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Button-Hole Inguinal Hernia Repair- A Single Surgeon’s 13 Years Experience

Katherine M Burnand, Alok Godse, Azad B Mathur

Department of Pediatric Surgery, Norfolk and Norwich University Hospital, Norwich, UK



Katherine Burnand

22 Brailsford Road, SW22TD

London, United Kingdom

Phone: +447792127570

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.


Purpose: Button-hole herniotomy (BHH) is a novel approach to repair paediatric inguinal hernias which involves only a very small incision in the external oblique muscle. We reviewed our 13 year experience of BHH.

Patients and Methods: Children who underwent BHH repair at our unit between 1996 and 2009 were included in the study. Hospital notes were reviewed retrospectively and presenting symptoms, hernioscopy, simultaneous procedures including repair of contralateral side, duration of operation, postoperative complications and follow up were recorded.

Results: One hundred seventy-six patients (46 girls, 130 boys) had a BHH; the mean age at operation was 5.72 (range 1.01–15.18) years. There were 63% right, 31% left, and 5% bilateral. Hernioscopy was performed in 47 patients. A patent contralateral internal ring was seen in 6 patients (13.0%). Mean follow up was 3.5 (range 1-12) months. There were 2 recurrences (1.1%) and the contralateral side had to be repaired in 3 patients who had not had hernioscopy (1.7%).

Conclusion: BHH repair is safe and effective in children. The technique enables drainage of hydrocele and hernioscopy at the same time. The complication rate, including recurrence, is comparable to other open and laparoscopic techniques.

Keywords: button-hole herniotomy, hernioscopy, recurrence



Inguinal hernia repair is the most common paediatric surgical operation. The overall incidence of inguinal hernia is 0.8%-4.4% in children aged from birth to 18 years [1]. Almost all groin hernias in children are indirect inguinal hernias. The operation is a high ligation of the hernia sac either open or laparoscopic. The contralateral side can be explored with a laparoscope.

Button- hole herniotomy (BHH) is a novel approach of repairing paediatric inguinal hernias which only involves a very small incision in the external oblique muscle. A similar ‘key-hole’ technique has previously been used for simple appendectomies [2]. Hernioscopy, a technique which allows the contralateral inguinal ring to be visualised with a 70 degree laparoscope can be performed simultaneously in selected cases. Given the low complication rate of hernia repair, any new approach to surgical management must meet or exceed a high standard. In this study we review a single consultant’s thirteen year experience with BHH including intraoperative data and postoperative follow up and complications.

Patients and Methods

Two hundred and ninety five inguinal hernias were repaired consecutively between January 1996 and March 2009 by a single consultant (AM). BHH is contraindicated in patients less than 1 year of age, obesity, recurrent hernias, previous abdominal surgery, abdominal wall defects or ipsilateral undescended testis. One hundred and seventy six patients had a BHH. Hospital notes for the 176 patients were reviewed retrospectively and presenting symptoms, hernioscopy, simultaneous procedures including repair of the contralateral side, duration of operation, postoperative complications and follow up were recorded.

Surgical Technique

Landmarks for the skin incision are the anterior superior iliac spine and the inferior epigastric artery pulsation over the deep inguinal ring (Fig. 1). The incision is placed in a skin crease over the pulsation and is approximately 1.5 cm long. Superficial fascia is divided until external oblique is encountered. The external oblique aponevrosis is opened, thus exposing the inguinal canal. The cremaster muscle fibres are split and the spermatic cord grasped. Blunt dissection enables the cord to be separated from surrounding structures so it is gradually drawn up and out of the incision. When the entire circumference of the spermatic cord has been isolated, an artery forceps is placed underneath the cord.

Figure 1: Landmarks for button - hole herniotomy incision a) theoretical, b) on a child

fig 3-1 fig 3-2

The hernia sac is gently dissected from the vas and vessels (Fig. 2). An artery forceps is placed on either edge of the hernia sac and the sac is opened. Blunt dissection is used to free the hernia sac from other cord structures so that high ligation of the proximal sac can be achieved. The sac is twisted and the spoon applied to protect the cord structures. The proximal hernia sac is transfixed and ligated twice using 3/0 Vicryl (Ethicon, UK) (Fig. 3). The redundant hernia sac is excised and the stump allowed to retract back. The defect in the external oblique and Scarpa’s fascia are closed using separate single 3/0 Vicryl (Ethicon, UK). The skin is closed using a single sub-cuticular absorbable 5/0 Monocryl (Ethicon, UK) leaving a very small cosmetical scar (Fig. 4).

fig 3-3 fig 3-4

Figure 2 - Blunt dissection of the sac away from vas and vessels

Figure 3 - The proximal sac is transfixed and ligated twice while the cord structures are protected with a silver spoon.

