Minilaparoscopic herniorrhaphy with hernia sac transection in children and young adults: a preliminary report

Laparoscopic Sac Disconnection and Peritoneal Closure of Pediatric Inguinal Hernia

Background: Laparoscopic sac disconnection and peritoneal closure represents an alternative to open pediatric hernia repair. We performed a retrospective review of our data to evaluate this alternative method. Materials and Methods: With REB approval, a retrospective chart review of all patients who underwent laparoscopic indirect inguinal hernia repair between June 2013 and July 2016 was conducted. Primary outcome was the recurrence rate. Secondary outcomes included length of surgery, postoperative hydrocele, and perioperative complications. Data were extracted from EPIC Hyperspace onto a standardized data extraction form. Results: A total of 243 patients were included, of which 82% were males. Age ranged from 1 month to 17 years of age. A total of 322 defects were repaired. Eighty (32%) had contralateral patent processus vaginalis. Twelve (4%) patients presented with incarceration and three (1.2%) had a direct inguinal hernia defect. Recurrence rate was 0.6% (n = 2). There were no intraoperative complications. Operative time was an average of 40 and 54 minutes for unilateral and bilateral repairs, respectively. No testicular ascents, testicular atrophy, vas deferens injury, postoperative hydroceles, and wound infections were reported. Conclusion: Laparoscopic sac disconnection and peritoneal closure of pediatric inguinal hernia is a safe, feasible method with one of the lowest reported recurrence rate among the other laparoscopic methods.

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 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 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.

Needlescopic Disconnection and Peritoneal Closure for Pediatric Inguinal Hernia Repair: A Novel Technique

BACKGROUND

There are many laparoscopic techniques for pediatric congenital inguinal hernia repair. Needlescopic surgery was introduced recently in pediatric patients aiming at getting excellent cosmetic outcomes.

PURPOSE

The aim of this study was to describe a novel technique for needlescopic inguinal hernia repair in children.

PATIENTS AND METHODS

Needlescopic division of the hernial sac was carried out on 369 children in 6 pediatric tertiary centers during the period from August 2016 to May 2019. All hernias were repaired by a novel needlescopic procedure that replicates all the steps of the open herniotomy.

RESULTS

A total of 369 patients with 410 hernias were included in this study. They were 232 (62.9%) males and 137 (37.1%) females, with a mean age of 3.58±1.26 (range=2 to 8 y) and mean internal inguinal ring diameter was 13.65±3.85 mm (range=8 to 20 mm). The mean operative time was 23.36±4.67 minutes for bilateral and 14.28±2.98 minutes for unilateral cases. All cases were completed without conversion to conventional laparoscopy. All cases were followed up for a mean of 19.6±3.2 months. None of our patients developed recurrence or testicular atrophy and the scars were nearly invisible 3 months postoperatively.

CONCLUSIONS

Needlescopic pediatric inguinal hernia repair using disconnection of the hernia sac at internal inguinal ring with purse-string suture closure of peritoneum is feasible and safe with no recurrence and with outstanding cosmetic results.

Laparoscopic Inguinal Hernia Repair in Children: To Cut or Not to Cut is the Question?

Context:

Laparoscopic repair of pediatric inguinal hernia is gaining popularity, however there is no consensus about the technique of operation.

Aims:

The aim of the study was to compare the results and complications of two techniques of laparoscopic pediatric hernia repair.

Settings and Design:

This retrospective study was conducted at the Department of Pediatric Surgery in All India Institute of Medical Sciences (AIIMS), Jodhpur.

Subjects and Methods:

All children who underwent laparoscopic inguinal hernia repair at AIIMS, Jodhpur, during the period of September 2016–March 2019 were retrospectively studied. Parameters studied included age, gender, side of hernia, technique used, operating time, complications, and hospital stay. Patients were divided into two groups depending on whether the hernial sac was divided or not divided before taking a purse-string suture.

Statistical Analysis Used:

Student's t-test and Fischer exact test were used to analyze data.

Results:

A total of 114 patients were included in the study. The median age was 36.4 months. Hernial sac was divided before suturing in 53 patients, while sac was left intact in 61 patients. The mean follow-up was 11.4 months (range: 4–16). Age, gender, side of hernia, complications, and hospital stay were comparable in both groups. There was a significant difference between the mean operating duration in patients who underwent division of hernia sac compared to patients in whom the sac was not divided before putting purse-string suture (92.5 min [45–150] vs. 65.7 [30–90], respectively, P = 0.0101). Hernia recurrence (3.8% in Group A vs. 1.6% in Group B) was comparable in the two groups.

