Laparoscopic versus open inguinal hernia repair in children ≤3: a randomized controlled trial

Wound cosmesis problems and other postoperative problems of laparoscopic compared to open paediatric inguinal hernia repair: A meta-analysis

A meta-analysis research was executed to appraise the wound cosmesis problems and other postoperative problems of laparoscopic compared to open paediatric inguinal hernia (IH) repair. Inclusive literature research until March 2023 was done and 869 interconnected researches were revised. The 11 picked researches enclosed 3718 paediatric inguinal hernia were in the utilised researches' starting point, 1948 of them were utilising laparoscopic IH repairs, and 1770 were utilising open IH repairs. Odds ratios (ORs) in addition to 95% confidence intervals (CIs) were utilised to appraise the wound cosmesis problems and other postoperative problems of laparoscopic compared to open paediatric IH repairs by dichotomous approaches and a fixed or random model. Laparoscopic IH repairs had significantly lower wound cosmesis problems (OR, 0.29; 95% CI, 0.16-0.52, P < .001), metachronous contralateral inguinal hernia (MCIH) (OR, 0.11; 95% CI, 0.03-0.49, P = .003), recurrence (OR, 0.34; 95% CI, 0.34-0.99, P = .04) and postoperative problems (OR, 0.35; 95% CI, 0.17-0.73, P = .005), and higher wound score (OR, 12.80; 95% CI, 10.09-15.51, P < .001) compared to open paediatric IH. Laparoscopic IH repairs had significantly lower wound cosmesis problems, MCIH, recurrence, and postoperative problems, and a higher wound score compared to open paediatric IH. However, when interacting with its values, caution must be taken since much of the research had low sample sizes.

Laparoscopic hernia repair in children: does recreating the open operation improve outcomes? A systematic review

PURPOSE

The use of laparoscopy for paediatric inguinal hernia repairs has increased significantly over the past 2 decades. However, there is significant variation in the reported recurrence rates in the literature, with many studies reporting higher rates than the open operation. This may be explained by the range of different techniques currently included under the term laparoscopic inguinal hernia repair. The purpose of this study is to determine whether dividing the hernia sac before ligation improves surgical outcomes following a paediatric laparoscopic inguinal hernia repair compared to ligation alone.

METHODS

A systematic review of the literature was performed following PRISMA guidelines of all studies reporting the outcomes following paediatric laparoscopic inguinal hernia repair where the technique was recorded as laparoscopic suture ligation alone (LS) or laparoscopic sac division and suture ligation (LSDS). Studies were assessed for risk of bias and exclusion criteria included reported follow-up of less than 6 months.

RESULTS

A total of 8518 LS repairs and 6272 LSDS repairs were included in the final analysis. LSDS repair was associated with a significantly lower recurrence rate (odds ratio 0.51, 95% CI 0.36-0.71, p = 0.001). There was no significant difference in the rates of testicular ascent or atrophy.

CONCLUSION

Recreating the open operation by hernia sac division followed by suture ligation significantly reduces the risk of hernia recurrence.

Laparoscopic vs. laparoscopically assisted pediatric inguinal hernia repair: a systematic review

This systematic review aims to compare the two major principles of laparoscopic pediatric inguinal hernia repair: totally laparoscopic repairs (LR) and laparoscopically assisted repairs (LAR), to find out the optimal approach for pediatric patients. A systematic literature search was performed via Pubmed, Embase MEDLINE, and Cochrane databases on all studies published in the last 20 years reporting outcomes on these principles including recurrences, complications, and operative time. Prospective studies for either principle or retrospective comparative studies were considered eligible. Fischer's exact and Student's t test were used for statistical analysis with p value < 0.05 considered statistically significant. Twenty-one studies, including two thousand one hundred and ninety-six patients (LR: 1008), of ages ranging from 9 days to 18 years-old and a male to female ratio of 2.55:1, met our inclusion criteria. Follow-up period varied from 3 months to 8 years. Recurrence rates were similar between the two categories (LR: 1.68% vs. LAR: 1.59%, p > 0.05). As regards post-operative complications, transient hydrocele development was higher in laparoscopic repairs (LAR: 1.01% vs. LR: 3.17% p < 0.005) while wound healing problems were more frequent in laparoscopically assisted repairs (LAR: 1.17% vs. LR: 0.30%, p = 0.019). Mean operative time was lower in laparoscopically assisted repairs both in unilateral (LAR: 21.49 ± 13.51 vs. LR: 29.73 ± 11.05, p = 0.131) and bilateral cases (LAR: 28.01 ± 15.08 vs. LR: 39.48 ± 16.35, p = 0.101) but without statistically significant difference. Both principles are equally effective and safe as their recurrence and overall complications rates are equivalent. Transient hydrocele occurs more often in laparoscopic repairs while wound healing problems are associated mostly with laparoscopically assisted repairs.

Laparoscopic Extraperitoneal Hernia Repair Versus Open Repair in Boys with Inguinal Hernia: A Meta-analysis

OBJECTIVE

Pediatric inguinal hernia is a common surgical problem in boys. Open hernia repair surgery (OH) has been traditionally used to treat this condition, but it leads to complications, such as testicular complications. Laparoscopic hernia repair by using the extraperitoneal method (LHE) is performed through the percutaneous insertion of sutures and extracorporeal closure of patent vaginalis processus; thus, injury to spermatic cord structures is avoided. However, a meta-analysis comparing LHE and OH is lacking.

METHODS

PubMed, EMBASE, and Cochrane Library databases were searched for relevant studies. A meta-analysis of the retrieved studies was performed, and a random-effects model was used to calculate the pooled effect size. The primary outcome was testicular complications, including ascending testis, hydrocele, and testicular atrophy. The secondary outcomes were surgical metachronous contralateral inguinal hernia (MCIH), ipsilateral hernia recurrence, and operation time.

RESULTS

In total, 6 randomized controlled trials (RCTs) and 20 non-RCTs involving 17,555 boys were included. The incidence of ascending testis (risk ratio [RR]: 0.38, 95% confidence interval [CI]: 0.18-0.78; p = 0.008) and MCIH (RR: 0.17, 95% CI: 0.07-0.43; p = 0.0002) was significantly lower in LHE than in OH. The incidence of hydrocele, testicular atrophy, and ipsilateral hernia recurrence did not differ between LHE and OH.

CONCLUSION

Compared with OH, LHE led to fewer or equivalent testicular complications without increasing ipsilateral hernia recurrence. Moreover, MCIH incidence was lower in LHE than in OH. Hence, LHE could be a feasible choice with less invasiveness for inguinal hernia repair in boys.

LEVEL OF EVIDENCE

Treatment study, LEVEL III.

