Long-term outcome of children with patent processus vaginalis incidentally diagnosed by laparoscopy

Perforation of barium sulfate enterography in an infant: A case report

RATIONALE

Barium peritonitis is an inflammatory response that occurs when barium accidentally enters the abdominal cavity during a barium test. In extreme circumstances, it has the potential to harm various organs and even result in death.

PATIENT CONCERNS

A 3-month-old infant was diagnosed with multiple organ failure after severe barium peritonitis.

DIAGNOSIS

Multiple organ dysfunction is associated with barium peritonitis.

INTERVENTIONS

The infant underwent surgical intervention and received ventilator support, anti-infection therapy, myocardial nutrition, liver and kidney protection, rehydration, circulation stabilization, and other symptomatic supportive care.

OUTCOMES

The patient experienced clinical death after treatment and resuscitation was unsuccessful.

LESSONS

Barium enema perforation complications are uncommon, but can lead to fatal injuries with a high mortality rate. This case highlights the importance of raising awareness among clinicians about the risks of gastroenterography in infants and children and actively preventing and avoiding similar serious complications. The mortality rate can be reduced by timely multidisciplinary consultation and joint management once a perforation occurs.

Patent processus vaginalis: role of ultrasound in pediatric population with unilateral inguinal hernia and other predictors

INTRODUCTION

Inguinal hernia (IH) repair is a common procedure in the daily practice of pediatric surgeons. In a developing country with limited facilities, it is important to be able to predict and diagnose contralateral patent processus vaginalis (CPPV) to avoid the risk and cost of further surgery.

OBJECTIVES

To assess the accuracy of ultrasound for the detection of CPPV, using laparoscopic evaluation as a confirmatory test. We also looked for various predictors of CPPV in our study population.

METHODS

141 patients were included in this 2-year, cross-sectional prospective study. Inclusion criteria were unilateral inguinal hernia elective patients with no major comorbidities and aged between 2 months and 8 years. Each patient was assessed in outpatient clinics and then a pre-operative ultrasound was conducted. This was followed by laparoscopic evaluation during repair of the hernia.

RESULTS

Of the 141 patients included, 110 (78%) were males, 121 (85.9%) were born at full term, and 96 (68.1) had right-sided hernia. Mean age was 2.64 ± 1.9 years. Ultrasound was 85.7% sensitive in the detection of CPPV, 90.8% specific, and 90.1% accurate. In our analysis of patients younger than 1 year, right-sided hernia and defect size more than 10 mm were statistically significant predictors for a CPPV.

CONCLUSIONS

Ultrasound has a high accuracy profile and is a useful alternative in limited resource settings with restricted access to minimally invasive surgery for the prediction of CPPV. Patients younger than 1 year with a right-sided hernia or a manifested hernia defect larger than 10 mm are at a higher risk of having a CPPV.

Ipsilateral and contralateral patent processus vaginalis in pediatric patients with a unilateral nonpalpable testis

This study aimed to investigate the incidence of patent processus vaginalis (PPV) in pediatric patients with a unilateral nonpalpable testis and explore the associated factors. From May 2014 to April 2017, 152 boys who were diagnosed with a unilateral nonpalpable testis and underwent laparoscopy in Shanghai Children's Hospital (Shanghai, China) were included in this study. The data were collected and reviewed, and the results were analyzed regarding the age at operation, side, development, and position of the nonpalpable testis. The mean age of the patients was 2.6 (standard deviation: 2.3) years. The testis was absent in 14 cases, nonviable in 81 cases, and viable in 57 cases. The incidence of PPV was 37.5% (57 of 152) on the ipsilateral side and 16.4% (25 of 152) on the contralateral side. The ipsilateral PPV was more prevalent when the nonpalpable testis occurred on the right side ( P < 0.01). Besides, patients with a viable testis had a greater incidence of ipsilateral PPV than those with a nonviable or absent testis ( P < 0.01). Moreover, this rate was the highest when the testis was in the abdominal cavity and the lowest when the testis was in the scrotum (both P < 0.01). However, the incidence of contralateral PPV was independent of all the factors. In conclusion, in children with a nonpalpable testis, the incidence of an ipsilateral PPV was significantly related to the side, development, and position of the testis, while it was independent of these factors on the contralateral side.

