Contralateral metachronous hernia following negative laparoscopic evaluation for contralateral patent processus vaginalis: a meta-analysis

Construction and validation of a predictive model for the risk of contralateral patent processus vaginalis in children with unilateral inguinal hernia or hydrocele

To develop a nomogram model for predicting contralateral patent processus vaginalis in children with unilateral inguinal hernia or hydrocele. A retrospective analysis was conducted on 259 children with unilateral inguinal hernia or hydrocele who underwent laparoscopic surgery at the Southern Hospital of Southern Medical University from January 2021 to December 2023. The patients were randomly divided into a training set (n = 207) and a validation set (n = 52) in an 8:2 ratio to analyze the characteristics of CPPV. Multivariate logistic regression analysis was used to screen for independent risk factors for CPPV, and a nomogram prediction model was constructed. The predictive ability, calibration, and clinical net benefit of the model were evaluated by plotting receiver operating characteristic (ROC) curves, calibration curves (HL), and clinical decision curves (DCA). Among children under 1 year old, the laparoscopic exploration revealed a CPPV incidence rate of 55.17%. The incidence rates for children aged 2-10 years ranged from 29.03 to 39.13%, and the incidence rate for children aged 11-14 years was 21.21%. Multivariate logistic regression analysis showed that age (OR = 0.9, 95%CI 0.82-0.99, P = 0.035) and female gender (OR = 2.42, 95%CI 1.21-4.83, P = 0.013) were independent risk factors for CPPV, and the incidence of CPPV decreased with age. The area under the ROC curve (AUC) for the training set of the constructed model was 0.632, and the AUC for the validation set was 0.708. The Hosmer-Lemeshow goodness-of-fit test indicated good model fit (training set P = 0.085, validation set P = 0.221), and the DCA curve suggested good clinical benefit.The nomogram model developed in this study demonstrates good clinical value. Children with unilateral inguinal hernia or hydrocele who are younger in age and female gender should undergo careful intraoperative exploration for the presence of CPPV. What is Known: • The probability of developing inguinal hernia in children with CPPV is 11%-25%, and redo surgery can increase surgical risks and financial burden. • The risk factors of unilateral inguinal hernia combined with CPPV are controversial. What is New: • Age and female gender are independent risk factors for CPPV. • A nomogram prediction model was constructed to provide a theoretical basis as well as an assessment tool for preoperative evaluation of whether children with unilateral indirect inguinal hernia are susceptible to CPPV.

Single-port robotic-assisted laparoscopic synchronous surgery in pediatric patent processus vaginalis

PURPOSE

Patent processus vaginalis (PPV) is usually observed in pediatric abdominal surgery; however, robotic single-port surgery in repairing processus vaginalis has not been reported in children. Herein, we present our clinical experiences in single-port robotic surgeries for PPV repair to evaluate both efficacy and safety.

METHODS

Retrospective analysis of patients underwent single-port robotic-assisted laparoscopic surgery for genitourinary diseases from May 2020 and May 2023 in our center. Among these patients, 21 children had PPV repaired at the same time. The case characteristics and follow-up data were recorded.

RESULTS

Twenty-one of the 53 children were found to have PPV during genitourinary surgery. The simultaneous treatment of the primary disease and PPV with a single-port robotic-assisted platform was both convenient and safe. There was no significant increase in total operation time, and no excessive intraoperative hemorrhage was observed in any of the operations. There were no complications observed on follow-up.

CONCLUSION

With a high incidence of PPV in children, a single-port robotic-assisted procedure is feasible and effective if simultaneously performed when addressing a primary abdominal disease.

Laparoscopic inguinal hernia repair (LIHR): the benefit of the double stitch in the largest single-center experience

AIM

To review our experience of laparoscopic inguinal hernia repair (LIHR) regarding complication rates, the practice of closing the asymptomatic patent processes vaginalis (PPV), and comparison of complication rates between pre-term (< 37 week gestation) and term infants.

METHODS

Retrospective review of LIHR performed between 2009 and 2021. Repair was performed by intracorporal single or double purse string/purse string + Z-stitch using a non-absorbable suture. Data were analyzed using Chi-squared/Mann-Whitney and are quoted as median (range).

RESULTS

1855 inguinal rings were closed in 1195 patients (943 (79%) male). 1378 rings (74%) were symptomatic. 492 (41%) patients were pre-term. Corrected gestational age at surgery was 55 weeks (31 weeks-14.6 years) and weight 5.9 kg (1-65.5). Closure of contralateral PPV was higher in the premature group (210/397 [53%] vs. 265/613 [43%] p = 0.003). There were 23 recurrences in 20 patients, of whom 10 had been born prematurely. The only factor significantly associated with a lower recurrence was use of a second stitch (p = 0.011).

