title: Lessons learned from ligation of indirect hernia sac: an alternative to reduction during endoscopic extraperitoneal inguinal hernioplasty.
abstract: BACKGROUND
  During endoscopic totally extraperitoneal inguinal hernioplasty (TEP), complete reduction of the hernia sac is not always feasible because a sac extends into the scrotum or is adhesed. In such circumstances, ligation of the hernia sac appears to be a sound alternative to reduction. The present study was undertaken to evaluate the safety of sac ligation and the clinical results for patients who underwent ligation of an indirect hernia sac during TEP.
  
  
  METHODS
  From September 1999 to July 2001, patients undergoing unilateral TEP for indirect inguinal hernia were recruited. Patients were divided into two groups. Group 1 (n = 65) underwent complete reduction of the hernia sac, whereas group II (n = 34) underwent ligation of the sac with a Vicryl suture followed by distal transection. Clinical parameters and outcome data were compared between the two groups of patients.
  
  
  RESULTS
  Demographic features and hernia types between the two groups were comparable. The mean operative times of patients from groups I and II were 58 and 62 minutes, respectively (P = NS). Intraoperative complications occurred in two patients in group II, including a vas deferens transection and a gonadal vessel division. Comparison of the lengths of hospital stay, postoperative pain scores at rest and on coughing, rates of postoperative morbidity, and incidences of groin collection showed no significant differences between the two groups.
  
  
  CONCLUSIONS
  Our findings highlight the importance of clear identification and protection of the vas deferens and gonadal vessels before transection of the ligated sac, particularly in patients with abundant preperitoneal adipose tissue. Ligation of an indirect hernia sac was associated with a higher incidence of intraoperative complications and should be performed with caution during TEP.
authors.affiliation: Department of Surgery, University of Hong Kong Medical Center, Tung Wah Hospital, Hong Kong. lauh@hkucc.hku.hk
authors.forename: Hung
authors.initials: H
authors.lastname: Lau
authors.forename: Francis
authors.initials: F
authors.lastname: Lee
mesh_terms: D016022:Case-Control Studies; D004724:Endoscopy / Q000379:methods*; D005260:Female; D006552:Hernia, Inguinal / Q000601:surgery*; D006801:Humans; D007431:Intraoperative Complications / Q000453:epidemiology; D007902:Length of Stay; D008026:Ligation; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D013536:Suture Techniques; D013997:Time Factors; D014649:Vas Deferens