Conclusions:

Laparoscopic pediatric hernia repair done with or without dividing the peritoneal sac gives comparable results, however operative duration is less if sac is not divided.

A 9-year experience study of single-port micro-laparoscopic repair of pediatric inguinal hernia using a simple needle

Purpose

As laparoscopic techniques and equipments improve, laparoscopic inguinal hernia repair has been gaining popularity. The objective of the study was to summarize 9 years of experience using a single-port micro-laparoscopic approach to repair pediatric inguinal hernias with a simple hernia needle.

Methods

1880 children with inguinal hernias were enrolled using micro-laparoscopic surgery between June 2009 and 2018. All patients underwent high ligation surgery using a single-port micro-laparoscopic technique. The clinical data were retrospectively analyzed.

Results

All micro-laparoscopic surgeries were successfully performed in the 1880 patients, who ranged in age from 2 months to 14 years (3.66 ± 2.96 years) including 1622 males and 258 females. Among them, 1299 cases were unilateral hernias and 581 cases were bilateral hernias. The average operating time was 12.5 ± 3.5 min for a unilateral hernia and 20.5 ± 4.5 min for bilateral hernias. All patients were discharged 1–2 days after surgery, and the average length of their hospital stay was 2–4 days. Complications of knot reaction and pneumoscrotum occurred in 5 cases (0.27%) and 54 cases (2.87%), respectively, but these cases were properly managed, with no major impact on the operational outcomes. All patients were followed up for 3–65 months; there were 13 recurrent cases (0.69%).

Conclusions

Single-port micro-laparoscopic herniorrhaphy in children using a simple hernia needle is a reliable and minimally invasive procedure.

Our Laparoscopic Surgical Technique and Experience in Treating Pediatric Inguinal Hernia Over the Past Decade

Background:

Over the past decade, laparoscopic hernia repair was the most performed operation in our department. Equally, it compromises 15% of all pediatric operations performed. We aim, in this study, to review all the cases performed and extrapolate important information like reoccurrences, the incidence of metachronous inguinal hernia, complications amongst other information.

Material and Methods:

All patients under the age of 18 whom underwent elective laparoscopic hernia repair between 03/01/2007 till the 18/05/2016 were included in our study. We recorded important clinical features and studied their post-operative follow up. Equally reoccurrences, the incidence of metachronous inguinal hernia, complications and other parameters were recorded and studied.

Results:

A total of 916 patients were operated on during the defined study period. There was a 0.17% reoccurrence rate and a 0.46% incidence of metachronous inguinal hernia. Equally a contralateral patent processus vaginalis was diagnosed and closed in 17.10%. There were no postoperative complications and we had a 0% postoperative hydrocele rate.

Conclusion:

Laparoscopic hernia repair is safe and carries all the benefits of minimally invasive surgery. We recommend that it is offered to patients and would like to refute previously claimed reports that it carries a higher reoccurrence rate or takes a long time to perform. Our reoccurrence rate of 0.17% is actually lower than many published reoccurrence rates after open repair.

Preliminary Assessment of a Dry-Lab Model for Laparoscopic Percutaneous Inguinal Ring Suture Training

INTRODUCTION

Laparoscopic percutaneous inguinal ring suturing (PIRS) is a valuable technique to repair indirect inguinal hernias in children. The aim of the study was to show the preliminary results of training in an easy-to-build dry-lab model for laparoscopic PIRS technique.

MATERIALS AND METHODS

The dry-lab model consists of two surgical gloves (being the smaller inside the larger). The entry of the glove is tied with a rubber letting a 5-mm trocar within it (optic). Carbon dioxide is inflated through the trocar at 8 mmHg pressure. The four long fingers of the glove simulate four internal inguinal rings. Eighteen participants without significant laparoscopic experience were asked to visualize a video showing a laparoscopic PIRS performed in a 4-year-old girl with a right inguinal hernia followed by a video showing the same technique performed in our dry-lab model. They were then asked to repeat the procedure in each of the four fingers, and the procedures were recorded. Two surgeons using the task-specific checklists (TSCs), global rating scale of operative performance (GRS), and time for the whole procedure evaluated the performance blindly.

RESULTS

We found significant improvement in median TSC (P < .05) and median GRS each time the procedure was repeated (P < .05). There was significant shortening each time the procedure was repeated (P < .05), except between the third and fourth finger (P = .068).

CONCLUSION

Our dry-lab model might be a good option for starting laparoscopic PIRS training.

