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 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.
Methods: A survey compiling the operative steps of an in-
guinal 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.
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 incising Scarpa’s fascia (61%), defining the
external ring by pushing down with retractors (34%), incis-
ing 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 fore-
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
Journal of Pediatric Surgery, Vol 37, No 5 (May), 2002: pp 745-751
finger into it (0%), bluntly dissecting the sac with forefin-
ger 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 bring-
ing external and internal oblique down to Poupart’s liga-
ment (10%), tightening the internal ring in both boys and
girls (19% and 41%), using no local anesthetic (14%), clos-
ing Scarpa’s fascia (94%), closing the skin with inter-
rupted subcuticular sutures (49%), covering the incision
with Collodion (48%), using the Stiles’ dressing (0%), and
only exploring the 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 evolving techniques, 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.
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
745
746 LEVITT ET AL

Table 1. Comparison of Drs Ladd and Gross’ Technique With Those of Our Survery Respondents

Percent of Respondents Who Use the Same

Drs Ladd and Gross’ Inguinal Hernia Steps Step in Their Hernia Repair Technique

Incising Scarpa’s fascia with scissors 65

Defining external oblique by pushing down with retractors 34
Incising external oblique with scissors 18
Identifying the ileoinguinal nerve 81
Cleaning one underside of the external oblique 22
Blunt spreading of the cremasteric fibers 90
Elevating the sac with sharp dissection of the vessels 53
Opening of the sac and inserting the forefinger into it 0
Bluntly dissecting the sac with gauze 0
Ligating the sac with a single ligature 22
Ligating the sac 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 (obliques to Poupart’s) 10
Tightening the internal ring in boys 19
Tightening the internal ring in girls 41
Not using local anesthetic 14
Closing Scarpa’s fascia 94
Closing skin with interrupted subcuticular sutures 49
Covering the incision with Collodion 48
Using a postoperative Stiles dressing 0

NOTE. The remainder of the surgeons surveyed use other techniques; please see text for details.

inguinal hernia description by Drs Ladd and Gross.1,5 We asked those ing with a mosquito (10%), or using scissors and retrac-
surveyed to describe their specific operative techniques (Table 1) as tors (8%). They defined the external ring by hooking it
well their management of several clinical situations (Table 2). We then
with a scissors (37%), pushing down with retractors
compared the survey respondents’ techniques and management deci-
sions to those of Drs Ladd and Gross in an attempt to assess the (35%), or did not define it at all, (14%). They incised the
variability of technique and to analyze whether a geneology of the
hernia repair exists.

RESULTS
A majority of the 640 surveys (70%) were returned.
Geneologic data show that 81% of respondents could
trace their hernia lineage to Drs Ladd and Gross.6 Dr.
Ladd and Gross describe their hernia repair steps in 2
textbooks1,5 with the clearest description of the exact
technique in Dr Gross’s textbook (Figs 1-3).1
When comparing these steps to the survey respon-
dents, there were many similarities and many differ-
ences. The variability among these steps are summarized
in Table 1. The pediatric surgeons surveyed responded
by indicating that they opened Scarpa’s fascia with
scissors (65%), with cautery (24%), or with knife (6%).
They defined the external oblique by spreading with
scissors (61%), spreading with retractors (17%), spread-

Table 2. Survey of Contralateral Exploration Decisions

Clinical Scenario Percentage

Routinely explore the contralateral side in boys ⬍2 yrs 40

Routinely explore the contralateral side in boys 2-5 yrs 13
Routinely explore the contralateral side in girls ⬍5 yrs 39
Routinely explore the contralateral side in prematures 51
Investigate contralateral side laparoscopically through
the sac 24
Fig 1. Inguinal hernia technique of Dr Gross, reproduced from his
Investigate contralateral side with air insufflation 5
original textbook.1
SURGERY FOR INGUINAL HERNIA 747

it, and 14% splash it in the wound. Ninety-four percent

(94%) close the Scarpa’s layer. For closure of the skin,
49% use interrupted absorbable suture, 44% using run-
ning subcuticular, and 2% do not close this layer with
suture. Sixty-five percent (65%) use steristrips, 48% use
collodion, and 23% use tegaderm to cover the wound. No
surgeon used a Stiles dressing postoperatively (Fig 4).
The interventions pediatric surgeons choose in various
clinical situations are shown in Tables 2 and 3. Forty
percent routinely explore the contralateral asymptomatic
side in boys less than 2 years of age; 13% do this
routinely for boys under 5 years of age. Thirty-nine
percent routinely explore the contralateral side in girls
younger than age 5 years, and 51% always explore the
contralateral side in premature infants. The techniques
for contralateral inspection included laparoscopic visual-
ization through the hernia sac (24%), and air insufflation,
the Goldstein test (5%). Management of the incarcerated
nontender ovary varied from repair at first available
elective time (50%), repair that week (28%), or repair
that day as an emergency (10%).

