الفهرس 
EMBRYOLOGY OF THE INGUINAL CANALOnly 14 pages are availabe for public view
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Abstract
A
randomly chosen group of 110 children and infants(96 boys and 14 girls), varying in age from 1 month to 11 years, with clinically diagnosed unilateral inguinal hernia were studied to detect the presence of a PPV on the contralateral side, during the period from September 2017 to August 2018, in Ahmed Maher Teaching Hospital, Cairo, Egypt.
US examination was done for all patients on both the symptomatic, and the asymptomatic sides. US examination of the symptomatic sides revealed the presence of hernia sac in all the groins and were proved surgically.
Sonographic examination of the asymptomatic contralateral sides showed positive findings in 39 patients (35.5%). The incidence of positive ultrasonic findings on the contralateral sides was 46.3% in infants below one year (group I) and it was 35.3% in children from 1 to 5 years (group II), while it was 22.9% in children more than 5 years (group III). In boys the incidence of positive ultrasonic findings was 34.4%, and in girls the incidence was 42.9%.
US examination proved non-significant difference of positive findings on the contralateral side in patients presented with right sided hernias and those with left sided hernias (33.9% versus 37.2%).
Upon surgical exploration, all the symptomatic sides proved to have a hernia sac. So the accuracy of ultrasound was 100% in this group.
Surgical exploration of the contralateral side was done for 39 patients with positive ultrasonic findings, and a sac of more than 2.0 cm in length was found in 36 of them on the contralateral side (92.3%). The remaining three patients proved to have negative operative results on the contralateral side, where no sac could be detected in two of them, and peritoneal protrusion less than 1 cm was found in the third patient and was regarded as negative operative finding.
The patients whose US results were negative on the contralateral side were followed up for a period ranged from 6 months to one year, and two boys, who were examined early in the study, returned back with a metachronous contralateral hernia.
Ultrasonic examination correctly diagnosed the presence of a PPV in 105 out of 110 asymptomatic contralateral groins in patient presenting with unilateral inguinal hernias, with accuracy of 95.5% and the procedure was both sensitive and specific in detecting or excluding an occult hernia.
US is widely available in nearly all medical centers, and proved to be a rapid, reliable, convenient, highly accurate, non-invasive, and safe screening technique for the diagnosis of the apparent and inapparent inguinal hernia in infants and children.
The results of this work coincides with those done previously by others, that a unilateral hernia has a high incidence of PPV on the opposite side not less than 30% in most series. Though it is not known whether all these patent structures will later develop a clinical hernia, however, a significant number will do, and should be taken into consideration during the management of unilateral inguinal hernia in infants and children.
CONCLUSION
I
f routine bilateral exploration is performed on all infants and children who exhibit evidence of unilateral inguinal hernia, CPPV will be found in a significant number of patients with an incidence of at least 30% of cases. Though it is not known whether all these patent structures will later develop a clinical hernia or not, however, a significant number will do, and should be taken into consideration.
The policy of routine bilateral exploration in cases of unilateral inguinal hernia is not recommended for:
The performance of many operations which otherwise would be unnecessary.
The possibility of damage to the cord structures which may pass unnoticed by the surgeon.
The policy of unilateral inguinal hernia repair without contralateral exploration is not justified, as nearly 20% of patients will return later on for repair of a hernia on the opposite side with a second hospitalization, administration of anesthesia, and a second operation. Also the emotional trauma to the child is greater when he has to return for another operation.
This controversy about therapy seems partially supported by the lack of a reliable, non-invasive test for the presence of a clinically inapparent inguinal hernia.
Several techniques have been used to diagnose occult contralateral hernias, but all have drawbacks, and none have been widely accepted. Preoperative herniography as well as intraoperative techniques such as probing, pneumoperitoneum, and laparoscopic examination of the internal inguinal ring aim to help eliminating the unnecessary inguinal explorations and decrease the return rate of patients for a contralateral hernia repair.
US examination of the inguinal region proved to be very safe, rapid, reliable, convenient, non-invasive, and easily performed screening technique for inguinal hernia in infants and children which not only detects the inapparent hernia or PPV, but also may give more information about the content of the hernia before surgery. In addition, it is so widely available and applicable to all cases.
Our data suggest that US can, with high accuracy (95.5%), guide surgeons to those inguinal canals that require prophylactic herniotomy while steering them away from those that do not.
We recommend the use of ultrasound so as to minimize unnecessary inguinal explorations, and to decrease the unnecessary returning of patients for a contralateral hernia repair. We suggest routine bilateral herniotomy in infants and children no longer be justifiable.