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.

Fifteen Years Experience with Laparoscopic Inguinal Hernia Repair in Infants and Children

BACKGROUND

Laparoscopic inguinal hernia repair (LIHR) is gaining popularity with more studies validating its feasibility, safety, and efficacy. The aim of this work is to review our experience with LIHR in infants and children during the past 15 years, and present and evaluate our innovations of laparoscopic techniques.

PATIENTS AND METHODS

A retrospective study of 1284 patients with congenital inguinal hernia (CIH) subjected to different techniques of LIHR from October 2000 to October 2015. The main outcome measurements included the following: operative time, hospital stay, hernia recurrence, hydrocele formation, testicular atrophy, iatrogenic ascent of the testis, and cosmetic results.

INCLUSION CRITERIA

All patients with CIH who were managed by LIHR during the period of study. They were bilateral cases, recurrent hernias, unilateral hernia in obese child, unilateral hernia with associated infantile umbilical hernia, and unilateral hernia with questionable contralateral side.

RESULTS

A total of 1284 patients with CIH were corrected with different laparoscopic procedures. They were 918 males and 366 females. The age range was variable from 6 to 78 months (mean 28.32 ± 24.46 months). All cases were completed laparoscopically without major intraoperative complications. Contralateral hernial defects were found in 294 patients (22.90%), a direct inguinal hernia (IH) was discovered in 15 patients (1.17%), and a femoral hernia was discovered in 3 patients (0.23%). Recurrence occurred in 9 boys (0.98%) who were among the early cases; however, in later group, no recurrence had been detected. Hydrocele occurred in 19 cases (males) (2.07%), without detection of testicular atrophy or iatrogenic ascent of the testis.

CONCLUSION

Our results lead us to believe that LIHR by expert hands is safe and effective. It enables the surgeon to discover and repair contralateral hernia and all forms of IHs. One should be able to tailor a suitable technique for each case according to the resources and expertise.

Laparoscopic pediatric inguinal hernia repair: a controlled randomized study

BACKGROUND

Inguinal hernia repair is one of the most frequently performed surgical procedure in infants and young children. Laparoscopic hernia repair in infancy and childhood is still debatable. There are many techniques available for laparoscopic hernia repair in pediatrics. The aim of the study is to compare laparoscopic intracorporeal purse-string suture ligation of the hernia defect leaving the sac intact versus disconnection of the hernia sac with intracorporeal suturing of proximal part.

PATIENTS AND METHODS

A prospective controlled randomized study of laparoscopic repair of congenital inguinal hernia (CIH) was conducted over a period of 2years and 8months from April 2014 to December 2016. All patients were randomized into two equal groups: Group I (n=66) received intracorporeal purse string suture ligation of the hernia sac at internal inguinal ring [IIR] leaving the sac intact; and Group II (n=66) received disconnection of the hernia sac with intracorporeal suture of proximal part at IIR.

INCLUSION CRITERIA

Male patient with bilateral CIH, questionable other side, cases of CIH associated with umbilical hernia and parental request.

EXCLUSION CRITERIA

Recurrent cases, complicated cases, hernia of canal of Nuck in females, inguinal hernia with undescended testis, parental refusal. The main outcome measurements were operative time, postoperative hydrocele formation, recurrence rate.

RESULTS

This study included 132 patients with 157 hernia defects. Their age ranged from 6months to 3years. Statistically significant differences regarding the demographic data of the groups. All cases were completed successfully without conversion. There was no statistically significant difference between groups regarding intraoperative complications and hospital stay. There was statistically significant difference in the operative time and post-operative complications between the studied groups.

CONCLUSIONS

Laparoscopic inguinal hernia repair by disconnection of the hernia sac at the IIR with peritoneal closure is safe and feasible method. It has a lower recurrence rate than the purse string suturing leaving the sac intact.

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

PURPOSE

Laparoscopy is being increasingly applied to pediatric inguinal hernia repair. In younger children, however, open repair remains preferred due to concerns related to anesthesia and technical challenges. We sought to assess outcomes after laparoscopic and open inguinal hernia repair in children less than or equal to 3 years.

METHODS

A prospective, single-blind, parallel group randomized controlled trial was conducted at three clinical sites. Children ≤3 years of age with reducible unilateral or bilateral inguinal hernias were randomized to laparoscopic herniorrhaphy (LH) or open herniorrhaphy (OH). The primary outcome was the number of acetaminophen doses. Secondary outcomes included operative time, complications, and parent/caregiver satisfaction scores.