CONCLUSION

This is the largest single-center reported series of LIHR. LIHR is safe at any age, the risk of recurrence is low, and can be corrected by re-laparoscopy. Use of a Z-stitch or second purse string is associated with a significantly lower rate of recurrence.

Metachronous Contralateral Occurrence of Hydrocele After Unilateral Hydrocelectomy in Children Younger Than 8 Years

BACKGROUND

Hydrocele on the contralateral side after surgical repair is an uncommon condition compared to surgical site recurrence. Although there has been much research on metachronous contralateral inguinal hernia in children, metachronous contralateral hydrocele, which share a common pathology with inguinal hernias, has not yet been investigated. We have investigated the incidence and risk factors for metachronous contralateral occurrence of communicating and noncommunicating hydroceles in children younger than 8 years.

METHODS

From January 2017 to June 2020, 302 children younger than 8 who were diagnosed with unilateral hydroceles were treated in our hospital without surgical exploration of contralateral hydrocele. The disease was classified into communicating and noncommunicating hydroceles. We divided patients into two groups according to the presence of metachronous contralateral hydrocele and analyzed the differences between the two groups.

RESULTS

Among 302 patients, the mean age was 36.4 ± 20.9 months. Metachronous contralateral hydrocele occurred in 15 (4.9%) patients as communicating hydroceles. Comparison between the two groups showed statistically significant differences in type of hydrocele (P = 0.047) at first diagnosis.

CONCLUSION

Clinically evident risk of metachronous contralateral hydrocele after unilateral hydrocelectomy was 4.9%. Despite the relatively low incidence rate, the risk of metachronous contralateral occurrence should always be consulted with parents before surgical treatment of hydroceles.

Review and Quality Assessment of Systematic Reviews and Meta-analyses on the Management of Pediatric Inguinal Hernias: A Descriptive Study

INTRODUCTION

Research quality in pediatric surgery has been challenged by multiple factors, including the low incidence of some congenital pathologies and rare event rates. With the rapid increase of pediatric surgical literature, there is a need for systematic reviews to synthesize evidence. It is important to assess the quality of these systematic reviews.

OBJECTIVE

This study aims to examine the reporting of systematic reviews and meta-analyses, using inguinal hernia repair as an index diagnosis.

METHODS

MEDLINE, Embase, and CINAHL databases were searched for systematic reviews and/or meta-analyses of interventions on inguinal hernia in the pediatric population. The quality reporting was assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and A MeaSurement Tool to Assess Systematic Reviews (AMSTAR) 2 tools.

RESULTS

Of 1449 unique reports, 21 studies were included (15 meta-analyses and six systematic reviews). Median percent reported items for PRISMA and AMSTAR 2 were 72.2% and 70.5%, respectively. The least reported items in PRISMA were protocol registration (27.6%), synthesis of results (13.0%), and a risk of bias across studies (20.6%). For AMSTAR 2, the least reported items were reporting of source of funding (14.3%), appropriate methods for statistical combination of results (25.0%), and pre-establishment of protocol (28.6%). All critical items were completely or partially fulfilled in 5/21 (23.8%) of the studies and completely absent in 1/21 (4.8%) studies.

CONCLUSIONS

The results of this study highlight relatively good reporting quality, yet a poor methodological quality of systematic reviews/meta-analyses in the pediatric surgery literature on inguinal hernia management.

The relationship between contralateral patent processus vaginalis and metachronous contralateral inguinal hernia in children with unilateral inguinal hernia: a prospective observational study

PURPOSE

Laparoscopic contralateral patent processus vaginalis (CPPV) repair in children is debatable due to the high CPPV rate, but low metachronous contralateral inguinal hernia (MCIH) rate. We conducted this study to find risk factors for MCIH.

METHOD

We conducted a prospective, observational trial with patients recruited from Shanghai Children's Hospital. Eligible participants were patients under 16 years old with unilateral inguinal hernia whose parents did not opt for simultaneous CPPV repair. The subjects were followed for 24 to 34.1 months. Patients who developed MCIH were analyzed to identify the relationship between CPPV and MCIH.