Laparoscopic versus Open Inguinal Hernia Repair Is Feasible in Infants with Caudal Anesthesia and Spontaneous Respiration

INTRODUCTION

 Minimally invasive surgery (i.e., laparoscopy) and minimally invasive anesthesia (i.e., caudal anesthesia with spontaneous respiration) have separately shown benefits for inguinal hernia repair in infants, yet to what degree these techniques can be combined remains unknown. This study investigated whether laparoscopy impacts the feasibility of performing caudal anesthesia with spontaneous respiration in infants.

METHODS

 Prospectively collected data of all infants less than 12 months old and over 3 kg weight who underwent laparoscopic indirect hernia repair (LAP) at our department from 2019 to 2021 were compared with a historical control-matched group of infants who underwent open repair (OPEN) from 2017 to 2021. We assessed the patients' characteristics, anesthesia, and surgical data as well as intra- and postoperative complications.

RESULTS

 A total of 87 infants were included (LAP n = 29, OPEN n = 58). Caudal anesthesia with spontaneous respiration was feasible in 62.1% of cases (LAP n = 55.2%, OPEN n = 65.5%; nonsignificant). Neither group registered anesthetic intra- or postoperative complications. Sedatives were utilized in 97% of LAP patients versus 56.9% of OPEN patients (p < 0.00001). The airway was secured with a laryngeal mask in 89.7% of patients during LAP versus 41.4% during OPEN (p < 0.00001). No significant differences were found regarding the use frequency of opioids (48.3% LAP vs. 34.5% OPEN; nonsignificant) or neuromuscular blockers (6.9% LAP vs. 5.2% OPEN; nonsignificant).

CONCLUSION

 This is the first comparative study on caudal anesthesia and spontaneous respiration in infants undergoing laparoscopic versus open inguinal hernia surgery. Laparoscopy increased the need for ventilatory support and sedatives but did not significantly impair the feasibility of caudal anesthesia and spontaneous respiration.

Outcome and learning curve for laparoscopic intra-corporeal inguinal hernia repair in children

BACKGROUND

Laparoscopic inguinal hernia repair is one of the procedures most commonly performed by paediatric surgeons. Current research on the learning curve for laparoscopic hernia repair in children is scarce. This study aims to evaluate the clinical outcome and learning curve of laparoscopic intra-corporeal inguinal hernia repair in children.

METHODS

A retrospective single-centre analysis of all paediatric patients who underwent laparoscopic intra-corporeal inguinal hernia repair between 2010 and 2019 was performed. The clinical outcomes were analysed. The data on the achievement of the learning curve by surgical trainees were evaluated with the CUSUM technique, focusing on operative time.

RESULTS

There were 719 patients with laparoscopic intra-corporeal inguinal hernia repair (comprising 1051 sides) performed during the study period. The overall ipsilateral recurrence rate was 1.8% without other complications detected. CUSUM analysis showed that there were 3 phases of training, for which the trainees underwent initial learning phase (Phase 1) for the first 7 cases. After mastering of the skills and extrapolating the skills to male patients with smaller body size (Phase 2), they then achieved performance comparable to that of the senior surgeons after 18 procedures (Phase 3).

CONCLUSIONS

18 procedures seem to be the number required to reach the learning curve plateau in terms of operative time by surgical trainees. The clinical outcomes show that laparoscopic intra-corporeal inguinal hernia repair is a safe and transferrable technique, even in the hands of trainees, with adequate supervision and careful case selection. It also provides skill acquisition for minimally invasive surgery.

Laparoscopic versus open inguinal hernia repair in infants: an initial experience

BACKGROUND

Inguinal hernia repair is a common operation performed in children. In Australia, open repair (OR) continues to be the preferred method of treatment in infants, despite laparoscopic repair (LR) gaining popularity amongst some international centres. Our aim was to analyse initial outcomes with LR at our paediatric centre.

METHODS

We conducted a retrospective review of all patients <1 year of age who received LR or OR between January 2017 and July 2021 at our institution. Data were retrieved from both electronic and scanned medical records. Data were analysed using an unpaired t-test, Mann-Whitney test, Fisher's exact test or simple linear regression. A P-value <0.05 was considered significant.

RESULTS

A total of 376 patients were identified: LR was performed in 73 patients, and OR in 303 patients. Bilateral repair was more common amongst patients receiving LR: 56.2% versus 21.5%, P = 0.0001, treating either a symptomatic hernia or an intra-operative contralateral inguinal defect (70%). All LR patients received general anaesthetic, compared to 82.8% of patients in the OR group, P = 0.0001. There were no recurrences following LR and 3 with OR (P = 1.0). The metachronous contralateral inguinal hernia rate following OR was 10% (21/206). There was no significant difference in other complications, including wound infection, haematoma, testicular atrophy, and hydrocele formation.

CONCLUSION

In our population OR was performed more often than LR. Operative complication rates were equivalent between OR and LR groups. However, infants that underwent OR were significantly more likely to develop a MCIH.

Laparoscopic inguinal hernia repair in children: Article review and the preliminary Maltese experience

BACKGROUND

In the past two decades, laparoscopy has provided an alternative approach to inguinal hernia repair. The aim of this review is to carry out a retrospective systematic analysis of articles dealing with laparoscopic hernia repair in children and a review of the Maltese experience.

METHODS

Data was obtained from publications from 2002 to 2019. The endpoints include: patient demographics, clinical presentations, laparoscopic tools, ports, suture used, technical remarks, length of surgery, hospital stay, complications and follow-up.

RESULTS

32 studies were included with a total of 10,183 patients. Most articles documented the use of 1 port. Length of surgery ranged from an average of 10 to 138 min. Ipsilateral recurrences were reported in 0.83% of cases, while 0.17% required conversion to open.

PRELIMINARY MALTESE EXPERIENCE

In our centre, a population of 514, 564 is covered (16% under the age of 18). A total of 14 cases of laparoscopic inguinal hernia repair were carried out from August 2018 till October 2020. The neonatal laparoscopic set-up involves a 30⁰ laparoscope, inserted via a 5 mm umbilical port, with 2 stab incisions allowing the use of 3 mm devices. Intra-corporeal purse string suture technique is used. The length of surgery ranged from 1 hr to 2 hr 30 min. There was 1 case of ipsilateral recurrence and another requiring conversion to open surgery.

CONCLUSIONS

Laparoscopic inguinal hernia repair in children is a versatile and safe procedure that can be carried out with minimal complications and low reoperation rates.

LEVEL OF EVIDENCE

Level IV.

Surgical Management of Pediatric Inguinal Hernia: A Systematic Review and Guideline from the European Pediatric Surgeons' Association Evidence and Guideline Committee

INTRODUCTION

 Inguinal hernia repair represents the most common operation in childhood; however, consensus about the optimal management is lacking. Hence, recommendations for clinical practice are needed. This study assesses the available evidence and compiles recommendations on pediatric inguinal hernia.

