Minimal access surgery of pediatric inguinal hernias: a review

Laryngeal Mask Airway as an Appropriate Option in Pediatric Laparoscopic Inguinal Hernia Repair: A Systematic Review and Meta-Analysis

OBJECTIVE

To elucidate the safety and effectiveness of laryngeal mask airway (LMA) use in pediatric patients undergoing laparoscopic inguinal hernia repair.

METHODS

Studies were searched on the PubMed, EMBASE, and Cochrane Library databases. Only randomized controlled trials (RCTs) were included. Primary outcomes were major perioperative respiratory adverse events (PRAEs), namely laryngospasm, bronchospasm, desaturation, and aspiration. Secondary outcomes were minor PRAEs, anesthesia time, and recovery time. A meta-analysis was performed to calculate risk ratios (RR), weighted mean difference (WMD), and 95 % confidence intervals (CI) by using random effects models.

RESULTS

In total, 5 RCTs comprising 402 patients were included. Regarding major PRAEs, laryngospasm (RR: 0.43, 95 % CI: 0.12 to 1.47; p = 0.18), bronchospasm, and aspiration all demonstrated no difference between the laryngeal and endotracheal groups. Desaturation exhibited a trend, but this trend was not sufficiently supported with statistical evidence (p = 0.09). For minor PRAEs, fewer patients experienced incidence of cough after laryngeal mask use (RR: 0.27, 95 % CI: 0.11 to 0.67; p = 0.005). Other PRAE, namely hoarseness (p = 0.06), sore throat (RR: 1.88, 95 % CI: 0.76 to 4.66; p = 0.18), and stridor, did not differ between the 2 groups. Additionally, both anesthesia time (WMD: -6.88 min, 95 % CI: -11.88 to -1.89; p < 0.00001) and recovery time (WMD: -4.85 min, 95 % CI: -6.51 to -3.19; p < 0.00001) were shortened in the LMA group.

CONCLUSION

LMA used in pediatric laparoscopic inguinal hernia repair demonstrated no greater safety risks than endotracheal tube intubation did. Thus, anesthesiologists may shift from conventional endotracheal tube use to LMA use. Moreover, anesthesia and recovery times were shortened in the LMA group, which resulted in more efficient use of the operating room. Because of these benefits, LMA could be an appropriate option for pediatric patients undergoing laparoscopic inguinal hernia repair.

LEVEL OF EVIDENCE

Treatment Study, LEVEL III.

Single-Port Laparoscopic Extraperitoneal Repair of Pediatric Inguinal Hernias and Hydroceles by Using Hernia Crochet Needle With a Cannula

PURPOSE

Numerous modifications laparoscopic techniques have mushroomed in recent years. Here we describe a modified technique of extracorporeal ligation of processus vaginalis in children using a hernia crochet needle with a cannula.

METHODS

Processus vaginalis repair was carried out on patients diagnosed with inguinal hernia or hydroceles using this novel technique between June 2021 and June 2022. The processus vaginalis was closed extracorporeally using a hernia crochet needle with a cannula. In the presence of patent processus vaginalis, the same procedure would be performed on the contralateral side. The primary outcomes was the safety and efficiency of this modified procedure, and the secondary outcomes was the post operative complications.

RESULTS

A total of 212 (165 inguinal hernia and 47 hydroceles) children were corrected by this novel technique. The mean operation time was 27.49 min for unilateral inguinal hernia cases and 36.55 min for bilateral cases. The unilateral hydrocele median operation time was 27.83 min and that for the bilateral cases was 37.30 min. During the mean of 10.92 months of follow-up, there was only a boy subject to a metachronous contralateral occurrence of hernia 10 months after surgery, and no other complications (knot reactions, testicular atrophy, postoperative hydrocele or iatrogenic) have been observed yet.

CONCLUSION

This study shown a unique procedure with using a hernia crochet needle with a cannula to be simple, safe, and effective in managing inguinal hernias and hydroceles in the pediatric population.

Comparison of Laparoscopic Percutaneous Extraperitoneal Internal Ring Closure by Two-Hook Hernia Needle and Open Repair for Pediatric Inguinal Hernia

Purpose: In children, pediatric inguinal hernia (PIH) is a prevalent condition. PIH is currently more frequently managed by laparoscopic closure of the hernia sac. We improved this minimally invasive technique; that is, laparoscopic two-hook hernia needle percutaneous extraperitoneal internal ring closure. Safety and effectiveness were evaluated by comparing the differences between laparoscopic repair (LR) and open repair (OR) in terms of operation time, surgical complications, contralateral metachronous hernia incidence, and recurrence rate. Methods: A retrospective clinical data analysis was performed on pediatric patients who had hernia surgery utilizing the LR or OR method between June 2019 and June 2021. Medical records of all of the children were gathered, and clinical traits, information about the procedure, and follow-up were all analyzed. Results: A total of 370 patients' inguinal hernias were repaired. For 136 patients undergoing OR and 234 patients undergoing LR, all procedures were completed satisfactorily. There were 98 cases of bilateral hernias and 272 cases of unilateral hernias (180 on the right side and 92 on the left). In the LR group, 58 patients who had been initially diagnosed with unilateral hernias developed contralateral occult hernias intraoperatively. Inguinal hernia operations took an average of 13.82 (LR) and 32.07 (OR) minutes for unilateral cases, and 21.00 (LR) and 54.85 (OR) minutes for bilateral cases. For LR and OR, the average follow-up time was 22.41 months and 23.10 months, respectively. The perioperative complications included peritoneal rupture in 3 patients, scrotal edema or hematoma in 5, hydrocele in 3, and groin pain in 6. In the LR group, 1 patient experienced the postoperative recurrence, whereas 8 individuals in the OR group did. Conclusions: Our initial research showed that laparoscopic two-hook hernia needle percutaneous extraperitoneal internal ring closure inguinal hernia repair is a safe and effective procedure. The LR method has the benefits of concealing the incision, a quicker procedure, having a lower risk of complications, and finding contralateral patent processus vaginalis. Therefore, promoting and using this surgical technique in clinical practice are merited. Clinical Trial Registration number: Medical Association of Xiangtan (2022-xtyx-28).

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.

Evolution of outcomes and complications of flip flap laparoscopic repair for inguinal hernia in children: 5 years' experience and practical implication in a third level Italian center

BACKGROUND

Inguinal hernia repair is one of the most common pediatric surgeries that can be approached with an open or laparoscopic approach. The aim of this study was to describe outcomes and complications of flip flap inguinal hernia repair analyzing our experience in the last 5 years.