RESULTS

Between October 17, 2018, and July 31, 2019, we included 184 patients and 182 completed follow-up. MCIH occurred in ten patients, of which 7 (7.53%) had CPPV and three (3.37%) had no CPPV. Univariate analysis showed that age (p = 0.025, OR = 0.938) and CPPV diameter (p = 0.003, OR = 1.783) were related to the development of MCIH. In multivariate analysis, only diameter of CPPV (p = 0.008, OR = 1.411) was associated with MCIH. The receiver operating characteristic (ROC) curve was used to test, and it was found that when the diameter of CPPV was greater than 4 mm, the Youden index was the highest, with a specificity of 62.8% and a sensitivity of 100%.

CONCLUSION

The incidence of MCIH was not statistically higher in patients with CPPV compared with those without CPPV, so there is no indication for routine CPPV repair. The risk of MCIH development increases with CPPV diameter. 4 mm is the optimal cutoff point. Large CPPVs (> 4 mm) could be treated to prevent future hernias.

TRIAL REGISTRATION

The Chinese Clinical Trial Registry ( www.chictr.org.cn ), number ChiCTR2000041307.

Laparoscopic totally extraperitoneal ligation for pediatric inguinal hernia: a novel surgical treatment

BACKGROUND

Laparoscopic repair is widely performed for the management of pediatric inguinal hernia (PIH), and different laparoscopic surgical methods are used. Herein, we present the application of laparoscopic totally extraperitoneal ligation (TEPL), which is a novel surgical method for PIH repair and is similar to traditional high ligation.

METHODS

In this study, 103 pediatric patients underwent laparoscopic TEPL for inguinal hernia. Data including demographic characteristics, clinical presentation, time of surgery, length of hospital stay, and postoperative complications were analyzed retrospectively.

RESULTS

The patient's median age at surgery was 4.3 years, and the median body weight at surgery was 18 kg. The preoperative diagnoses were as follows: n = 53, right inguinal hernia; n = 45, left inguinal hernia; and n = 5, bilateral inguinal hernia. All patients were discharged on the day of surgery. The operative times were 27.2 min for unilateral inguinal hernia and 28.8 min for bilateral inguinal hernia. All patients, except one who had scrotal bruise, did not present with postoperative complications.

CONCLUSIONS

Laparoscopic TEPL, which is similar to traditional high ligation, is used for the treatment of PIH. Moreover, it is safe, beneficial, and feasible. Double ligation is performed on the extraperitoneal space, and the assessment of contralateral patent processus vaginalis is not complex. However, further studies should be conducted to assess for long-term outcomes.

Is it worth to explore the contralateral side in unilateral childhood inguinal hernia?: A PRISMA-compliant meta-analysis

BACKGROUND

It is still not clear if the contralateral side should be explored in children with unilateral inguinal hernias. The primary aim of the present study was to assess the incidence of metachronous contralateral inguinal hernias (MCIHs) in the pediatric population. The second aim was to assess factors associated with increased risk of MCIH development.

METHODS

Prospective studies including patients from 0-19 years undergoing unilateral inguinal hernia repair without surgical exploration of the contralateral side between 1947 and April 2020 with a minimal follow-up of one year were searched. Searches included EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials.

RESULTS

Seven studies involving 1774 children (1452 boys (82%) and 322 girls (18%) were identified. Overall the incidence of MCIH was 6%. Incidence of MCIH development was significantly higher in children with initial left-sided (9%) versus right-sided (3%) hernia (OR 2.55 with 95% CI from 1.56 to 4.17; P = 0.0002), in female (8%) versus male (4%) children (OR 1.74 with 95% CI from 1.01 to 3.01; P = 0.0469) and in patients with open (14%) versus closed (3%) contralateral processus vaginalis (CPV) (OR 4.17 with 95% CI from 1.25 to 13.9; P = 0.0202). There was no significant difference in MCIH development depending on follow-up duration (follow-up of ≤2 years (i.e. 1-2 years): calculated MCIH incidence 5% (95% CI from 0.00 to 0.11%; 3 studies; 569 patients), follow-up of ≥3 years (i.e. 3-4 years): 6% (95% CI from 0.03 to 0.09; 3 studies, 983 patients)) or patients' age (MCIH incidence in children <1 year: 6.9%; older children: 4.5%; OR 1.87 with 95% CI from 0.97 to 3.62; P = 0.0618).

CONCLUSIONS

Overall incidence of MCIH development is 6%. Initial left-sided hernia, female gender and open CPV are risk factors for MCIH development.

Transinguinal laparoscopic evaluation of contralateral side during unilateral inguinal hernia repair for children

BACKGROUND

Inguinal hernia repair is a common procedure in daily pediatric surgical practice.