MATERIALS AND METHODS

 The European Pediatric Surgeons' Association Evidence and Guideline Committee addressed six questions on pediatric inguinal hernia repair with the following topics: (1) open versus laparoscopic repair, (2) extraperitoneal versus transperitoneal repair, (3) contralateral exploration, (4) surgical timing, (5) anesthesia technique in preterm infants, and (6) operation urgency in girls with irreducible ovarian hernia. Systematic literature searches were performed using PubMed, MEDLINE, Embase (Ovid), and The Cochrane Library. Reviews and meta-analyses were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement.

RESULTS

 Seventy-two out of 5,173 articles were included, 27 in the meta-analyses. Laparoscopic repair shortens bilateral operation time compared with open repair. In preterm infants, hernia repair after neonatal intensive care unit (NICU)/hospital discharge is associated with less respiratory difficulties and recurrences, regional anesthesia is associated with a decrease of postoperative apnea and pain. The review regarding operation urgency for irreducible ovarian hernia gained insufficient evidence of low quality.

CONCLUSION

 Laparoscopic repair may be beneficial for children with bilateral hernia and preterm infants may benefit using regional anesthesia and postponing surgery. However, no definite superiority was found and available evidence was of moderate-to-low quality. Evidence for other topics was less conclusive. For the optimal management of inguinal hernia repair, a tailored approach is recommended taking into account the local facilities, resources, and expertise of the medical team involved.

Efficacy of dexmedetomidine versus magnesium sulfate as an adjuvant to intraperitoneal bupivacaine in pediatric laparoscopic surgery: a randomized clinical trial

BACKGROUND

We evaluated the efficacy of dexmedetomidine versus magnesium sulfate as an adjuvant to intraperitoneal (IP) bupivacaine in pediatric laparoscopic inguinal herniorrhaphy.

METHODS

Ninety-seven male children, ASA I-II, 1-6 years old, undergoing laparoscopic inguinal herniorrhaphy, were randomized to receive before peritoneal insufflation, IP 2 mg.kg-1 bupivacaine 0.5% combined with either 1 μg.kg-1 of dexmedetomidine (Group D), 30 mg.kg-1 of magnesium sulfate (Group M), or normal saline (Group C). All tested drugs were diluted to the volume of 10 mL with normal saline. FLACC pain scores, need for rescue analgesics, time to flatus and first stool, emetic events, adverse effects, functional recovery, and parents' satisfaction were recorded for the first 48 h postoperatively.

RESULTS

FLACC scores were significantly higher in Group C than in the other two groups at 6, 8, 12, 18, 24, and 48 hours after surgery with no differences between Groups D and M. Rescue analgesia was significantly higher in Group C with none of the children in Groups D and M requiring rescue analgesia (p = 0.001). Times to first flatus and stool, emetic events, and adverse effects did not differ among groups. Times to return to normal functional activity were comparable in all groups. Parents' satisfaction was greater in Groups D and M than in Group C (p = 0.026).

CONCLUSION

Dexmedetomidine and magnesium sulfate added to IP bupivacaine improved the analgesia afforded by bupivacaine in the first two postoperative days in children scheduled for laparoscopic herniorrhaphy.

Pediatric Inguinal Hernia Repair, Laparoscopic Versus Open Approach: A Systematic Review and Meta-Analysis of the Last 10-Year Evidence

Aim: Since the first description of laparoscopic herniorrhaphy (LH), a lot of studies have compared outcomes between LH and open herniorrhaphy (OH) with inconsistent results. We designed this study to assess outcomes between both techniques now that pediatric surgeons have enough confidence with it. Methods: We performed a systematic review and meta-analysis of articles published in the last 10 years. Results: Twenty-seven articles reporting on 91,653 patients (26,920 LH and 64,733 OH) were included. No significant differences were found in overall operative time (OT) (P = .07). Subgroup analysis revealed significantly shorter OT for LH in unilateral (-8.87 minutes, P = .03) and bilateral hernias (-16.86 minutes, P = .004), but longer in unilateral hernias in females (+7.47 minutes, P = .006). Recurrence rate was similar (odds ratio [OR] 1.05, P = .66). Less complications were reported in LH (OR 0.51, P = .03). Contralateral patent processus vaginalis average rate was 39.61% and its closure reported a significant decrease of contralateral metachronous hernia (OR 0.11, P < .00001). Conclusion: Although OH is still considered the gold standard by some authors, LH has proven to be not only as safe as OH but also to have additional advantages that should make pediatric surgeons implement it in their daily practice and not in selected cases alone.

Laparoscopic inguinal herniotomy: Recreating the open operation optimises outcomes

BACKGROUND

Recent evidence suggests simple laparoscopic inguinal herniorrhaphy is associated with higher rates of recurrence and testicular ascent. We instigated a standardised approach to laparoscopic inguinal herniotomy (LIH), with circumferential sac division and 'purse-string' closure (4/0 monofilament polypropylene). An active follow-up programme was pursued. We reviewed our outcomes of this technique and compared them to an open herniotomy (OIH) cohort.

METHODS

LIH patients were identified prospectively (2017-2021): OIH retrospectively from 2016. Risk factors for complications were defined: extremely to very preterm (< 32 weeks), emergency presentation with incarceration, and redo surgery for recurrence. Data are presented as median [IQR]. Comparisons used Fisher's exact and Mann-Whitney U tests: significance defined as p < 0.05.

RESULTS

192 inguinal herniae in 140 patients were included in the LIH group and 214 herniae in 179 patients in the OIH group. Groups were similar in age and gender. The LIH group had a significantly larger proportion of cases that were premature, had emergency surgery, or had redo surgery after previous OIH. Follow-up was 24.4 months [10.8-33.6] vs. 66.4 [64.5-68.5] (LIH vs. OIH). Hernia recurrence occurred in 2/192 (1.0%) vs. 4/214 (1.9%) (LIH vs. OIH), p = 0.69. There was one known case of testicular ascent after OIH but none in the LIH group.

CONCLUSIONS

Recreation of the open herniotomy laparoscopically appears to confer excellent outcomes, with low rates of recurrence despite a high proportion of patients having known risk factors. Further long-term data on rates of testicular ascent after active follow-up are required.

Laparoscopic versus open inguinal hernia repair in children: A systematic review

Purpose

Considerable debates exist regarding the preferable technique to repair a paediatric inguinal hernia (PIH). This systematic review aims to compare the efficacy and safety of laparoscopic herniorrhaphy (LH) and open herniorrhaphy (OH) in PIH.

Methods

The randomised controlled trials (RCTs) that compared the outcomes of LH and OH in PIH without region and language restrictions searched from the following databases: PubMed, Web of Science Database, Cochrane Library, SciELO Citation Index, Russian Science Citation Index, China National Knowledge Infrastructure, WanFang Data and China Science and Technology Journal Database.