DISCUSSION
Repair of an inguinal hernia is the most common
operation that pediatric surgeons perform. It is not sur-
Fig 2. Inguinal hernia technique of Dr Gross, reproduced from his
prising that there is variability in the technique used. We
original textbook.1

external oblique with knife (46%), scissors (18%), stab-

bing with knife and then cutting with scissors (12%), by
cutting on top of scissors (7%), or not incising this layer
at all (9%). Eighty-one percent specifically identify the
ileoinguinal nerve, whereas 18% do not look for it. They
clean both undersides of the external oblique (45%), only
one side (22%), or not at all (27%). To do this maneuver,
32% use forceps, 14% use forceps and a sponge, 6% use
a peanut, and 5% use a sponge alone. The respondents
opened the cremasteric fibers by teasing them apart with
forceps (90%) or cutting the cremasterics with scissors
(5%). Fifty-three percent (53%) of surgeons defined the
upside down “V,” 46% do not. Again, 53% loop the
vessels to help separate them from the sac, whereas 47%
do not. Sixty-six (66%) twist the sac, 34% do not twist it,
and 78% doubly ligate the sac, whereas 22% only singly
ligate it. Forty-six percent (46%) send the hernia sac to
pathology for inspection, and 54% discard it. Thirty-
three percent (33%) excise the distal sac, 22% cauterize
its edges, and 45% leave it completely alone. Twenty
percent (20%) of surgeons routinely inspect the testicle;
79% do not. Ten percent perform a formal floor repair;
79% do not. When asked whether they tighten the inter-
nal ring, 19% do so in boys, and 41% do so in girls.
Eighty-six percent of respondents use some form of local Fig 3. Inguinal hernia technique of Dr Gross, reproduced from his
anesthesia (83% bupivocaine, 8% lidocaine), 76% inject original textbook.1
748
Fig 4. Stiles’ dressing for postoperative herniorraphy used by Dr
Gross.1
were interested in understanding why such variability
has developed from the original description by Drs Ladd
and Gross. Eighty-one percent of the responders to our
survey could trace their lineage back to these forefathers,
which is similar to the results obtained when the gene-
ology of pediatric surgery training was investigated.6 In
that review, 66% of pediatric surgeons identified, 75% of
those with official training and 73% of training directors,
could trace their lineage to Dr Ladd.6 We theorize that
the variability that has developed over the years has
resulted from evolving techniques, experiences, and
analysis of outcomes.
The way in which Drs Ladd and Gross performed their
inguinal herniorraphy was influenced by the Mitchell-
Banks operation, which was used in England and Scot-
land at the time they were working in Boston.1 In this
technique, the hernia sac is teased out through the exter-
nal ring, is tied off, and the excess sac is cut away. The
inguinal canal is not repaired. Dr Gross, in his textbook,
comments that “the success of this simple procedure is
based on the widely accepted principle that removal of a
hernial sac, or closure of its neck, is the most important
single step in curing an indirect inguinal hernia.”1 He
notes, however, that this technique “would sometimes
seem to be inadequate, particularly in those infants in
whom the walls of the canal have been greatly thinned
and stretched out by a large hernial mass.”1 Drs. Ladd
and Gross preferred “to employ a more thorough opening
LEVITT ET AL
of the canal and repair of the same.”1 They advocated a
modification of the Ferguson herniorraphy, the steps of
which are reprinted from the original textbook1 in Figs 1,
2, and 3, and listed in Table 1. Dr Gross noted that it is
rare that a Bassini reconstruction is necessary, and this is
mainly because of the congenital etiology of the pediatric
hernia, which does not involve a weakened inguinal floor
like an adult direct hernia. Of interest, 9% of our survey’s
respondents do not incise the external oblique at all, and
therefore use a technique more similar to the Mitchell-
Banks operation rather than the Ferguson technique ad-
vocated by Drs Ladd and Gross.
When one closely reviews the technique Drs Ladd and
Gross describe, it is clear they made some modifications
to better adapt the technique to children. They realized
the importance of opening the external oblique, particu-
lary in children with large hernias and thinned layers.
They clearly define Poupart’s ligament by freeing the
underside of the external oblique, with the plan to repair
the floor during the closure. Many of the surgeons in our
survey have choosen not to perform the formal floor
repair on closure and thus avoid this part of the initial