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Figure 4 - Small scar from button- hole herniotomy measuring 1.5 cm 

Figure 5 - Proximal sac opened to allow hernioscopy to be performed

Hernioscopy can be performed before ligation of the proximal sac to evaluate the contralateral deep inguinal ring (Fig. 5.). A 5mm laparoscopy port is inserted into the peritoneal cavity via the opening of the hernia sac. A sling is passed around the sac and port to ensure an airtight seal. A pneumo-peritoneum is established. A 9F or 11F 70 or 30 degree laparoscope (Karl Storz, UK) is passed to visualise the contralateral deep inguinal ring. The vas is demonstrated by applying gentle traction to the ipsilateral testis. The vas can be followed to the ipsilateral deep inguinal ring where it meets the ipsilateral testicular vessels. Then the contralateral inguinal ring can be assessed for its patency (Fig. 6). An open deep ring, positive Goldstein test [3] i.e. presence of crepitance in the scrotum or fluid/gas bubbles appearing at the deep ring following groin palpation are considered positive indicators for a contralateral patent processus vaginalis (CPPV) and potential hernia. Contralateral groin exploration is subsequently performed. Following hernioscopy the sling and port can be removed.

Figure 6 - a) Closed and b) Open contralateral internal ring

fig 3-7.png fig 3-8


Data in these 176 patients who underwent a BHH was collected retrospectively. The mean age at operation was 5.72 (range 1.01-15.18) years. There were 130 boys and 46 girls. One hundred and eleven (83 male, 28 female) patients had a clinically evident hernia on the right, 56 (46 male, 10 female) on the left and 9 (1 male, 8 females) with a bilateral hernia. Emergency repair was done in three patients (1.7%) and hydroceles were found in three patients (1.7%).

At operation, hernioscopy was done on 47 patients (24 male, 23 female). The mean age was 5.55 (1.01-13.44) years. A patent contralateral internal ring was seen in 6 patients (13.0%); all had their contralateral side repaired at the same time. Nine patients had another procedure at the time of surgery: two epigastric hernia repairs, one umbilical hernia repair, two circumcisions, a meatal dilatation, an excision of a sinus at the base of the penis (embryological), an excision of a penile cyst and a division of preputial adhesions. Mean operating time was 32 minutes for unilateral, 36 minutes for unilateral plus hernioscopy and 57 minutes for bilateral inguinal hernia. Follow up was not arranged for 6 patients and 22 patients did not attend follow up.

Mean follow up was 3.5 (range 1-12) months. There were 2 uncomplicated recurrences (1.1%) presenting at 5 months and 8 months after initial BHH. The patients had their recurrences repaired open and laparoscopically respectively. There was a metachronous contralateral inguinal hernia in 3 patients who had not had hernioscopy (2.3%). There was no metachronous hernia in any of the 41 patients who had a hernioscopy but had a closed contralateral internal ring. Superficial wound dehiscence occurred in 1 patient (0.6%). No testicular atrophy or scrotal haematoma were observed during follow up.


A variety of open and laparoscopic surgical techniques are used to repair paediatric inguinal hernias. Each technique has its drawbacks and may be better suited for a specific age group and clinical situation. Open techniques include trans-inguinal approach, excising the hernia sac through the superficial inguinal ring, pre-peritoneal approach and trans-peritoneal closure of the deep ring. BHH is an adaption of the trans-inguinal approach. Ligation of the hernia sac is done through a small nick in the external oblique at the deep ring without opening the superficial ring. Laparoscopic repair is also now commonly performed since 2005 and offers the surgeon the ability to easily examine the contralateral groin to repair any hernia found [4]. However they were initially associated with high recurrence rates [5] and the small groin incision of the BHH technique is more easily hidden by clothing than the port sites required in the mid abdomen.

The male-to-female ratio of 4:1 noted in this study agrees with that quoted in the literature of 3:1 to 10:1, as does the higher incidence of right sided hernia [6-8]. In this study, surgical complications were limited to two recurrences (1.1%) and one superficial wound infection (0.6%) which compares favourably to that reported in other series [6, 9 ,10]. The cause of the two recurrences was unknown but could be due to the sac being completed missed, incompletely repaired, or not being repaired high enough.