OBJECTIVES

The present study was planned to find out whether transinguinal laparoscopic exploration (TILE) of the contralateral groin is effective in reducing the need of operation for contralateral metachronous inguinal hernia (CMIH) in children.

STUDY DESIGN

Charts of 1103 children who underwent inguinal hernia repair between 2006 and 2016 were retrospectively analyzed. Eighty-eight children with bilateral hernia at the presentation were excluded, and 705 patients whose parents could be contacted by phone to get the latest information about children's condition were included in the study.

RESULTS

Of the 705 children with unilateral inguinal hernia repair, 362 (51.4%) and 343 (48.6%) of them had right-sided and left-sided inguinal hernia, respectively. Transinguinal laparoscopic exploration was performed in 479 of the 705 children with unilateral hernia and a hernia or contralateral patent processus vaginalis (PPV) was found and ligated in %28.3 (n = 136) of them. Mean follow-up time was 60 ± 36 months. Fifteen (4.3%) of 479 patients who had TILE and 31 (13.6%) of 226 the patients who did not have TILE developed CMIH. When the videos of 15 patients who developed CMIH were reviewed, overlooked PPV was found in 10 (3.3%) patients who had TILE during early phases of institutional learning curve.

DISCUSSION AND CONCLUSIONS

TILE of the contralateral side during pediatric inguinal hernia repair is a simple and effective method to evaluate contralateral PPV. This approach clearly and significantly reduces the need of operation for a metachronous hernia at a later date.

Independent risk factors for contralateral patent processus vaginalis undetected by pre-operative ultrasonography in boys with unilateral inguinal hernia

PURPOSE

Many trials have been done to make sure probability of metachronous contralateral side hernia (MCH) and contralateral patent processus vaginalis (CPPV). But the necessity of contralateral side exploration is still on debate. The aim is to investigate the risk factors for the consideration of contralateral examination on operation.

MATERIALS AND METHODS

The study was designed as retrospectively. Patients with unilateral inguinal hernia from January 2010 to May 2015 were enrolled. Pre-operative ultrasonography was done in all patients. Patients with obvious contralateral side hernia on pre-operative US were excluded. The presence of CPPV was evaluated by transinguinal laparoscopy during the operation.

RESULTS

In univariate analysis, hernial sac size only shows difference (P value: 0.001). The others, location of the hernia, age at surgery, gestational age (preterm), low birth weight and parent's age, did not show statistically significant differences. Multivariate analysis also demonstrates CPPV is more common in patients with large hernial sac (Odds ratio: 2.727, 95% confidence interval 1.495-4.974, P value: 0.001).

CONCLUSION

We propose that surgeons should consider contralateral evaluation during operation in case with large ipsilateral hernial sac, although CPPV was not detected by pre-operative US.

Reliability of Preoperative Inguinal Sonography for Evaluating Patency of Processus Vaginalis in Pediatric Inguinal Hernia Patients

Background: Among childhood illnesses requiring surgery, inguinal hernia is the most common entity. Pediatric inguinal hernia has been traditionally operated through a small incision in the inguinal region. Contralateral metachronous inguinal hernia has been the topic of discussion in pediatric surgeon's domain for a long time. Many studies have been conducted to prevent it from occurring. Although patency of processus vaginalis is known to be the cause of metachronous inguinal hernia, it is difficult to know the status of contralateral processus vaginalis preoperatively when the patient is non-symptomatic. Recently, the introduction of laparoscopic surgery has facilitated the observation and surgery of contralateral inguinal hernia during scheduled surgery of unilateral hernia repair while the processus vaginalis is intact. The standard treatment for inguinal hernia is herniotomy. Laparoscopic inguinal hernia repair has not been widely applied in Korea. The objective of this study was to analyze the accuracy of preoperative sonography results of inguinal lesion on the contralateral side in patients that needed laparoscopic operation of inguinal hernia. Methods: Data of 107 patients who received laparoscopic inguinal hernia repair and evaluation by preoperative ultrasonography at Dongguk University Ilsan Hospital from 2011 to 2015 were analyzed. Results: Preoperative sonography for inguinal lesion had a sensitivity of 20.5%, a specificity of 95.2%, a positive predictive value of 75%, and a negative predictive value of 63.2%. Its accuracy was 64.5%. A total of 107 patients had no inguinal hernia recurrence or metachronous contralateral inguinal hernia. Conclusion: Ultrasonography performed prior to traditional pediatric herniotomy is not enough for accurate diagnosis of patency of processus vaginalis in our retrospective study. Multicenter prospective study is needed to estimate accuracy of sonographic diagnosis for patency of processus vaginalis.

