A single-blinded, randomized comparison of laparoscopic versus open bilateral hernia repair in boys

An Objective Evaluation of Intraoperative and Postoperative Pain in Infants Undergoing Open Inguinal Herniotomy and Laparoscopic Inguinal Hernia Repair Using the Newborn Infant Parasympathetic Evaluation (NIPE™) Monitor

PURPOSE

The heart rate variability-derived Newborn Infant Parasympathetic Evaluation (NIPE) monitor is an objective, non-invasive tool for the assessment of pain in children under 2 years of age. The aim of this study was to objectively compare pain in infants undergoing open and laparoscopic inguinal hernia surgery using the NIPE monitor.

METHOD

This prospective observational study included neonates and infants (<2 years of age) undergoing elective open inguinal herniotomy and laparoscopic inguinal hernia repair under general anaesthesia with a caudal block. The NIPE monitor was connected to the electrocardiogram monitor with continuous monitoring performed intraoperatively, and postoperatively in the Post Anaesthesia Care Unit. The NIPE index was recorded at different intraoperative steps. The median NIPE index (NIPEm) was calculated for the entire procedure and postoperative period. The NIPE index ranges from 0 to 100; lower values indicate greater levels of pain, values < 50 indicate severe pain. P values < 0.05 were considered significant.

RESULTS

There were 40 infants recruited: 27 underwent open herniotomy and 13 underwent laparoscopic repair. Intraoperatively, NIPEm was found to be significantly lower in the laparoscopic group (59.00 vs. 77.00, p = 0.0018). Postoperatively, NIPEm was also found to be significantly lower in the laparoscopic group (49.00 vs. 57.50, p = 0.0001).

CONCLUSION

This is the first study to objectively demonstrate that laparoscopic inguinal hernia repair is more painful intraoperatively and leads to greater levels of pain in the early postoperative period compared to open inguinal herniotomy. This difference might explained by painful stimuli in anatomical areas not covered by the caudal block.

TYPE OF STUDY

Treatment Study/Prospective Study.

LEVEL OF EVIDENCE

Level II.

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

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

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

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

Contralateral patent processus vaginalis repair in boys: a single-center retrospective study

To ascertain the prevalence of contralateral patent processus vaginalis (CPPV) in life and the significance of the prevalence trends for treatment. We performed a retrospective review of all inguinal hernias (IHs) that underwent repair in our hospital from 2014 to 2018. We analyzed the frequency of occurrence and treatment in boys. We assessed and compared the history, initial sides of hernia, CPPV and prognoses in different age groups. We assessed all IH cases repaired in our hospital and selected male patients of a variety of ages, including boys and men. Recurrent cases were not enrolled. A total of 3243 cases were enrolled: 2489 [right-sided IH 1411 (56.69%) vs. left-sided IH 975 (39.17%), bilateral IH 103 (4.14%)] in children and 754 [right-sided IH 485 (64.32%) vs. left-sided IH 236 (31.30%), bilateral IH 33 (4.38%)] in adults. A total of 1124 CPPVs were identified in children with unilateral IH (2386), and 12 were identified in adults (267) (p < 0.0001). There were no significant differences in recurrence rate between different subgroups of children (p > 0.05). The incidence of IH in boys was significantly higher than that in men. The number of incident cases declines rapidly with age in boys. The processus vaginalis is normally obliterated and involuted but may instead remain patent for a long period before closure; routine exploration on the contralateral side may eliminate the possibility of spontaneous PPV closure.

Perioperative opioid use in paediatric inguinal hernia patients: A systematic review and retrospective audit of practice

BACKGROUND

Opioids play a major role in postoperative pain management in children, but their administration remains an under investigated topic. This study aimed to describe perioperative opioid prescribing practices for paediatric inguinal hernia patients in the literature and at The Royal Children's Hospital (RCH) in Melbourne, Australia.

MATERIAL/METHOD

A systematic review of English articles (published from 2009 to 2019) was conducted on paediatric (0-18y) inguinal hernia patients who received a postoperative or discharge opioid prescription, or both. The review was combined with a retrospective audit of RCH patients. Demographic, surgical, and analgesic details were collected from the electronic medical records.