Comparing Outcomes of Single-Incision Laparoscopic Herniorrhaphy in Newborns and Infants

BACKGROUND

As surgical techniques progress, laparoscopic herniorrhaphy is now performed more often in premature babies. The aim of this study was to analyze the outcomes of newborns and infants who underwent single-incision laparoscopic herniorrhaphy (SILH) at our center.

METHODS

We retrospectively reviewed patients younger than 12 months old who received SILH at our department from 2016 to 2020. SILH involved a 5 mm 30-degree scope and 3 mm instruments with a 3-0 Silk purse-string intracorporeal suture for closure of the internal ring. At the time of surgery, Group 1 newborns, whose corrected age was 2 months and below, were compared to the Group 2 infants, whose age was above 2 months. We assessed the patients' characteristics, anesthesia, surgical data, and complications.

RESULTS

A total of 197 patients were included (114 newborns in Group 1 and 83 infants in Group 2). The mean age and body weight in Group 1 were 1.2 months and 3.8 kg, respectively, whereas in Group 2, they were 3.2 months and 6.7 kg, respectively. There were no significant differences in operative time (Group 1 = 34.1 min vs. Group 2 = 32.3 min, p = 0.26), anesthetic time (Group 1 = 80.0 min vs. Group 2 = 76.3 min, p = 0.07), length of hospitalization (Group 1 = 2.3 days vs. Group 2 = 2.4 days, p = 0.88), postoperative complications including omphalitis (Group 1 = 5.3% vs. Group 2 = 1.2%, p = 0.13), wound infection (Group 1 = 0.9% vs. Group 2 = 1.2%, p = 0.81), and hydrocele (Group 1 = 0.35% vs. Group 2 = 8.4%, p = 0.14). No recurrence, testicular ascent or atrophy, or mortality was observed in either group during the 2-year follow-up period.

CONCLUSIONS

Single-incision laparoscopic herniorrhaphy is a safe and effective operation for inguinal hernia repair in infants, even those with prematurity, lower body weight at the time of surgery, or cardiac and/or pulmonary comorbidities. Comparable results revealed no significant differences in perioperative complications despite younger ages and lower body weights.

Natural history and consequence of patent processus vaginalis: An interim analysis from a multi-institutional prospective observational study

BACKGROUND

The prevalence and natural history of patent processus vaginalis (PPV) are unknown. An interim analysis was performed of a multi-institutional, prospective, observational study in neonates undergoing laparoscopic pyloromyotomy during which bilateral inguinal canals were evaluated.

METHODS

Infants under 4 months undergoing laparoscopic pyloromyotomy were enrolled at 8 children's hospitals. The presence of a PPV was evaluated and measurements recorded. Patients with a PPV are undergoing annual phone follow-up to 18 years of age. Interim analysis was performed.

RESULTS

In a cohort of 610 patient, 80 did not have a PPV examined, 4 had consent issues and were excluded, leaving 526 patients. Of these, 433 (82%) were male, median age 1.2 months (IQR 0.9, 1.6), median weight 3.89 kg (IQR 3.4, 4.46), and EGA 39 weeks (IQR 37, 40). There were 283 PPVs, 132 bilateral (47%), 116 right (41%), and 35 left (12%). Patients with a PPV were significantly younger (1.1 months (IQR 0.9, 1.5) vs 1.3 months (IQR 0.9, 1.7), p=0.02), weighed less (3.76kg (IQR 3.35, 4.26) vs 3.9kg (IQR 3.4, 4.5) p=0.03) and had a significantly lower EGA at birth (38 weeks (IQR 37, 40) vs 39 weeks (IQR 38, 40) p=0.003). Of 246 eligible infants, 208 (85%) responded to at least one annual follow-up. Two patients had an inguinal hernia repair for a symptomatic hernia, 49- and 51-days post pyloromyotomy. One had an orchiopexy and incidental inguinal hernia repair 120 days post pyloromyotomy; for a total of 3 (1.2%) hernia repairs. No additional hernias were identified in 116 patients with the PPV patients who have been followed for > 1 year.