Laparoscopic repair of inguinal hernia in infants: Comparison with open hernia repair

PURPOSE

This study aimed to evaluate the usefulness of laparoscopic repair of inguinal hernia (LR) in infants in comparison with open hernia repair (OR).

METHODS

We retrospectively analyzed the clinical data of 465 infants treated for inguinal hernia from January 2006 to December 2015. Among them, 124 underwent LR and 341 underwent OR.

RESULTS

In the OR group, 16.1% (55/341) primarily underwent bilateral inguinal hernia repair and 13.6% (42/308) subsequently developed metachronous contralateral inguinal hernia during follow-up. In the LR group, 75.8% (94/124) underwent primary bilateral inguinal hernia repair and only 1.6% (2/123) developed metachronous contralateral inguinal hernia. The mean operation times of unilateral inguinal hernia repair showed no statistical differences between LR and OR. However, the mean operation times of bilateral inguinal hernia repair were shorter in LR (39.8±10.4 vs. 51.1±14.4min, p<0.001). Postoperative recurrence and wound infection showed no statistical differences between the groups, but postoperative scrotal swelling was more common in OR (0.0% vs. 4.0%, p=0.006).

CONCLUSION

LR in infants showed a lower incidence of metachronous hernia, shorter operation times, and better postoperative course than OR. LR could be considered the primary operation method in infants with inguinal hernia.

LEVELS OF EVIDENCE

Prognosis Study, Retrospective Study, Level III.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Efficacy of Laparoscopic Percutaneous Extraperitoneal Closure for Unilateral Inguinal Hernia in Children and Significance of Simple Exploration Maneuver for Contralateral Patent Processus Vaginalis: A Retrospective Study

To evaluate the efficacy of laparoscopic percutaneous extraperitoneal closure (LPEC) for unilateral inguinal hernia in children and effect of intraoperative laparoscopic exploration for finding contralateral patent processus vaginalis (CPPV) on prevention of the metachronous contralateral hernia (MCH). We retrospectively analyzed unilateral inguinal hernia ligation in children, which can be diveded into two groups: a total of 252 cases with open surgical ligation from January 2010 to December 2012 (open group), a total of 184 cases underwent laparoscopic percutaneous peritoneal hernia sac high ligation LPEC from January 2013 to March 2015 (LPEC group). Then, we observed postoperative complications, recurrence of hernia, and the postoperative MCH in the two groups and analyzed the influence factors of the MCH. In Open groups and LPEC groups, the complication incidences, respectively, were 4.4 and 1.6 per cent, having statistical difference ( P > 0.05), the average postoperative follow-up duration, respectively, were 42 months and 22 months, whereas the overall incidence of MCH, respectively, were 5.2 and 0.5 per cent ( P < 0.05). In the first 24 months follow-up time, the overall incidence of MCH, respectively, were 3.6 and 0 per cent. Laparoscopic evaluation was positive for CPPV in 67 cases. We found the prevalence of 56.1 per cent of CPPV in LPEC groups aged 0.6 to 2 years old, finding the incidence gradually decline with the increase of age, until 14.3 per cent to 10 to 12 years old group. Our study shows LPEC has proven efficacy in treatment of unilateral inguinal hernia in children, and routine laparoscopic exploration with this simple maneuver should be actively performed to observe CPPV in all chidren.

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.

Effects of Laparoscopic Hernia Repair by PIRS (Percutan Internal Ring Suturing) Technique on Testicular Artery Blood Supply

Purpose: Percutaneous internal ring suturing technique (PIRS) is a minimally invasive technique in pediatric inguinal hernia repair. In the present study, a negative effect on testicular blood flow using PIRS technique has been investigated. Methods: Forty male patients were included in the study prospectively. Two groups were formed as conventional open surgery (Group I) and PIRS technique (Group II). The resistive index (RI) value of the testicular artery was measured prospectively by using SMI (superb micro-vascular imaging) software with the color doppler ultrasound technique preoperatively and postoperatively at the first month. Results: Inguinal hernia was present on the left in 35% (n = 14) of the patients and on the right in 65% (n = 26) of the patients. There was no statistically significant difference (p = 0.727) between Group I and II with regard to preoperative RI value (0.66 ± 0.07 vs. 0.66 ± 0.45, respectively). Similarly, there was no statistically significant difference (p = 0.220) between Group I and II with regard to the RI values measured at the postoperative first month (0.58 ± 0.04 vs. 0.60 ± 0.04, respectively). Although the postoperative RI values decreased compared to the preoperative values in both groups, this difference was not statistically significant. (p = 0.447 in Group I, and p = 0.175 in Group II for intragroup comparison). Conclusions: Besides PIRS technique has the advantages provided by all other laparoscopic techniques defined for inguinal hernia repair, there is no significant difference between this technique and conventional open surgery with regard to testicular blood flow. It is an innovative candidate technique instead of the open surgery method besides its additional advantages.