RESULTS

Fifteen studies (n = 1166; combined mean age 4.93y) met the systematic review criteria. The percentage of patients receiving opioids postoperatively overall ranged from 3.33-100%, and doses ranged from 0.07 to 0.35 mg/kg oMEDD. At the RCH, perioperative opioid use was analyzed from 150 inguinal hernia patients (male - 113, median age - 3 months old). Postoperatively, 26 (17.3%) patients received opioids. The most commonly administered opioids were fentanyl (0.04-0.60 mg/kg oMEDD) in the post anaesthesia care unit and oxycodone (0.14-0.40 mg/kg oMEDD) in the first 24 h postoperatively. Older age at surgery, female sex and absence of regional anaesthesia were significantly associated with higher risk of total opioid use. No patients received an opioid prescription at discharge.

CONCLUSION

There is demonstratable variability in opioid prescribing practices for paediatric inguinal hernia patients as described in the literature. At our institution opioids were not used frequently in postoperative period.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

Purpose

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

Methods

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

Results

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

Conclusion

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

[Laparoscopic phelps approach in children with inguinal hernia: a retrospective comparative study]

OBJECTIVE

To evaluate the effectiveness of a new method of inguinal hernia repair in children (PHELPS) first proposed by the authors compared to another laparoscopic method (SEAL).

MATERIAL AND METHODS

The study demonstrated the results of laparoscopic treatment of 729 patients with inguinal hernias. Of these, 255 patients underwent PHELPS procedure. Other 474 patients underwent SEAL procedure. The difference between both methods is that hernial ligature is passed around the hernial sac in case of PHELPS. SEAL procedure implies capture of tissues of anterior abdominal wall (muscles and aponeurosis) into this knot. We analyzed whether this factor can lead to less incidence of recurrence and hydrocele.

RESULTS

Both groups were comparable by age, body weight and gender. Median of surgery time including correction of unilateral and bilateral hernia was similar (20.0 [10.0; 20.0] min versus 15.0 [15.0; 20.0] min; p=0.666). We found faster patient recovery after PHELPS procedure for inguinal hernia including much less doses of postoperative analgesia (1.0 [1.0; 1.0] versus 1.0 [1.0; 2.0]; p<0.001) and shorter hospital-stay (8.0 [8.0; 8.0] hours versus 8.0 [8.0; 9.0] hours; p=0.010). There were no significant differences in the incidence of postoperative hydrocele (0 versus 6; p=0.097). Nevertheless, recurrence rate differed significantly (0 versus 17; p=0.001).

CONCLUSION

PHELPS procedure is characterized by lower incidence of recurrence and accelerated postoperative recovery compared to SEAL technique.

Results of using the method of full extraperitoneal endoscopically assisted ligation of the hernial sac with inguinal hernia in children

BACKGROUND/PURPOSE

The aim of this study was to evaluate the effectiveness of a new technique for inguinal hernia repair in children: pediatric hernia extra-peritoneal ligation and percutaneous suturing (PHELPS) in comparison with another laparoscopic technique, subcutaneous endoscopically assisted ligation (SEAL).

METHODS

We demonstrate the results of laparoscopic treatment of 680 patients with inguinal hernias. Of these, 206 patients were operated using the new PHELPS technique. The remaining 474 children received the SEAL technique. The difference between the methods is that PHELPS consists of ligating the hernia around the neck of the hernial sac, including an intra-peritoneal component (aponeurosis and muscles), while the SEAL technique ligates the hernia sac only. We examined whether this factor may lead to more recurrence and hydrocele in the SEAL technique.

RESULTS

Both groups of patients were comparable in terms of age, body weight at the time of surgery, and gender. The average total duration of inguinal herniorraphy, including the time of surgery in patients with one-and two-sided hernia localization, was comparable in both groups (17.50 min versus 17.22 min; p = 0.518). The study demonstrated a faster recovery of patients after using the PHELPS technique for the treatment of inguinal hernias, consisting in a statistically significantly lower number of doses of postoperative analgesia (1.01 versus 1.31; p < 0.001) and a shorter time of patient stay in the hospital (8.06 h versus 8.78 h; p = 0.031). Despite the fact that there were no statistically significant differences in the frequency of postoperative hydrocele (0 versus 6; p = 0.090), we found a statistically significant difference between the groups in terms of recurrence (0 versus 17; p < 0.001).