RESULTS

Forty-one patients were randomized to unilateral OH (n = 10), unilateral LH (n = 17), bilateral OH (n = 5) and bilateral LH (n = 9). Acetaminophen doses, LOS, complications, and parent/caregiver scores did not differ among groups. Laparoscopic unilateral hernia repair demonstrated shorter operative time, a consistent finding for overall laparoscopic repair in univariate (p = 0.003) and multivariate (p = 0.010) analysis. No cases of testicular atrophy were documented at 2 (SD = 2.7) years.

CONCLUSION

Children ≤3 years of age in our cohort safely underwent LH with similar pain scores, complications, and recurrence as OH. Parents and caregivers report high satisfaction with both techniques.

Laparoscopic management of recurrent inguinal hernia in childhood

BACKGROUND

Open repair of recurrent inguinal hernias [RIH] in infancy and childhood is difficult and there is definite risk of damaging the vas deferens and testicular vessels. Laparoscopic repair of RIH has the benefit of avoiding the previous operative site. The aim of this study is to present our experience with laparoscopic repair of RIH either after open or laparoscopic hernia repair with stress on technical refinements to prevent recurrence.

PATIENTS AND METHODS

This is a retrospective study of laparoscopic repair of RIH. Records of 38 patients with 42 recurrent hernial defects that have been subjected to laparoscopic inguinal hernia repair [LIHR] for RIH were reviewed and evaluated. The primary outcome measurements of this study include; operative time and recurrence rate. The secondary outcomes include intraoperative and postoperative complications, hydrocele formation and testicular atrophy.

RESULTS

In this study 38 children with 42 recurrent hernial defects [4 patients had bilateral recurrent hernia] were operated upon laparoscopically. They were 34 males and 4 females with a mean age of 2.54±1.989years (range=0.58-10.00years). In 35 hernial defects the recurrence developed after open herniotomy, while in 7 hernial defects it occurred after laparoscopic repair. All procedures were completed laparoscopically without any conversion and there were no intraoperative or postoperative complications during this study. Mean operating time was 15±2.3minutes for unilateral and 20±1.7minutes for bilateral inguinal hernia. All patients achieved full recovery and were discharged on the same day of admission. Two patients developed hydroceles that responded well to conservative management. At mean follow-up of 12.7±2months (range=8-38.4months), there was no recurrence, no testicular atrophy.

CONCLUSION

Laparoscopic repair of RIH in infancy and childhood is an attractive option that avoids the difficulties of redo surgery in scarred operative field with delicate structures liable to injury even with expert operator.

Single-port laparoscopic percutaneous double ligation for pediatric inguinal hernias: report of a new technique and early results

PURPOSE

Several single-port laparoscopic hernial repair methods have been designed to treat inguinal hernia in children, but reliable and safe ligation of the hernial sac should be further investigated. This study aimed to investigate a new technique for laparoscopic percutaneous double ligation for pediatric inguinal hernias with a set of home-made instruments.

METHODS

Before each operation, a set of home-made instruments were prepared, including a curved puncture needle, a lasso suture, a dual ligation suture, and occasionally, a flat-headed puncture needle for obese patients. After a series of operational steps, the hernial sac was doubly extracorporeally ligated, leaving only one puncture point in the inguinal region and one incision in the navel.

RESULTS

Between October 2011 and September 2013, 236 children (211 boys and 25 girls) underwent hernial repair using this novel technique. In 38.8 % (85/219) of patients with the preoperative diagnosis of unilateral inguinal hernia, contralateral patent processus vaginalis was confirmed during the laparoscopic surgery and subsequent repair was performed. In 134 cases of unilateral repair, the mean operative time was 11 min (range 5-16 min), and it was 19 min (range 13-29 min) in 102 cases of bilateral repair. No recurrence or complications have been observed to date.

CONCLUSIONS

This study shows a unique technique of percutaneous double ligation of the hernial sac using a minimally invasive technique with the aid of a transabdominal 5-mm telescope and a set of home-made instruments. Single-port laparoscopic hernial repair using this technique is feasible and appears to be safe.

Laparoscopic repair of hernia in children: Comparison between ligation and nonligation of sac

Aim:

The essence of the current techniques of laparoscopic hernia repair in children is suture ligation of the neck of the hernia sac at the deep ring with or without its transection. Some studies show that during open hernia repair, after transection at the neck it can be left unsutured without any consequence. This study was aimed to see if the same holds true for laparoscopic hernia repair.