Results

A total of 13 RCTs that involving 1207 patients included in the review. The LH displayed a shorter operative time for bilateral hernia repair (weighted mean difference = -8.23, 95% confidence interval [CI]: -11.22~-5.23, P < 0.00001), a lower complication rate (odds ratio [OR] = 0.32, 95% CI: 013-0.83, P = 0.02) along with a lower wound infection (OR = 0.14, 95% CI: 0.04-0.55, P = 0.005) and major male-specific post-operative complications (OR = 0.10, 95% CI: 0.04-0.24, P < 0.00001) and a less contralateral metachronous inguinal hernia (CMIH) incidence rate (OR = 0.09, 95% CI: 0.02-0.42, P = 0.002). No significant difference was found for unilateral operative time, time to full recovery, length of hospital stay, recurrence and hydrocele rates between the two techniques.

Conclusion

The present review reiterates that both the LH and OH techniques for the PIH repair are comparable. However, in some aspects, the LH is superior to the OH in terms of operative time for bilateral hernias, post-operative complications rate and CMIH incidence rate. Rigorously designed RCTs are anticipated to confirm the clinical effects of both LH and OH.

Laparoscopic Hernia Repair with the Extraperitoneal Approach versus Open Hernia Repair in Pediatric Inguinal Hernia: A Systematic Review and Meta-Analysis

OBJECTIVE

This systematic review and meta-analysis investigated the feasibility and effectiveness of laparoscopic hernia repair with the extraperitoneal approach in pediatric inguinal hernias.

SUMMARY BACKGROUND DATA

Inguinal hernia repair is the most common operation in pediatric surgical practice. Although open hernia repair (OHR) is a well-established procedure with good outcomes, studies have reported acceptable or even better outcomes of laparoscopic hernia repair with the extraperitoneal approach (LHRE). However, a meta-analysis comparing LHRE with OHR is lacking.

METHODS

PubMed, EMBASE, and Cochrane Library databases were searched for randomized controlled trials (RCTs) and comparative studies (prospective or retrospective). Outcomes were metachronous contralateral inguinal hernia (MCIH), hernia recurrence, surgical site infection, operation time, and hospitalization length. A meta-analysis was performed, and risk ratios (RR), weighted mean difference (WMD), and 95% confidence intervals (CI) were calculated using random-effects models.

RESULTS

Five RCTs and 21 comparative studies involving 24,479 patients were included. Lower MCIH incidence (RR: 0.11, 95% CI: 0.07 to 0.17; p < 0.00001) and a trend of shorter operation time (WMD: -11.90 min, 95% CI: -16.63 to -7.44; p < 0.00001) were found in the LHRE group. No significant differences in ipsilateral recurrence hernias, surgical site infection, and length of hospitalization were found between the groups.

CONCLUSIONS

LHRE presented lower MCIH incidence and shorter operation times, with no increase in hernia recurrence, surgical site infection, or length of hospitalization. As more surgeons are increasingly becoming familiar with LHRE, LHRE would be a feasible and effective choice for pediatric inguinal hernia repair.

Laparoscopy is increasingly used for pediatric inguinal hernia repair

INTRODUCTION

Inguinal hernia repairs (IHR) are commonly performed by pediatric surgeons in the United States. The operative approach depends on surgeon preference with no definitive prospective studies comparing laparoscopic inguinal hernia repair (LIHR) versus traditional inguinal hernia repair (TIHR). We aim to assess current practice, hypothesizing that laparoscopy is increasingly used for pediatric IHR.

MATERIAL & METHODS

The Children's Hospital Association (CHA) Pediatric Health Information System was queried for IHRs performed between 01/01/2009 and 12/31/2018. Demographics, procedure type, hernia laterality, and cost were obtained. Patients were grouped by procedure type (laparoscopic/traditional).

RESULTS

125,249 IHRs were performed at 32 CHA hospitals during the ten-year study period. 115,782 (92.4%) were TIHR and 9467 (7.6%) LIHR. Use of laparoscopy increased 5-fold from 3% to 15% over the study period. When comparing laparoscopic to traditional IHR groups, there were more females (28.3% vs 12.6%), African-Americans (19.7% vs 14.4%), government-insured (50% vs 45.2%), younger patients (4.2 vs 4.4 years), bilateral IHRs (11.4% vs 7.9%), and higher adjusted total hospital cost ($3,791 vs $2995) in the laparoscopic group (p<0.0001, all comparisons).

CONCLUSIONS

Laparoscopy for pediatric IHR is increasing at CHA hospitals where nearly 1 in 6 children currently undergoes a laparoscopic repair. The long-term outcomes with laparoscopic repair are worthy of future study.

The history of the pediatric inguinal hernia repair

The history of inguinal hernia repair is a rich one. For centuries, hernia healers, doctors, anatomists, surgeons and quacks have been devoted to this pathology that has afflicted mankind throughout its evolution. The development of surgical correction mainly focused on adult pathology, with treatments that often involved the loss of the testis. Hernia management in children, however, also dates from antiquity. Described as a swelling on the surface of the belly in ancient papyri, it was treated with tight bandages by the early physicians of Alexandria. For centuries, conservative treatment had been used for the child using primordial trussess, many prayers, and often pagan rituals as the arboreal passage of children described by Marcello of Bordeaux, doctor of the Emperor Theodosius I (347-395 AD), reserving medical intervention only for cases of strangulation in which only reduction was attempted. The middle ages were characterized by an increase in cultural and scientific exchange, during which the first comprehensive surgical textbooks and atlases were written. Different approaches to the inguinal hernia were not taught and passed down through generations of surgeons. The modern era brought a better understanding of the inguinal anatomy, which led to surgical techniques associated with less post-operative complications. Today, the pediatric inguinal hernia repair is one of the most common pediatric operations performed. It is considered a safe procedure with very low complication rate.

Surgical site infection after open and laparoscopic surgery in children: a systematic review and meta-analysis

Surgical site infections (SSIs) are the most common healthcare-associated infections in patients undergoing surgery. Various randomised control trials (RCTs) indicate that laparoscopic procedures can be associated with better outcomes compared to open procedures. However, how open versus laparoscopic approaches compare across various paediatric procedures with respect to SSI rate remains poorly defined. In this review, we examined RCTs that directly compare SSI rates after open versus laparoscopic operations for appendicitis, gastro-esophageal reflux, inguinal hernia, and pyloric stenosis. MEDLINE, Embase, and Web of Science were searched for RCTs comparing four types of open versus laparoscopic operations in children. The operations included appendectomy, fundoplication for gastro-esophageal reflux, inguinal hernia repair, or pyloromyotomy. 364 records were identified and screened, 54 full-text articles were assessed for eligibility, and 17 RCTs were included in the analysis. SSI rate was the primary outcome. Operative time and length of stay (LOS) were the secondary outcomes. A meta-analysis was conducted using RevMan 5.4 software. Laparoscopic appendectomy had a lower SSI rate than open appendectomy (odds ratio of 2.22 [1.19, 4.15] p = 0.01). Laparoscopic fundoplication for gastro-esophageal reflux, inguinal hernia repair, or pyloromyotomy for pyloric stenosis were not associated with lower SSI rate compared to open surgery. Operative time was shorter in open fundoplication (- 71.22 min [- 89.79,  - 52.65] p < 0.00001) than laparoscopic fundoplication. There was no significant difference in operative time of any of the other procedures. There was no significant difference in LOS between open and laparoscopic procedures for all types of operations analysed. Based on the findings of this review, it is recommended to utilise the laparoscopic approach over the open approach to reduce SSI risk in paediatric appendectomy.