CONCLUSIONS

The PHELPS technique shows improved results in terms of recurrence and hydrocele as compared to SEAL.

LEVEL OF EVIDENCE

Level III TYPE OF STUDY: Retrospective Comparative Study.

Laparoscopy is increasingly used for pediatric inguinal hernia repair

INTRODUCTION

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

MATERIAL & METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of laparoscopic percutaneous extraperitoneal closure and laparoscopic intracorporeal suture in pediatric hernia repair

BACKGROUND

Laparoscopic inguinal repair use is rapidly growing because it is a minimally invasive surgery (MIS) technique. However, there is insufficient evidence to support the use of one MIS over others. We compared laparoscopic intracorporeal suture (LIS) and laparoscopic percutaneous extraperitoneal closure (LPEC) to determine which technique is superior.

METHODS

Between February 2017 and December 2019, 260 children who underwent LPEC and 214 children who underwent LIS were enrolled. Operative time, recovery score, and patient cosmetic satisfaction were compared. A total of 108 propensity score-matched pairs were analyzed using paired t-test for continuous measurements and McNemar test for categorical variables.

RESULTS

The mean surgery time was lower in the LPEC group for both unilateral (15.76 ± 5.35 vs. 19 ± 5.71 min; p = 0.04) and bilateral (21.56 ± 5.7 vs. 26.38 ± 6.94 min; p = 0.01) surgeries. The LPEC group required shorter time for complete recovery (p = 0.017). The mean rating for scar visibility was higher in the LIS group (p = 0.02); however, both groups had high levels of cosmetic satisfaction (p = 0.125).

CONCLUSION

LPEC for hernia repair is safe and efficient in children and reduced operative time, hastened recovery, and provided excellent cosmetic results.

Comparison of Postoperative Pain and Analgesic Requirements Between Laparoscopic and Open Hernia Repair in Children

Background

This study analyses the impact of anaesthetic blockade and intraperitoneal local anaesthetic infiltration on paediatric laparoscopic inguinal hernia repair.

Method

A retrospective review of paediatric laparoscopic hernia repairs versus open repairs. Anaesthetic blockade, analgesic consumption and postoperative pain scores were compared between groups.

Results

155 children underwent laparoscopic repair, 150 underwent open repairs. Median age was 7.2 months (16 days–14 years) in the laparoscopic group, 6 months (17 days–13 years) in the open group. Anaesthetic blockade varied significantly; 62.7% of open cases had caudal blockade compared to 21.6% laparoscopic (p < 0.001). A subset of laparoscopic patients had peritoneal local anaesthetic infiltration. 10.1% of laparoscopic cases required recovery analgesia, compared to 1.3% of open cases (p = 0.001). Postoperative analgesic consumption was significantly higher in the laparoscopic group. Peritoneal infiltration reduced analgesic consumption in the laparoscopic group (p = 0.038). Age < 2 was associated with use of caudal (p < 0.001), which reduced analgesic consumption.

Conclusions

Laparoscopy was associated with increased use of recovery analgesia. Caudal reduced the need for rescue and postoperative analgesia. Intraperitoneal infiltration of local anaesthetic is associated with reduced postoperative analgesia in laparoscopy. In suitable patients undergoing laparoscopic surgery, combination caudal and peritoneal infiltration may prove a useful adjunctive analgesic strategy.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Percutaneous hernia repair in children: Safe to introduce

BACKGROUND AND OBJECTIVE

In 2014 we introduced percutaneous internal ring suture as an alternative to open surgery for the treatment of inguinal hernia. This study aims to evaluate the introduction of the procedure at our institution.

METHODS

In total, 100 consecutive patients operated with percutaneous internal ring suture were compared with 100 consecutive patients operated with open surgery. The patients were operated from August 2014 until November 2017. Patient demographics, clinical history, operative time, time in theater, and postoperative complications were extracted from charts.

RESULTS

The mean operative time for percutaneous internal ring suture was 26.54 min and for open surgery 39.94 min, P < 0.0001. The total mean operative theater time for percutaneous internal ring suture was 108.95 min and for open surgery 118.4 min, P = 0.0343. During follow-up, two percutaneous internal ring sutures were operated for recurrent hernia. In the open surgery-group, three patients were operated for recurrent hernia, three for secondary testicular retention, and three for metachronous contralateral hernia.

