A Modified Approach for Inguinal Hernias in Children: Hybrid Single-Incision Laparoscopic Intraperitoneal Ligation

Laparoscopic hernia repair in children: does recreating the open operation improve outcomes? A systematic review

PURPOSE

The use of laparoscopy for paediatric inguinal hernia repairs has increased significantly over the past 2 decades. However, there is significant variation in the reported recurrence rates in the literature, with many studies reporting higher rates than the open operation. This may be explained by the range of different techniques currently included under the term laparoscopic inguinal hernia repair. The purpose of this study is to determine whether dividing the hernia sac before ligation improves surgical outcomes following a paediatric laparoscopic inguinal hernia repair compared to ligation alone.

METHODS

A systematic review of the literature was performed following PRISMA guidelines of all studies reporting the outcomes following paediatric laparoscopic inguinal hernia repair where the technique was recorded as laparoscopic suture ligation alone (LS) or laparoscopic sac division and suture ligation (LSDS). Studies were assessed for risk of bias and exclusion criteria included reported follow-up of less than 6 months.

RESULTS

A total of 8518 LS repairs and 6272 LSDS repairs were included in the final analysis. LSDS repair was associated with a significantly lower recurrence rate (odds ratio 0.51, 95% CI 0.36-0.71, p = 0.001). There was no significant difference in the rates of testicular ascent or atrophy.

CONCLUSION

Recreating the open operation by hernia sac division followed by suture ligation significantly reduces the risk of hernia recurrence.

Comparison of Surgical Outcomes of Laparoscopic Glue and Laparoscopic Suture Hernioplasty in Pediatric Female Inguinal Hernia

This study aimed to report the surgical outcomes of laparoscopic glue hernioplasty (LGH) compared with conventional laparoscopic suture hernioplasty (LSH) in pediatric female inguinal hernia repair. We retrospectively analyzed 465 female pediatric patients who underwent laparoscopic inguinal hernia repair between January 2013 and December 2020. LGH and LSH were performed in 95 and 370 cases, respectively. Surgical outcomes (length of hospital stay, operative time, complications, and recurrences) were compared between the LGH and LSH groups. We found that the operation times for bilateral hernia repair were shorter in the LGH group (LGH: 35.5 ± 8.2 min, LSH: 45.2 ± 11.6 min; p < 0.001). No significant differences in complications or recurrences were observed between the two groups during the follow-up period. Our findings suggest that LGH is a feasible and easily applied surgical technique for the treatment of pediatric female inguinal hernia.

Comparison study of three laparoscopic ligation procedures for pediatric inguinal hernia: a multicenter cohort of 5523 cases

PURPOSE

Single-site laparoscopic percutaneous extraperitoneal ligation (SLPEL) for pediatric inguinal hernia has gained popularity worldwide. However, complications associated with extraperitoneal knotting are not rare. This study evaluated the effectiveness of a modified SLPEL (M-SLPEL) to decrease adverse events associated with ligation knotting by comparing it with two other methods: classical SLPEL (C-SLPEL) and intracorporeal purse-string suturing (IPS).

METHODS

A multicenter retrospective comparative study was conducted among 5523 pediatric inguinal hernia patients. Cases were divided into three groups according to the surgical procedure: the M-SLPEL, C-SLPEL, and IPS groups. Data describing the clinical characteristics, operative time, and complications were collected.

RESULTS

All procedures were performed uneventfully. There were no significant differences in the age at operation (mean 2.62 ± 1.38 years). The operative time was shorter in the M-SLPEL group both for unilateral hernias (12.5 ± 1.8 min in C-SLPEL, 11.7 ± 1.3 min in M-SLPEL, and 17.6 ± 2.9 min in IPS) and for bilateral hernias (15.1 ± 2.1 min, 14.6 ± 1.7 min, and 23.9 ± 2.3 min, respectively). The overall incidence of adverse events in the inguinal region was 0% for M-SLPEL, 2.2% for C-SLPEL, and 0.5% for IPS. All patients were followed up for 12-93 months (mean 54 months). Recurrence occurred in 8 cases in the C-SLPEL group, 1 case in the M-SLPEL group, and 8 cases in the IPS group, with no significance between groups. No scrotal hematoma, testicular atrophy, or iatrogenic cryptorchidism occurred in any group.

CONCLUSION

The M-SLPEL procedure has time-consumption efficiency equivalent to that of C-SLPEL and even fewer adverse events in the inguinal region than IPS and C-SLPEL.

Re-evaluation of jumping purse-string suturing in pediatric laparoscopic hernia repair

BACKGROUND

Reported recurrence rates using jumping purse-string suturing in laparoscopic hernia repair (LH) are higher than that of intact purse-string. This study aims to compare the outcomes of LH using transabdominal jumping purse-string suturing (TJS) with those using transabdominal intact purse-string suturing (TIS) and percutaneous extraperitoneal intact purse-string suturing (PEIS).