There is still much controversy over contralateral groin exploration since high incidence of CPPV was first reported [11, 12]. Opponents argue that the presence of a CPPV is not equivalent to a hernia. We do not regularly perform hernioscopy presently but this study is over 13 years and our practice has reflected various trends in hernioscopy. Studies have shown hernioscopy to be safe, cost effective and beneficial even in the older age groups [13-15]. Hernioscopy also has benefits in girls because it enables visualisation of female internal genitalia. In this study 47 patients had hernioscopy, almost half were females. The incidence of metachronous contralateral hernia is thought to be from 3.6% to 10% much lower than the occurrence of CPPV [16-19]. In our study the incidence of CPPV with hernioscopy was 13.0% and the incidence of metachronous hernia was 1.7% of all patients and 2.3% of patients who had not had contralateral hernioscopy.

The study is retrospective and has relied on hospital notes of the patients for follow-up. A prospective or randomised study is preferred. In this instance the mean follow up is three and a half months. We appreciate that a longer follow-up period may have detected some children with testicular atrophy. It is also possible that more children had metachronous hernias or recurrences but a presented to a different paediatric centre or hospital though it is very likely that this would be brought to our attention. The review of the BHH technique is only looking at one consultant surgeon and therefore the success of the technique may be operator dependent.


Button- hole herniotomy repair is safe and effective in children. The technique enables drainage of hydrocele and hernioscopy at the same time. The results of our study indicate that button- hole herniotomy complication rate including recurrence is comparable to other open and laparoscopic techniques. We also believe that the approach may offer a less traumatic and better cosmetic result.




1. Bronsther B, Abrams M, Elboim. Inguinal hernias in children – a study of 1,000 cases and a review of the literature. J Am Med Womens Assoc 1972;27:522-5

2. Shah RC. Key hole open appendicectomy. J Indian Med Assoc 2004;102:565-7.

3. Powell RW. Intraoperative diagnostic pneumoperitoneum in pediatric patients with unilateral inguinal hernias: the Goldstein test. J Pediatric Surg. 1985;20:418-421.

4. Niyogi A, Tahim AS, Sherwood WJ, Caluwe D et al.. A comparative study examining open inguinal herniotomy with and without hernioscopy to laparoscopic inguinal hernia repair in a pediatrc population. Pediatr Surg Int 2010; 26:387-392.

5. Schier F, Montupet P, Esposito C. Laparoscopic inguinal herniorrhaphy in children: a three-center experience with 933 repairs. J Pediatric Surg 2002 37:395-397.

6. Ein SH, Njere I, Ein A. Six thousand three hundred sixty-one pediatric inguinal hernias: a 35-year review. J Pediatric Surg 2006; 41:980-986.

7. Kapur P, Caty M, Glick P. Pediatric hernias and hydroceles. Pediatric Clin North Am 1998; 45:773-89

8. Weber TR, Tracy Jr TF. Groin hernias and hydroceles. In: Ashcraft KW, editor. Pediatric Surgery. 5th ed. St Louis, Mosby, 1998; 69:1071-86.

9. Audry G, Johanet S, Achrafi H et al. The risk of wound infection after inguinal incision in pediatric outpatient surgery. Eur J Pediatric Surg 1994; 4:87-89.

10. GrosfeldJL, Minnick , Shedd F. Inguinal hernia in children: factors affecting recurrence in 62 cases. J Pediatric Surg 1991; 26:283-287.

11. Rothernerg RE, Barnett T. Bilateral herniotomy in infants and children. Surg 1955; 37:947-950.

12. Gilbert M, Clatworthy HW. Bilateral operations for inguinal hernia and hydrocele in infancy and childhood. Am J Surg 1959; 97:255-259.

13. Bhatia AM, Gow W, Heiss KF, Barr G, Wulkan ML. Is the use of laparoscopy to determine presence of contralateral patent processus vaginalis justified in children greater than 2 years of age. J Paediatric Surg. 2004; 39:778-781.

14. Lee AL, Sydorak RM, Lau ST. Laparoscopic contralateral groin exploration: is it cost effective? J Pedaitric Surg 2010; 45:793-795.

15. Wulkan ML, Wiener ES, VanBalen N, Vescio P. Laparoscopy through the open ipsilateral sac to evaluate presence of contralateral hernia. J Pediatric Surg 1996; 31:1174-1777.

16. Given JP, Rubin SZ: Occurrence of contralateral inguinal hernia following unilateral repair in a pediatric hospital. J Pediatric Surg 1989; 24: 963-965.

17. Ulman I, Demircan M, Arikan A, et al: Unilateral inguinal hernia in girls: Is routine contralateral exploration justified? J Pediatri Surg 1995; 30:1684-1686.

18. Miltenburg DM, Nuchtern JG, Jaksic T et al. Meta-analysis of the risk of metachronous hernia in infants and children. Am J Surg 1997; 174:741-744.

19. Nassiri SJ. Contralateral exploration is not mandatory in unilateral inguinal hernia in children. A prospective 6-year study. Pediatric Surg Int 2002; 18:470-471.