by MBT supercially to the external ring. The median ages were 5.1 years (range, 2.0
16.2) in the FH group and 4.6 years (2.014.6) in the MBT group. The total complication rates were 2.3% in the
FH group and 2.9% in the MBT group (P N .05). Early complications such as wound infection, scrotal edema,
and hematoma were seen in 13 (0.8%), 15 (1%), and 10 (0.6%) in the FH group, and 12 (0.5%), 18 (0.7%), and 15
(0.6%) in the MBT group, respectively (P N .05). Late complications such as recurrence, trapped undescended
testis, and testicular atrophy were seen in 2 (0.12%), 1 (0.06%), and 2 (0.12%) in the FH group, and 3 (0.12%),
1 (0.04%), and 2 (0.08%) in the MBT group (P N .05).
Conclusion: The Mitchell-Banks technique is a simple and safe procedure in older boys.
2014 Elsevier Inc. All rights reserved.

Elective repair of an inguinal hernia, the most common surgery

performed by pediatric surgeons, is universally accepted as the
treatment of choice. The exact technique and steps involved in the
repair differ widely among pediatric surgeons [1]. After incising the
external oblique aponeurosis, many pediatric surgeons open the roof
of the inguinal canal while preserving the external ring or by including
the ring as described by Ferguson and Gross [1,2]. This repair known as
a modication Ferguson hernioplasty (FH). This technique allows
exposure of the internal inguinal ring to ensure high ligation of the sac
at that level. In the b 2 year-old, the inguinal canal is so short that the
external and internal rings virtually lie over each other, therefore all of
the surgery can be done distal to the unopened external ring this
technique described by MitchellBanks in 1882 [1,3,4].
The MitchellBanks technique (MBT) has been also used safely in
children aged up to 11 years to make use of its advantages and with a
recurrence rate similar to FH in previous studies [2,3], but the two
techniques have not been compared in terms of early and late results.
Corresponding author at: Yeni Girne Bulvar 1825 Sok., No:12 Karsiyaka, Izmir.
Tel.: +90 232 399 50 50; fax: +90 232 367 05 59.
E-mail address: eturk19@yahoo.de (E. Trk).
http://dx.doi.org/10.1016/j.jpedsurg.2013.09.065
0022-3468/ 2014 Elsevier Inc. All rights reserved.

The aim of this study was to retrospectively compare postoperative

early and late results in children aged 216 years who were operated
with MBT and FH for indirect inguinal hernia.

1. Material and methods

We retrospectively reviewed the ofce medical records of all boys
who were at least 2 years old and underwent inguinal herniotomy
procedure between January 1997 and June 2012. Hernia complicated
by irreducibility, strangulation or connective tissue disease were
excluded from this study. Based on the medical record, boys were
categorized in to two groups; the rst group underwent MBT and the
second group underwent FH.
Patients were followed up the rst day, rst week, and third and
sixth months after the procedure. The medical records were reviewed
for the following complications; scrotal edema, hematoma and wound
infection in the early period, and recurrence, iatrogenic undescended
testis, hydrocele and atrophic testis in the late period during the
follow-up. Testicular examination was later taught to the families and
they were told to return only if the child had a problem.

1160

E. Trk et al. / Journal of Pediatric Surgery 49 (2014) 11591160

Table 1
Demographic characteristics of the patients participating in the study.
Mean age

Right
Left
Bilateral
Total

Table 2
Early and late complications seen in both groups.