Re-evaluation of jumping purse-string suturing in pediatric laparoscopic hernia repair

BACKGROUND

Reported recurrence rates using jumping purse-string suturing in laparoscopic hernia repair (LH) are higher than that of intact purse-string. This study aims to compare the outcomes of LH using transabdominal jumping purse-string suturing (TJS) with those using transabdominal intact purse-string suturing (TIS) and percutaneous extraperitoneal intact purse-string suturing (PEIS).

METHODS

A total of 3340 patients from three centers who have undergone laparoscopic hernia repair from January 2016 to June 2019 were retrospectively reviewed. Of these, 1460 patients received TJS, 724 patients received TIS, and 1006 patients received PEIS. One hundred and fifty patients were excluded due to the loss of follow-up. Demographic characteristics, intraoperative findings, and postoperative complications were analyzed.

RESULTS

The hernia distribution characteristics and mean length of hospital stay were similar among the three groups (p > 0.05, p > 0.05). While the overall complication rates were similar among the three groups (0.34% in TJS vs. 0.41% in TIS vs. 0.50% in PEIS, TJS & TIS p = 0.502; TJS & PEIS p = 0.813), the incidence of intraoperative hematoma in TIS group and postoperative subcutaneous knot in PEIS group was significantly higher ((0.83% in TIS and 0.34% in TJS vs. 0.2% in PEIS, TJS & TIS p = 0.018; TJS & PEIS p = 0.163), (0% in TIS and 0% in TJS vs. 0.2% in PEIS, TJS & TIS p = 0.415; TJS & PEIS p = 0.025)). There were no differences in the recurrent rate in both unilateral and bilateral cases.

CONCLUSIONS

Transabdominal jumping purse-string suturing is not associated with a higher recurrence rate and is the recommended surgical approach.

Comparison of surgical outcomes between laparoscopic percutaneous extracorporeal closure (LPEC) and open repair for pediatric inguinal hernia by propensity score methods and log-rank test analysis

BACKGROUND

Despite a number of studies comparing laparoscopic inguinal hernia repair (LH) and open herniorrhaphy (OH), the putative advantage of LH remains controversial due to a paucity of firm evidence. We hypothesized that LH has both advantages and disadvantages compared to OH and sought to clarify them by comprehensively analyzing the retrospective data using the combination of multiple statistical methods.

METHODS

Operative data for inguinal hernia during the period from February 1999 to December 2019 were examined. The patients were assigned into two groups according to the surgical procedure: laparoscopic percutaneous extraperitoneal closure (LPEC, n = 2410) and OH (n = 2038). Operative and anesthesia times and incidence of postoperative complications were evaluated using the propensity score methods and log-rank test.

RESULTS

In comparison with OH, operative time of LPEC was longer for unilateral repair (21.59 ± 8.1 min vs 18.01 ± 8.0 min; p < 0.001) and shorter for bilateral repairs (28.55 ± 10.1 min vs 33.23 ± 11.7 min; p < 0.001), while anesthesia times were longer for both unilateral repair (57.67 ± 10.1 min vs 40.62 ± 11.9 min; p < 0.001) and bilateral repairs (65.95 ± 12.5 min vs 56.35 ± 15.1 min; p < 0.001). LPEC significantly reduced the risk of metachronous contralateral hernia (MCLH) (0.52% vs 9.29%; p < 0.001), but the recurrence rate was higher (0.21% vs 0.04%; p = 0.002) than OH. Orchiectomy due to testicular atrophy or torsion was required in 3 cases of OH (0.19%), whereas it was not seen in LPEC.

CONCLUSIONS

LPEC had a less risk of MCLH and testicular complications but was associated with a higher recurrence rate and longer anesthesia time. Propensity scoring techniques can enhance the robustness of retrospective comparisons between groups over several years of data collection, which is frequently required in pediatric surgery studies.

Laparoscopic versus open herniorrhaphy for children with inguinal hernia: A meta-analysis of randomized controlled trials

PURPOSE

The aim of this study was to compare the effectiveness between laparoscopic herniorrhaphy (LH) and open herniorrhaphy (OH) in children with inguinal hernia.

METHODS

PubMed, EmBase, and the Cochrane library were searched to select trials from their inception till April 2019. The summary of relative risks (RRs) and weighted mean differences (WMDs) with corresponding 95% confidence intervals (CIs) were employed to evaluate the treatment effectiveness between LH and OH.

RESULTS

Six randomized controlled trials (RCTs) including a total of 594 children were selected. No significant differences were observed between LH and OH regarding the risk of postoperative complications. However, LH significantly reduced the risk of major postoperative complications when compared with OH. Moreover, LH showed association with a shorter operative time in bilateral inguinal hernia when compared with OH, whereas no significant difference between groups for unilateral inguinal hernia. Finally, children who received LH showed association with longer time to discharge than those who received OH, whereas no significant difference was observed between the groups for time to resume full activity.

CONCLUSIONS

These findings suggested that children who received LH had protection against major postoperative complications than those who received OH. Moreover, children who received LH had shorter operative time, and longer time to discharge.

Modified percutaneous internal ring suturing with peritoneal injury in children: matched comparison to open hernia repair

BACKGROUND

The aim of this study was to elucidate the outcomes of percutaneous internal ring suture (PIRS) technique for inguinal hernia repair augmented with thermal peritoneal injury compared to open inguinal hernia repair (OHR) in a large population of contemporary pediatric patients. Thermal injury with PIRS has been shown to reduce recurrence in animal models and is increasingly being incorporated into clinical practice.

METHODS

Retrospective review of all PIRS procedures and OHR between Jan-2017 to Sept-2018 was performed. Data regarding patient characteristics, characteristics of the hernia, operative details, postoperative complications, and recurrence were collected. Non-parametric tests were used and p < 0.05 was regarded as statistically significant. 1:1 Propensity score matching was performed using "nearest-score" technique. Matching was done based on age, sex, follow-up time, side of hernia, repair of contralateral hernia, and number of additional procedures.