CONCLUSIONS

The presence of a PPV at the time of pyloromyotomy is common but the need for hernia repair is rare within the first year of life. Continued long-term longitudinal follow-up of this cohort is needed.

LEVEL OF EVIDENCE

II.

Tele-consent using mixed reality glasses (NREAL) in pediatric inguinal herniorrhaphy: a preliminary study

There is an increasing demand and need for patients and caregivers to actively participate in the treatment process. However, when there are unexpected findings during pediatrics surgery, access restrictions in the operating room may lead to a lack of understanding of the medical condition, as the caregivers are forced to indirectly hear about it. To overcome this, we designed a tele-consent system that operates through a specially constructed mixed reality (MR) environment during surgery. We enrolled 11 patients with unilateral inguinal hernia and their caregivers among the patients undergoing laparoscopic inguinal herniorrhaphy between January through February 2021. The caregivers were informed of the intraoperative findings in real-time through MR glasses outside the operating room. After surgery, we conducted questionnaire surveys to evaluate the satisfaction and usefulness of tele-consent. We identified contralateral patent processus vaginalis in seven out of 11 patients, and then additionally performed surgery on the contralateral side with tele-consent from their caregivers. Most caregivers and surgeons answered positively about the satisfaction and usefulness of tele-consent. This study found that tele-consent with caregivers using MR glasses not only increased the satisfaction of caregivers and surgeons, but also helped to accommodate real-time findings by adapting surgical plan through the tele-consent.

Could increased expression of aquaporin-1 be an etiological cause in childhood noncommunicating hydroceles that do not regress spontaneously?

BACKGROUND

Aquaporins are membrane water channel proteins that are expressed in the epithelium and endothelium. Their primary function is to control the flow of water in the membranes of the cells.

OBJECTIVE

In this study, we investigated whether there is increased expression of aquaporin-1 in the tunica vaginalis of hydrocele patients in childhood that do not regress spontaneously an whether it has an effect on the etiology of hydrocele.

STUDY DESIGN

Boys who were diagnosed with hydrocele and scheduled for surgery were included and formed the hydrocele group. Boys in the same age range who underwent surgery for inguinal hernia or undescended testicles were included as a control group. Aquaporin-1 expression was evaluated by immunohistochemical examination of capillaries in tissue samples taken from the tunica vaginalis during the operation. Aquaporin-1-positive vessels were counted by selecting 5 unrelated areas with the highest vascular density, and the average number of vessels was calculated for each case.

RESULTS

A total of 48 male patients were included in the study. Of these, 27 constituted the hydrocele group (mean age 3.51 ± 2.59 years), and 21 constituted the control group (inguinal hernia, n = 17; undescended testicle, n = 4) (mean age 3.95 ± 3.80 years). The mean ages of both groups were statistically similar (p = 0.32). The mean numbers of aquaporin-1-positive vessels at the capillaries in the tunica vaginalis of the patients were 20.74 ± 7.10 in hydrocele group and 17.23 ± 4.07 in the control group. The expression of aquaporin-1 in the hydrocele group was significantly higher (p = 0.037).

DISCUSSION

It was shown that aquaporin-1 expression was higher in adult cases with hydrocele. Also an increase in aquaporin-1 expression was detected in tunica vaginalis of children with hydrocele in our study.

CONCLUSION

It was thought that aquaporin-1 overexpression may play a role in non-communicating hydroceles in children.