Group I (N2 y)
MitchellBanks

Group II (N2 y)
Ferguson hernioplasty

5.1 0.19 years

(2.016.2)

4.6 1.15 years

(2.014.6)

1,348
541
199
2,388

56.4
22.6
20.9
100

854
427
326
1,607

53.1
26.6
20.2
100

2. Results
A total of 4,520 inguinal herniotomy procedures (3,470 unilateral, 525 bilateral) performed in 3,995 boys aged two years or older
were included in the study. There were 1,607 cases (40.2%) operated
on by FH after opening the inguinal canal, and 2,388 cases (59.8%)
by MBT supercial to the external ring. The median age was
5.1 years (range, 2.016.2 years) in the FH group and 4.6 years
(range, 2.014.6) in the MBT group (Table 1). Early complications
were wound infection, scrotal edema and hematoma in 13 (0.8%), 15
(1%) and 10 (0.6%) cases in the FH group, and 12 (0.5%), 18 (0.7%)
and 15 (0.6%) cases in the MBT group, respectively (P N .05). Late
complications included recurrence, trapped undescended testis,
testicular atrophy and hydrocele in 2 (0.12%), 1 (0.06%), 2 (0.12%),
and 3 (0.18%) patients in the FH group, and 3 (0.12%), 1 (0.04%), 2
(0.08%), and 4 (0.16%) patients in the MBT group, respectively
(P N .05). The complication rate was 2.3% in the FH group and 2.9%
in the MBT group (P N .05) (Table 2). No mortality was seen in
either group.
3. Discussion
Inguinal hernia repair is the signature operation for pediatric
surgeons and has evolved into a myriad of forms, each being a unique
patchwork of a surgeons training, experience, and analysis of
outcomes over time [1]. Still, most pediatric surgeons prefer FH
when treating inguinal hernia. In MBT, the hernia sac is teased out
through the external ring and tied off, and the excess sac is cut away.
The inguinal canal is not repaired. The inguinal canal is different
in young children from adults and older children in several respects,
as it is shorter, obviously lies in a less oblique plane in a more
anterioposterior direction, and the tissues involved are more elastic
[1]. All these factors provide some freedom to the surgeon for moving
the spermatic cord and visualizing the inguinal canal.
The length of the inguinal canal is another important factor
affecting the success of this operation. The internal and external
rings are quite close to each other in children. Some studies indicate
a canal length of 4-23 mm in children in children aged 012 years,
reaching the adult length of 4050 mm during adolescence. [58].
Because the shorter inguinal canal in children and the exible fascia
enable the inner and outer rings to move closer to each other with
traction applied on the hernia sac toward the caudal axis, this allows
better visualization of the inner ring. Dilatation of the outer ring
opening with Metzenbaum scissors or by making an incision of a few
mm in the outer ring enables easier visualization of the neck of the

Complications

Short-Term
- Scrotal edema
- Wound infection
- Scrotal hematoma
Long-Term
- Recurrences
- Testicular atrophy
- Hydrocele
- Iatrogenic undescended testis
- Mortality
Total

Group I (N2 y)

Group II (N2 y)

18
12
15

0.7%
0.5%
0.6%

15
13
10

1%
0.8%
0.6%

3
2
4
1
55

0.12%
0.08%
0.16%
0.04%
2.3%

2
2
3
1
46

0.12%
0.12%
0.18%
0.06%
2.9%

sac from the inner ring level in cases with less exibility. It was
possible to perform high ligation with MBT in 59.7% of the children
included in our study, so we think that the length of the canal of
children up to the age of 16 is short enough to allow high ligation of
the hernia sac.
The complication rate in children after inguinal hernia repair is
usually 2% or less [9]. The most important factor in preventing complications is adequate surgical training and experience, and minimal
handling. The incidence of postoperative wound infection should
ideally be 1% or less. Scrotal swelling or hematoma is common
when there is a large inguino-scrotal sac. A non-communicating
postoperative hydrocele will usually resolve within a month after the
surgery. Testicular atrophy has been reported after 1% of routine
hernia repairs. Recurrent pediatric inguinal hernias are uncommon,
with most large series reporting recurrence rates of b1%. Iatrogenic
cryptorchidism may occur after repair of a large inguino-scrotal
hernia, or when the testis is caught up in scar tissue in the inguinal
canal. The complication rate in both groups of patients was found to
be consistent with the literature in our study.
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