Materials and Methods:

Sixty patients (52 boys and eight girls, 12-144 months) with indirect inguinal hernia were randomized for laparoscopic repair either by transection of the sac alone (Group I) or transection plus suture ligation of sac at the neck (Group II). Outcome was assessed in terms of time taken for surgery, recurrence, and other complications.

Result:

Thirty-eight hernia units in 28 patients were repaired by transection alone (Group I) and 34 hernia units in 29 patients were repaired by transection and suture ligation (Group II). Three patients were found to have no hernia on laparoscopy. Recurrence rate and other complications were not significantly different in the two groups. All recurrences occurred in hernias with ring size more than 10 mm.

Conclusion:

Laparoscopic repair of hernia by circumferential incision of the peritoneum at the deep ring is as effective as incision plus ligation of the sac.

Single-port laparoscopic extraperitoneal repair of pediatric inguinal hernias and hydroceles by using modified Kirschner pin: a novel technique

BACKGROUND

The development of laparoscopic processus vaginalis repair has provided an alternative approach to the management of inguinal hernia and hydroceles in children. Here we describe our new technique for laparoscopic extraperitoneal ligation of processus vaginalis with subumbilical single-port using a modified Kirschner pin.

METHODS

A 5-mm trocar for an operative laparoscope was placed through an infraumbilical incision. A Kirschner pin with a hole in one flat terminal was inserted at the point of the internal inguinal ring. The processus vaginalis was closed extracorporeally by a non-absorbable suture, which was introduced into the abdomen through the Kirschner pin performing dissection within the extraperitoneal space in a series of movements. When a contralateral patent processus vaginalis is present, laparoscopic-assisted extracorporeal ligation is performed during the same operation.

RESULTS

Between September 2010 and September 2012, 211 children (130 cases of inguinal hernia and 81 cases of hydrocele) underwent processus vaginalis repair using this novel technique. A contralateral patent processus vaginalis was present and thus simultaneously closed in 20 patients with unilateral inguinal hernias and 12 patients with unilateral hydroceles. The mean operative time was 18 min (8-35 min). The mean follow-up period is 12 months (range 5-24 months), and no recurrence and complications has been observed to date.

CONCLUSIONS

This article describes a unique technique of extracorporeal circuit ligation of processus vaginalis using a minimally invasive technique as afforded by a reused modified Kirschner pin. Single-port laparoscopic processus vaginalis repair using this instrument is feasible and seems to be safe.

Comparative mid-term results between inguinal herniotomy and single-port laparoscopic herniorrhaphy for pediatric inguinal hernia

BACKGROUND

Some recent papers have advocated single-port laparoscopic herniorrhaphy and obtained satisfactory results. The aim of this study was to compare the mid-term outcomes of conventional inguinal herniotomy and single-port laparoscopic herniorrhaphy.

METHODS

Between April 2007 and March 2009, 202 records of infants and children with inguinal hernia treated were retrospectively reviewed. Of them, 86 patients were treated by conventional inguinal herniotomy (IH group), and 116 patients by single-port laparoscopic herniorrhaphy with preperitoneal hydrodissection, a totally extraperitoneal enclosing suture and extracorporeal knot tying (LH group). Follow-up data were collected using a telephone questionnaire and last outpatient follow-up.

RESULTS

Mean follow-up was 35.7±7.2 months. Both procedures could achieve compete repair without recurrence. Operation time of unilateral repair was significantly longer in the LH group than in the IH group (40.1 vs. 20.0 min; P<0.001); however, operation time of bilateral repairs was comparable in both groups (46.0 vs. 37.5 min; P=0.291). Metachronous hernia developed in 6 of 80 patients (7.5%) initially presenting with unilateral hernia in the IH group and in no patient in the LH group (P=0.005).

CONCLUSIONS

Accompanied by the method of preperitoneal hydrodissection and a totally extraperitoneal enclosing suture, single-port laparoscopic herniorrhaphy would be an effective procedure as conventional inguinal herniotomy. Single-port laparoscopic herniorrhaphy was associated with long operation time and a reduction in contralateral hernia development. However, every 4 patent processus vaginalis would require intervention to prevent 1 metachronous hernia.