METHODS

Between 2015 and 2020, 280 children admitted at our department with inguinal hernia requiring surgery were included. Secondary aim was to investigate how confidence of surgeons regarding VLS approach increase during time and how this particular technique represents a primary procedure useful to increase surgeons' skills in performing laparoscopic sutures.

RESULTS

One hundred sixty children (57%) underwent open approach, whereas 120 (43%) laparoscopic ligations of hernia. For each group, clinical and surgical data were recorded. We focused on comparing postoperative complications: the most frequent complication was hydrocele (N.=4, 1.4%). Reported postoperative complication were not statistically different between two groups (open N.=3, 1.8% vs. laparoscopy N.=1, 0.8%). No other postoperative complications were documented in our cohort for both groups. In laparoscopic group we registered 3 cases of ipsilateral recurrence (1.6%) and no cases of metachronous hernia. The choice of laparoscopic approach significantly increased from 22% in 2015 to 74% in 2020 (P<0.05) as well as the percentage of male underwent to laparoscopic procedure (38% in 2015 to 74% in 2020, P<0.05).

CONCLUSIONS

It is known that the rate of complication or recurrence is similar for open or minimally invasive inguinal hernia repair. Laparoscopy offers advantages such as the possibility of visualizing contralateral internal inguinal ring, reducing the incidence of metachronous inguinal hernia. Moreover, taking confidence with a minimally invasive technique such Flip Flap hernioplasty by performing it repeatedly over time, leads to an improvement of surgeons' skills also in performing laparoscopic sutures, that can be helpful for other complex or tricky procedures.

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.

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.

Comparison of intra- and extra-corporeal laparoscopic hernia repair in children: A systematic review and pooled data-analysis

BACKGROUND

Laparoscopic surgery is increasingly used to repair paediatric inguinal hernias and can be divided into intra- or extra-corporeal closing techniques. No statement regarding the superiority of one of the two techniques can be made. This study aims to provide evidence supporting the superiority of intra- or extra-corporeal suturing technique.

METHODS

A systematic literature search was conducted using PubMed, Embase, MEDLINE, and Cochrane Library databases. Randomised controlled trials and prospective studies comparing different laparoscopic techniques were eligible for inclusion. Data were pooled using a random-effects model, comparing single-port extra-peritoneal closure to intra-peritoneal purse string suture closing. Primary outcome was recurrence rate. Secondary outcomes were duration of surgery (min), peri‑ and post-operative complications (i.e. injury of spermatic vessels or spermatic cord, tuba lesions, bleeding and apnoea, haematoma/scrotal oedema, hydrocele, wound infection, iatrogenic ascent of the testis and testicular atrophy), contralateral patent processus vaginalis (CPPV) rate, post-operative pain, length of hospital stay and cosmetic appearance of the wound.

RESULTS

Fifteen studies (n = 3680 patients, age range 0.5-12 years, follow-up range 3-10 months) were included is this systematic review. Intra-corporeal hernia repair was performed in 738 children and extra-corporeal repair was performed in 2942 children. A pooled data analysis could only be performed for the single port extra-corporeal closing technique and the three port intra-corporeal closing technique. We found that recurrence rate was lower in the single-port extra-corporeal closing technique compared to the intra-corporeal purse suture closing technique (0.6% vs 5.5%, 95% CI 0.107 (0.024-0.477); p < 0.001). Operation time was shorter for extra-corporeal unilateral and bilateral inguinal hernia repair compared with intra-corporeal approach, but no pooled data analysis could be performed. Due to the presence of substantial heterogeneity, it was not possible to assess other outcome measures.

CONCLUSION

Single-port extra-corporeal closure seems to result in less recurrent hernias and a shorter operative time compared to intra-corporeal purse suture closing technique. No difference regarding peri‑ and post-operative complications could be found and no statements regarding the length of hospital admission, post-operative pain and cosmetics could be made due to substantial heterogeneity.

LEVEL OF EVIDENCE

Level II.

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 Open Repair and Laparoscopic Percutaneous Internal Ring Suturing Method in Repairing Inguinal Hernia in Children

Introduction

An inguinal indirect hernia is one of the most frequent surgical conditions in children. In this study the experience with laparoscopic percutaneous internal ring suturing (PIRS) and open inguinal hernia surgery and their relations evaluated.

Methods

All children over 90 days of age and without having prior inguinal region surgery with a diagnosis of indirect inguinal hernia underwent surgical repair with open or laparoscopic PIRS technique. Patients' gender, age at surgery, inguinal hernias side, surgery duration, recurrence, complications, and follow-ups were collected.

Results

A total of 488 inguinal hernias of 405 patients were repaired. The diagnoses were unilateral inguinal hernia in 360 (88.9%) and it was bilateral in 33 (8.1%) patients. The operative technique was laparoscopic PIRS for 227 and open inguinal hernia surgery for 178 patients. In the PIRS group, a contralateral hernia was found in 48 of 205 children (23.4%). The surgery times were 23.3 (PIRS) and 33.7 (open) min for unilateral and 28 (PIRS) and 53.1 (open) min on average for bilateral inguinal hernia surgery. Mean follow-up was 30.4 months for PIRS and 24.4 months for open technique. Recurrence was observed in seven (3%) patients in PIRS and one (0.5%) in the open group and postoperative complications in three (1.3%) in PIRS and four (2.2%) in the open group.

Conclusion

PIRS method has the advantage to evaluate contralateral hernia at the same session, minimal scar related to surgery, and preserve the spermatic cord from manipulation. PIRS is an alternative feasible method and easy to perform to repair the inguinal hernia with/without communicating hydrocele in children.

Laparoscopic Repair of Pediatric Inguinal Hernia: Disconnection of the Hernial Sac Versus Disconnection and Peritoneal Closure

Background/Purpose: Many techniques have been described for the treatment of pediatric inguinal hernia (PIH). Some authors emphasized the importance of disconnecting the sac, to create a scar, and to close the peritoneum mimicking the open approach. Others stated that peritoneal disconnection alone is enough for treatment of PIH regardless of the size of the internal ring. In this study, we compare the short-term results of laparoscopic disconnection of PIH sac versus disconnection and peritoneal closure. Patients and Methods: The study was carried from March 2016 to March 2017, on 34 patients with 40 PIH. Patients were randomly divided into two groups: group A, subjected to laparoscopic hernia sac disconnection and group B, subjected to laparoscopic hernia sac disconnection with peritoneal closure. Both groups were compared regarding the operative details, including complications and conversion, postoperative complications and recurrence. Results: Group A included 20 hernias in 15 patients, whereas group B included 20 hernias in 19 patients. The age ranged from 1 to 23 months. In group A, the mean operative time (OT) was 34.6 and 39.4 minutes, for unilateral and bilateral cases, respectively, whereas in group B, it was 45.1 minutes for unilateral cases and 65 minutes for 1 bilateral case. The OT was significantly shorter in group A for unilateral cases. There was no conversion and no intraoperative complications. Three recurrences occurred in group A (15% of hernias/20% of cases) with no recurrences in group B; difference was statistically insignificant. All 3 recurrences occurred in hernias with an internal ring diameter (IRD) >10 mm. Hospital stay was statistically shorter in group B. Conclusion: Both laparoscopic sac disconnection with internal ring closure and sac disconnection only are safe and effective treatments of PIH. However, the latter technique is not recommended for cases with IRD >10 mm because of the unacceptable high recurrence with rings >10 mm.