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.

Pre-operative Spermatic Cord Ultrasonography Helps to Reduce the Incidence of Metachronous Inguinal Hernia in Boys

Background/purpose: Thickening of the spermatic cord is a clinical sign of an inguinal hernia. We therefore tested whether pre-operative spermatic cord ultrasonography could reduce the incidence of metachronous inguinal hernia (MIH). Methods: Boys under 2 years old with an initial unilateral inguinal hernia were enrolled in this study. In whom the width of the asymptomatic-sided spermatic cord was ≥0.5 cm, these patients underwent contralateral groin exploration. Age at initial operation, weight, initial operation side, the sonographic width of the spermatic cord, the operative findings and presence of MIH were recorded, and the relationship among them was studied. Boys in the US group underwent an open herniorrhaphy with pre-operative ultrasound examination; the non-US group included boys who did not undergo a pre-operative ultrasound examination. A receiver operator curve (ROC) analysis was performed to evaluated predictive value of the sonographic width of the spermatic cord for contralateral hernia. Results: A total of 24 months' follow-up data were obtained from 1,793 boys (US group 1,162, non-US group 631). In the US group, the width of the hernia-sided spermatic cord (0.75 ± 0.18 cm) was larger than the normal side (0.37 ± 0.05 cm, P < 0.001). And the width of normal side spermatic cord had no significant difference between the groups regarding other factors such as age and weight. In whom the width of the asymptomatic-sided spermatic cord was ≥0.5 cm, the corresponding incidence of CIH was 86.4% (57/66). The width of the spermatic cord predicted the presence of contralateral hernia with ROC area under the curve = 0.943 (95% CI = 0.919-0.966). The total incidence of MIH was 4.1% (74/1793). The incidence of MIH in the US group was 2.2% (25/1162) much lower than 7.8% (49/631) in the non-US group (P < 0.001). If the width of the asymptomatic-sided spermatic cord was 0.5 cm and 0.54 cm, the corresponding sensitivity was 0.682 and 0.294, respectively, the corresponding specificity was 0.991 and 1.000, respectively. Conclusion: If the width of the asymptomatic-sided spermatic cord of boys with initial unilateral inguinal hernia sonographic width was ≥0.5 cm, contralateral groin exploration was recommended, and it help to reduce the incidence of MIH.

Risk factors for contralateral inguinal hernia repair after unilateral inguinal hernia repair in male adult patients: analysis from a nationwide population based cohort study

Background

To identify the rate of and risk factors for contralateral inguinal hernia (CIH) after unilateral inguinal hernia repair in adult male patients.

Methods

This retrospective cohort study identified from the Taiwan National Health Insurance Research Database (NHIRD). Information on all adult patients who underwent primary unilateral inguinal hernia repair without any other operation was collected using ICD-9 diagnostic and procedure codes. The exclusion criteria were laparoscopic hernia repair, non-primary repair, complicated hernia, other combined procedures, female and undetermined gender.

Results

A total of 170,492 adult male patients were included, with a median follow-up of 87 months. The overall CIH rate was 10.5%, with a median time of 48 months to a subsequent hernia operation. The 1-year, 2-year, 3-year and 5-year-recurrent rate was 2.6, 3, 4.3, and 6.7% respectively. Further, 3.7% patients who underwent CIH repair had a complicated inguinal hernia. Multivariate analysis demonstrated that age > 45 y, direct hernia, cirrhosis (HR = 1.564), severe liver disease (HR = 1.663), prostate disease (HR = 1.178), congestive heart failure (HR = 1.138), and history of malignancy (HR = 1.116) had a significantly higher risk of CIH repair.

Conclusions

Among adult male patients undergoing long-term follow-up, we identified several significant risk factors for CIH repair. If these risk factors are presented, the surgeon should inform the following risk of CIH repair to patients so that it can be repaired as soon as possible.

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.

A systematic review of the quality of conduct and reporting of systematic reviews and meta-analyses in paediatric surgery

OBJECTIVE

Our objective was to evaluate quality of conduct and reporting of published systematic reviews and meta-analyses in paediatric surgery. We also aimed to identify characteristics predictive of review quality.

