Incarcerated ovarian hernia is a common type of incarcerated inguinal hernia and one of the emergency diseases in paediatric surgery. As recently reported[5–6], the incidence of incarcerated ovarian hernia ranges between 6% and 15% of inguinal hernias in female infants.
For female infants with incarcerated ovarian hernias, emergency surgical treatment is needed when manual reduction fails. The traditional surgical approach is to perform high ligation of the hernia sac through the inguinal incision. For children with incarcerated hernias, local inguinal tissue congestion and oedema are obvious, and the operation is difficult. To reduce the difficulty of the operation and tissue identification, the surgical incision is often larger than that of non-incarcerated hernia, the structure of the inguinal canal is more traumatic, and the scar is more obvious after operation. Family members of female children often have higher requirements for postoperative cosmetology. Meanwhile, traditional operations cannot detect and properly address contralateral concealed hernia, while bilateral and contralateral concealed hernia are more common in infants and young children's inguinal hernia, with an incidence rate of approximately 21.2%[7–11]. These children may have a risk of secondary surgical treatment for contralateral hernia. The advent of minimal access techniques has revolutionized the traditional management of inguinal hernia. With the development of endoscopic equipment and technology, the laparoscopic approach is gaining popularity because of the potential advantages of faster recovery, attenuated pain, improved cosmesis, and low recurrence rate [12–14].
Laparoscopic high ligation of extraperitoneal hernia sac with an epidural needle is a simple, reliable and simple puncture technique that can be accomplished by external ligation. It has the advantages of minimal trauma, fast recovery, low recurrence rate and good cosmetic effects[15–19]. Compared with traditional high ligation of the hernia sac, it has the following advantages. First, female infants with ovarian incarcerated hernia have obvious local tissue congestion and oedema, and traditional surgery is prone to damaging local tissues, such as ovaries and Fallopian tubes. Laparoscopic operation does not dissect the structure of the inguinal canal, avoiding the influence of local tissue congestion and oedema on the operation. Second, Shalaby et al. [20] reported that incarcerated hernia is easier to reposition under laparoscope because the hernia contents are pulled by grasping forceps without damage to the abdominal cavity, and then the hernia contents are repositioned by an external technique. In addition, the pneumoperitoneum pressure enables carbon dioxide to be blown into the inner ring mouth, thereby expanding the inner ring mouth. Among the 38 children in this group, incarcerated hernia was not reduced before surgery. The application of laparoscopy with an operation channel for non-invasive grasping forceps can enlarge the internal ring mouth and assist in pulling the hernia contents. Incarcerated hernia is relatively easy to reduce. Third, contralateral concealed hernia can be found under laparoscopy and treated simultaneously[3, 21]. In this group, contralateral concealed hernia was found in 24 children during the operation, and these children underwent high ligation of the hernia sac to prevent the risk of reoperation caused by the contralateral hernia. Fourth, the ovary is an important endocrine organ in women and is also the source of female reproductive cells, which play a very important role in women’s lives. Therefore, when incarcerated inguinal hernia occurs in female children and the hernia contents are suspected to be the ovaries, it is extremely important to judge the nature and vitality of the hernia contents in a timely manner to guide subsequent treatment. Laparoscopy can accurately observe the reduction process of the incarcerated hernia contents [22]. It is clear that there is no damage to the ovary after reduction. If ovarian ischaemia and necrosis are found, urgent treatment should be provided to prevent the serious consequences of blind manual reduction for children[1]. In this group, seven cases were incarcerated for a long period of time, and the suspected disorder of incarcerated ovarian blood supply was found during the operation. After laparoscopic-assisted reduction, the observation time was prolonged, and the blood supply of ovaries recovered, thus preventing ovariectomy. Fifth, under the microscope, the hernia sac is ligated at a higher position through external operation of the epidural puncture needle, and no space is left for the suture of the inner ring orifice, which is helpful to prevent recurrence after operation [23]. Sixth, the incision is concealed, there is no obvious scarring after the operation, and the cosmetic effect is good, which can reduce feelings of inferiority that may occur in the psychological development of female children and is more readily acceptable by their families.
Although this retrospective study had a certain size, there are still several limitations. First, this was a retrospective study with a limited number of patients from a single centre, and more research from multiple centres is needed to assess the effectiveness and complications of this technique. Second, the median follow-up duration was relatively short, and a longer follow-up period is warranted.