Single-port laparoscopic percutaneous closure of the internal ring for scarless repair of inguinal hernias in girls

Purpose: The purpose of this study was to summarize the clinical experience with laparoscopic percutaneous extraperitoneal closure of the internal ring using an epidural needle for inguinal hernias in girls.Material and methods: A total of 462 girls with inguinal hernias participated in this study from January 2013 to June 2019. Laparoscopic percutaneous extraperitoneal closure of the internal ring via an epidural needle was used to treat these patients.Results: All 462 girls with an inguinal hernia successfully underwent laparoscopic surgery. The operative times for unilateral and bilateral inguinal hernias were 15 (11-25) minutes and 23 (18-33) minutes, respectively. All patients were discharged 1-2 days after the operations. During the hospitalization and follow-up periods, none of the following complications were observed: hernia recurrence, umbilical hernia, abdominal wall vascular injury, intestinal injury or bladder injury. However, there were six patients with complications: two cases of poor healing of the umbilical incision, three cases of suture granulomas and one case of groin traction pain and discomfort.Conclusion: Laparoscopic percutaneous extraperitoneal closure of the internal ring using an epidural needle is a safe and feasible method for the treatment of inguinal hernias in girls. This method has the advantages of limited trauma, no scarring and a good cosmetic effect.

Single-site laparoscopic percutaneous extraperitoneal closure (SLPEC) of hernia sac high ligation using an ordinary taper needle: a novel technique for pediatric inguinal hernia

PURPOSE

Laparoscopic high ligation of the internal inguinal ring is an alternative procedure for treatment of pediatric inguinal hernia (PIH), with a major trend toward increasing use of extracorporeal knotting and decreasing use of working ports. We have utilized this laparoscopic technique to treat the entire spectrum of PIH (including incarcerated cases) for more than 17 years, and the technique continues to evolve and improve. We herein report our latest modification of this minimally invasive technique, namely single-site laparoscopic percutaneous extraperitoneal closure (SLPEC) of hernia sac high ligation using an ordinary taper needle, and evaluate its safety and efficacy.

METHODS

From July 2016 to July 2019, 790 children with indirect PIH were treated by laparoscopic surgery. All patients underwent high ligation surgery with a modified single-site laparoscopic technique mainly performed by extracorporeal suturing with an ordinary closed-eye taper needle (1/2 arc 11 × 34). The clinical data were retrospectively analyzed.

RESULTS

All surgeries were successful without serious complications. A contralateral patent processus vaginalis (CPPV) was found intraoperatively and subsequently repaired in 190 patients (25.4%). The mean operative time was 15 min (8-25 min) for 557 unilateral hernias and 21 min (14-36 min) for 233 bilateral hernias. The mean postoperative stay was 20 h. Minor complications occurred in five patients (0.63%) and were managed properly, with no major impact on the final outcomes. No recurrence was noted in the patients who were followed up for 6-42 months. No obvious scar was present postoperatively.

CONCLUSION

Modified SLPEC of hernia sac high ligation using an ordinary taper needle for repair of indirect PIH is a safe, reliable, and minimally invasive procedure with satisfactory outcome, with no special device being needed. It is easy to learn and perform and is worthy of popularization in the clinical setting.

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.

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.

Reoperation After Laparoscopic Inguinal Hernia Repair in Children: A Retrospective Review

Background: Laparoscopic inguinal hernia repair (LIHR) is increasingly widely accepted in pediatric surgery. However, reoperation risks remain unknown. We summarized our single-center experience with reoperations after laparoscopic percutaneous extraperitoneal closure (LPEC) and single-incision LPEC (SILPEC). Materials and Methods: We retrospectively reviewed reoperation cases of hernia repair greater than or equal to two times between 2000 and 2018, wherein the first hernia repair was performed laparoscopically. Primary outcomes were recurrence type and screening sufficiency for contralateral patent processus vaginalis (cPPV). Secondary outcomes were associated with details of recurrences. Results: Of the 2112 patients who underwent LPEC/SILPEC, 14 (recurrence rate = 0.7%) showed recurrences after treatment and 8 (incidence rate = 0.4%) showed contralateral metachronous inguinal hernia (CMIH). Concerning the primary outcome of recurrence type, the orifice was inside the previous ligation (Inside group), suggesting loosened first ligation, in 6 (42.9%) patients and outside the previous ligation (Outside group) in 7 (50.0%); and 1 (7.1%) patient showed no orifice. Regarding CMIH, 3 (37.5%) patients were suspected of insufficient screening for cPPV, 1 (12.5%) underwent sufficient screening, and 1 (12.5%) had cPPV but treatment was deemed unnecessary. Concerning secondary outcomes, 4 (66.7%) and 6 (85.7%) patients from the Inside and Outside groups were treated with single ligation, respectively. One patient from the Outside group (14.3%) had a massive peritoneum injury during the first operation. Conclusions: Some preventable factors, such as loosened ligation, torn peritoneum, and use of single ligation in recurrences and insufficient screening for cPPV in CMIH, were observed. These should be taken care to prevent reoperations in LIHR.

Single-Site Laparoscopic Percutaneous Extraperitoneal Closure Versus Modified Transumbilical Two-Port Laparoscopic Suturing of the Hernia Sac for the Treatment of Pediatric Inguinal Hernia: Comparison of the Outcomes of Two Different Approaches

OBJECTIVE

To evaluate the surgical outcomes of single-site laparoscopic percutaneous extraperitoneal closure (SLPEC) and modified transumbilical two-port laparoscopic suturing (M-TTLS) of the hernia sac for the treatment of pediatric inguinal hernia (PIH) and determine whether one approach was superior to another.