METHODS

A total of 3340 patients from three centers who have undergone laparoscopic hernia repair from January 2016 to June 2019 were retrospectively reviewed. Of these, 1460 patients received TJS, 724 patients received TIS, and 1006 patients received PEIS. One hundred and fifty patients were excluded due to the loss of follow-up. Demographic characteristics, intraoperative findings, and postoperative complications were analyzed.

RESULTS

The hernia distribution characteristics and mean length of hospital stay were similar among the three groups (p > 0.05, p > 0.05). While the overall complication rates were similar among the three groups (0.34% in TJS vs. 0.41% in TIS vs. 0.50% in PEIS, TJS & TIS p = 0.502; TJS & PEIS p = 0.813), the incidence of intraoperative hematoma in TIS group and postoperative subcutaneous knot in PEIS group was significantly higher ((0.83% in TIS and 0.34% in TJS vs. 0.2% in PEIS, TJS & TIS p = 0.018; TJS & PEIS p = 0.163), (0% in TIS and 0% in TJS vs. 0.2% in PEIS, TJS & TIS p = 0.415; TJS & PEIS p = 0.025)). There were no differences in the recurrent rate in both unilateral and bilateral cases.

CONCLUSIONS

Transabdominal jumping purse-string suturing is not associated with a higher recurrence rate and is the recommended surgical approach.

A Modified Approach for Single-Port Laparoscopic Repair of Inguinal Hernias in Children

Background:

Although traditional open groin incision repair has been used routinely for decades, the benefit of the minimally invasive surgery has challenged the traditional open method. Nowadays, laparoscopic herniorraphy has evolved to making it more minimally invasive from 3 to 2 and now single port and from intracorporeal to extracorporeal knotting. This study aimed to evaluate a new modification of single port laparoscopic herniorraphy in children with congenital inguinal hernia.

Materials and Methods:

In this single-institution randomized case–control study 190 children who suffered from congenital inguinal hernia were divided into two groups randomly: Group 1 (N = 73) undergone a single-port modified extracorporeal purse-string sutures (laparoscopic surgery [LS]) and Group 2 (N = 117) undergone open surgery (OS).

Results:

The mean age of the patients at operation time was 28.79 ± 11.45 months. Overall, three patients (1.57%) had intraoperative retroperitoneal hemorrhage. The duration of anesthesia and operation for those undergoing bilateral operation were significantly shorter in LS group. There was no statistically significant difference in individual postoperative complication rates between the groups. The proportion of overall post-operative complications was 4 (5.4%) in LS and 13 (11.1%) in OS group (P = 0.18). Proportion of trapped cryptorchidism was significantly higher in the OS group.

Conclusion:

In conclusion for children with inguinal hernia, we had found the benefits of single-port modified extracorporeal purse-string for reduction the operative time, trapped testes and better cosmetics and parents' satisfaction.

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.

Single-port laparoscopic herniorrhaphy using a two-hooked cannula device with hydrodissection

BACKGROUND

Laparoscopic percutaneous extraperitoneal closure (LPEC) with variable devices seems to be one of the most simple and reliable methods. We described our modifications of single-port laparoscopic herniorrhaphy using an inner two-hooked cannula device with preperitoneal hydrodissection.

PATIENTS AND METHODS

1568 children with 2114 inguinal hernias were treated by single-port LPEC. Under laparoscopic visualization, the two-hooked cannula device carrying a silk suture was inserted at the point of the internal ring and could be readily kept in an identical path. The hernia orifice was completely lassoed extraperitoneally by the suture with the assistance of hydrodissection. Any huge hernias of more than 1.5 cm were repaired with the incorporation of medial umbilical fold flap as reinforcement.

RESULTS

All hernia repairs were successfully performed by LPEC. 1022 patients had unilateral inguinal hernia repair, and 546 patients underwent bilateral inguinal hernia repair. Of these, additional medial umbilical flap reinforcement was necessary in 68 cases, and an assisted grasping instrument was used in 19 cases owing to omental adhesion or sliding hernia. Mean operating times for unilateral and bilateral inguinal hernia repairs were 9.8 ± 2.1 min and 13.6 ± 2.2 min, respectively. There were no operative complications. Two recurrences and three hydroceles were observed during 6 to 30 months of follow-up.

CONCLUSIONS

One-puncture LPEC using the two-hooked cannula device with preperitoneal hydrodissection has proved to be a safe and effective procedure with excellent cosmetic results.

LEVEL OF EVIDENCE

IV.