dissection. This may be because of their realization that
a formal floor repair is unnecessary, because the problem
usually is isolated to the presence of the indirect sac.
Over time they realized no change in recurrence rates
with or without formal floor repair. This is because the
most common cause of a recurrent indirect inguinal
hernia repair is failure to identify or to completely ligate
the indirect inguinal hernia sac at the level of the internal
ring.
The act of separation of cord and vessels from hernial
sac performed by the surgeons we surveyed is similar to
that of Drs Ladd and Gross who specifically noted the
care one must take during this step to avoid tearing the
sac.1 This practice has been maintained clearly through
the generations.
Drs Ladd and Gross inserted a finger in the hernia sac
and bluntly dissected with gauze toward the neck of the
sac. The technique of dissection was not used by those
surveyed, and this is likely because of the more common
practice among modern pediatric surgeons of operating
on very small infants in whom the sac is extremely thin.
Dr Gross noted no hesitation operating on a baby who
weighs more than 6 pounds and notes that only on some
occasions was the procedure performed on prematures.1
The operation on premature infants requires more metic-
ulous care to avoid tearing the sac, and improvements in
anesthesia, lighting, and use of magnification not avail-
Table 3. Management of the Incarcerated Nontender Ovary
Repair that day 10%
Repair that week 28%
Repair first elective time 50%
SURGERY FOR INGUINAL HERNIA
able in Drs Ladd and Gross’ era, have contributed to our
routine inguinal hernia operation in former prematures
who now weigh significantly less than 6 pounds. Perhaps
this explains the difference in technique of hernial sac
dissection.
Drs Ladd and Gross would not twist the sac and would
singly ligate it with silk suture. The majority of surgeons
surveyed twisted the sac and doubly ligated it. The
etiologies of the sac twist and the double ligation are
unclear but may have origins in surgical mentors after
Drs Ladd and Gross. Longer-lasting absorbable suture
material that is available now usually replaces the use of
silk in this step. The double ligation may be an attempt to
reduce recurrences.
Drs Ladd and Gross reconstruct the inguinal canal by
suturing external oblique fascia and internal oblique
muscle to Poupart’s ligament. This practice, in large part,
has been abandoned by our survey’s respondents. This is
likely because of the continued observation which Ladd
and Gross mention, that the key to the pediatric hernia is
the presence of an indirect sac. Over time perhaps it
became clear to many that a formal floor repair was not
necessary.
For final skin closure, 49% of surgeons used inter-
rupted subcuticular and 44% used running subcuticular.
Modification of Drs Ladd and Gross’ closure has oc-
curred with the use of a running subcuticular technique
and avoidance of a nonabsorbable suture material. Dr
Gross used interrupted silk for this layer (Randolph J,
personal communication, July 13, 2001). Observation of
a favorable skin closure using a running technique or not
closing this layer at all, and avoidance of reactions to
nonabsorbable suture material such as silk perhaps ac-
count for these changes.
The choices of postoperative dressings reflect the use
of new materials such as tegaderm and steristrips. Still,
nearly half of the surgeons surveyed still use collodion
just like Dr Gross did. The use of the Stiles’ dressing (Fig
4) has been abandoned because the majority of children
are discharged to home on the same day as their opera-
tion. Change in the dressing technique certainly repre-
sents a sign of progress, but it is a great loss for historical
reasons.
Ladd and Gross and most pediatric surgeons for de-
cades did not recognize that infants and children expe-
rience pain. Now pain assessment is considered the fifth
vital sign. Although 14% of respondents to our survey
use no local anesthesia, a majority (86%) do. These are
similar to Wiener’s findings that 63% of those surveyed
use bupivicaine, caudal, or regional anesthesia.4 The
mode of delivery, ie, local infiltration, splash, caudal, or
regional block is of academic interest only because all
techniques are of proven efficacy. The most important
aspect is that administration of local anesthesia is being
749
done. Dr Gross avoided local anesthesia because he was
concerned about affecting healing with injection of the
anesthetic into the wound (Randolph J, personal commu-
nication, July 13, 2001).