Laparoscopic Hernia Repair versus Open Herniotomy in Children: A Controlled Randomized Study

Background. Laparoscopic hernia repair in infancy and childhood is still debatable. The objective of this study is to compare laparoscopic assisted hernia repair versus open herniotomy as regards operative time, hospital stay, postoperative hydrocele formation, recurrence rate, iatrogenic ascent of the testis, testicular atrophy, and cosmetic results. Patients and Methods. Two hundred and fifty patients with inguinal hernia were randomized into two equal groups. Group A was subjected to laparoscopic inguinal hernia repair. Group B was subjected to open herniotomy. The demographic data were matched between both groups. Assessment of the testicular volume and duplex assessment in preoperative, early, and late postoperative periods were done. Results. All cases were completed successfully without conversion. The mean operative time for group A was 7.6 ± 3.5 minutes, 9.2 ± 4.6 minutes and 11.4 ± 2.7 minutes, for unilateral hernia, unilateral hernia in obese child, and bilateral hernia, respectively. The recurrence rate was 0.8% in group A, whereas in group B the recurrence rate was 2.4%. Conclusion. Laparoscopic hernia repair by RN is an effective line of hernia repair. It resulted in marked reduction of operative time, low rate of recurrence, no testicular atrophy, no iatrogenic ascent of the testis, and excellent cosmetic results.

Laparoscopic herniotomy in children: prospective assessment of tertiary center experience in a developing country

PURPOSE

We aimed to assess prospectively the feasibility and outcome of laparoscopic herniotomy (LH) in children in a tertiary center with limited resources.

METHODS

Fifty-six children with unilateral pediatric inguinal hernia (PIH) were treated for an 18-month period. All cases were subjected to LH in a way similar to the classic open technique following exploration of the contralateral patent processus vaginalis (CPPV) without ligation of the sac. Exclusion criteria included prematurity, age <6 months, irreducible or recurrent hernia, and cases with internal ring diameter >2 cm. Operative findings, postoperative results, and complications were assessed.

RESULTS

We have 56 cases presented with unilateral PIH, and they are aged between 6 months and 15 years. Thirty-two presented with Rt hernia including 12 associated with CPPV and 24 cases Lt hernia with 10 associated with CPPV. Two cases showed adhesions and 2 cases showed direct defects that were repaired in the same session. Hydrocele of the hernia sac was reported once. In the total of 78 hernias, the mean operative time was 20.5 min in unilateral cases and 42.5 min in bilateral cases. No conversion was reported. Postoperative pain lasts for a mean time of 11.2 h. Patients regained peristalsis by a mean of 7 h. Two cases developed wound infection and were treated conservatively. No case of recurrence, testicular atrophy, or hydrocele was reported in the mean follow-up period of 20.5 months.

CONCLUSIONS

Laparoscopic herniotomy is feasible and safe for PIH. It provides a superior tool to diagnose CPPV or rare hernias that can be managed in the same session with minimal postoperative complications reported even in developing countries. Laparoscopic herniotomy is proved to be beneficial for PIH since it provides an excellent view on the cord structures, and they can be guarded well during the procedure. Larger studies and longer follow-up are needed to support our encouraging results.

Laparoscopic approach for inguinal hernia in children: resection without suture

BACKGROUND/PURPOSE

The laparoscopic treatment of inguinal hernia in children presents a higher frequency of relapse when suture technique procedures are used. Here, we present an alternative technique consisting of laparoscopic resection of the hernia sac without suture according to the physiopathology of pediatric inguinal hernia.

METHODS

In prospective studies from June 2006 to January 2011, pediatric patients with a diagnosis of inguinal hernia were subjected to surgery as follows: resection of the hernia sac without suture was performed with a 3-port laparoscopic approach. Age, surgical time, recurrence, and complications were analyzed.

RESULTS

We analyzed 285 patients, who ranged from 1 month to 15 years old. They included 233 males, and 52 females. A percentage of 31.92 were bilateral (375 inguinal canals). The surgery time ranged from approximately 5 to 12 minutes. They were followed up 6 to 55 months, with an optimal evolution in 99.2%. Recurrence was observed in only 2 patients (0.53%), both of whom underwent incomplete resection.

CONCLUSIONS

In this study, we demonstrate that resection of the hernia sac without sutures allows for the treatment of inguinal hernia with a low recurrence rate.

Single-site laparoscopic herniorrhaphy using needle instruments for inguinal hernias in children: a novel technique

We describe our new technique for laparoscopic herniorrhaphy with subumbilical single-site access to treat inguinal hernias in children. First, we inserted a transparent 3-mm trocar and a 2-mm minitrocar at the umbilicus. We then inserted a 3-mm 45° camera through the 3-mm trocar and needle-grasping forceps through the 2-mm trocar. We closed the hernia defect by using a 19-gauge hooked injection needle with a nonabsorbable suture. We treated 11 consecutive female children with inguinal hernia using this operation. The mean operating time was 26.7 min (range 21-36 min) and the procedure was technically successful, without the need for additional trocars, in all 11 patients. There were no intraoperative complications and all the patients were discharged on the same day after the surgery. Single-site laparoscopic herniorrhaphy using needle instruments is feasible and seems to be safe. Further studies are required to determine whether this approach would benefit patient compared with standard laparoscopic herniorrhaphy.