CONCLUSIONS

Even when established as a new technique, the percutaneous internal ring suture procedure is safe and results in shorter operative time and shorter theater time compared to open surgery.

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

III.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Single-port laparoscopic percutaneous extraperitoneal closure of inguinal hernia using "two-hooked" core needle apparatus in children

OBJECTIVE

The aim of this study is to evaluate the surgical outcomes of single-port laparoscopic percutaneous extraperitoneal closure of inguinal hernia using "two-hooked" core needle apparatus in children.

METHODS

This study was conducted at Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine between January 2016 and June 2018. Five hundred and eighteen patients under the age of 12 years with inguinal hernias were subjected to single-port laparoscopic percutaneous extraperitoneal closure (SPLPEC) using non-absorbable suture by "two-hooked" core needle apparatus. Description of the technique is as follows: Under general anesthesia, a 0.5-0.8 cm trans-umbilical skin incision was done for insertion of a 0.5 cm port. A "two-hooked" core needle apparatus was used for insertion of a non-absorbable suture around internal ring. The suture knot was tied extracorporeally.

RESULTS

Among 518 child patients with inguinal hernias, there were 406 males and 112 females with a mean age of 4.6 ± 3.5 years. One hundred and six cases were subjected to bilateral surgery including 91 cases of contralateral patent processus vaginalis (PPV). Three cases converted to open surgery and additional 0.5 cm port was done in five cases. The mean operative time was 13.2 ± 3.5 min for unilateral hernia repair and 16.9 ± 4.6 min for bilateral cases. All patients achieved full recovery without complications such as surgical site infection (SSI), testicular atrophy, or iatrogenic ascent of the testis. At the mean follow-up time of 18.72 ± 5.27 months, two cases had recurrences (0.39%) and one case had postoperative hydrocele (0.19%).

CONCLUSION

SPLPEC of inguinal hernia using "two-hooked" core needle apparatus in children is a feasible and reliable minimal invasive procedure. It has the advantages of short operating time, low complication rate, low recurrence rate and better cosmetic result.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TYPE OF STUDY

Retrospective study.

LEVELS OF EVIDENCE

Level III.

Evidence supporting laparoscopic hernia repair in children

PURPOSE OF REVIEW

Pediatric inguinal hernias are a commonly performed surgical procedure. Currently, they can be approached via open or laparoscopic surgery. We summarize the current evidence for laparoscopic inguinal hernia repairs in children.

RECENT FINDINGS

Laparoscopic and open inguinal hernia repair in children are associated with similar operative times for unilateral hernia, as well as similar cosmesis, complication rates and recurrence rates. Bilateral hernia repair has been shown to be faster through a laparoscopic approach. The laparoscopic approach is associated with decreased pain scores and earlier recovery, although only in the initial postoperative period. Laparoscopy allows for easy evaluation of the patency of contralateral processus vaginalis, although the clinical significance of and need for repair of an identified defect is unclear.

SUMMARY

Laparoscopic surgery for pediatric inguinal hernias offers some advantages over open repair with most outcomes being equal. It should be considered a safe alternative to open repair to children and their caregivers.

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

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

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

BACKGROUND

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

PATIENTS AND METHODS

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

INCLUSION CRITERIA

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

RESULTS

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

CONCLUSION

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

It is time for a better clip applier - 3 mm, percutaneous, non-crushing and locking

INTRODUCTION

Since the advent of laparoscopy there have been attempts to minimize abdominal wall incisions. For this purpose smaller instruments have been produced. Our aim was to develop the first 3 mm percutaneous clip applier and to make it better than the standard clips of today.

MATERIAL AND METHODS

The ClipTip clip is made of Nitinol and has a crocodile shaped jaws, which when apposed effectively seal vessels. The shaft operates as a retractable needle permitting percutaneous insertion. Closing, reopening and reclosing is possible. The physical properties of the device were compared to three commercially available clip appliers. Surgeries were performed on porcine animals by experienced surgeons.

RESULTS

In comparison to available clips, the superiority of the ClipTip is a combination of wide effective length alongside the ability to withstand strong forces. In live animal studies the Cliptip was inserted into the peritoneal cavity without any injuries. Vessels were ligated successfully and no clip dislodgement or leakage occurred.