Safety and Efficacy of Laparoscopic Management of Intracanalicular Testes in Pediatrics

Introduction: Undescended testis is a relatively common congenital anomaly in male children with a prevalence of 1%-2% in live births. Upon discovering an empty scrotum, it is important to determine whether the testis is palpable, ectopic, retractile, or nonpalpable. A canalicular or "emergent" testis is a peeping one that freely slides to and fro between the abdominal cavity and inguinal canal. It may be impalpable initially, but at a time, it emerges from the internal ring to be palpable when it is "milked" down (where it was concealed from detection). It is reported that 15%-40% of cryptorchidism are viable peeping/canalicular testis. The laparoscopic approach for treating intracanalicular undescended testes offers many advantages over open inguinal orchiopexy. It maintains the integrity of the inguinal canal and eliminates the need to divide the epigastric vessels during dissection. The ability to dissect the testicular vessels at a higher level would increase the vessel length available to bring the testis down to the scrotum without strain. The aim of this study is to present our experience and evaluate laparoscopic approach for management of intracanalicular testes regarding operative safety, efficacy, and postoperative outcomes. Patients and Methods: This is a prospective study conducted at Department of Pediatric Surgery, MCH Hospital, Bisha, Saudi Arabia and Pediatric Surgery Department, Al-Azhar University Hospitals, Cairo, Egypt, in the period from October 2018 to August 2020 to evaluate the safety and efficacy of laparoscopic orchiopexy for intracanalicular testis. Patients with retractile testes, ectopic testes, testes located distal to the external inguinal ring, and nonpalpable testes were excluded from the study. Results: The study was conducted on 62 male children with 70 intracanalicular (peeping) testes, with age range from 8 months to 48 months (mean age: 24 months). Among them, 26 cases (∼42%) were left-sided, 28 (∼45%) were right-sided, and 8 (∼13%) cases were affected bilaterally. Postoperatively, all testes maintained good size without postoperative hydrocele or inguinal hernia. One case (1.4%) required open redo-orchiopexy because of testicular re-ascent to the level of scrotal neck. Moreover, there was no evidence of testicular atrophy confirmed by postoperative ultrasonography. All patients had good satisfied cosmetic results obtained by parent's questionnaire at postoperative follow-up visits. Conclusion: Laparoscopic orchiopexy for management of (intracanalicular) undescended testes is safe, effective, less invasive, without disturbance of inguinal canal anatomy, and with better cosmetic results.

Short-term outcomes of pediatric laparoscopic inguinal hernia repair in Korea based on Korean Health Insurance Big Data: 2011-2015

PURPOSE

For pediatric inguinal hernia repairs (IHRs), open IHR (high ligation) has long been a gold standard. Recently laparoscopic IHR (LIHR) was introduced as a new treatment modality and has been performed more frequently in Korea. Unlike adults, LIHR in children is still controversial. In the present study, we investigate the short-term outcomes of pediatric LIHR in Korea using nationwide inpatient data.

METHODS

We analyzed clinical practice for IHRs from 2011 to 2015 using Korean Health Insurance Review and Assessment Service-National Inpatient Sample.

RESULTS

A total of 5281 patients 15 years old or younger underwent 5356 IHRs: 4507 OIHRs and 849 LIHRs. M:F ratio was 2.4:1. The proportion of LIHRs was only 1.8% at the beginning but had been continuously increased up to 29.8% at the end of the study period. LIHRs were closely related to synchronous bilateral inguinal hernia repairs (SBIHRs). Overall, SBIHRs were performed in 10.9% of open and 49.2% of LIHRs. Metachronous contralateral IHRs (MCIHRs) after initial unilateral IHRs were significantly more frequent after OIHRs (1.7%, 69/3, 951) than after LIHRs (0.2%, 1/427). Recurrence rate per side during study period was 0.1% (6/4, 993) after OIHRs and 0.2% (2/1, 259) after LIHRs, respectively (statistically insignificant).

CONCLUSION

Nationwide inpatient data showed that LIHRs in pediatric patients had recently been increasingly performed in Korea. LIHRs facilitated SBIHRs, which, in turn, decreased the needs of MCIHRs. However limited numbers of patients might actually have benefited from them. Early recurrence after primary IHRs in children is quite low regardless of way of approach.