METHODS

From January 2014 to June 2017, a total of 599 children had undergone SLPEC or M-TTLS in our department. SLPEC and M-TTLS were the most frequently performed single-site laparoscopic procedures for PIH in our department, which represented the extraperitoneal and intraperitoneal approaches, respectively. All patients were followed up at the out-patients' clinics and the medical records were reviewed with respect to all operative outcomes.

RESULTS

There were 412 patients undergoing SLPEC and 187 patients undergoing M-TTLS, of which 358 hernias were on the right side, 172 on the left and 69 bilaterally. Two hundred and thirty-one unilateral hernias with contralateral patent processus vaginalis underwent contralateral repair at the same session. Mean operation time was 10.81 minutes in unilateral repair and 17.00 minutes in bilateral repairs, respectively. The perioperative complications included minor extraperitoneal hematoma in four (0.44%) patients, recurrence in one (0.11%), hydrocele in five (0.56%), and contralateral metachronous inguinal hernia in three (1.00%). No other complication developed in either group. There was no significant difference of complications between the two approaches except for the longer operation time in M-TTLS.

CONCLUSIONS

Both SLPEC and M-TTLS were the safe and effective methods for PIH. The complications were comparable for M-TTLS and SLPEC, but operation time was significantly longer in M-TTLS than in SLPEC.

Is two-port laparoendoscopic single-site surgery (T-LESS) feasible for pediatric hydroceles? Single-center experience with the initial 59 cases

INTRODUCTION

Although T-LESS is increasingly being used to treat pediatric inguinal hernia, there is no study regarding T-LESS for pediatric hydrocele.

OBJECTIVE

To further evaluate the feasibility of T-LESS and present our single-center experience for repair of pediatric hydroceles.

STUDY DESIGN

From January 2016 to July 2016, all boys undergoing T-LESS for hydrocele in our institute were retrospectively reviewed. A laparoscope and a needle-holding forceps were introduced at umbilicus. A round needle with silk suture was stabbed through the abdominal wall. The peritoneum around the internal ring was sutured continuously in a clockwise direction. After a complete purse-string suture, a triple knot was performed by using a single-instrument tie technique. The contralateral patent processus vaginalis (PPV) was repaired simultaneously if present.

RESULTS

Overall, 59 boys with hydrocele were included (22 on the left side, 32 on the right side, and 5 bilaterally) (Table). During the procedure, all hydroceles were observed with a PPV but the fluid needed to be aspired in 39 boys. A contralateral PPV was present in 24 boys with unilateral hydrocele, and finally 88 repairs were performed. Mean operative time was 18.3 min for unilateral repair and 27.5 min for bilateral repair, respectively. All procedures were uneventful besides a minor injury to the inferior epigastric vessels. After a mean follow-up of 10.7 months, neither recurrence nor other postoperative complication was observed. There were no visible scars on the abdominal wall.

DISCUSSION

Compared with open repair of pediatric inguinal hernia and hydrocele, laparoscopic surgery had several advantages, such as exploration of contralateral PPV, identification of rare hernias, diminished postoperative pain, improved cosmesis, faster recovery, and fewer complications. Differing from the laparoscopic retroperitoneal approach, T-LESS included no subcutaneous tissue in the ligature, and its knot was completely in the peritoneal cavity which could radically prevent the severe pain and suture granuloma in the ligated region. Furthermore, the skin incisions after T-LESS were hidden in umbilicus, which could achieve an excellent cosmetic result. By performing T-LESS for pediatric hydroceles, the current study showed very satisfactory results, such as high success rate, minor complication, and excellent cosmesis. However, because of the difficult learning curve of T-LESS, some technical details (e.g. avoiding injury to the spermatic cord, completely suturing the peritoneal folds and reducing disturbance between the instruments) still need to be improved in the future.

CONCLUSION

T-LESS appears to be a safe and effective method for repair of pediatric hydroceles.

Does the laparoscopic treatment of paediatric hydroceles represent a better alternative to the traditional open repair technique? A retrospective study of 1332 surgeries performed at two centres in China

Purpose

To evaluate the safety, efficacy and merits of laparoscopic repair in children with hydroceles by comparing the outcomes of laparoscopic repair and the traditional open repair (OR) procedure. The outcomes of the following three laparoscopic percutaneous extra-peritoneal closure (LPEC) approaches were also compared: conventional two-port surgery, transumbilical single-site two-port surgery and single-port surgery.

Methods

We retrospectively compared the demographic, perioperative and follow-up data from the consecutive records obtained for 382 boys who underwent OR and 950 boys who underwent LPEC at two children’s medical centres in China. In the LPEC group, regardless of the hydrocele form, one of the three approaches with percutaneous aspiration was performed: conventional two-port surgery was performed in 387 cases, single-site two-port surgery was performed in 468 cases and single-port surgery was performed in 95 cases. The clinical data and complications were statistically analysed.

Results

Postoperative follow-up data were obtained for all the patients. The mean follow-up time was 36 months (24–48 months) in the OR group and 32.5 months (20–44 months) in the LPEC group. Significant differences in recurrence were not observed between the groups (five in the OR and 10 in the LPEC; P = 0.69). However, the operation time, postoperative hospital stay, incidence of scrotal oedema, incision infection and contralateral metachronous hernia or hydrocele were significantly higher in the OR group than those in the LPEC group (P < 0.01). Eighteen children (4.71%) had a negative exploration of the patent processus vaginalis (PPV) in the OR group. Fourteen children (1.47%) in the LPEC group had a closed internal ring and were converted to a scrotal procedure. Significant differences in the clinical data or complications were not observed between the two centres for the laparoscopic procedure (P > 0.05). Contralateral PPV (cPPV) was found in 18 patients in the single-port group (18.9%). Of the patients affected with cPPV, significant differences were observed between the single-port group and the two-port LPEC group (122 patients, 31.5%, P = 0.016) and the single-site two-port group (the 148 patients, 31.6%, P = 0.013). A contralateral metachronous hernia or hydrocele was found in zero, zero and two cases in these groups, respectively, and significant differences were observed (P < 0.01) between the single-site surgery and the other two laparoscopic approaches.

Conclusions

LPEC is safe, feasible and effective for treating hydroceles in children and has the same recurrence rate as OR. However, LPEC is superior in operation time, hospital stay, occurrence of scrotal oedema, incision infection and occurrence of metachronous hernia or hydrocele. The transumbilical single-site two-port procedure has the same cosmetic effect as the single-port LPEC. According to our experience, the two-port LPEC approach is better for diagnosing cPPV and reducing metachronous hernia or hydrocele than the single-port LPEC procedure.