RESULTS

90 modified PIRS patients were matched to 90 OHRs. Patient demographics, hernia characteristics, and follow-up time were similar between the two groups after matching. There were no differences in recurrence rates (1 vs. 3 in OHR and PIRS, respectively, p = 0.6), complication rates (1 vs. 4 in OHR and PIRS, respectively, p = 0.4), and OR time [44.5 vs. 43 min in OHR and PIRS, respectively, p = 0.8]. There were no intraoperative complications for either technique. For OHR, laparoscopic look was performed in 23%. When successful, it revealed a contralateral PPV (patent processus vaginalis-PPV) in 41% of cases (9.4% of all OHR), all of which were repaired. For the PIRS procedures, a contralateral PPV was found in 25.6%, all of which were repaired. In the unmatched population, OHR had a metachronous hernia rate of 1.8%, none of whom had the contralateral PPV repaired at the original procedure.

CONCLUSIONS

PIRS with peritoneal injury has comparable efficacy and good safety compared to OHR. Recurrence and complication rates should further improve with increasing experience. Future studies should elucidate long term outcomes.

Single-incision approach for bilateral inguinal hernia repair in children: A retrospective study

To introduce the use of a new surgical approach named single-incision bilateral inguinal herniorrhaphy (SBIH) in pediatric surgical population.This was a STROBE-compliant retrospective cohort study using data from 101 patients who had undergone bilateral inguinal herniorrhaphy in our institution. Children with bilateral inguinal hernias without contraindications for surgery, ranging in age from 6 months to 12 years, were included. Fifty-six children with bilateral inguinal hernias underwent SBIH (SBIH group) and 45 patients underwent laparoscopic bilateral inguinal herniorrhaphy (LBIH) (LBIH group). Differences in operative time, postoperative pain, recurrence, and complications between the 2 groups were analyzed. Patient satisfaction with cosmetic result was also investigated using questionnaires.There were no statistically significant differences in operative time (P = .2257), postoperative pain (P = .0607), recurrence (P = .8756), and complications (P = .7467) between the 2 groups. Interestingly, the operation time of girls in SBIH group was significantly shorter than that of the boys in this group (P < .0001), but also shorter than that of girls in LBIH group (P = .0038). Postoperative pain for boys was lower in SBIH group than in the LBIH group (P = .0340). No ascending testis, testicular atrophy, and hydrocele occurred in either group. According to the questionnaire, both procedures had equally high levels of satisfaction for cosmetic results (P = .7531).Initial results show that SBIH for pediatric patients, regardless of gender, is a safe and feasible procedure compared with LBIH with an equally low recurrence rate, few complication, and satisfactory cosmetic outcomes.

Laparoscopic versus open inguinal hernia repair in children: which is the true gold-standard? A systematic review and meta-analysis

PURPOSE

Hernia repair is one of the most common operations performed in children. Traditionally, an open surgical approach has been utilized; however, laparoscopic repair has been gaining favour within the surgical community. We aimed to determine whether open or laparoscopic hernia repair is optimal for pediatric patients by comparing recurrence rates and other outcomes.

METHODS

We searched CENTRAL, MEDLINE, and EMBASE from 1980 onwards, including studies that compared laparoscopic and open repair for pediatric inguinal hernia.

RESULTS

Our initial search yielded 345 unique citations. Of these, we reviewed the full text of 28, and included 21 in meta-analysis. The results showed that patients who underwent laparoscopic surgery were more likely to experience wound infection (p = 0.003), but less likely to experience ascending testis (p = 0.05) and metachronous hernia (p = 0.0002). There were no differences in recurrence rates (p = 0.95), surgical time (p = 0.55), length of hospitalization (p = 0.50), intra-operative injury, bleeding, testicular atrophy, or hydrocele.

CONCLUSION

Laparoscopic and open surgeries are equivalent in terms of recurrence rates, surgical time, and length of hospitalization. Laparoscopic repair is associated with increased risk of wound infection, but decreased risk of ascending testis. Laparoscopic surgery allows the opportunity to explore and repair the contralateral side, preventing metachronous hernia.

LEVEL OF EVIDENCE

III.

Laparoscopic versus open pediatric inguinal hernia repair: state-of-the-art comparison and future perspectives from a meta-analysis

BACKGROUND

Laparoscopic inguinal hernia repair in children is increasingly performed as it allows contralateral inspection and potentially results in shorter operation time and less complications. Evidence from meta-analyses of randomized controlled trials (RCTs) regarding the superiority of laparoscopic versus open hernia repair is lacking.

METHODS

A systematic literature search was performed querying PubMed, Embase, MEDLINE, and the Cochrane Library databases. RCTs comparing laparoscopic with open hernia repair in children were considered eligible, without year and language restrictions. Cochrane Risk of Bias tool was used for quality assessment. Data were pooled using a random-effects model. Subgroup analyses were performed according to the laparoscopic suturing technique (i.e., intracorporeal or extracorporeal).

RESULTS

Eight RCTs (n = 733 patients; age range 4 months-16 years) were included in this meta-analysis. Laparoscopic (LH) and open (OH) hernia repair was performed in 375 and 358 patients, respectively. Complications (seven RCTs, n = 693; pooled OR 0.50, 95% CI 0.14 to 1.79), recurrences (seven RCTs, n = 693; pooled OR 0.88, 95% CI 0.20 to 3.88), and MCIH rates (four RCTs, n = 343; pooled OR 0.28, 95% CI 0.04 to 1.86) were not different between the groups. LH resulted in shorter bilateral operation time (Five RCTs, n = 194; weighted mean difference (WMD) - 7.19, 95% CI - 10.04 to - 4.34). Unilateral operation time, length of hospital stay, and time to recovery were similar. There was insufficient evidence to assess postoperative pain and wound cosmesis, and evidence of substantial heterogeneity between the included studies. Subgroup analyses demonstrated less complications and shorter unilateral operation time for extracorporeal suturing and shorter length of hospital stay for intracorporeal suturing.

CONCLUSIONS AND RELEVANCE

No definite conclusions to decide on the superiority of one of either treatment strategies can yet be drawn from the available literature. There was evidence of substantial heterogeneity and the clinical relevance of most estimated effects is very limited.

Laparoscopic versus open repair for inguinal hernia in children: a retrospective cohort study

PURPOSE

We compared the outcomes of laparoscopic surgery (LS) with those of open surgery (OS) for unilateral and bilateral pediatric inguinal hernia.

METHODS

Using a nationwide claim-based database in Japan, we analyzed data from children younger than 15 years old, who underwent inguinal hernia repair between January 2005 and December 2017. Patient characteristics, incidence of reoperation, postoperative complications, length of hospital stay, and duration of anesthesia were compared between LS and OS for unilateral and bilateral hernia.