CONCLUSIONS

We developed the next generation clip applier with better properties. Advantages include its length, the needleoscopic caliber, non-crushing effect, locking mechanism and wide aperture. The device has performed safely and effectively in pre-clinical tests. Further studies are planned in humans.

Choice of Repairing Inguinal Hernia in Children: Open Versus Laparoscopy

Inguinal hernia is a common disorder of childhood that requires surgical repair at diagnosis. Traditionally, it is operated upon by open inguinal incision. However, with the introduction of laparoscopic repair in 1990, opinion of scientific community is divided concerning the best method of pediatric herniotomy. Educated parents, who long to have the choicest of the best, often gather information from internet and prefer to discuss their concerns with primary care physicians. This descriptive review is intended to provide practicing pediatricians with updated evidence-based information which will enable them to counsel parents regarding the choice of hernia repair. Based on careful analysis of current literature, unacceptable standards are defined in this paper and rationalized recommendations are proposed. Laparoscopy appears to be beneficial in bilateral hernia of girls, giant hernia, recurrence following failed open repair and in hernia associated with undescended testis or ambiguous genitalia. On the other hand, open herniotomy appears to be advantageous in male inguinal hernia, unilateral female hernia, premature newborns, failed laparoscopic repair and in hernia associated with serious co-morbidity.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The International Pediatric Endosurgery Group Evidence-Based Guideline on Minimal Access Approaches to the Operative Management of Inguinal Hernia in Children

Introduction: Minimally invasive surgery (MIS) for inguinal hernia repair (IHR) in children has been reported for more than two decades. The International Pediatric Endosurgery Group (IPEG) Evidence-Based Review Committee chose MIS IHR as the inaugural topic for review and presentation at the 2016 IPEG annual meeting. Materials and Methods: English language articles published between January 1, 2009, and December 31, 2015, were reviewed and included in this evidence-based review after searching PubMed, Cochrane Reviews, ClinicalTrials.gov, Google Scholar, and EMBASE. Results: Level 1a and 1b evidence supports the recommendations that operative time for bilateral IHRs should be considered shorter and postoperative complications rates should be considered lower in MIS repair over open. Recurrence rates are similar between the two methods (level 1a and 1b evidence). No level 1 evidence exists to support one MIS technique over another or that operating on a detected contralateral patent processus vaginalis during laparoscopy makes any difference in long-term outcome to the patient. Conclusions: The advantages of lower postoperative complications and shorter operative times have been found in studies of surgeons experienced in MIS repair and differences were small. The evidence in this review supports that MIS repair is a safe, effective method of IHR with proper training and mentorship.

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 comparative study on trans-umbilical single-port laparoscopic approach versus conventional repair for incarcerated inguinal hernia in children

PURPOSE

The purpose of this study is to determine whether singleport laparoscopic repair (SLR) for incarcerated inguinal hernia in children is superior toconventional repair (CR) approaches.

METHOD

Between March 2013 and September 2013, 126 infants and children treatedwere retrospectively reviewed. All the patients were divided into three groups. Group A (48 patients) underwent trans-umbilical SLR, group B (36 patients) was subjected to trans-umbilical conventional two-port laparoscopic repair (TLR) while the conventional open surgery repair (COR) was performed in group C (42 patients). Data regarding the operating time, bleeding volume, post-operative hydrocele formation, testicular atrophy, cosmetic results, recurrence rate, and duration of hospital stay of the patients were collected.

RESULT

All the cases were completed successfully without conversion. The mean operative time for group A was 15 ± 3.9 min and 24 ± 7.2 min for unilateral hernia and bilateral hernia respectively, whereas for group B, it was 13 ± 6.7 min and 23 ± 9.2 min. The mean duration of surgery in group C was 35 ± 5.2 min for unilateral hernia. The recurrence rate was 0% in all the three groups. There were statistically significant differences in theoperating time, bleeding volume, post-operative hydrocele formation, cosmetic results and duration hospital stay between the three groups (P < 0.001). No statistically significant differences between SLR and TLR were observed except the more cosmetic result in SLR.

CONCLUSION

SLR is safe and effective, minimally invasive, and is a new technology worth promoting.