Inguinal Hernia

Laparoscopy is a safe and effective technique in the repair of inguinal hernias. This article describes the different laparoscopic herniorrhaphy technique, as well as controversial topics, such as premature infants, contralateral repair, and incarcerated hernias.

Laparoscopic intra-abdominal patent processus vaginalis ligation in pediatric urology practice

INTRODUCTION AND OBJECTIVE

Inguinal hernias and communicating hydroceles from a patent processus vaginalis (PPV) are common problems in children. This study provides a detailed description of the laparoscopic intra-abdominal patent processus vaginalis ligation (LIPPL) procedure along with its results in pediatric urology patients.

METHODS

Prospectively collected data were captured from children (<18 years) who underwent LIPPL from 2012 to 2014. Demographics as well as postoperative characteristics were reviewed and descriptively analyzed. LIPPL is performed using a 5-mm camera through the umbilicus. A loop of polypropylene suture is passed through a spinal needle percutaneously on one side of the internal ring. The needle is reinserted on the opposite side and the tail of the suture is fed through the original loop such that a purse-string is created around the peritoneum of the internal ring above the spermatic vessels and the vas; the suture is tied extracorporeally.

RESULTS

142 patients (3 female) were evaluated with 197 PPV sites repaired using LIPPL at median 24 (1-216) months of age. Median operating time was 35 (20-91) and 43 (27-85) minutes for unilateral and bilateral repairs, respectively. There were no intraoperative complications. During the 14 (1-34) months from surgery, there were no hernia recurrences, one surgical site infection, seven patients with residual small non-communicating hydroceles, and one patient who developed a suture granuloma.

CONCLUSIONS

LIPPL is a safe and effective technique with minimal rate of hernia recurrence and few complications. LIPPL allows for easy repair of all sizes of PPV, with patients receiving the benefits of minimally invasive surgery including the ability to evaluate the contralateral inguinal ring.

Comparison of single-incision laparoscopic percutaneous extraperitoneal closure (SILPEC) and open repair for pediatric inguinal hernia: a single-center retrospective cohort study of 2028 cases

BACKGROUD

Recently, laparoscopic percutaneous extraperitoneal closure (LPEC) has gained increased popularity for pediatric inguinal hernia repair. To improve cosmesis, we developed single incision LPEC (SILPEC). The aim of this study was to assess the safety and feasibility of SILPEC compared with traditional open repair (OR).

METHODS

This was a single-center retrospective cohort study of 2028 children who underwent inguinal hernia repair between April 2005 and August 2014. Nine hundred and ninety-five patients underwent OR and 1033 patients underwent SILPEC. Medical records were reviewed with respect to operative time, recurrence, incidence of contralateral metachronous inguinal hernia (CMIH), and complications. Patient satisfaction with cosmetic result was also investigated using questionnaires sent by mail.

RESULTS

All SILPEC procedures were completed without conversion. Operative time was longer in the SILPEC group than in the OR group for both unilateral and bilateral surgery regardless of sex (unilateral male: p = 0.0006, unilateral female: p < 0.0001, bilateral male: p < 0.0001, bilateral female: p < 0.0001). There was no statistically significant difference in recurrence rate (p = 0.43). The incidence of CMIH was significantly higher in the OR than in the SILPEC group (p < 0.0001). No postoperative testicular atrophy was found in either group. There was no statistically significant difference in ascending testis (p = 0.09), but the frequency of surgical site infection was higher in the SILPEC than in the OR group (p = 0.0013). According to the questionnaire, operative scar was more invisible in the SILPEC than in the OR group (p < 0.0001), but both procedures had equally high levels of satisfaction for cosmetic results (p = 0.58).

CONCLUSION

SILPEC proved to be a safe and feasible procedure compared with OR with an equally low recurrence rate, more effectiveness for preventing CMIH, and more invisible scar.

A comparison between totally laparoscopic hydrocelectomy and scrotal incision hydrocelectomy with laparoscopic high ligation for pediatric cord hydrocele

BACKGROUND

The purpose of this study is to report clinical characteristics and to investigate the feasibility and safety of totally laparoscopic hydrocelectomy (TLH) compared to scrotal incision hydrocelectomy with laparoscopic high ligation (SIH) for pediatric cord hydrocele (CH).

METHODS

From September 2011 to February 2016, 148 patients underwent SIH, and 342 patients underwent TLH for CH. In the TLH group, a large hydrocele that could not pass through the internal ring was removed after percutaneous syringe aspiration. Age, laterality of hydrocele, inguinal comorbidities, operation time, surgical complications, and recurrences were evaluated.

RESULTS

All the patients had spermatic cord cysts and patent processus vaginalis in proximity to hydrocele (mixed type). The mean age of CH patients was 34.1 ± 22.1 months. CHs are more common on the right side (61.0%) than on the left (35.7%). Bilaterality occurred in 3.3%. Comorbidities such as hernia (8.6%) and cryptorchidism (1.2%) were observed. There were no complications except for two cases of wound hematoma in SIH group. There was one (0.7%) case of recurrence appeared in communicating hydrocele in SIH group. There were no significant differences in the age, laterality of hydrocele, inguinal comorbidities, operation time, complications, and recurrences between TLH and SIH groups. However, TLH for unilateral cord hydrocele had significantly shorter operation time compared to SIH. The mean operation time in TLH group was 15.6 ± 5.96 min and there was no conversion to open surgery.

CONCLUSIONS

TLH for pediatric CH is a feasible and safe procedure without additional incisions. Therefore, TLH can be one of the surgical options for pediatric CH especially in mixed type.

A systematic review and meta-analysis concerning single-site laparoscopic percutaneous extraperitoneal closure for pediatric inguinal hernia and hydrocele

BACKGROUND

Single-site laparoscopic percutaneous extraperitoneal closure (SLPEC) of hernia sac/processus vaginalis has been widely performed for repair of inguinal hernia/hydrocele in children. However, a variety of surgical instruments and techniques were used, and significant differences existed among the SLPEC reports.

METHODS

A literature search was performed for all available studies concerning SLPEC for pediatric inguinal hernia/hydrocele in PubMed, Embase and Cochrane library. The surgical details and operative outcomes were pooled and analyzed with software StataSE 12.0.