RESULTS

Among 5554 patients, 2057 underwent LS (unilateral 1095, bilateral 962) and 3497 underwent OS (unilateral 3177, bilateral 320). The incidence of recurrence was not significantly different between OS and LS (unilateral: OS 0.2% vs. LS 0.3%, p = 0.44, bilateral: OS 0.6% vs. LS 0.6%, p = 1.00). The incidence of metachronous hernias was significantly higher in the OS group than in the LS group (4.8% vs. 1.0%, p < 0.001). The surgical site infection rate was significantly lower after OS than after LS for unilateral surgeries (0.9% vs. 2.2%, p = 0.002). There was no difference between OS and LS in the length of hospital stay.

CONCLUSION

Both OS and LS had a low incidence of recurrence in children; however, the incidence of metachronous hernias was lower for LS, which may influence operative technique decisions.

Outcomes following laparoscopic versus open surgery for pediatric inguinal hernia repair: Analysis using a national inpatient database in Japan

BACKGROUND

This study compared perioperative outcomes between laparoscopic surgery (LS) and open surgery (OS) for pediatric inguinal hernia repair, using a national inpatient database.

METHODS

Using the Diagnosis Procedure Combination database in Japan, we compared duration of anesthesia, postoperative complications, recurrence, and metachronous hernia (MH) between LS and OS for children undergoing inguinal hernia repair from July 2010 to March 2016. We used multivariable logistic regression analysis for postoperative complications and Cox regression analysis for recurrence.

RESULTS

For 75,486 eligible patients (LS 20,186 vs. OS 55,300), the median follow-up was 815 (381-1350) days in LS and 1106 (576-1603) days in OS. The duration of anesthesia was significantly longer in LS than in OS for unilateral surgery (80 vs. 70min, p<0.001) but shorter for bilateral surgery (86 vs. 96min, p<0.001). LS had a lower proportion of MH than OS (0.3% vs. 3.4%, p<0.001). There was no significant difference between LS and OS in complications (odds ratio: 0.55; 95% confidence interval: 0.22-1.38; p=0.20) or recurrence (hazard ratio: 1.24; 95% confidence interval: 0.86-1.79; p=0.89).

CONCLUSIONS

LS patients had lower proportions of MH than OS patients. Complications and recurrence did not differ significantly between LS and OS.

TYPE OF STUDY

Retrospective study.

LEVELS OF EVIDENCE

Level III.

Features and Techniques of Laparoscopic Percutaneous Extraperitoneal Closure for Ovarian Hernia

PURPOSE

The purpose of this report was to evaluate the safety and efficacy of the simple laparoscopic percutaneous extraperitoneal closure (LPEC) method for treating ovarian hernia patients, including newborns and low-birth-weight infants.

METHODS

We retrospectively reviewed the cases of ovarian hernia that were treated in our institution from May 2012 to September 2017.

RESULTS

Thirty-four infants were included in this study (right side, n = 8; left side, n = 22; bilateral, n = 4). The mean corrected age was 2.3 ± 2.8 months and the mean body weight was 4.4 ± 1.6 kg. The contralateral positive rate was 53%, and 34% of the cases showed sliding of the fallopian tube. Umbilical hernias were observed in 24 cases (71%). The mean operative time was 53 ± 20 minutes. The LPEC procedure was successful in 32 cases; two cases were converted to open surgery.

CONCLUSION

Small infants with ovarian hernia have some specific features such as a shortened round ligament and the presence of peritoneum cavities that require skillful techniques when being surgically repaired. The simple LPEC procedure can be performed safely with a low risk of recurrence, even in infants with sliding of the fallopian tube.

Laparoscopic radical cystectomy with pelvic re-peritonealization: the technique and initial clinical outcomes

Background

Delayed bowel function recovery and postoperative ileus are relatively serious complications of laparoscopic radical cystectomy (LRC). Our study aimed to determine whether performing pelvic re-peritonealization reduces the incidence of these complications.

Methods

Clinical data of 78 patients who had undergone LRC with pelvic re-peritonealization from August 2015 to December 2017 were retrospectively collected and compared with those of 92 patients who had undergone LRC alone between January 2013 and July 2015 in our institution. Differences in duration of surgery, estimated blood loss, time to recovery of bowel function, the complications of intestinal and blood vessel injury, and incidence of postoperative ileus between the two groups were analyzed.

Results

Baseline characteristics such as age, sex and BMI were balanced between the two groups. There were no significant differences in duration of surgery (P = 0.072), estimated blood loss (P = 0.717), or incidence of intestinal obstruction (P = 0.225) between the two groups. Interestingly, patients who had undergone pelvic re-peritonealization recovered bowel function more rapidly than those had not (2.79 d vs. 3.72 d, P = 0.001). Additionally, hospitalization stay was significantly shorter for patients with re-peritonealization than for those without (5.46 d vs. 6.68 d, P = 0.029).

Conclusions

Compared with LRC alone, LRC with pelvic re-peritonealization as described in the present study had comparable perioperative complications, but was associated with more rapid gastrointestinal recovery and shorter hospitalization stay.

Comparison of laparoscopic and open pediatric inguinal hernia repairs at two institutions

BACKGROUND/PURPOSE

The proposed benefits of laparoscopic inguinal hernia repair in the pediatric population include easier access to the contralateral groin and avoidance of manipulation of the spermatic cord; however, some studies also report higher recurrence rates. Due to these differences, the traditional open technique is still used by many pediatric surgeons. The objective of this study is to compare the outcomes of two institutions that employed different techniques.

METHODS

We retrospectively reviewed pediatric patients who had open repair of inguinal hernias at hospital A or laparoscopic repair at hospital B. Data collection included age of patients, laterality, operative time, and complications.

RESULTS

From 2010 to 2015, 154 patients underwent open repair at hospital A and 220 patients underwent laparoscopic repair at hospital B. The mean operative time was 52 min for the open technique and 23 min for the laparoscopic technique (p < 0.01). There were 2.6% complications and 0.65% recurrences with the open technique, compared to 4.6% complications and 2.7% recurrences with the laparoscopic technique (p > 0.2).

CONCLUSION

Laparoscopic hernia repairs at hospital B are associated with shorter operative times and have similar outcomes as open repairs at hospital A. A prospective study with both techniques done at the same institution is warranted.

Laparoscopic inguinal hernia repair by modified peritoneal leaflet closure: Description and initial results in children

INTRODUCTION

Inguinal hernias are common in infants and children. While the gold standard for hernia repair in the pediatric period has been via an open inguinal incision with dissection and high ligation of the hernia sac, over the past two decades laparoscopic herniorrhaphy has increased in popularity. The advantages of laparoscopy include decreased post-operative pain, improved cosmetic results, ability to easily assess the contralateral side for an open internal inguinal ring, and decreased risk of metachronous hernias. Herein, we describe a modified laparoscopic herniorrhaphy using a peritoneal leaflet closure and report our operative experience with intermediate-term results.