Laparoscopic vs open herniorrhaphy in the management of pediatric inguinal hernia: a systemic review and meta-analysis

PURPOSE

Laparoscopic herniorrhaphy (LH) has been evolved as a minimally invasive technique for pediatric inguinal hernias (PIHs). Considerable debate exists regarding the benefits of LH over conventional open herniorrhaphy (OH). The aim of this review was to critique the current literature to determine the efficacy of LH.

METHODS

Published studies until July 30, 2010, were searched from Medline, Embase, Ovid, Web of Science, and Cochrane databases. Randomized controlled trials (RCTs) and observational clinical studies (OCSs) with a comparison of LH and OH were included. A systemic review and meta-analysis were performed using the odds ratios (ORs) for dichotomous variables and weighted mean differences (WMDs) for continuous variables.

RESULTS

Of 138 studies, 3 RCTs and 4 OCSs were eligible for inclusion criteria, comprising 1543 cases of LH and 657 cases of OH. Compared with OH, shorter operative time for bilateral hernias (WMD = -11.14; 95% confidence interval [CI], -20.61 to -1.68; P = .02) and lower rate of metachronic contralateral hernia (OR, 0.26; 95% CI, 0.09-0.76; P = .01) were noted in LH. However, no significant difference was observed between LH and OH in patients' age, sex, affected side, operative time for unilateral hernias, duration of hospital stay, time to resume full activity, recurrence, and complications.

CONCLUSIONS

Laparoscopic herniorrhaphy is superior to OH in the repair of bilateral PIH and lower rate of metachronic contralateral hernia, with similar operative time for unilateral hernias, length of hospital stay, recurrence, and complication rates. Because of the publishing bias, a series of RCTs with standard report format and uniform unit are necessary to explore the efficiencies of LH in the management of PIH.

Minilaparoscopic herniorrhaphy in pediatric inguinal hernia: a durable alternative treatment tostandard herniotomy

BACKGROUND

The purpose of the article is to report our long-term results of minilaparoscopic inguinal hernia repair in children.

METHODS

Between September 2003 and September 2008, 161 children with inguinal hernia were treated with minilaparoscopic herniorrhaphy. The asymptomatic contralateral internal ring was routinely explored and repaired if a patent processus vaginalis of not less than 2 cm was noted. Patients who were followed for less than 1 year and those who were lost to follow-up were excluded from the study. Intraoperative and postoperative complications and hernia recurrences were documented.

RESULTS

In total, 146 patients were eligible for final analysis. A total of 196 minilaparoscopic herniorrhaphies were performed. The mean follow-up period was 3 years. There were 4 hernia recurrences (2%) in 3 boys. There were no procedure-related complications. None of the patients with a negative contralateral exploration or a contralateral patent processus vaginalis of less than 2 cm had a contralateral metachronous inguinal hernia.

CONCLUSIONS

Our long-term results reveal that minilaparoscopic herniorrhaphy combined with hernia sac transection is a safe and effective alternative treatment to standard open herniotomy.

Laparoscopic pediatric inguinal hernia repair: no ligation, just resection

BACKGROUND

There have been descriptions of several techniques for congenital inguinal hernia (CIH) repair in the pediatric population by doing high ligation of the sac, without a definitive advantage over the open procedure. High recurrence rates have been reported with using these minimally invasive techniques in which the patent processus vaginalis has been ligated and left in place completely or partially.

METHODS

With approval of the ethics committee, a proper informed consent was obtained. During July 2003 to April 2008, we performed the inguinal hernia repair on 91 patients (76 males and 15 females), using a laparoscopic technique in which we completely resected the patent processus vaginalis and the parietal peritoneum surrounding the internal inguinal ring. This allowed the peritoneal scar tissue to close the area of the ring. Also, this scarring occurs in the extent of the inguinal canal where the dissection took place, therefore causing the same peritoneal scarring and sealing of the inguinal floor. In this series, a purse string was done only in the cases with an internal ring wider than 10 mm.