RESULTS

49 studies fulfilled the predefined inclusion criteria of this review and 37 studies were finally included in the meta-analysis. The mean incidence of CPPV was 29.1% (range 5.73-43.0%). The average of mean operative time was 19.56 min (range 8.30-41.19 min) for unilateral SLPEC and 27.23 min (range 12.80-48.19 min) for bilateral SLPEC. The total incidence of injury, conversion, recurrence, hydrocele formation, knot reaction, severe pain, and scrotal swelling was 0.32% (range 0-3.24%), 0.05% (range 0-0.89%), 0.70% (range 0-15.5%), 0.23% (range 0-3.57%), 0.33% (range 0-3.33%), 0.05% (range 0-4.55%), and 0.03% (range 0-1.52%), respectively. There was no development of testicular atrophy. Subgroup analyses showed an inverse correlation between the injury incidence and adoption of assisted forceps, hydrodissection, and blunt puncture device, between the conversion rate and adoption of hydrodissection, between the recurrence/hydrocele incidence and adoption of assisted forceps, hydrodissection, nonabsorbable suture and the preventive measures to avoid ligating the unnecessary subcutaneous tissues, and between the rate of knot reaction and adoption of assisted forceps, hydrodissection, and the preventive measures.

CONCLUSIONS

SLPEC was a well-developed procedure for repair of pediatric inguinal hernia/hydrocele. Adoption of assisted forceps, hydrodissection, nonabsorbable suture, and the preventive measures to avoid ligating the unnecessary subcutaneous tissues could significantly reduce the intra- and postoperative complications.

Learning Curves for Laparoscopic Repair of Inguinal Hernia and Communicating Hydrocele in Children

INTRODUCTION

We analyzed the department and surgeon learning curves during implementation of the percutaneous internal ring suturing (PIRS) technique in our department.

METHODS

Children proposed for inguinal hernia or communicating hydrocele repair were included (n = 607). After mentorship, all surgeons were free to propose open or PIRS repair. From gathered data, we assessed department and surgeon learning curves through cumulative experience focusing in perioperative complications, conversion, ipsilateral recurrence, postoperative complications, and metachronous hernia, with benchmarks defined by open repair.

RESULTS

Department-centered analysis revealed that perioperative complications, conversion, and ipsilateral recurrence rates were higher in the beginning, reaching the benchmarks when each surgeon performed, at least, 35 laparoscopic repairs. Postoperative complications and metachronous hernia rates were independent from learning curves, with the metachronous hernia rate being significantly lower in PIRS patients. During the program, the percentage of males in those operated by PIRS progressively increased reaching the percentage of males, in our sample, when department operated over 230 cases.

CONCLUSION

Thirty-five laparoscopic cases per surgeon are required for perioperative complications, conversion, and ipsilateral recurrence reach the benchmark. The gap between the percentage of males, in those operated by PIRS and in those proposed for surgery, monitors the confidence of the team in the program.

Complications in common general pediatric surgery procedures

Complications related to general pediatric surgery procedures are a major concern for pediatric surgeons and their patients. Although infrequent, when they occur the consequences can lead to significant morbidity and psychosocial stress. The purpose of this article is to discuss the common complications encountered during several common pediatric general surgery procedures including inguinal hernia repair (open and laparoscopic), umbilical hernia repair, laparoscopic pyloromyotomy, and laparoscopic appendectomy.

A Modified Technique with a New Device of Laparoscopic Percutaneous Extraperitoneal Closure for Pediatric Inguinal Hernia

INTRODUCTION

Laparoscopic percutaneous extraperitoneal closure (LPEC) in boys is more complex than in girls, because the vas deferens and testicular vessels must be separated from the peritoneum. We therefore developed a needle-shaped surgical instrument that enables blunt separation. Here, we report the effectiveness of this new device.

SURGICAL TECHNIQUE

The new device is a ligature carrier consisting of (1) an inner tube (19-G blunt needle) through which slides a rod with a loop wire at its tip that can catch and release suture materials and (2) an outer tube (17-G needle) with a cutting edge. The blunt-structured inner tube enables blunt separation. All actions (stabbing, separation, and catching) in the LPEC procedure that are required to close the hernia orifice using a thread are facilitated through a simple small incision by switching between the inner and outer tubes.

SUBJECTS AND METHODS

From January 2013 to September 2015, 73 boys with inguinal hernia or hydrocele underwent LPEC, and the new device was used in 45 of these cases. We compared surgical results between cases wherein the new (group A) and conventional devices (LPEC needle; group B) were used.

RESULTS

The mean surgery duration was 33.4 and 34.8 min for groups A and B, respectively. Neither group experienced complications during or after surgery.

CONCLUSION

Our findings suggest that the newly developed needle device may improve the safety of the LPEC procedure for boys, although further investigation involving more cases and long-term follow-up is needed in the future.

Effects of single-port laparoscopic percutaneous extraperitoneal closure on the orientation of the vas deferens and testicular perfusion and volume: Experience from a single center

OBJECTIVE

To investigate the influence of single-port laparoscopic percutaneous extraperitoneal closure (LPEC) on the orientation of the vas deferens and testicular perfusion and volume in pediatric patients undergoing inguinal hernia repair.

METHODS

A total of 92 consecutively enrolled boys preoperatively diagnosed with a unilateral inguinal hernia underwent single-port LPEC between June 2013 and June 2014. The orientation of the vas deferens and the testicular perfusion and volume of these patients were ultrasonographically assessed preoperatively, one month after surgery and six months after surgery.

RESULTS

The surgical procedures were performed successfully without conversion or serious perioperative complications. Ultrasonography showed no angulation or distortion of the vas deferens on the surgical side during a six-month follow-up period. Similarly, there were no perioperative changes in testicular perfusion or volume.

CONCLUSION

Our experience suggests that the single-port LPEC technique can be safe and effective in pediatric patients with an inguinal hernia and that this technique does not affect the orientation of the vas deferens or testicular perfusion or volume.

Efficacy of laparoscopically assisted high ligation of patent processus vaginalis in children

INTRODUCTION

Laparoscopic hernia repairs have been proven to be efficient and safe for children, despite the slightly higher recurrence rate compared with the classic surgical repair. They have the advantage of easy and precise identification of the type of defect and its correction, both in ipsilateral and contralateral sides.

OBJECTIVES

The objectives of this study were to evaluate the efficacy, safety and outcome of the laparoscopically assisted piecemeal high ligation of a patent processus vaginalis (PPV) in children.