Laparoscopic orchiopexy of palpable undescended testes_ experience of a single tertiary institution with over 773 cases

Background

Discuss the superiority of laparoscopic orchiopexy in the treatment of inguinal palpable undescended testes.

Methods

Inclusion criteria: Preoperative examination and color Doppler ultrasound examination confirmed that the testes were located in the inguinal canal and could not be pulled into the scrotum, except for retractive and ectopic testes. The surgical steps were depicted as follow. The retroperitoneal wall was carved by ultrasonic scalpels, separates the spermatic vessels closed to the inferior pole of the kidney if necessary, dissects the peritoneum of vas deferens, cuts the testicular gubernaculum, and pulls back the testicle into the abdominal cavity. Besides, protect the vas deferens, and descend the testes to the scrotum and fix them without tension.

Results

There were 773 patients with 869 inguinal undescended palpable testes, 218 cases on the left side, 459 cases on the right side and 96 cases with bilateral undescended testes, whose age ranged from 6 months to 8 years, with an average of 20 months. All testes were successfully operated, no converted to open surgery. The average operation time was (34.8 ± 5.4) min. There were 692 testes have an ipsilateral patent processus vaginalis (89.5%); In 677 cases of unilateral cryptorchidism, 233 cases (34.4%) have a contralateral patent processus vaginalis, and laparoscopic percutaneous extraperitoneal closure the hernia sac carry out during the surgery. There was no subcutaneous emphysema during the operation, no vomiting, no abdominal distension, no wound bleeding and obvious pain after surgery, especially wound infection is rarely. Doppler ultrasound was evaluated regularly after surgery. The patients were followed up for 6 to 18 months. All the testes were located in the scrotum without testicular retraction and atrophy. No inguinal hernia or hydrocele was found in follow-up examination.

Conclusion

Laparoscopic orchiopexy manage inguinal palpable cryptorchidism is safe and effective, and there are obvious minimally invasive advantages. Furthermore, It could discover a contralateral patent processus vaginalis, and treat at the same time, which avoid the occurrence of metachronous inguinal hernia.

The clinical significance of an incidentally detected open internal inguinal ring

INTRODUCTION AND OBJECTIVE

An open internal inguinal ring (IIR) may be discovered incidentally either in the context of correcting pathology involving the contralateral side or at the time of surgical exploration for reasons unrelated to a patent processus vaginalis (PPV). The aim of this study is to determine the evolution of an incidentally encountered open IIR in patients undergoing laparoscopy for reasons not associated with unilateral inguinal hernia or cryptorchidism.

MATERIALS AND METHODS

The authors conducted a prospective study of all patients who underwent laparoscopic surgery in the department of pediatric surgery at Agios Loukas hospital between 2004 and 2013 for various indications. Patients operated for inguinal hernia and cryptorchidism were excluded. During this period, 572 patients underwent laparoscopy for reasons not related to PPV. The median age at time of initial laparoscopy was 9,4 years (range 2 days-16 years). The IIRs were always inspected. No attempt was made to repair the open IIRs, as they were asymptomatic. Parents were informed after the operation, and instructions were given to inform us, in case that inguinal hernia symptoms manifested. The duration of the follow-up was 4 years.

RESULTS

Among these 572 patients, 39 patients with 44 open IIRs were found (6,82%). From the 39 patients, 35 were male and four were female; 22 had a right open IIR, 12 had a left one, and five of them a bilateral open IIR. The median age was 7,82 years (3-14 years). Four patients were lost during follow-up. Of the remaining 35 patients with 40 open IIRs, four developed an inguinal hernia (11,43%) and were operated on with laparoscopically assisted (subcutaneous endoscopically assisted ligation [SEAL]) technique at the time of diagnosis. The study results are demonstrated on Fig. 1.