METHODS

We retrospectively reviewed our IRB-approved registry for all children who underwent initial laparoscopic herniorrhaphy at our tertiary care center over a 2.5-year period. All surgeries were performed by a single surgeon using a technique we have termed the peritoneal leaflet closure. This technique involves incising the peritoneum circumferentially around the open internal ring and developing peritoneal leaflets which are then closed together over the ring with a running non-absorbable barbed stitch (Figure). Intraoperative findings and complications, operative times, and post-operative complications were reviewed for all children.

RESULTS

A total of 50 initial laparoscopic hernia repairs (4 bilateral, 42 unilateral) were performed in 46 children (43 boys, 3 girls) at a median age of 5.9 years (range 0.5-16.7). Median operative time was 73 min (range 48-138) for unilateral and 106 min (range 104-135) for bilateral herniorrhaphy. No patient had an intraoperative complication. Two children (4%) had contralateral open rings discovered at time of surgery and underwent unplanned bilateral laparoscopic hernia repair. All patients went home on the same day as the procedure and three children (6%) had minor post-operative complaints (umbilical bulge, thigh pain, and urine holding) that all self-resolved. Thirty-nine children had follow-up data available. Intermediate-term complications occurred in two children (5%): one boy developed a contralateral hydrocele (despite a closed ring at surgery) and one boy had a hernia recurrence that required open repair. Overall, operative success with the modified peritoneal leaflet closure technique was therefore 97% (38 of 39 children with follow-up). All 37 boys who followed up had bilateral descended testes of normal size and consistency.

CONCLUSIONS

Laparoscopic herniorrhaphy using a peritoneal leaflet closure technique is safe and effective when used in infants and children to close an indirect hernia (i.e. patent processus vaginalis). No intraoperative complications occurred in this cohort and success rate was 97%.

Experience with peritoneal thermal injury during subcutaneous endoscopically assisted ligation for pediatric inguinal hernia

BACKGROUND

Subcutaneous endoscopically-assisted ligation (SEAL) for pediatric inguinal hernia repair has gained in popularity although variations in techniques exist. Peritoneal scarring by thermal injury has been described as an adjunct. We explored the hypothesized inverse-correlation between peritoneal scarring and recurrence after SEAL.

METHODS

We conducted a single-center retrospective review of all patients <18years old undergoing SEAL between 2010 and 2016 (REB-20172727). Demographics and outcomes were investigated. Univariate and multivariable logistic regressions were performed to evaluate the association between peritoneal scarring and recurrence.

RESULTS

We identified 272 patients. Median age was 3years, 35% were female, and 19% were born premature. Median follow-up was 30months, ≥1 visit/patient. Bilaterality was noted in 35%. There were no reported cases of metachronous hernia, vas injury, testicular atrophy or chronic pain, and recurrence rate was 4.6%. Prematurity, unilateral repair, incarceration, and suture-type (Ti-Cron® vs. Ethibond®) had significant correlation with recurrence on univariate analysis (p<0.25). Surgeon experience did not. Peritoneal scarring, performed in 195 cases (72%), was not predictive of recurrence (adjusted OR=0.87, p=0.830) on multivariable analysis.

CONCLUSION

The rate of complications with SEAL compares favorably to published data. Thermal injury was not associated with improved recurrence rates. The benefits of peritoneal scarring may not outweigh the risks.

LEVEL OF EVIDENCE

III - Retrospective Case-Control Study.

Algorithm of Laparoscopic Technique in Pediatric Inguinal Hernia: Results from Experience of 10 Years

BACKGROUND

Many laparoscopic techniques have been evolved along years for pediatric inguinal hernia (PIH) with no standardization of technique. No single technique suits all varieties of hernia.

PURPOSE

To propose an algorithm for allocation of PIH to laparoscopic technique based on internal ring (IR) diameter to improve outcomes.

PATIENTS AND METHODS

Along 10 years, 459 cases with unilateral PIH were treated in Tanta University Hospital. In the first 5 years (phase I), 214 cases included then an algorithm for stratification was designed and applied in the second 5-year period (phase II), where 245 cases managed. This algorithm included evaluation of the hernia based on IR diameter as measured by the laparoscope from inside by a piece of suture. When the IR diameter is from 4 to 15 mm, complete sac disconnection is used. When IR diameter lies from 15 to 25 mm a purse string is added. When IR diameter is >2.5 cm or recurrent cases, the interrupted muscular arch repair after sac disconnection is used.

RESULTS

In phase I, 170 boys and 44 girls from 6 to 180 months of age were treated. All cases managed by laparoscopy were 84 herniotomy, 82 by purse string, and 44 by interrupted muscular arch. In phase II, 180 boys and 65 girls from 3 to 180 months of age were included. Eighty were managed by herniotomy, 137 by purse string, and 25 by interrupted muscular arch. Recurrence rate decreased significantly in phase II.

CONCLUSIONS

Application of Tanta algorithm reduces the recurrence rate significantly. The laparoscopic technique should be tailored according to criteria of each group of PIH to get the best outcome and reduced recurrence rate.

Single-center, retrospective study of the outcome of laparoscopic inguinal herniorrhaphy in children

Laparoscopic hernia repairs are used increasingly in children.The purpose of this single-center cohort observational research study was to analyze the outcome of children treated surgically for unilateral or bilateral inguinal hernia using laparoscopy.We did a STROBE-compliant retrospective outcome analysis of pediatric, laparoscopic hernia repair. Consecutive laparoscopic herniorrhaphies in 123 children done between March 2, 2010, and March 1, 2014, were included in this analysis. Data analysis was based on reviewing the hospital records and a prospective questionnaire. We evaluated postoperative hernia recurrence rate, occurrence of postoperative complications, duration of postoperative pain medication, and wound cosmesis.We first performed laparoscopic inguinal herniorrhaphy according to the techniques described by Schier et al and Becmeur et al in March 2010. We treated 46 girls and 77 boys with laparoscopically confirmed inguinal hernias, and their ages ranged from 0 to 16 years. Of these, 77 children suffered from unilateral hernias, 30 from unilateral hernias with contralateral patency of the vaginal process, and 16 from indirect bilateral hernias. The median follow-up interval was 38 months (range: 13-58 months). Overall, 8 (6.5%) of these 123 patients experienced a recurrence of the inguinal hernia. Two patients (1.6%) suffered a postoperative infection. Postoperative pain medication was administered by parents for 1 to 3 days in 67 (63.8%) of the 105 families who answered the question, and no pain medication was administered by 5 (4.0%) parents. Wound cosmesis was rated by the parents as invisible or barely visible in 106 (86.2%) of 123 patients and esthetically disturbing in 4 (3.2%) children.Laparoscopic inguinal hernia repair carries a learning curve and is safe and efficient in children thereafter. Further prospective studies are required to evaluate the long-term outcome of laparoscopic inguinal hernia repair in children.