BACKGROUND

Systematic reviews summarise evidence by combining sources, but are potentially prone to bias. To counter this, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was published to aid in reporting. Similarly, the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) measurement tool was designed to appraise methodology. The paediatric surgical literature has seen an increasing number of reviews over the past decade, but quality has not been evaluated.

METHODS

Adhering to PRISMA guidelines, we performed a systematic review with a priori design to identify systematic reviews and meta-analyses of interventions in paediatric surgery. From 01/2010 to 06/2016, we searched: MEDLINE, EMBASE, Cochrane, Centre for Reviews and Dissemination, Web of Science, Google Scholar, reference lists and journals. Two reviewers independently selected studies and extracted data. We assessed conduct and reporting using AMSTAR and PRISMA. Scores were calculated as the sum of reported items. We also extracted author, journal and article characteristics, and used them in exploratory analysis to determine which variables predict quality.

RESULTS

112 articles fulfilled eligibility criteria (53 systematic reviews; 59 meta-analyses). Overall, 68% AMSTAR and 56.8% PRISMA items were reported adequately. Poorest scores were identified with regards a priori design, inclusion of structured summaries, including the grey literature, citing excluded articles and evaluating bias. 13 reviews were pre-registered and 6 in PRISMA-endorsing journals. The following predicted quality in univariate analysis:, word count, Cochrane review, journal h-index, impact factor, journal endorses PRISMA, PRISMA adherence suggested in author guidance, article mentions PRISMA, review includes comparison of interventions and review registration. The latter three variables were significant in multivariate regression.

CONCLUSIONS

There are gaps in the conduct and reporting of systematic reviews in paediatric surgery. More endorsement by journals of the PRISMA guideline may improve review quality, and the dissemination of reliable evidence to paediatric clinicians.

Risk factors for recurrence and contralateral inguinal hernia after laparoscopic percutaneous extraperitoneal closure for pediatric inguinal hernia

BACKGROUND

The use of laparoscopic percutaneous extraperitoneal closure (LPEC) for pediatric inguinal hernia has recently been increasing. Recurrence and contralateral metachronous inguinal hernia (CMIH) are important problems for LPEC. This study analyzed the risk factors for recurrence and CMIH.

METHODS

This study included 1530 patients. The mean follow-up period was 48months. Of 1530 patients, 847 were boys and 683 were girls. The mean age at operation was 3.9years. The asymptomatic contralateral internal ring was routinely observed during the operation, and when a patent processus vaginalis (PPV) was confirmed, prophylactic surgery was performed.

RESULTS

Recurrence was seen in 0.48% of patients (8/1653 sides), all of whom were male (P=0.01: male versus female). On multivariate analysis, age less than 1year was the only risk factor for recurrence in male patients (hazard ratio: 4.54, 95% CI: 1.07-19.25, P=0.04). CMIH was seen in 0.22% of the patients (3/1382), again only in male patients (P=0.12: male versus female). As a result of intraoperative observation, 44.6% of patients were confirmed to have an asymptomatic contralateral PPV and underwent prophylactic LPEC. Female, age 1year or older, right side, and surgeon's experience were identified as factors associated with asymptomatic contralateral PPV.

CONCLUSIONS

To prevent recurrence, surgeons need to be careful when operating on young male patients. Whereas no specific factor could be identified as a risk factor for CMIH, some factors associated with asymptomatic PPV were identified. Further study and discussion will be needed to identify correlations between CMIH and these factors for PPV.

LEVEL OF EVIDENCE

Level III.

Potential value of routine contralateral patent processus vaginalis repair in children with unilateral inguinal hernia

BACKGROUND

The development of laparoscopy as a means of evaluation and treatment of inguinal hernia in children has raised the question of whether simultaneous closure of a contralateral patent processus vaginalis (CPPV) is justified. The present study aimed to determine the rate of metachronous inguinal hernia (MIH) in children with CPPV.

METHODS

Children with unilateral inguinal hernia from two hospitals underwent either open or laparoscopic repair, and were followed up for MIH. The presence of CPPV was evaluated during laparoscopy and, if detected, the CPPV was closed. The relationship between CPPV and subsequent MIH was studied.