DISCUSSION

The percentage of an incidentally discovered open IIR in this study is lower in comparison with studies including patients with PPV pathologies. There is a possibility, in those patients, of underlying pathology which can affect both sides. It is also lower in comparison with previous studies including younger patients. However, gender and side predominance is in accordance with most published studies. In this study group, the possibility of developing a symptomatic hernia from an asymptomatic open IIR is rather small.

CONCLUSIONS

An incidentally discovered open IIR in patients without symptoms, excluding those with contralateral inguinal hernias or cryptorchidism, has relatively low chance of developing an inguinal hernia. Thus, the authors support the strategy of close follow-up in these patients.

Risk of incarceration in children with inguinal hernia: a systematic review

BACKGROUND

Surgical repair is recommended for all children with inguinal hernia due to fear of incarceration. The aim of this study was to assess the risk of incarceration and strangulation of inguinal hernias in children treated with delayed surgery or no surgery.

METHODS

Systematic searches were conducted in three databases. We included studies reporting on children with inguinal hernia, with the majority ≤ 10 years old. The interventions were non-acute inguinal hernia surgery or no surgery. The main outcomes were incarceration and strangulation. Secondary outcomes were postoperative complications. Randomized controlled trials, non-randomized controlled trials, and observational studies were included.

RESULTS

We included 22 studies with 14,959 children. All studies reported on elective repairs. None of the studies specifically reported on watchful waiting. Of the studies reporting wait time as mean or median, the median wait time was 46 days (range 1-552). The crude incarceration rate across the included studies was 7% for all children and 11% for preterm children. The testicular atrophy rate was 1% and the recurrence rate was 1%.

CONCLUSIONS

The risk of incarceration in children awaiting inguinal hernia surgery is substantial. In general, we cannot support delaying surgery unnecessarily. However, there may be benefits of delaying surgery in individual cases. In such cases, the surgeon should assess if the benefits may overrule the risk of incarceration.

Variation in the use of laparoscopy with inguinal hernia repairs in a sample of pediatric patients at children's hospitals

INTRODUCTION/BACKGROUND

Metachronous contralateral inguinal hernias (MCH) occur in approximately 10% of pediatric patients following unilateral inguinal hernia repairs (UIHR). Laparoscopic evaluation of the contralateral internal ring is a method of identifying high-risk individuals for prophylactic contralateral exploration and repair.

OBJECTIVE

The objective of this study was to assess variation in utilization of diagnostic laparoscopy, and report costs associated with the evaluation of a contralateral patent processus vaginalis during hernia repair in pediatric hospitals.

STUDY DESIGN

The Pediatric Health Information System database was searched to identify outpatient surgical encounters for pediatric patients with a diagnosis of inguinal hernia during a 1-year period (2014). Records were identified that contained diagnostic codes for unilateral or bilateral inguinal hernia in combination with a procedure code for open hernia repair with or without diagnostic laparoscopy.

RESULTS

After exclusions there were 3952 hernia repairs performed at 30 hospitals; median age was 4 years (IQR 1-7), 78.8% were male, and 64.9% Caucasian. Three-quarters (76.7%) had UIHR, 8.6% had unilateral repairs with laparoscopy (UIHRL), 12.2% had bilateral inguinal hernia repairs (BIHR), and 2.4% had bilateral repairs with laparoscopy (BIHRL). Where laparoscopy was used, 78% resulted in a unilateral repair and 22% in a bilateral procedure. The percent of patients undergoing laparoscopy varied from 0 to 57% among hospitals, and 0-100% among surgeons. Pediatric surgeons were more than three times more likely to perform a diagnostic laparoscopy compared with pediatric urologists. Median adjusted costs were $2298 (IQR 1659-2955) for UIHR, $2713 (IQR 1873-3409) for UIHRL, $2752 (IQR 2230-3411) for BIHR, and $2783 (IQR 2233-3453) for BIHRL. Median costs varied over two-fold among hospitals ($1310-4434), and over four-fold among surgeons ($948-5040).