METHODS

A total of 40 children were enrolled into this prospective study; they were aged ≥ 6 months and had an inguinal hernia. The peritoneal cavity, including the contralateral side, was inspected for the possibility of bilateral hernias using a 3-mm 30° telescope. Another 3-mm port was introduced through the same infra-umbilical incision. The hernia was manually reduced or with the aid of a working infra-umbilical grasper. A prolene or vicryl 2/0 or 3/0 suture on a curved semicircle round-bodied taper-ended 25-30 mm needle was introduced through a very small inguinal skin-crease incision. It was passed through the abdominal wall layers to the peritoneum and was manipulated by the laparoscopic grasper to pick up the peritoneum in piecemeal all around the internal ring. The needle was then pushed to the outside near to the entrance site, thus forming a semicircle around the internal ring. The suture was then tied and the knot was subcutaneously buried. The primary outcome of the procedure was the incidence of intraoperative diagnosis and surgical repair of contralateral hernias in pre-operatively diagnosed unilateral cases. The secondary outcomes were defined as the incidence of complications and hernia recurrence.

DISCUSSION

The exploratory laparoscopy found contralateral patent processus vaginalis (CPPV) with a detection rate of 28.1%. Chan et al., Esposito et al., Toufique et al. and Niyogi et al. reported similar figures for laparoscopic contralateral hernia detection rates of 28%, 39%, 39.7% and 29.2%, respectively. The limitations of this study were the small sample size, plus the risk factors and clinical significance for CPPV.

CONCLUSION

Laparascopically assisted piecemeal closure of the internal inguinal ring in children is a safe and effective procedure. It helps in detecting a contralateral hernia without prolonging the operative time.

Laparoscopic percutaneous inguinal hernia repair in children: review of technique and comparison with open surgery

INTRODUCTION

Minimally-invasive approaches for inguinal hernia repair have evolved from conventional laparoscopy requiring placement of three ports and intracorporeal suturing to simple, one and two port extraperitoneal closure techniques. We utilize a single port laparoscopic percutaneous repair (LPHR) technique for selected children requiring operative intervention for inguinal hernia. We suspect that compared to open surgery, LPHR offers shorter operative duration with comparable safety and efficacy. Our objectives are to (1) illustrate this technique and (2) compare operative times and surgical outcomes in patients undergoing LPHR versus traditional open repair.

METHODS

We reviewed operative times, complications, and recurrence rates in 38 patients (49 hernias) who underwent LPHR at our institution between January 2010 and September 2013. These data were compared with an age-, gender-, weight-, and laterality-matched cohort undergoing open repair during the same 3 year period. All cases were performed by a pediatric urologist or pediatric surgeon.

RESULTS

Thirty-eight patients with a median age of 21.5 months underwent LPHR, and 38 patients with a median age of 23 months underwent open repair. In both groups, 27/38 patients (71%) had unilateral repairs, and 11/38 patients (29%) had bilateral repairs. For unilateral procedures, average operative duration was 25 min for LPHR and 59 min for OHR (p < 0.001). For bilateral procedures, average operative duration was 31 min for LPHR and 79 min for OHR (p < 0.001). There were no intraabdominal injuries in either group. In the LPHR group, there were no vascular or cord structure injuries and no conversions to open technique. Median follow-up was 51 days for the LPHR group and 47 days for the OHR group (p = 0.346). No hernia recurrence was observed in either group.

CONCLUSIONS

In select patients, LPHR is an efficient, safe, and effective minimally invasive alternative to OHR, with reduced operative times but without increased rates of complications or recurrences. The technique has a short learning curve and is a practical alternative to OHR for pediatric urologists who infrequently utilize pure laparoscopic technique.

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.

A novel technique for laparoscopic inguinal hernia repair in children: single-port laparoscopic percutaneous extraperitoneal closure assisted by an optical forceps

AIM

The aim of this study was to describe and report the results of our new pediatric inguinal hernia repair technique, in which single-port laparoscopic percutaneous extraperitoneal closure (SPEC) technique was modified by using optical foreign-body forceps (OFF) of the rigid bronchoscope.

MATERIALS AND METHODS

Between January 2012 and January 2014, a total of 79 children who were operated using SPEC assisted with OFF (SPEC-OFF) were included in this study. Demographic and clinical features of the children were obtained and reviewed retrospectively.

RESULTS

Ninety-nine hernia repairs were performed on a total of 79 children (51 boys, 28 girls). All of the patients were operated by SPEC-OFF without the need of introducing extra forceps, with or without an additional trocar. The mean operating time was 17.6 ± 5.5 min. The mean follow-up period was 17.5 ± 7.1 months. There were six recurrences (two boys, four girls). No wound infection, hydroceles or testicular atrophy occurred in any patients during post-surgery follow-up. The technique left a very small scar with excellent cosmesis in the umbilicus and groin area.

CONCLUSIONS

SPEC-OFF is a simple, safe and effective technique for laparoscopic inguinal hernia repair, and for determining contralateral hernia. There is no need to use additional working forceps for the technique and the surgeon can perform the procedure without any assistance for laparoscope.

Laparoscopically assisted simple suturing obliteration (LASSO) of the internal ring using an epidural needle: a handy single-port laparoscopic herniorrhaphy in children

BACKGROUND

Many different laparoscopic techniques for pediatric inguinal hernia (PIH) have been developed, with a trend toward increasing use of extracorporeal knotting and decreasing use of working ports. Single-port laparoscopic percutaneous extraperitoneal closure is one of the most simple and reliable methods. We describe our modifications of laparoscopically assisted simple suturing obliteration (LASSO) using an epidural needle with preperitoneal hydrodissection.

MATERIALS AND METHODS

Two hundred and seven patients with PIH were treated with single-port LASSO from February 2010 to July 2013. Under laparoscopic visualization, an 18-gauge epidural needle was inserted at the corresponding point of the internal ring. The hernia defect was obliterated extraperitoneally by a nonabsorbable suture that was introduced into the abdomen on one side and withdrawn on the opposite side in an identical subcutaneous path around the internal ring using the hydrodissection-lasso technique.

RESULTS

A total of 251 PIHs were successfully performed by LASSO, 163 patients had unilateral inguinal hernia repair, and 44 patients underwent repair of bilateral inguinal hernias. Mean operating time for unilateral and bilateral inguinal hernia repairs was 18.1±5.4min and 26.6±4.8min, respectively. There were no perioperative complications. Only one recurrence was observed to date.

CONCLUSIONS

LASSO using an epidural needle with preperitoneal hydrodissection as a handy technique has proved to be a safe and effective procedure. It is easy to perform with high parent satisfaction, invisible scarring, and good cosmetic results, and therefore is a worthy choice for PIH.

Comparison of inguinal hernia and asymptomatic patent processus vaginalis in term and preterm infants

INTRODUCTION

The aim of this study was to evaluate the characteristics of inguinal hernia (IH) and patent processus vaginalis (PPV) in term and preterm infants less than the age of 6months.

