Comments and New Ideas on the Article: A New Intraperitoneal Technique for Safe Repair of Incarcerated Inguinal Hernias: A Novel Technique to Consider”, by A. D. Ram and R. A. Wheeler.

Dear Editor,

We read the recently published article by A. D. Ram and R. A. Wheeler entitled “A New Intraperitoneal Technique for Safe Repair of Incarcerated Inguinal Hernias: A Novel Technique to Consider” with great interest.

In our hospital we use a slightly different technique, which was developed as an open alternative to laparoscopic hernia repair with preperitoneal mesh placement in adult patients. We have used this technique in pediatric cases, but without mesh placement. In a single case, simple small bowel resection was performed.

Like the authors, the internal annulus is approached from behind through the preperitoneal space. In our approach we use the rectus sheath to open the preperitoneal space. The skin incision is parallel to the inguinal ligament, slightly lateral from the midline at the point where the iliac vessels cross the ligament. This is where the internal annulus is localized. Via this incision, the anterior rectus sheath is opened and the rectus muscle fibers are kept medially together with the epigastric vessels. A great overview of the orifice of Fruchaud is achieved, allowing all areas to be inspected for possible hernias.

In cases of incarceration, we prefer this technique because the hernia can easily be reduced, and after opening the peritoneal sac we get a clear impression of the vitality of the patient’s intestines. In cases of hydroceles or recurrent hernia, the posterior approach offers a different dynamics. The processus vaginalis can be identified by gently lifting the peritoneal sac as was also described by A. D. Ram in his article. Thereafter it can easily be separated from the ductus and the vessels and transected.

Unlike A. D. Ram in his article, we never close the internal annulus. As in anterior hernia repair in infants, the annulus is always left untouched. So far we have not seen any adverse results of this policy.

In conclusion, we agree with the authors that simple alternative techniques should definitely be considered and can be useful to treat hernias in infants instead of the current golden standard, the anterior inguinal approach. The posterior technique through the preperitoneal space gives excellent access, allowing safe hernia repair, bowel inspection, and even resection if necessary. Closure of a (wide) internal annulus is unnecessary in our opinion.