DISCUSSION

Data suggested that <10% of patients with clinically unilateral inguinal hernias developed MCH. A negative diagnostic laparoscopy ensured that 0.9-1.31% developed MCH. However, up to 30% of patients underwent contralateral exploration/repair when diagnostic laparoscopy was used. The current study found increased costs associated with the use of laparoscopy, with considerable variation in costs among surgeons and hospitals. These data elucidate competing financial and clinical consequences associated with the use of diagnostic laparoscopy with clinically unilateral hernias.

CONCLUSIONS

Variation existed in the use of laparoscopy during inguinal hernia repairs and associated costs within the current sample from children's hospitals in the United States. The additional costs of laparoscopic evaluation must be considered against the clinical utility and therapeutic consequences of identifying individuals with a higher risk of metachronous contralateral inguinal hernia.

Inguinal hernia repair by Bianchi incision in boys: a retrospective study

OBJECTIVE

Open inguinal hernia repair by Bianchi incision is a potential alternative technique for the treatment of IH. This study aims to retrospectively analyze boys with IH, who underwent open IH repair by Bianchi incision.

METHODS

A total of 3300 boys (1-144 months) with IH from April 2007 to September 2015 were enrolled into this study. An open high scrotal incision (Bianchi incision) to ligate the processus proximal to the internal inguinal ring was performed in patients for IH repair. Then, all patients were followed up after 7 days, 1 month, and 1 year. Operation time, hernia recurrence, hydrocele, testicular atrophy, cosmetic results, and the satisfaction of parents were evaluated.

RESULTS

Among these 3300 boys, 1662 (50.36%) and 1349 (40.88%) boys with IH were operated on the right and left side, respectively, while 289 (8.76%) patients underwent bilateral surgery. The average operation time was 13.0 ± 2.3 min for unilateral cases and 25.2 ± 4.2 min for bilateral cases. Furthermore, among these 3300 boys, 309 boys (9.36%) were lost to follow-up, and the remaining 2991 boys underwent a total of 3245 IH repairs. The complications included 20 recurrences who were repaired with the same technique, one wound rupture, and one acquired undescended testis. No infection, obvious scrotal hematoma, testicular atrophy, and vas deferens injury were found during the follow-up. In most instances, the scars were invisible, obtaining an excellent cosmetic effect.

CONCLUSION

Inguinal hernia repair by Bianchi incision is a safe, easy and effective technique with cosmetic benefits, which could be a reliable alternative for the treatment of pediatric inguinal hernia.

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.

Etiology of Inguinal Hernias: A Comprehensive Review

Background

The etiology of inguinal hernias remains uncertain even though the lifetime risk of developing an inguinal hernia is 27% for men and 3% for women. The aim was to summarize the evidence on hernia etiology, with focus on differences between lateral and medial hernias.

Results

Lateral and medial hernias seem to have common as well as different etiologies. A patent processus vaginalis and increased cumulative mechanical exposure are risk factors for lateral hernias. Patients with medial hernias seem to have a more profoundly altered connective tissue architecture and homeostasis compared with patients with lateral hernias. However, connective tissue alteration may play a role in development of both subtypes. Inguinal hernias have a hereditary component with a complex inheritance pattern, and inguinal hernia susceptible genes have been identified that also are involved in connective tissue homeostasis.

Conclusion

The etiology of lateral and medial hernias are at least partly different, but the final explanations are still lacking on certain areas. Further investigations of inguinal hernia genes may explain the altered connective tissue observed in patients with inguinal hernias. The precise mechanisms why processus vaginalis fails to obliterate in certain patients should also be clarified. Not all patients with a patent processus vaginalis develop a lateral hernia, but increased intraabdominal pressure appears to be a contributing factor.

The risk of developing a symptomatic inguinal hernia in children with an asymptomatic patent processus vaginalis

BACKGROUND

Children with a symptomatic indirect inguinal hernia have a patent processus vaginalis (PPV). However, the reverse is unknown, as the natural history of PPV is unclear. Currently, there are little data regarding the incidence and time frame for developing a symptomatic hernia with a known asymptomatic PPV.