RESULTS

There were no conversions. Operative time was in the range of 35-72 minutes (average, 40). Close follow-up in the clinic has been 5 months to 4 years without a single recurrence. In 4 cases, 3 months later, we did a laparoscopic evaluation of the contralateral side due to associated cryptorchidism, in which we were able to confirm a complete closure of the interior inguinal ring. Two small hematomas were followed until they were gone, without further need for intervention.

DISCUSSION

No recurrences have been observed. We conclude that laparoscopic repair of CIH is feasible using this technique of complete resection of the processus vaginalis and surrounding parietal peritoneum. This series does not conclude on the need for the internal ring to be closed when found to be wider than 10 mm.

A simple single-port laparoscopic-assisted technique for completely enclosing inguinal hernia in children

Single-port endoscopic-assisted percutaneous extraperitoneal closure of inguinal hernia with variable devices is a novel technique in minimal-access surgery for pediatric inguinal hernias. However, a small peritoneal gap of the suture at the location of spermatic vessels and vas deferens may be left untouched, whereas some subcutaneous tissues, including nerves and muscles, may cause injury by their inclusion in the upper portion of the circuit suturing. The technique may fail to entirely enclose the hernia defect and has the potential to lead to higher incidence of hydrocele and hernia recurrence. The authors describe the modification of single-port endoscopic-assisted ligation with a homemade hooked injection needle, which is designed to cause hydrodissection to the preperitoneal space, tautly enclose the hernia defect without upper subcutaneous tissues and a lower peritoneal gap, and aid in the achievement of a near-zero recurrence rate.

Minilaparoscopic nerve-sparing extravesical ureteral reimplantation for primary vesicoureteral reflux: a preliminary report

BACKGROUND

To validate its safety and efficacy, we evaluated our preliminary results of the three-port minilaparoscopic nerve-sparing extravesical ureteral reimplantation for patients with vesicoureteral reflux (VUR).

METHODS

Between July 2005 and February 2007, 9 consecutive patients (4 girls and 5 boys) with a mean age of 3.4 years (range, 7 months to 5 years) underwent a minilaparoscopic nerve sparing extravesical ureteral reimplantation for VUR. A 30-degree 3-mm telescope and two 3-mm trocars were used for the reimplantation. Minimal handling and dissection of the ureter and ureterovescial junction was adhered to spare the nerves.

RESULTS

A total of 14 ureters were reimplanted (4 unilateral and 5 bilateral). Mean follow-up period was 8.7 months. The mean operative time was 170 minutes in unilateral reimplantations and 218 minutes in the bilateral one. There was no intraoperative complication. All patients resumed oral intake in the first postoperative morning. The Foley catheters were removed within 24-36 hours after surgery. None of them had urinary retention after catheter removal. Voiding cystourethrography was done 3-4 months after surgery. A complete resolution of reflux was identified in 11 of 14 units, a downgrading of reflux in 2 of 14 units, and ureterovesical junction stenosis in 1 of 14. Open reimplantation was done for the ureter with postoperative ureterovesical junction stenosis.

CONCLUSIONS

The three-port minilaparoscopic nerve-sparing extravesical ureteral reimplantation was a safe, effective techinique for the treatment of VUR.

One-trocar laparoscopic transperitoneal closure of inguinal hernia in children

BACKGROUND

Laparoscopy is an alternative procedure for pediatric inguinal hernia; however, reported techniques necessitate two or three trocars and excellent intra-abdominal skills. This study was designed to describe and evaluate the preliminary result of one-trocar laparoscopic-assisted transperitoneal closure for inguinal hernia in children.

METHODS

A total of 33 children with inguinal hernia (body weight range, 2270 g to 58 kg) were included in this study from March to November 2007. Under a 5-mm laparoscopic guidance, the hernia defect was enclosed by a nonabsorbable suture, which was introduced into the abdomen by an 18-gauge vascular access on one side of the hernia defect and withdrawn on the opposite side by a homemade hook-pin through a needle puncture wound. Then, extracorporeal knot tying was performed.

RESULTS

A total of 52 procedures were performed, and the mean operating time was 46.2 +/- 16.2 (range, 18-87) minutes. No cauterization was used during the operations and there was no serious operative morbidity. The mean follow-up period was 7.6 +/- 2.5 (range, 4-12) months. No recurrence was observed during this period.

CONCLUSIONS

This easy technique provides the benefits of laparoscopic herniorrhaphy and combines the advantages derived from the novel use of a hook-pin and vascular access simplicity, low cost, safety, minimized tissue trauma, and improved cosmetics. In addition, only one umbilical trocar wound and another needle puncture point were made. Therefore, this procedure is recommended for pediatric inguinal hernia.