RESULTS

The study included children who had complete follow-up (90·0 per cent of those having open repair and 92·2 per cent of those undergoing laparoscopic repair). Of 2538 children who had open hernia repair, 62 (2·4 per cent) developed MIH (30 on the right side and 32 on the left; P = 0·015). Among 2855 children who underwent laparoscopic repair, a CPPV was identified and closed in 1469 (51·5 per cent). The rate of MIH after negative laparoscopic evaluation for CPPV was three of 2855 (0·1 per cent). There were no significant differences in the rate of CPPV between sexes and either the right or left side (P = 0·072 and P = 0·099 respectively). Ipsilateral recurrence was less frequent after laparoscopic repair: seven (0·2 per cent) versus 26 (1·0 per cent) for open repair (P < 0·001).

CONCLUSION

Laparoscopic inguinal hernia repair was associated with a lower recurrence rate than open repair. Routine repair of CPPV reduced the rate of subsequent MIH, but 21 CPPVs needed to be closed to prevent one MIH.

Morphology-based investigation of metachronous inguinal hernia after negative laparoscopic evaluation - is it acquired indirect inguinal hernia?

PURPOSE

Patients who developed apparent metachronous contralateral inguinal hernia (MCIH) after negative laparoscopic diagnosis have been reported. We performed this study to investigate the morphological characteristics and etiology of this phenomenon.

PATIENTS AND METHODS

A consecutive series of 1,747 patients (858 boys and 889 girls) with symptomatic unilateral inguinal hernia were studied. During laparoscopic percutaneous completely extraperitoneal closure, morphological appearances at the asymptomatic groin were inspected for contralateral patent processus vaginalis (CPPV) with definitive criteria. If positive CPPV was identified, it was closed by the same technique used for the affected side. The patients were reviewed for occurrence of metachronous contralateral hernia.

RESULTS

A total of 755 patients (43.2%) had positive CPPV. Of the 992 patients whose CPPVs were evaluated as true negative, eight (seven boys, one girl) developed MCIH (time taken, three months to five years six months). During second-look operations, morphological appearances of the CPPV that was originally considered as true negative CPPV was found to be wide open.

CONCLUSIONS

Despite a true negative evaluation by laparoscopy, there was a 0.8% chance of developing a MCIH. This phenomenon was male-oriented and may be acquired indirect inguinal hernia without preceding of CPPV.

Incidence of metachronous contralateral inguinal hernias in children following unilateral repair - A meta-analysis of prospective studies

PURPOSE

The objective of this review was to systematically evaluate the incidence of a metachronous contralateral inguinal hernia (MCIH) in children with unilateral inguinal hernia and therefore to propose or to reject routine contralateral groin exploration.

METHODS

Electronic searches restricted to prospective studies with a minimal follow-up of 1year included MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials.

RESULTS

Six studies involving 1669 children were included. Overall MCIH was 6% (95% CI from 4% to 8%). The odds for MCIH development were significantly larger in children with an initial left-sided hernia (OR 2.66 with 95% CI from 1.56 to 4.53) and in children with open contralateral processus vaginalis (CPV) (OR 4.17 with 95% CI from 1.25 to 13.9).

CONCLUSIONS

The overall incidence of MCIH following unilateral inguinal hernia repair in children is 6%. Initial left-sided hernia (8.5%) and open CPV (13.8%) are risk factors for MCIH development. Female gender (8.2%) and younger age (<1year) (6.9%) non-significantly increase the risk of MCIH.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Laparoscopic assisted extraperitoneal hernia sac high ligation vs traditional surgery for inguinal hernia in preschool children

AIM: To compare the clinical effects of laparoscopic assisted extraperitoneal hernia sac high ligation with traditional surgery in the management of inguinal hernia in preschool children.

METHODS: Preschool children with inguinal hernia treated at Suqian People's Hospital from March 2013 to January 2015 were divided into two groups to receive either laparoscopic assisted extraperitoneal hernia sac high ligation (observation group, n = 53) or traditional surgery (control group, n = 49). Operative time, hospital stay, and postoperative complications were compared for the two groups.

RESULTS: All surgical procedures were successful in the two groups. The mean operation time and hospital stay were significantly better in the observation group than in the control group (15.35 min ± 2.11 min vs 20.45 min ± 3.74, 2.0 d vs 3.5 d, P < 0. 05). The postoperative follow-up duration was 6 mo, during which no postoperative recurrence was observed in the observation group. One case of contralateral hernia developed in patients with unilateral inguinal hernia in the observation group. In the control group, 7 cases of contralateral hernia appeared.

CONCLUSION: Laparoscopic assisted extraperitoneal hernia sac high ligation treatment of inguinal hernia in preschool children is feasible and convenient, with shorter hospital stay and fewer postoperative complications.