METHODS

A retrospective chart review was conducted in children who were evaluated for a PPV during nonhernia laparoscopic surgery by a single pediatric surgeon (GWH) from 2000 to 2014. Those patients with intraoperative findings of PPV were followed up by chart review and phone inquiry.

RESULTS

1548 children underwent a laparoscopic operation, with 308 having an asymptomatic PPV. Phone contact was successful in 125 (43%) of these patients at a median of 8.1years (range 4.8-12.7) after the initial laparoscopic operation. Nineteen (13%) patients returned with a symptomatic hernia at a median age of 17months (range: 5-74) and a median presentation of 9months (range: 1-66) after the initial laparoscopy. Ten hernia repairs were unilateral and 9 bilateral. None of those who were contacted via phone inquiry reported hernia symptoms or hernia repair.

CONCLUSIONS

These data suggest that the risk of developing a symptomatic hernia during childhood in the presence of a known PPV is relatively low.

LEVEL OF EVIDENCE

Level 3; type of study: retrospective study.

Case report of migration of 2 ventriculoperitoneal shunt catheters to the scrotum: Use of an inguinal incision for retrieval, diagnostic laparoscopy and hernia repair

•

A ventriculoperitoneal shunt catheter migrated through an inguinal hernia into the scrotum.

•

A single incision was used to for diagnostic laparoscopy, catheter removal and hernia repair.

•

Prompt surgical removal of fractured shunt catheters is recommended to prevent organ injury.

Backgroud

Ventriculoperitoneal shunts are commonly used in the treatment of hydrocephalus, and catheter migration to various body sites has been reported. Pediatric and general surgeons are asked on occasion to assist with intraabdominal access for these shunts, particularly when there may be extensive adhesions or other complicating factors.

Methods

We describe a case in which an old shunt catheter was never removed from the abdomen, and it migrated through an inguinal hernia into the scrotum. The catheter became entangled and fibrosed to the testicle. A second and more recent shunt catheter was also in the scrotum. A single incision in the inguinal region was used to remove both shunt catheters, repair the inguinal hernia and perform diagnostic laparoscopy to assist in placing a new ventriculoperitoneal shunt.

Results

Prompt surgical removal is recommended for catheters remaining in the abdomen after ventriculoperitoneal shunt malfunction. These catheters may cause injury to the testicle, or possibly other intraabdominal organs. General or pediatric surgical consultation should be obtained for lost catheters or inguinal hernias.

Conclusion

In the case of an inguinal hernia containing a fractured shunt catheter, the hernia sac can be used to remove the catheter, repair the hernia and gain laparoscopic access to the abdomen to assist with shunt placement.

Long-Term Outcome of Low Scrotal Approach Orchiopexy without Ligation of the Processus Vaginalis

PURPOSE

We performed low scrotal approach orchiopexy in patients with prescrotal cryptorchidism. The processus vaginalis was not ligated if it was not widely patent. We retrospectively evaluated the long-term outcomes of low scrotal approach orchiopexy without processus vaginalis ligation.

MATERIALS AND METHODS

A total of 137 patients (227 testes) were diagnosed with prescrotal cryptorchidism between October 2009 and April 2014. All patients underwent low scrotal approach orchiopexy. Mean age at surgery was 34.9 months. The processus vaginalis was deemed to be not widely patent when a sound could not be passed into the abdominal cavity through the internal inguinal ring, and the processus vaginalis was not ligated in such cases.

RESULTS

Intraoperative findings revealed that the processus vaginalis was widely patent in 10 testes and was not widely patent in 217. A widely patent processus vaginalis was closed via scrotal approach in 5 testes, while an inguinal approach was necessary in 5. Median followup was 44 months (range 20 to 73). Postoperative complications included reascending testis in 1 case where an inguinal approach was necessary. No patient manifested testicular atrophy or inguinal hernia.

CONCLUSIONS

Low scrotal approach orchiopexy is a useful and safe procedure for treating patients with prescrotal cryptorchidism. Ligation is unnecessary when the processus vaginalis is not widely patent.