Drs Ladd and Gross did not operate on the asymptom-
atic contralateral side. This was likely because of their
desire to reduce anesthesia time and their understanding
of the operative risk to the testicle.1 This practice began
to change when the subject drew controversy in 1955
when Rothenburg and Barnett reported that 100% of
infants younger than 1 year, and 65% of children older
than 1 year, with a clinically apparent unilateral inguinal
hernia actually had bilateral hernias.7 They and others
recommended the practice of routine contralateral groin
exploration; however, their choices of age under which
routine exploration should be performed differed.7-11 In
our survey, 51% of surgeons routinely explore the con-
tralateral side in premature infants, 40% perform con-
tralateral exploration in all boys less than 2 years of age,
and 13% explore routinely in boys less than 5 years of
age.
Many other investigators refuted this idea, challenging
the reported incidence of positive explorations and em-
phasizing the vulnerability of the testes and vas defer-
ens.12-15 The practice changed again with increasingly
selective use of contralateral exploration.
Despite arguments against contralateral examination,
Rowe and Marchildon3 in their 1981 survey of the
practices of 40 pediatric surgeons, reported that 80%
routinely explored the opposite side in boys, and 90% did
so in girls less than 1 year of age. They later noted that
only 20% of patients with unilateral hernia have a con-
tralateral hernia and, therefore, concluded that contralat-
eral exploration was unnecessary in 80%.16 But, Wiener
et al4 found that 65% of surgeons performed routine
contralateral exploration in boys under 2 years of age,
which is more than the surgeons in our survey.
Many surgeons believe that contralateral exploration
should be performed in all girls presenting with a clini-
cally obvious unilateral hernia.17,18 However, very little
follow-up data are available in the literature. A major
reason proposed for why more contralateral explorations
are performed in girls than boys is the relative rare
finding of female reproductive structures that could be
damaged during surgery.16 In our study, routine explo-
ration was performed by 39% of surgeons in all girls
under age 5 years. Wiener et al4 found that 84% of
surgeons perform contralateral exploration in girls up to
age 4.
It seems from our report that this practice may be
changing toward an even more selective use of contralat-
eral exploration, particularly in boys. In our series, sur-
geons routinely explored 40% of boys under age 2, and
13% under age 5. There was more liberal use of con-
750
tralateral exploration of girls but less than in previous
surveys. The potential injury to the ileoinguinal and
ileohypogastric nerves in both sexes is ignored in these
arguments, but care should be taken to preserve both
nerves in both sexes at any age.
Why has there been so much change in practice
management of this clinical situation since Drs Ladd and
Gross? The risks of increased anesthesia time has been
minimized, and the potential risk to the testicle of an
inguinal exploration has been observed for many de-
cades. Surgeons have reviewed their own series and
reevaluate their practices regularly based on new find-
ings in the literature. Wide variability in practice still
exists. We agree with the conclusion of Kapur et al11 that
the decision to recommend exploration of the contralat-
eral groin to the parents of a patient with a unilateral
hernia will undoubtedly be left to the judgment of the
individual surgeon.
With new technology, new modalities of contralateral
investigation have been developed and have made the
subject even more complicated. These modalities change
costs, equipment needs, and anesthesia time, but reduce
the risk to the testicle, vas, gonadal vessels, and the
ileoinguinal and ileohypogastric nerves if they help
avoid an unnecessary groin exploration. Of course if an
asymptomatic hernia is found, the theoretical risk of an
incarceration is eliminated and a second anesthetic is
avoided.
In an attempt to reduce surgical exploration of the
contralateral groin to a minimum, a number of investi-
gative procedures have been developed. Laparoscopic
evaluation of the contralateral groin at the time of sur-
gical repair of an inguinal hernia has been proposed as a
safe and accurate method of identifying a patent proces-
sus vaginalis.19-27 In a review of surgeon’s practices by
Wiener et al4 laparoscopic evaluation of contralateral
side was used in 6%, 40% of whom used the open
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