METHOD

Between January 2004 and December 2012, 246 term and 165 preterm infants underwent laparoscopic herniorrhaphy within the first 6months of life. Preoperative clinical presentation and intraoperative anatomical findings during the laparoscopic procedure were evaluated. Additionally, initial side of hernia, laterality of IH and PPV were analyzed in term and preterm infants.

RESULTS

In the group of term infants, most infants presented with a primary right-sided IH (58.5%) versus 17.9% left-sided and 23.6% bilateral IH. Babies with primary unilateral IH were found to have a contralateral PPV in 41.0% of cases. A difference between left-sided PPV and right-sided PPV could not be identified. In the group of preterm infants, initial bilateral presentation was predominant (38.8%) versus right-sided (30.3%) and left-sided IH (30.9%). Infants with primary unilateral IH were found to have a contralateral PPV in 56.4%. We identified a slight difference between left-sided PPV (54.0%) and right-sided PPV (58.8%).

CONCLUSION

IH is predominantly right sided in term infants, whereas preterm infants mostly present with bilateral IH. The incidence of PPV was found to be significantly higher in the preterm group. Regarding the incidence of a contralateral PPV in term and preterm infants, no difference between initial left-sided and right-sided IH could be identified between both groups.

Suture choice matters in rabbit model of laparoscopic, preperitoneal, inguinal hernia repair

PURPOSE

We evaluated the effect of different suture materials in a laparoscopic preperitoneal ligation of the patent processus vaginalis in a rabbit survival model.

MATERIALS AND METHODS

New Zealand White rabbits underwent laparoscopic assisted preperitoneal ligation of the patent processus vaginalis. The processus vaginalis was closed with silk (n=10), polyglactin 910 (Vicryl(®); Ethicon, a Johnson & Johnson Company, Somerville, NJ) (n=10), or polypropylene (Prolene(®); Ethicon) (n=10). At necropsy, the suture was removed, and repair integrity was evaluated.

RESULTS

All rabbits survived to necropsy without complications. No suture material was identified during necropsy of the Vicryl group. Eight (80%) of the Vicryl closures failed, with six (60%) failing at initial inspection. Following removal of suture material, nine (90%) of the Prolene closures failed, and only one (10%) of the silk closures failed (P=.009).

CONCLUSIONS

The silk suture resulted in an improved closure rate. Ligation with silk suture probably incited an increased inflammatory response that likely created a scar while persisting long enough for the scar to become established. In contrast, the Vicryl sutures probably failed because the sutures dissolved before a scar was able to fully develop. Finally, the Prolene closures were suture dependent as evidenced by failure when the suture was removed. Nonabsorbable braided suture may improve closure of pediatric indirect inguinal hernias during laparoscopic-assisted preperitoneal ligation.

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 percutaneous extraperitoneal closure using an innovative apparatus for pediatric inguinal hernia

BACKGROUND

Laparoscopic procedures for pediatric inguinal hernia (PIH) have numerous techniques and continue to evolve, with a trend toward increasing use of extracorporeal knotting and decreasing use of working ports and endoscopic instruments. Single-port laparoscopic percutaneous extraperitoneal closure (SPLPEC) with variable devices seems to be one of the most simple and reliable methods. Here the authors describe and evaluate the applicable effects of SPLPEC using an innovative two-hooked core hernia apparatus.

MATERIALS AND METHODS

Between June 2008 and October 2011, 72 children with indirect inguinal hernia underwent SPLPEC with an innovative two-hooked core hernia apparatus. A 5-mm laparoscope was placed through a transumbilical port. Without an assistant working port, the two-hooked core hernia apparatus with a 2-0 nonabsorbable suture was inserted at the point of the internal inguinal ring. It could be readily kept in an identical subcutaneous path for introducing and withdrawing the suture. The extraperitoneal knot-tying could tautly enclose the hernia defect without peritoneal gaps and upper subcutaneous tissues. During the same period, 63 cases with PIH underwent SPLPEC with a single-hooked hernia device. Technical essentials, mean operation time, and intra- and postoperative complications were compared.

RESULTS

The internal orifice was closed faster by SPLPEC with the innovative two-hooked core apparatus than with a single-hooked device (unilateral, 13.21±3.86 versus 17.92±4.37 minutes [P<.05]; bilateral, 17.18±4.69 versus 25.36±7.38 minutes [P<.01]). There were no postoperative complications or evidence of early recurrence in the two-hooked group. However, one recurrence and one subcutaneous knot granuloma were postoperatively observed in the single-hooked group.

CONCLUSIONS

SPLPEC with the two-hooked core apparatus was proved to be a successful procedure without leaving a peritoneal gap and ligating subcutaneous tissues. It is safe, feasible, and reliable for PIH.

Modified single-port minilaparoscopic extraperitoneal repair for pediatric hydrocele: a single-center experience with 279 surgeries

PURPOSE

The purpose of the study is to introduce our experience of a modified single-port minilaparoscopic technique for the treatment of pediatric hydrocele.

METHODS

Between June 2008 and May 2012, 279 boys (115 communicating hydrocele and 164 "non-communicating" hydrocele, diagnosis based on preoperative physical examination and scrotal ultrasound) underwent the modified single-port minilaparoscopic repair in our institution. During surgery, a 3-mm laparoscope was inserted into the abdomen through a mini-umbilical incision. The hydrocele sac orifice was closed by an extraperitoneal purse-string suture placed around the internal ring with an ordinary taper needle and an endoclose needle.

RESULTS

Of all the 279 patients, 16 (5.7 %) were found to have a potential patent processus vaginalis (PPV) on the contralateral side. Of the 164 boys diagnosed with "non-communicating" hydrocele preoperatively, 5 (3.0 %) had no PPV identified in laparoscope and the other 159 (97.0 %) had PPV actually. A total of 274 single-port minilaparoscopic procedures were performed, and all cases were successful without serious complications. The mean operative time was 19.5 and 24.8 min for unilateral and bilateral operations, respectively. Postoperative complications were noted in 4 cases, 2 (0.7 %) patients with scrotal edema, 1 (0.4 %) patient experienced an umbilical hernia, and 1 (0.4 %) patient with suture site abscess. During a median follow-up period of 9 months (range 6-24 months), postoperative hydrocele recurrence was seen in 2 patients (0.7 %).

CONCLUSIONS

This modified single-port minilaparoscopic technique is a safe, effective, and reliable procedure for pediatric hydroceles.